QUALITY IMPROVEMENT. Articles of Importance to Read: Quality Improvement Program. Winter Pages 1, 2, 3, 4 and 5 Quality Improvement

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1 Important information for physicians and other health care professionals and facilities serving UnitedHealthcare Medicaid members Winter 2009 QUALITY IMPROVEMENT Quality Improvement Program The Quality Improvement Program at UnitedHealthcare consists of components such as: Quality Improvement measures and studies Clinical practice guidelines Health promotion activities Service measures and monitoring Ongoing monitoring of key indicators (e.g., over and underutilization, continuity of care) Health plan performance information analysis and auditing (e.g., HEDIS) Care Coordination SM Educating members and physicians Risk management Articles of Importance to Read: Pages 1, 2, 3, 4 and 5 Quality Improvement Quality Improvement Program HEDIS Childhood Immunizations Pages 5 and 6 Policies and Procedures Provider ID Number Requirements Well-Child Visit Billing Pages 7 and 8 For Your Information Utilization Management Decision Rules Member Rights and Responsibilities Privacy of Individually Identifiable Health Information Anti-Discrimination Policy Cultural Competency Compliance with all external regulatory agencies The State of Florida Agency for Healthcare Administration ( Agency ) requires the below HEDIS and Agency-defined measures for all Medicaid health plans. The UnitedHealthcare of Florida, Inc. M*Plus (Medicaid) results for the 2007 measurement year (HEDIS 2008) are included below. For the indicators not yet required to be measured, the first measurement year (not HEDIS year, which is the year the indicator is submitted) is noted.

2 UnitedHealthcare of Florida, Inc. - M*Plus (Medicaid) Performance/Outcome Measure Results 2007 Measurement Type (HEDIS/Agency- Defined) Reform Results/ Due Date Non-Reform Results/ Due Date QI Breast Cancer Screening HEDIS Cervical Cancer Screening HEDIS 54.50% 54.01% Childhood Immunization (Combo 3) HEDIS Adolescent Immunization (AIS) HEDIS 2009 n/a* Well Child First 15 Months (Six or more visits) HEDIS 48.66% 48.66% Well Child Third, Fourth, Five, Six Years HEDIS 70.58% 68.66% Adolescent Well Care HEDIS 35.04% 35.80% Number Enrollees Admitted to State Mental Hospital Agency-Defined Follow-up After Hospitalization for Mental Illness (7 Days) HEDIS 20.95% 23.94% Follow-up After Hospitalization for Mental Illness (30 Day) HEDIS 40.20% 43.83% Antidepressant Medication Management HEDIS Use of Appropriate Medications for People w/asthma (ASM) HEDIS Controlling High Blood Pressure HEDIS 39.42% 52.80% Comprehensive Diabetes Care (HbA1c Testing) HEDIS 72.99% 72.75% Comprehensive Diabetes Care (Poor HbA1c Control) HEDIS 52.31% 50.12% Comprehensive Diabetes Care (Good HbA1c Control) HEDIS 30.66% 30.41% Comprehensive Diabetes Care (Eye Exam) HEDIS 30.41% 42.09% Comprehensive Diabetes Care (LDL-C Screening) HEDIS 74.04% 72.75% Comprehensive Diabetes Care (LDL-C Level < 100) HEDIS 26.03% 29.44% Comprehensive Diabetes Care (Monitor nephropathy) HEDIS 73.48% 73.24% Adults Access to Preventive/Ambulatory HEDIS Annual Dental Visits HEDIS 4.87% No Benefit** Timeliness of Prenatal Care HEDIS 71.78% 76.64% Postpartum Care HEDIS 45.26% 58.88% Frequency of Ongoing Prenatal HEDIS Ambulatory Care (ER Visits/1000mm) HEDIS Readmission Rate [Replaces Mental Health Utilization - Inpt D/C & ALOS] Agency-Defined Mental Health Utilization - Inpt Intermediate & Ambulatory HEDIS 2009 n/a* Follow-up Care for Children Prescribed ADHD Medication HEDIS 2009 n/a* Lead Screening HEDIS page 2 Provider Service Center:

3 Measurement Type (HEDIS/Agency- Defined) Reform Results/ Due Date Non-Reform Results/ Due Date All Disease Management (Reported as Aggregate for all DM Program Enrollment) Smoking (Total, Former) Agency-Defined 50.00% n/a* Body Weight Agency-Defined 2009 n/a* Medication Regime Adherence Agency-Defined 2009 n/a* Diabetes Foot Exam Annually Agency-Defined 2009 n/a* Blood Glucose Self-Monitoring Agency-Defined 2009 n/a* Hypertension Lipid Profile Annually Agency-Defined 2008 n/a* Congestive Heart Failure ACE/ARB Agency-Defined 2008 n/a* Asthma Use of Beta Agonist (Total) Agency-Defined % n/a* Use of Appropriate Medications for People w/asthma (ASM) - DM Population Specific [Replaced Use of Rescue/Use of HEDIS 2008 n/a* Controller Measures] Asthma Action Plan Agency-Defined 2009 n/a* HIV/AIDS CD4 Agency-Defined 2009 n/a* Viral Load Agency-Defined 2009 n/a* * This measure is not required by the Agency for non-reform membership **As there is no benefit for this service, this measure is not reported The Child Health Check-Up (CHCUP, also known as EPSDT ) scores for the 2007 measurement year (Oct 1, 2006 to Sept 30, 2007) are below. Screening Ratio (%) Participation (%) Screening Ratio (Florida) (%) Reform Non-Reform Goal Actual Goal Actual Goal Actual page 3 Provider Service Center:

4 The goals reflect contractual and regulatory requirements for routine child health check-up screening as defined by the State of Florida periodicity table. The periodicity table describes the number of expected screening visits by age range, as listed below. Age Range Number of Expected Visits Less than 1 year years years years years years years 2 Please call Provider Services at for helpful Child Health Check-Up tools and information. You can also request a detailed description of our Quality Improvement Program and information on our progress in meeting our goals. HEDIS Childhood Immunizations Children must receive all of their childhood immunizations to prevent many life endangering diseases. HEDIS specifications indicate that children must be fully immunized before turning age two. Complete immunization includes the following: 4 DTaP, 3 IPV, 3 Hepatitis B, 1 MMR, 3 HiB (for 2009, at least 2 due to shortage of vaccine), 1 Varicella, 4 PCV, and 3 Rota. Each antigen is counted separately; therefore, it is important to code each antigen correctly. Combination vaccines are often used and are included in the overall count of antigens in immunizations. All immunizations should be supplied from the Vaccines for Children program and should not be billed to the health plan. The health plan will pay for the administration of the vaccine if billed with an SL modifier. To ensure all immunizations are captured by data systems, please submit appropriate codes to the health plan for all vaccines administered. If there is a contradiction to a vaccination, or for the rare parental refusal of administration, please document the medical record accordingly. The appropriate codes for immunizations are as follows: page 4 Provider Service Center:

5 Immunization CPT HCPCS ICD-9-CM Diagnosis ICD-9-CM Procedure DTaP 90698, 90700, 90721, Diptheria & tetanus Diptheria Tetanus IPV 90698, 90713, MMR 90707, Measles & rubella Measles Mumps Rubella Hib , 90698, 90721, Hepatitis B* 90723, 90740, 90744, 90747, G , 070.3, V02.61 VZV 90710, Pneumococcal conjugate G0009 *Recombivax not included on this table as the recommendation for that specific two-dose antigen is for children between 11 and 14 years old. Please call Provider Services for information on coding for exclusions, or if additional assistance is needed, at POLICIES AND PROCEDURES Provider ID Number Requirements As a reminder, AHCA now requires that all providers participating with a Managed Care Organization for the Medicaid product have a unique Florida Medicaid Provider number. This unique provider number indicates that you have completed and submitted the necessary paperwork to AHCA, and are an approved Medicaid provider in accordance with section VIII h.2.i of the AHCA contract. If you are eligible but do not currently participate with the state of Florida s Medicaid program, and therefore do not have a Medicaid ID #, you can complete a Florida Medicaid Provider Enrollment Application in order to obtain a unique number that can be used in lieu of a Medicaid ID. The Florida Medicaid Provider Enrollment Application can be downloaded on the following Web site: ollment/tabid/50/default.aspx, and can be completed and returned to the plan for submission to AHCA. UnitedHealthcare Attn: Compliance NW 12th St. Sunrise, FL Fax: Attn: Compliance (954) AHCA has also mandated that all providers submit to the Managed Care Organizations their National Provider Identifier (NPI) in page 5 Provider Service Center:

6 accordance with section 1173(b) of the Social Security Act, as enacted by section 4707(a) of the balanced Budget Act of You can obtain more information, (including how to apply) on the State Web site at: nd/06_implementation.asp. If you have questions or need help complying with these new requirements, please contact your Provider Relations Representative: South Florida North/Central West Coast Well-Child Visit Billing Billing to receive deserved credit for a wellchild visit requires some consideration. The codes associated with a usual office visit indicate if the patient is new or established, and the length of time the provider spent with the patient. A sick visit will generate an office visit code only; however, a sick visit combined with a well-visit, completed simultaneously, should generate both a preventive visit code and an office visit code. If you are uncertain of what these services are, please refer to your periodicity schedule Office/outpatient visit, new patient 10 minutes w/ provider Office/outpatient visit, new patient 20 minutes w/ provider Office/outpatient visit, new patient 30 minutes/ provider Office/outpatient visit, new patient 45 minutes w/ provider Office/outpatient visit, new patient 60 minutes w/ provider Office/outpatient visit, established patient 5 minutes w/ provider Office/outpatient visit, established patient 10 minutes w/ provider Office/outpatient visit, established patient 15 minutes w/ provider Office/outpatient visit, established patient 25 minutes w/ provider Office/outpatient visit, established patient 40 minutes w/ provider Preventive visit, new, infant (under 1 year) Preventive visit, new, age Preventive visit, new, age Preventive visit, new, age Preventive visit, new, age Preventive visit, established, infant (under 1 year) Preventive visit, established, age Preventive visit, established, age Preventive visit, established, age Preventive visit, established, age Initial care, normal newborn (H&P) Newborn care not in hospital (normal) page 6 Provider Service Center:

7 FOR YOUR INFORMATION Utilization Management Decision Rules Utilization Management decision-making is based only on appropriateness of care and service and existence of coverage. Practitioners or other individuals are not specifically rewarded for issuing denials of coverage or service. Financial incentives for Utilization Management decision-makers do not encourage decisions that result in underutilization, nor are incentives used to encourage barriers to care and service. Member Rights and Responsibilities We inform our members that they have certain rights and responsibilities, all of which are intended to help uphold the quality of care and services they receive from you. We encourage our contracted providers to review these rights and responsibilities, which are included in the Physician Administrative Manual available on Click on Physicians, select Florida, then click on Physician Manual under the Resources section. Privacy of Individually Identifiable Health Information The privacy regulations ensure a national floor of privacy protections for patients by limiting the ways that health plans, pharmacies, hospitals and other covered entities can use patients' personal medical information. The regulations protect medical records and other individually identifiable health information, whether it is electronic, paper or oral. The major purposes of the regulation are to protect and enhance the rights of consumers by providing them access to their health information and controlling the inappropriate use of that information. Another objective is to improve the efficiency and effectiveness of health care delivery by creating a national framework for health privacy protection that builds on efforts by states, health systems, and individual organizations and individuals. Security The Security Regulations require covered entities meet basic security objectives. 1. Ensure the confidentiality, integrity and availability of all electronic PHI the covered entity creates, receives, maintains and transmits; 2. Protect against any reasonably anticipated threats or hazards to the security or integrity of such information; 3. Protect against any reasonably anticipated uses or disclosures of such information that are not permitted or required under the Privacy Regulations; and 4. Ensure compliance with the Security Regulations by the covered entity s workforce. UnitedHealthcare of Florida expects all participating providers to be in compliance with the HIPAA regulations that apply to their practice or facility within the established deadlines. Additional information on HIPAA regulations can be obtained at page 7 Provider Service Center:

8 Anti-Discrimination Policy UnitedHealth Group does not discriminate against its members based on race, ethnicity, national origin, religion, sex, age, mental or physical disability, medical condition, or sexual orientation. Participating providers are required to have anti-discrimination practice policies that demonstrate that they accept for treatment any of our members that are in need of the health care services that they provide. Cultural Competency CME Resources We want to link you to a valuable resource for providing culturally competent care to a growing number of patients, our increasingly racially and ethnically diverse membership. Better understanding of cultural and language differences can improve communications and patient compliance while assisting with clinical encounters. UnitedHealth Group has partnered with the U.S. Department of Health and Human Services, Office of Minority Health to make available cultural competency education modules. You can find this free, CME resource on and Resources>Training and Education. Cultural Competency Plan The UnitedHealthcare of Florida, Inc. M*Plus Cultural Competency Plan (Plan) is available on Click on Physicians, select Florida, then click on Cultural Competency Program under the Materials section. A paper copy of this plan can be printed out, or you can request one by mail at no charge by calling Provider Services. The Plan describes how UnitedHealthcare of Florida, Inc. will ensure that services are provided to our members in a culturally competent manner, including for those with limited English proficiency, sight and hearing deficits, and reading comprehension challenges. It describes how our Health Plan staff, network providers, and contracted ancillary service providers will effectively and appropriately provide services to people of all races, cultures, religions, ethnic backgrounds, education, and medical status in a manner that recognizes, values, affirms and respects the worth of each individual member, and protects and preserves the dignity of each NW 12th Street Sunrise, FL Practice Matters is a periodic publication for physicians and other health care professionals and facilities in the UnitedHealthcare network. M /09 AHCA-B /09-08/09