California Fall practicematters. For More Information. Call our Provider Services Center at Visit UHCCommunityPlan.

Transcription

1 California Fall 2018 practicematters For More Information Call our Provider Services Center at Visit UHCCommunityPlan.com

2 In This Issue... CMO Corner Rady Children s Hospital San Diego Now Participating in UnitedHealthcare s Medi-Cal Care Provider Network Requesting Radiology Prior Authorization on Link Case Managers Help Members with Complex Needs Accessing Patient Care Opportunity Reports Offering Language Assistance to Our Members Patient Access and Availability Survey p.1 Attend Instructor-Led Provider Training National MedTrans Celebrating Health Care Heroes in California Clinical Practice Guidelines Initial Health Assessment Care Provider Training Department of Health Care Services Proposition 56 Directed Payments for State Fiscal Year Provider Enrollment Requirements Cervical Cancer U.S. Preventive Services Task Force (USPSTF) Recommendations and Guidelines We hope you enjoy the fall issue of Practice Matters. In this issue, you can read about accessing patient care opportunity reports, how case managers can help members with complex needs, celebrating health care heroes in California, and much more. Practice Matters: CA Fall 2018 Provider Services Center:

3 CMO Corner Jennifer Nuovo, MD, Chief Medical Officer, UnitedHealthcare Community Plan of California A warm hello as we launch our first edition of Practice Matters. Thank you for serving our UnitedHealthcare Community and State Medi-Cal members. I understand how complex our members health care needs are, as well as the social and economic challenges they face. I m humbled every day by the great work you do to focus on our members health care. We strive to make your experience with us hassle-free, and we always welcome your feedback. We also welcome your participation on our Provider Advisory Committee (PAC)! If you d like to share your insights with us at our PAC quarterly meetings, contact Jessica Gonzalez, our Quality Analyst, at jessica_m_gonzalez@uhc.com. I was excited to join UnitedHealthcare in June to provide clinical oversight for this unique line of business. We have much to look forward to over the next few months, including launching our Diabetes Prevention Program, building the Health Homes model collaboratively with your practice sites, expanding our Palliative Care network and enhancing our Whole Person Care model of case management. The Medi-Cal program is complex, but we re here to help make the care and management of this population as seamless as possible. Thank you again, and I look forward to working with you in the months and years to come. 1

4 Rady Children s Hospital San Diego Now Participating in UnitedHealthcare s Medi-Cal Care Provider Network Rady Children s Hospital San Diego and UnitedHealthcare have established a new network relationship, giving members enrolled in UnitedHealthcare Medi-Cal plans network access to Rady Children s Hospital, facilities and physicians in Southern California. This new relationship provides UnitedHealthcare Medi Cal plan members with access to Rady s facilities, physicians and other care providers who share UnitedHealthcare s commitment to improving access to quality care, enhancing clinical outcomes and creating an exceptional patient experience. Rady Children s and its physicians are committed to providing children and families with quality, costeffective medical services. Our new relationship with UnitedHealthcare will enable us to extend our reach and impact by serving more children and the families in Southern California, said Charles Davis, MD, senior vice president of Care Redesign and Managed Care and COO of Rady Children s Specialists of San Diego. Rady Children s Hospital San Diego is an important community provider and offers California children and their families served by UnitedHealthcare greater choice and access to quality, cost-effective care, said Kevin Kandalaft, CEO, UnitedHealthcare Community Plan of California. We are grateful for the collaborative relationships we share with care providers like Rady Children s who are committed to improving the quality and cost of care and the overall patient experience. UnitedHealthcare of California serves more than 3 million people enrolled in Medi-Cal, Medicare and employersponsored and individual health plans with a network of 403 hospitals and approximately 100,000 physicians and other care providers statewide. Requesting Radiology Prior Authorization on Link Did you know you can submit radiology prior authorization requests online using the Prior Authorization and Notification tool on Link? Sign in to Link by going to UHCprovider.com and clicking on the Link button in the top right corner. Then, select the Prior Authorization and Notification tile on your Link dashboard. With the Prior Authorization and Notification tool, you can: Determine if prior authorization or notification is required for a radiology service Initiate your request for prior authorization if it s required Upload medical notes or other attachments when required Check the status of your prior authorization requests, including those made by phone For more information about requesting prior authorization for radiology procedures, go to UHCprovider.com/radiology. 2

5 Case Managers Help Members with Complex Needs The UnitedHealthcare Community Plan Case Management program provides a holistic approach to caring for members with complex needs, especially those with chronic conditions. The program s goal is to help our members get the care and services they need. Here s what our case managers can provide to your eligible members: Phone contact with members and home visits as needed Health education and educational materials A health assessment with stratification of diagnosis and severity of condition and psychosocial needs Referral to community resources Assistance with medical transportation Arrangements for durable medical equipment and ancillary services Outreach to members to help them keep appointments Help identifying and addressing barriers to following their plan of care For more information or to make a referral, call our referral line at Accessing Patient Care Opportunity Reports The Patient Care Opportunity Report (PCOR) is now available. We created PCOR to make it easier for you to identify which UnitedHealthcare Community Plan members may have preventive care or screening services that have not been completed. With your personalized PCOR, you ll have quick access to current actionable patient data, reporting and resources specific to your practice. The report is released each month, and you can filter and sort the data to meet your practice s needs. Historical records and services you provided while the member was with another health plan are not included in this report. How to Access Your PCOR Go to UHCprovider.com/pcor. f this is your first time signing in, click on New User at the top of the home page and follow the registration instructions. Click on Go to Reports and enter your Optum ID and password. All users will be prompted to choose an account. If you have more than one, pick which account you d like to view reports for. When the Document Vault tool opens, click on the Physician Performance & Reporting button and choose Open My Reports. Select the report you want to see. If this is your first time accessing your report, please use your personal identification number (PIN) to sign in. Your medical group practice will have one PIN number to log in and access reports. The PIN is the same for UnitedHealthcare Community Plan, Medicare Advantage and commercial members. If you don t know your PIN, contact your UnitedHealthcare representative or call our Health Care Measurement Resource Center at If you have questions about viewing your report, click on the envelope icon on the Open My Reports page and complete the Contact Us form. If you need additional assistance, contact your UnitedHealthcare representative or call our Health Care Measurement Resource Center at We hope you find the PCOR to be a valuable tool in managing your patients care. If you have any questions, our Quality Department at UHCCSCAQualityDepartment_DL@ds.uhc.com. 3

6 Offering Language Assistance to Our Members Linguistic and cultural barriers can negatively affect access to health care participation. Meeting a patient s language needs requires collaboration among the care provider, health plan and patient. Section 1557 of the Affordable Care Act stipulates that both care provider and health plan are covered entities under the law. Therefore, we must work together to meet the language needs of our members. To help you meet those needs, UnitedHealthcare Community Plan has developed a Cultural Competency Program. We require care providers to meet this obligation for our members. UnitedHealthcare Community Plan offers the following language support services: Language Interpretation Line: UnitedHealthcare Community Plan provides oral interpreter services 24 hours a day, seven days a week to its members, free of charge. Services for over 240 non-english languages and services for the hearing impaired are available. If a UnitedHealthcare Community Plan member needs Interpreter Services, UnitedHealthcare Community Plan prefers you use a certified interpreter instead of family members. To access a professional interpreter during regular business hours, contact the Provider Call Center at After hours, you may contact and enter the Client ID (do not hit #). Press 1 for Spanish and 2 for all other languages. Cultural Member Materials: We provide simplified materials written at or below a 6th grade reading level to members with limited English proficiency and who speak languages other than English or Spanish. We also provide materials to visually impaired members and in alternative format. For additional support to translated materials or materials format, contact the Provider Call Center at Cultural Competency Training: Every care provider must undergo training in cultural competency, integrity and compliance. You can access the Cultural Competency Training and additional resources on UHCprovider.com. 4

7 Patient Access and Availability Survey We want to make sure the care providers we work with are following the required timely access to care standards. Each year, we ask randomly selected care providers in primary care and certain specialties to complete a Patient Access and Availability Survey. The 2018 survey will be sent at the end of We are asking for your help completing the survey and want to remind your staff about these California access standards when assisting members with appointments. In 2017, UnitedHealthcare Community Plan of California conducted a care provider appointment availability and language assistance survey to make sure our care providers are following the California Department of Managed Health Care (DMHC) requirements for these services. The survey results are listed in the following chart Appointment Availability Survey Results Description Primary Care Providers Primary Care Provider (PCP) Urgent Care Access (within 48 hours with no prior authorization) Number Surveyed Non- Compliant Compliant (Compliance Rate > 80 percent) (23.93%) 196 (70%) N Non-Urgent PCP Visits (within 10 days) (21.07%) 221 (78.93%) N Specialists Urgent Care Gastroenterology Access (within 96 hours with prior authorization) Non-Urgent Gastroenterology Physicians Visits (within 15 days) Urgent Care Endocrinology Access (within 96 hours with prior authorization) Non-Urgent Endocrinologists Physicians Visits (within 15 days) Urgent Care Cardiologist Access (within 96 hours with prior authorization) (41.94%) 16 (51.61%) N 31 9 (29.03%) 22 (70.97%) N 25 7 (28%) 15 (60%) N 25 4 (16%) 21 (84%) Y (20%) 54 (77.14%) N Non-Urgent Cardiologist Physicians Visits (within 15 days) (14.29%) 60 (85.71%) Y Ancillary Providers Non-Urgent Ancillary Providers Visits (within 15 days): MRI (.33%) 303 (99.67%) Y Non-Urgent Ancillary Providers Visits (within 15 days): Physical Therapy 1, (6.36%) 1,282 (93.64%) Y Goal Met (Y/N) (continued on next page) 5

8 (continued from previous page) Patient Access and Availability Survey (continued) 2017 Language Assistance Survey Results Type Number Surveyed Rate of Confirmed Interpreter Services Provided by Phone, Video Conference or In-Office Goal Met (Y/N) Primary Care Providers (89.64%) N Specialists Cardiologists (88.57%) N Gastroenterologist (87.10%) N Endocrinologist (100%) N Ancillary Providers Ancillary: MRI (97.70%) Y Ancillary: Physical Therapy 1, (59.53%) Y Timely Access to Care Standards The California Department of Managed Health Care (DMHC) requires that appointment requests be completed within specific timeframes. Following these standards guarantees that, for the majority of patients and most conditions, timely and appropriate access is provided: Appointment Type Time Frame Urgent Appointments Urgent Care (Prior authorization not required by health plan) Urgent Care (Prior authorization required by health plan) 48 hours 96 hours Non-Urgent Appointments Non-Urgent Doctor Appointment (primary care physician) Non-Urgent Doctor Appointment (specialty physician) Non-Urgent Mental Health Appointment (non-physician 1 ) Non-Urgent Appointment (ancillary provider 2 ) 10 Business Days 15 Business Days 10 Business Days 15 Business Days 1 Examples of non-physician mental health providers include counseling professionals, substance abuse professionals and qualified autism service providers. 2 Examples of non-urgent appointment for ancillary services include lab work or diagnostic testing, such as mammogram or MRI, and treatment of an illness or injury such as physical therapy. We re working with network care providers on action plans to improve compliance rates. 6

9 Reimagining Service When National MedTrans entered the market, nonemergency medical transportation was rudimentary: pick up someone and drive them to an appointment. However, each user has a unique set of needs and cultural considerations. For instance, a member may have limited mobility and need extra help or they may require a vehicle that can accommodate a wheel chair, or perhaps they don t speak English and need a transportation provider who s fluent in Russian. Attend Instructor-Led Provider Training Having trouble verifying member eligibility and benefits? Do the services you render need prior authorization? Does your member need to fill a prescription? You re invited to join us for an instructor-led Care Provider Training. You ll have the opportunity to learn more about UnitedHealthcare Community Plan of California. We ll provide an overview of our online tools and resources such as how to verify eligibility, submit claims and prior authorization requirements. Webinars are also available monthly. Please note that pre-registration is required. Go to uhc.webex.com > Training Center tab to get started. National MedTrans In line with efforts to provide a whole person approach to care and address the social determinants of health, UnitedHealthcare acquired non-emergency medical transportation company National MedTrans in the fall of Today, National MedTrans services are available to UnitedHealthcare s Medicare and Medicaid members in seven states, and we re continuing to expand to provide access to all of our members in the United States. To address this concern, National MedTrans began building smart profiles for their members, cataloging information that often contributed to delays or missed connections between members and their drivers, via machine learning and used these smart profiles to match members with the transportation providers who would best meet their needs. Personalizing services to each member s needs showed great results. That prompted National MedTrans to design Frances, an app that s also available by computer desktop and smartphone, and it integrates with National MedTrans telephones for members who prefer to call. Frances is unique in the market because it combines health plan, member and transportation provider data in a transparent way. All UnitedHealthcare plans that use National MedTrans services have access to Frances, and National MedTrans continues to promote adoption of the app, including for transportation providers. California members can use their transportation service by calling California facilities can schedule transportation for members by calling or logging into the provider portal found at natmedtrans.com. 7

10 Celebrating Health Care Heroes in California In recognition of National Health Center Week (Aug ), our team set out to honor the Home of America s Healthcare Heroes. Health care heroes in various roles gathered in front of the photo backdrops throughout the week to have their pictures snapped as documentation of their everyday Super Powers! The outreach team worked with several of our FQHCs to recognize care providers and staff at 48 clinic locations. We provided the opportunity for patients to recognize their health care heroes with thank-you cards, posters and coloring sheets. In addition, we created a festive breakroom environment by providing healthy snacks and sending a photographer to capture fun moments in front of the cape backdrops. Clinical Practice Guidelines The 2018 Clinical Practice Guidelines have been uploaded to the provider portal and are available at UHCprovider.com/en/health-plans-by-state/californiahealth-plans/ca-comm-plan-home/ca-cp-policies.html. Initial Health Assessment Care Provider Training UnitedHealthcare Community Plan of California wants to help ensure that members receive an Initial Health Assessment, which will allow our care providers to have a comprehensive view of their patients health care needs. For this reason, our quality department has created a short training that encompasses the Department of Health Care Services (DHCS) Policy Letter and is a new requirement from the state for participation in the Medi-Cal program. You can complete the Initial Health Assessment Care Provider Training in 15 minutes or less. Follow these steps to complete this new training: 1. Go to UHCprovider.com/training and click on Initial Health Assessment Care Provider Training. 2. Download the Initial Health Assessment Care Provider Training document and Initial Health Assessment Care Provider Training Attestation Form. 3. Review all the educational topics and links. 4. Once you complete the training, fill out the attestation form and it to UHCCSCAQualityDepartment_DL@ds.uhc.com. The quality department routinely monitors Initial Health Assessment completion rates through random sampling of practice sites. Your office may be selected as part of the random sample methodology. If requested, please return pertinent medical record content, including the Staying Healthy Assessment Form, immunization records, lab results and evidence of a complete physical. Results of the review will be shared with you and published in the Annual Quality Management Program Evaluation. We thank you and your staff for participation in this monitoring activity. Department of Health Care Services Proposition 56 Directed Payments for State Fiscal Year Early this year the Department of Health Care Services (DHCS) announced to Medi-Cal managed care health plans (MCPs) the policy on directed payments for certain services funded by the California Healthcare, Research and Prevention Tobacco Tax Act of 2016 (Proposition 56) for State Fiscal Year (SFY)

11 Directed Payment Qualifications Eligible network providers are network providers who are qualified to provide and bill for the CPT codes specified in the table listed below. Federally Qualified Health Centers, Rural Health Clinics, and American Indian Health Programs, as well as Cost-Based Reimbursement Clinics, are not eligible network providers for the purposes of Proposition 56. A qualifying service is one provided by an eligible network provider where a specified service is provided to a member, enrolled in UnitedHealthcare Community Plan, who is not dually eligible for Medi-Cal and Medicare Part B. Medi-Cal managed care health plans such as UnitedHealthcare Community Plan have received funds from Proposition 56 to direct payments to individual care providers rendering qualifying 2017/2018 services for the 13 CPT codes in the table listed below. We ve started payments for eligible claims received for qualifying services between our initial enrollment date of Oct. 1, 2017 and June 30, 2018; other plans date back to July 1, The directed payments are in addition to whatever other payments eligible network providers would normally receive from UnitedHealthcare Community Plan or UnitedHealthcare s delegated entities and subcontractors. DHCS has proposed to extend Proposition 56 supplemental payments for qualifying services between July 1, 2018 and June 30, UnitedHealthcare Community Plan will coordinate the process and payments with DHCS when the extension has been approved. Please call Provider Services at or caprop56@uhc.com with any questions you have about Proposition 56. CPT Description Directed Payment Office/Outpatient Visit New $ Office/Outpatient Visit New $ Office/Outpatient Visit New $ Office/Outpatient Visit New $ Office/Outpatient Visit New $ Office/Outpatient Visit Est $ Office/Outpatient Visit Est $ Office/Outpatient Visit Est $ Office/Outpatient Visit Est $ Office/Outpatient Visit Est $ Psychiatric Diagnostic Eval $ Psychiatric Diagnostic Eval with Medical Services $ Pharmacologic Management $5.00 9

12 Provider Enrollment Requirements To comply with Department of Health Care Services (DHCS) requirements and pursuant to Section 1902(a) (27) of the Social Security Act and Section of the Welfare & Institutions Code, effective Jan. 1, 2018, any care provider treating managed Medi-Cal members enrolled with UnitedHealthcare Community plan is required to also enroll with the DHCS. Who has to enroll? DHCS Enrollment is required for all ordering, treating and referring care providers, including those who are only participating in Managed Medi-Cal health plans. This includes all medical, behavioral health, pharmacy, facility, transportation and home-based providers. Care providers can download and complete the enrollment application form relevant to their provider type and specialty by going to dhcs. ca.gov/provgovpart/pages/applicationpackages AlphabeticalbyProviderType.aspx. The application process also requires additional information including but not limited to license, tax identification information, NPI, ownership disclosure and certificate of liability insurance. Please consult the DHCS enrollment site for further details Where can I verify provider enrollment? To verify enrollment, UnitedHealthcare Community Plan will check the California Health and Human Services Open Data Portal site using the provider s NPI #. How can I provide UnitedHealthcare with confirmation of my enrollment with DHCS? pcdm_ff_intake@uhc.com Mail: UnitedHealthcare Provider Contract & Data Management, 780 Shiloh Road, MS-1.700, Plano, TX Fax: Cervical Cancer U.S. Preventive Services Task Force (USPSTF) Recommendations and Guidelines UnitedHealthcare Community Plan of California provides and promotes preventive services as defined by the following entities: American Academy of Pediatrics Bright Futures TM guidelines (AAP), U.S. Preventive Services Task Force (USPSTF) A and B recommendations, the Advisory Committee on Immunization Practices (ACIP) and certain medical specialty organizations, such as American College of Obstetrics and Gynecology (ACOG). These recommendations may change from time to time, and any changes published by USPSTF, ACIP, AAP and the Department of Healthcare Services (DHCS) through an All Plan Letter will be routinely monitored on a regular basis. When there are changes, we will notify you through this Provider Newsletter, however, we encourage you to also regularly check these sources as well as your specialty society s website for changes to preventive health guidelines. For example, the task force recently released a final recommendation statement on screening for cervical cancer. It found that women ages 21 to 65 benefit from screening. The task force recommends the Pap test for women ages 21 to 29 and three strategies to screen women ages 30 to 65: Pap test, HPV test, or both in combination (co-testing). The task force recommends against screening in women younger than age 21 and in women older than 65 who have had adequate prior screening. The task force also recommends against screening at any age in women who do not have a cervix. To view the recommendation and the evidence on which it is based, please go here. The final recommendation statement can also be found in the August 21 online issue of the Journal of the American Medical Association (JAMA). UnitedHealthcare Community Plan of California s policy references both USPSTF and the American College of Obstetricians and Gynecologists (ACOG) cervical cancer screening recommendations. If you have questions, contact Provider Services at or call your Network Account Manager 10

13 California practicematters Practice Matters is a quarterly publication for physicians and other health care professionals and facilities in the UnitedHealthcare network. CPT is a registered trademark of the American Medical Association Doc#: PCA _ UnitedHealth Group, Inc. All Rights Reserved. For more information, visit UHCprovider.com