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1 Summer 2011 Important information from UnitedHealthcare Community Plan for physicians and other health care professionals and facilities serving UnitedHealthcare Medicaid members Important Information: Getting Ready for 5010/ICD-10 The federal government has mandated that all covered entities (including health care providers, clearinghouses and health plans) must transition to the latest version of the Health Insurance Portability and Accountability Act (HIPAA) electronic transaction standards and code sets. Two key dates are: Jan. 1, 2012 The 5010 version of the electronic transactions standards will replace the current 4010 version. Oct. 1, 2013 The International Classification of Diseases 9th Revision, Clinical Modification (ICD-9-CM), the current code set for reporting diagnosis, will be replaced by ICD-10-CM. UnitedHealthcare encourages physician practices and facilities to begin the preparation for these two important changes as soon as possible to streamline the process and reduce administrative burdens and potential rework. If you are not familiar with 5010 and/or ICD-10 and what it may mean to your practice, a number of resources are available from industry groups like the American Medical Association (AMA), The American Academy of Professional Coders (AAPC), and the Medical Group Management Association (MGMA) that can help in educating you and your staff on the electronic transaction standards and code sets. For more information Call our Provider Service Center at Visit Articles of Importance to Read: Important Information: Getting Ready for 5010/ICD UnitedHealth Group is First to Achieve CAQH Core Certification Using 5010 Testing Platform Wellness Includes Emotional, Mental and Physical Health They All Work Together to Make Your Patients Feel Better High Costs Associated with Asthma and Asthma Therapy Immunization Code Information Medical Record Criteria Quality Improvement Program Medicaid Free Access Family Planning and Reproductive Health Services HIV Information Anti-Discrimination Policy Clinical Practice Guidelines Medical Director Meetings Personal Care Services (PCS) under UnitedHealthcare Community Plan Pharmacy Benefit Changes We Need Your Help to Get Our Children to the Dentist New York State/City MCD/FHP Contract Changes Vaccines for Children Program Frequently Asked Questions Reminder to Use Network Laboratory Providers Did you know? Talk to Your Patients Who Are UnitedHealthcare Members About the Cost of Smoking New Health Care Electronic Transactions Standards Versions 5010, D.0, and National Provider Identifier Information Access and Availability Electronic Claim Submission Tips

2 It is an industry accepted standard that the first steps to a 5010 implementation plan is to speak with your practice management software vendor to ensure your system will be compliant with the upcoming changes. The Medical Group Management Association (MGMA) has developed a list of vendor-specific questions to assist you in this discussion. To view the questions, please visit the MGMA website. Once you determine that your systems are compliant, the next step is to ensure that testing is conducted of your practice management and electronic medical record system with your vendor and/or clearinghouse. At UnitedHealthcare, our 5010/ICD-10 implementation plan is underway, and we are actively engaged in 5010 Trading Partner Testing. For ICD-10, we plan to be code ready six to nine months in advance of the 2013 mandate. (Please note that we will not ask our network participants to comply with any mandates early; rather, these timelines ensure that UnitedHealthcare has the ability to support your needs and conduct a thorough Trading Partner Testing program.) We want to assure you that we will be ready and we are eager to consult with our provider and facility network as they begin their implementation planning. Have you started external testing of version 5010? All HIPAA-covered entities that submit transactions electronically are required to upgrade from Version 4010/4010A to Version 5010 transaction standards by Jan. 1, We strongly suggest you develop a plan for testing (both internally and with external business partners) in preparation for the Jan. 1, 2012, deadline. Testing transactions using Version 5010 standards will ensure that you are able to send and receive compliant transactions effectively. Testing early will allow you to identify any potential issues and address them in advance. Here are key dates to know to ensure you are ready for the Version 5010 and ICD-10 transitions: Jan. 1, 2011 Begin external testing of Version 5010 for electronic claims. Dec. 31, 2011 External testing of Version 5010 for electronic claims must be complete to achieve Version 5010 compliance. Jan. 1, 2012 All electronic claims must use Version 5010; Version 4010 claims are no longer accepted. Oct. 1, 2013 Claims for services provided on or after this date must use ICD-10 codes for medical diagnoses and inpatient procedures; CPT codes will continue to be used for outpatient services. Additional HIPAA 5010 and ICD-10 resources are posted on the UnitedHealthcare Online website. UnitedHealth Group is First to Achieve CAQH Core Certification Using 5010 Testing Platform 5010 data transactions include patient eligibility/verification and claim status Faster and more predictable administrative transactions enable doctors and hospitals to spend more time caring for patients CAQH and UnitedHealth Group (NYSE: UNH) announced on April 12, 2011 that UnitedHealth Group had completed the Committee on Operating Rules for Information Exchange (CORE ) Phase I and II testing process. This process certifies that UnitedHealth Group can deliver more efficient and predictable patient-eligibility and claims-verification information to doctors, hospitals, physician offices and other care providers, according to operating rules developed by CORE. I Summer Provider Service Center:

3 UnitedHealth Group is the first health care organization to complete certification using the updated platform, which builds on nonmandated aspects of the Health Insurance Portability and Accountability Act (HIPAA) version 5010 requirements. This is an important milestone in the company s efforts to streamline patient-eligibility and claims status transactions, so that care providers can spend less time on administrative functions and more time treating patients. The CORE operating rules streamline administrative information exchanges and improve provider access to patient benefits coverage and financial information at the pointof-care. CORE is a multi-phase, collaborative health care industry initiative aimed at improving access to electronic patient administrative and payer information for care providers before or at the time of service, using any technology. Each phase expands the available data criteria and augments the functional requirements for electronic data exchange. CORE certification reflects UnitedHealth Group s commitment to streamlining administrative processes with doctors, hospitals and other care providers so they can spend more time providing quality care for their patients, said Timothy Kaja, senior vice president, UnitedHealth Group Provider and Network Service Operations. By becoming CORE certified, UnitedHealth Group is demonstrating that the concept of operating rules as mandated by the Patient Protection and Affordable Care Act (ACA) is an important part of making health care work better. We are pleased that UnitedHealth Group is CORE certified. The operating rules will ensure an effective flow of administrative data between us, said Murray E. Fox, M.D., FACOG, a Plano, Texas-based practicing physician and founder, president and CEO of Patient Physician Network, a 650-physician member network whose primary goal is to respond to the changing health care environment in the Dallas- Fort Worth area. Being able to rely on UnitedHealth Group for consistent and accurate electronic information about benefits coverage and financial obligations enables us to streamline our internal processes and offer complete and timely information to our patients. Robin Thomashauer, executive director of CAQH, said: We are pleased to see UnitedHealth Group join the growing number of companies that have become CORE certified and the first to become CORE certified in a 5010 format. Advances such as this are essential to establishing the foundation for true administrative simplification, leading to improved transparency and reduced cost in health care. Continued advances in CORE operating rules and adoption by companies such as UnitedHealth Group and its physician partners will accelerate our nation s progress to that end. Wellness Includes Emotional, Mental and Physical Health They All Work Together to Make Your Patients Feel Better In treating your patients, mental health is as important as physical health. The rich online resources at liveandworkwell.com can assist you and your patients to improve overall wellness. It can assist to manage benefits, use interactive tools and find clinician reviewed information to support wellness and deal with life s challenges. Patients and their families have convenient, confidential information and support to help cope with stress, emotional/mental health, substance abuse/addictions and grief or trauma. We also provide support for people living with chronic conditions such as diabetes, asthma, or arthritis. I Summer Provider Service Center:

4 Support is available online 24/7 at liveandworkwell.com to you and your patients. Try it you ll find something new that you need to know (screen shot on the back!): Mental Health Clinician Search Tool My Claims & Coverage: self-manage and monitor your behavioral benefit coverage, visit certification and claims any time Interactive self-help programs to address depression, anxiety, stress, alcohol, drugs and smoking Behavioral health and wellness newsfeeds Extensive information and resources: 28 Mental Health Condition Centers: Depression, ADHD, Autism, Dementia, Bipolar Disorder, Personality Disorders, Abuse, Anger, Alcohol and Drug Dependency, Anxiety, Post-traumatic Stress, Grief, Eating Disorders and more Coping with Stress Center as well as child and teen specific stress centers Videos, podcasts and self-paced Webinars (see Multimedia area) Available in English and Spanish How to use the site: Go to liveandworkwell.com Patients with UBH behavioral health coverage can register/login directly for access to all resources, or You can enter anonymously by selecting click here to enter with only an Access Code then enter Clinician and utilize the resources available in your practice and with patients The information and therapeutic approaches in this content are provided for informational and/or educational purposes only. They are not meant to be used in place of professional clinical consultations for individual health needs. Certain treatments may not be covered in some benefit Care giving and Living with Chronic Disease Centers: guides, information, search tools and resources Nutrition and Fitness Centers for adults, kids and teens Drug information, drug interaction checker, alternative medicine and health database Age-appropriate kid and teen health and life info and games I Summer Provider Service Center:

5 High Costs Associated with Asthma and Asthma Therapy Nearly 4,000 Americans die yearly from asthma. Asthma s impact on health, quality of life and the economy is substantial. 1 Although, the onset of asthma can not be prevented, and asthma cannot be cured, it is a disease that can be successfully controlled. 1 The National Heart, Lung and Blood Institute (NHLBI) defines asthma as a chronic lung disease that inflames and narrows the airways. 2 Symptoms of asthma cause chest tightness, shortness of breath and coughing. The American College of Allergy, Asthma and Immunology (ACAAI) reported that the total annual cost for asthma management in 2007 was $19.7 billion dollars. 3 Over 30 percent ($6.2 billion) of the total costs were directly linked to pharmaceutical spend. 3 It is believed that much of the costs associated with asthma therapy can be avoided or at least reduced. In 2007, the National Asthma Education and Prevention Program (NAEPP) issued the Expert Panel Report 3 (EPR-3): Guidelines for the Diagnosis and Management o Asthma Full Report The guidelines indicate that short acting beta agonists (SABA) are the preferred treatment for intermittent asthma. Inhaled corticosteroids (ICS) have remained the mainstay of therapy for persistent asthma. For patients that can not utilize ICS, alternative therapies such as cromolyn, theophylline and leukotriene receptor antagonists are considered appropriate treatment options. Adherence to these guidelines will help drastically reduce the total yearly costs associated with asthma. Table 1 illustrates a stepwise approach for managing intermittent to severe persistent asthma as outlined by the EPR-3. UnitedHealthcare Community Plans offer a broad portfolio of preferred medications that cover each step of the treatment guidelines. Table 2 indicates the average price of each preferred medication covered by UnitedHealthcare Community Plans. Please take a moment to look at these tables. Please contact your Provider Advocate if you have any questions regarding this information. Table: 1 Guideline Steps Intermittent Asthma Persistent Asthma SABA Preferred: Low-dose ICS Alternative: Cromolyn, LTRA, Nedocromil, or Theophylline Preferred: Low-dose ICS + LABA OR Medium-dose ICS Alternative: Low-dose ICS + either LTRA, Theophylline Preferred: Medium-dose ICS + LABA Alternative: Medium-dose ICS + either LTRA, Theophylline Preferred: High-dose ICS + LABA AND Consider Omalizumab for patients who have allergies Preferred: High-dose ICS + LABA + oral corticosteroid AND Consider Omalizumab for patients who have allergies I Summer Provider Service Center:

6 Table: 2 Cost of Preferred Products: UHC C&S Drug Class Drug Estimated Monthly Cost ($) SABA Ventolin HFA ICS Qvar Flovent Asmanex LABA Foradil Serevent ICS/LABA Combo Advair Dulera LTRA Singulair (ST) Oral Steroids Prednisone Methylprednisolone Other Cromolyn Inhalation Theophylline Biologic Xolair References 1. accessed 3/21/ accessed 3/21/11 3. American College of Allergy, Asthma & Immunology. Asthma Management and the Allergist: Better Outcomes at Lower Cost. accessed 3/21/11 4. National Heart, Lung, and Blood Institute. Expert Panel Report 3: Guidelines for the Diagnosis and Management of Asthma. Accessed September 9, Immunization Code Information The UnitedHealthcare Employer & Individual Frequently Asked Questions (FAQ) document has recently been discussed in regards to the 2011 immunization codes changes. The staff of the UnitedHealthcare Community Plan Payment Policy team has been hard at work researching the differing State specific regulations, the Vaccines for Children (VFC) requirements related to these new codes, and gathering information from health plan representatives in order to determine how each market should be billing for immunizations with respect to these new codes. After much research, state specific FAQ documents have been drafted, based on the differing methods of reimbursement being utilized by the different markets. For those markets utilizing immunization administration cost on VFC serum codes, nothing has changed, and thus no new document was drafted. For the remaining markets, these documents will be forwarded to the health plan representatives to be dispersed to providers for educational purposes. If you would like more information on the 2011 immunization code changes, please contact your Provider Advocate. I Summer Provider Service Center:

7 Medical Record Criteria UnitedHealthcare is contractually obligated to submit accurate, detailed and complete encounter data to the states. Consequently, UnitedHealthcare participating providers are required to submit accurate, detailed and complete claims data and to maintain and provide, when requested, medical record documentation to support the claims. Here is a short checklist for your office to maintain medical records: Medical records must include: history & physical; allergies and adverse reactions; problem list; medications; preventive services/screening; and documentation of clinical findings for each visit All medical records are to be stored securely Only authorized personnel should have access to medical records Staff receive periodic training in patient confidentiality Medical records are organized and stored in a manner that allows easy retrieval Please call your Provider Relations Advocate if you have any questions regarding medical records criteria. Resources are available to you at UnitedHealthcareOnline.com > Clinician Resources > Patient Safety Resources > Medical Record Tools & Templates. Quality Improvement Program Each year, an annual evaluation of the QI Program is conducted to assess the overall effectiveness of the health plan s quality improvement processes. The evaluation reviews all aspects of the Quality Improvement Program, emphasizing whether the Program has demonstrated improvements in the quality of care and service provided to members. The annual evaluation includes: A summary of completed and ongoing quality improvement activities that address quality and safety of clinical care and quality of service A review of the HEDIS 2010 performance for dates of service in 2009 Trending of measures to assess performance in the quality and safety of clinical care and quality of service Analysis of the results of all initiatives including potential and actual barriers to achieving goals Evaluation of the overall effectiveness of the program including progress toward influencing safe clinical practices. Some accomplishments for 2010 include the following: Received a 1% quality incentive bonus from New York State Scored 20 points out of 20 points for ambulatory sensitive hospital admissions Served meals to the needy in NYC and Syracuse food pantries Successfully implemented a fourth quarter incentive program for members and providers Painted Murals in pediatric clinics Opened an office in the Bronx Walked in rainstorms to raise funds for charity Encouraged and fostered teamwork across the business segments Moved to a new office Interviewed over 300 applicants and hired 60 sales reps Rebranded to UnitedHealthcare Community Plan I Summer Provider Service Center:

8 In collaboration with our UHN colleagues, hired and trained 7 contractors for upstate expansion In collaboration with Medicare and Retirement signed up over 500 members to the AARP Medicare product Received approval to implement a new enrollment system Passed CHP audits Passed Article 44/49 focused review with 0 deficiencies Trained Member service staff and passed NYSDOH secret shop audits Deployed 4 brand new RV s Implemented hiring plan to support 2011 growth Established a provider data management team Fostered new community relationships If you would like further information about our Quality Improvement Program, our annual goals or our progress towards meeting our goals, please call Medicaid Free Access This means that Medicaid (not Family Health Plus or Child Health Plus) enrollees may obtain Family Planning and Reproductive Health services, and HIV testing and pre- and post-test counseling when performed as part of a Family Planning and Reproductive Health encounter, from either a network provider, or from any provider who will accept the member's Medicaid card for services. NO referral from the PCP or preauthorization is required to access services. Family Planning and Reproductive Health Services Family Planning and Reproductive Health services are defined as offering, arranging and furnishing of those health services which enable UnitedHealthcare members, including minors who may be sexually active, to prevent or reduce the incidence of unwanted pregnancies. UnitedHealthcare covered Family Planning and Reproductive health services include the following medically necessary services, related drugs and supplies which are furnished or administered under the supervision of a physician, licensed midwife or certified nurse practitioner during the course of a Family and Reproductive Health visit for the purposes of: A) contraception, including all FA-approved birth control methods, devices such as insertion/ removal of an intrauterine device (IUD) or insertion/ removal of contraceptive implants and injection procedures involving pharmaceuticals such as Depo-Provera; B) emergency contraception; C) sterilization; D) screening, related diagnosis, and referral to a Participating Provider for pregnancy; E) medically necessary induced abortions, which are procedures, either medical or surgical, that result in the termination of pregnancy. The determination of medical necessity shall include positive evidence of pregnancy, with an estimate of its duration. Family Planning and Reproductive health services include medically necessary ordered contraceptives and pharmaceuticals. In addition, Family Planning and Reproductive Health services include those education and counseling services necessary to render the services effective. UnitedHealthcare members may obtain the full range of Family Planning and Reproductive I Summer Provider Service Center:

9 Health services, including HIV counseling and testing when performed as part of a Family Planning and Reproductive Health encounter, from the participating providers without referral, approval or notification. Participating providers may share patient information with appropriate UnitedHealthcare personnel for the purposes of claims payment, utilization review and quality assurance, unless the provider agreement with UnitedHealthcare provides otherwise. Providers must ensure that any patient's use, including a minor's use of Family Planning and Reproductive Health Services remains confidential and is not disclosed to family members or other unauthorized parties, without the patient's consent to the disclosure. Note for Reimbursement for Family Planning and Reproductive Health Services All family planning and reproductive services must be billed to the plan and not to Medicaid fee-for-services program. HIV Information HIV Confidentiality Excerpts from Public Health Law (PHL) relating to HIV Reporting and Partner Notification Article 27-F is the section of New York State Public Health Law that protects the confidentiality and privacy of anyone who has: Been tested for HIV; Been exposed to HIV; HIV infection or HIV/AIDS-related illness; or Been treated for HIV/AIDS-related illness HIV Counseling and testing is a routine part of medical care. As such all Plan members are eligible to receive HIV education, counseling and HIV testing with their written consent in accordance with Article 27-F of the PHL. A refusal of testing must be documented in the member s medical record. All physicians are prohibited from disclosing HIV related information without the requisite consent from the member. An exception to this disclosure is that all network physicians are required to report positive HIV test results and diagnoses and known contacts of such persons to the New York State Commissioner of Health. In New York City, these shall be reported to the New York City Commissioner of Health. Access to partner notification services must be consistent with 10 NYCRR Part 63. An HIV positive member will be treated by a qualified physician in accordance with the CDC and New York State HIV/AIDS Program guidelines. All network physicians are required to develop policies and procedures to safeguard patient information in general and HIV-related information in particular in accordance with applicable Federal and State requirements including Section 2782 of NYS Public Health Law (see information that follows that details those requirements). Network physicians are required to provide counseling to all pregnant women in their care and offered a prenatal HIV test. Network physicians are to refer any HIV positive women in their care to clinically appropriate services for both the women and their newborns. Counseling and education regarding perinatal transmission of HIV available treatment options for the mother and newborn infant will be made available during the pregnancy and/or to the infant within the first months of life. As part of its annual review of HIV practice guidelines, the Plan s medical director will inform physicians of any changes to local HIV prevention and control programs. The Plan can provide specific information about HIVreporting requirements and the role of physicians in working with HIV infected patients to inform I Summer Provider Service Center:

10 their contacts. Additionally, the Plan can provide information to network physicians on how to obtain information about the availability of Experienced HIV Providers and HIV Specialist Primary Care Physicians by accessing the UHCNY web site or calling the provider services helpline at: For assistance with questions regarding HIV confidentiality and disclosure of HIV related information, physicians should contact the Legal Action Center by calling The Center is funded by the NYS Department of Health AIDS Institute to provide HIV-related technical assistance to health care physicians statewide. For the full text of NYS Regulation Part 63 (HIV/AIDS Testing, Reporting and Confidentiality of HIV Related Information), go to the following link: 63.htm HIV Counseling Prior to being HIV tested, the law requires that patients be counseled; those concepts are included in Part A of the informed consent form. There are 7 points of law that must be provided to patients who will be asked to consent to HIV testing. These include the following explanations: Information about HIV as the virus which causes AIDS and possible modes of transmission; it also includes Transmission by pregnant women; Treatment for HIV/ AIDS; Safe practices; About voluntary and anonymous testing and the availability of public health centers; Confidentiality of testing; Prohibition of discrimination based on patient s test results; Discussion about informed consent The 7 points of law can be accessed at g/amended_law/faqs.htm HIV Testing The law states that anyone can consent to an HIV test if they have the capacity to consent. Otherwise, for a minor (under 18 years of age) a parent or legal guardian can consent; or for adults, a court appointed guardian with authority to make health care decisions or a health care proxy may authorize an HIV test. The New York State Health form - Informed Consent to Perform HIV Testing contains basic information to help a person make a decision about being tested for HIV and must be reviewed by any person considering HIV. By signing the form, the patient agrees to be tested for HIV. LAB TESTS HIV-1/HIV-2 (Single Assay) $15.17 HIV Antibody, Confirmatory (Western Blot) $26.75 Amended HIV Testing Law On September 1, 2010 an amended HIV testing law went into effect. The key provisions of that law is that HIV testing must be offered to all persons between the ages of 13 and 64 receiving hospital or primary care services with limited exceptions noted in the law. The offering must be made to inpatients, persons seeking services in emergency departments, persons receiving primary care as an outpatient at a clinic or from a physician, physician assistant, nurse practitioner or midwife. Key provisions of the law include that consent for HIV testing may be part of a general consent I Summer Provider Service Center:

11 to medical care, though specific opt out language for HIV testing must be included; also, consent for rapid HIV testing can be oral (except in correctional facilities) and noted in the medical record. Frequently asked questions about the amended law can be accessed at mended_law/faqs.htm The Availability of Experienced HIV Providers and HIV Specialist PCPs UnitedHealthcare can provide information about the availability of experienced HIV Providers and HIV Specialist Primary Care Physicians by calling the Quality Management Department at Providers may also find a list of HIV/ AIDS facilities listed in the Provider Directory at HIV Reporting Excerpts from -PHL relating to HIV Reporting and Partner Notification In New York State, HIV reporting means that doctors and laboratories must report all cases of HIV infection to the New York State Department of Health. Public Health Law requires HIV case reporting by name. Additionally, laboratories must report HIV nucleic acid tests (viral load tests), CD4 lymphocytes tests, and drug resistance and subtype tests to the State Department of Health. Reporting helps the State Department of Health to accurately monitor the HIV epidemic, assess how the epidemic is changing, and create programs for HIV prevention and medical care that best serve affected people and communities. All reported information is protected by strict confidentiality laws. Partner notification is important so that people can become aware of their HIV risk and receive counseling and testing. Then they can take steps to protect themselves and their loved ones and get medical care sooner if they are infected. Giving doctors or the Health Department the names of partners is voluntary. While doctors are required to report known partners of their HIV infected patients to the Health Department for the purpose of partner assistance, doctors are also required to talk with their patients about how they would prefer to let sex partners and needle-sharing partners know they may have been exposed to HIV. For more information on partner notification options and assistance available through the partner Notification Assistance Program (PNAP) or the Contact Notification Assistance Program (CNAP) in New York City please refer to the following website: questions/publichealthlaw.htm The national Centers for Disease Control and Prevention has issued guidelines urging all states to collect and report data on HIV cases to track the epidemic on a national basis. Within the next several years, HIV data will become the basis for funding formulas that allocate federal money for HIV care and treatment under the Ryan White Care Act. Healthy First Steps Hi Mom Book for your patients who are UnitedHealthcare members UnitedHealthcare Community Plan is pleased to announce a Healthy First Steps initiative for providers of obstetrical care services. This initiative will make available member education books, titled Hi Mom by KRAMES. As a I Summer Provider Service Center:

12 participating obstetrical or family practice provider, each month your office can order up to 500 copies of the booklet in packs of 100. This brief overview will acquaint you with the contents: Cartoon art and easy-to-read text deliver the facts and advice patients need at every stage from conception to delivery. Comprehensive guide to pregnancy Stages of fetal development Prenatal care, common aches and pains Tips for nutrition, activities, rest and sex Special conditions during pregnancy Stages of labor, hospital delivery, anesthesia Postpartum care for baby and mom 32 pages, full-color cartoon Book available in English and Spanish To order your books please or fax the following information: Your provide name or group Your provider ID number Complete mailing address Phone number Number of packets (100 booklets each packet) Maximum order is 5 packets (500 booklets) each month Indicate English or Spanish version Healthy First Steps fax number is Healthy First Steps address is hfs@uhc.com We appreciate your efforts to improve pregnancy outcomes and your willingness to partner with HFS. If you would like additional information about Healthy First Steps or have questions, please call your provider advocate at Informational Section 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. The first point of contact at a provider s office is most often the non-clinical staff. Member complaints to the Plan are occasionally attributed to the attitude, language, and behavior exhibited by the office staff during their visit. Frequently addressed courtesy issues experienced by members: Members should not be discriminated against or denied covered treatment because of their Medicaid/Medicare status. The specific cost of services that any insurance plan does or does not reimburse should not be addressed with the member, as Medicaid members should not be balance billed for any reason. Your office should not request payment from any UHCCP Medicaid and/or Family Health Plus member. Explanation that a service is covered or not covered is sufficient. If a language barrier arises, the Plan or your office s affiliated medical center may be able to provide interpreter services. Members who have arranged for transportation should be accommodated if their transportation provider arrives late to bring them to the appointment. I Summer Provider Service Center:

13 Members always have a right to request their medical records, and should be provided access within days. Please note that there is no fee for the copy of medical records. Family Health Plus members who are unable to pay the copayment at the time of service should not be denied care because of their inability to pay. Your office is permitted to bill members for their scheduled copayment. Only UnitedHealthcare Community Plan can approve the use of non-participating providers. You must call Prior Authorization at to request the use of a non-participating provider. Clinical Practice Guidelines For your reference is the Clinical Practice Guidelines (CPG), which is available at: Topics include: Acute Myocardial Infarction (MI), Asthma, Attention Deficit Hyperactivity Disorder (ADHD), Bipolar Disorder Adults, Children and Adolescents, CHF Chronic Heart Failure, Cardiovascular Disease, Cholesterol Management, Chronic Stable Angina, CAD Coronary Artery Disease, Diabetes, Depression (Major), Hyperlipidemia, Hyperbili-rubinemia in the newborn, Hypertension, Smoking Cessation, Immunization (Adult and Pediatric), Overweight and Obesity, HIV, COPD - Chronic Obstructive Pulmonary Disease, SCD - Sickle Cell Disease, Hemophilia, Schizophrenia, Spinal Stenosis, Preventive Services, Prenatal Care Clinical Conditions, and Domestic Violence. Medical Director Meetings UnitedHealthcare Community Plan s Medical Director shall participate in the Medical Directors Meetings with the medical directors of other Managed Care Organizations (MCOs) participating in the MMC Program in New York City and representatives of the New York City Department of Health and Mental Hygiene. The purpose of these meetings are: Sharing of public health information and data Generating recommendations that certain public health information be relayed to participating providers by the MCOs Discussing public health strategies, outreach efforts, and potential collaborative projects Encouraging the development of MCO policies that support public health strategies Offering a means of communication between the MCOs participating in the MMC program and the various bureaus and divisions of the NYC Department of Health and Mental Hygiene The Medical Director shall attend all periodic meetings, which shall not exceed one every two months. If the Medical Director cannot attend, the Plan will appoint a substitute to attend the meeting. DOHMH may create workgroups on specific public health topics based on recommendations of the Medical Directors. The Plan s Medical Director may participate in any or all workgroups, but must participate in at least one of the workgroups. I Summer Provider Service Center:

14 Personal Care Services (PCS) under UnitedHealthcare Community Plan What is it? Products Impacted New Members? New ID Cards? Network Impact Functional Impact? New plan benefit (currently administered by Fee For Service Medicaid) for personal care services, i.e. housekeeping and home health aide Medicaid No, currently ~400 Community Plan members receiving these services from FFS Medicaid No UnitedHealthcare Community Plan has established contracts with Personal Care providers and we are continuing to expand our network with these providers. We will be mailing out an addendum to our Provider Directory. As of 8/1, members who are identified with a need for these services will receive them through UnitedHealthcare Community Plan. The same referral form (M-11Q) for these services will be accepted. Once completed, the form should be faxed to to initiate the process. Pharmacy Benefit Changes Effective October 1, 2011, Medicaid beneficiaries who are currently enrolled in managed care plans will also begin to receive their pharmacy benefits through their plans. Look for communication in early September from UnitedHealthcare Community Plan with more details about the changes, the PDL, where to call for authorizations, etc. We Need Your Help to Get Our Children to the Dentist The UnitedHealthcare Community Plan s Fluoride Varnish program has been established to help improve the oral health care of children, increase awareness of the importance of good oral health care in young children, and to assist in the establishment of a dental home. We have created a pediatric and member-based incentive program designed to engage pediatricians, who see members much earlier and more frequently than dentists, in beginning the discussions with parents and caregivers around good, early preventive dental care. The program is designed for children as young as 6 months through 7 years of age. The program involves providing a topical application fluoride varnish for moderate to high caries risk patients, which is delivered in a single visit to the entire oral cavity. The procedure may be done up to four times per calendar year per member, as determine to be required by the PCP. Reimbursement is $30 per application. Claims are submitted on a CMS 1500 form or current ADA claim form. UnitedHealthcare Community Plan is providing complimentary fluoride varnish to participating pediatricians, who have been trained, for the first year. All UnitedHealthcare Community Plan participating pediatricians are eligible for participation in the program. I Summer Provider Service Center:

15 New York State/City FHP Contract Changes New Contract Requirements for Medicaid/FHPlus members - Prevention & Treatment of Sexually Transmitted Diseases Par Providers are responsible for educating members about the risk and prevention of sexually transmitted diseases (STDs). This includes screening for STDs and providing all necessary treatment. Providers are responsible for reporting cases of STDs to the LPHA and cooperate in contact investigation, in accordance with existing state and local laws and regulations. EPSDT Services Members are covered from birth until age 21.EPSDT services, include dental services and transportation to obtain these services. Midwifery Services Midwifery services include the management of normal pregnancy, childbirth and postpartum care as well as primary preventive reproductive health care to essentially healthy women and shall include newborn evaluation, resuscitation and referral for infants. The care may be provided on an inpatient or outpatient basis including in a birthing center or in a member s home as appropriate. The midwife must be licensed by the NYS Education Dept and have a collaborative relationship with a physician or hospital that provides obstetric services, as described in Education Law , that provides for consultation, collaborative mgmt & referral to address the health status and risks of patients and includes plans for emergency medical OB/GYN coverage. Communication with Members 1. Par Providers who wish to let their patients know of their affiliations w/one or more MCOs must list each MCO w/whom they have contracts. 2. Par Providers who wish to communicate with their patients about managed care options must advise patients taking into consideration ONLY the MCO that best meets the health needs of the patient. Such advice, whether presented verbally or in writing, must be individually based and not merely a promotion of one plan over another. 3. Par Providers may display the Plan s marketing materials provided that appropriate notice is conspicuously posted for all other MCOs w/whom the Provider has a contract. 4. Upon termination of a Provider Agreement with the Plan, a provider that has contracts with other MCOs that offer MMC or FHP products may notify their patients of the change in status and the impact of such change on the patient. Vaccines for Children Program Frequently Asked Questions Question: How will the change in CPT codes affect vaccine administration fees under the VFC program? Answer: The two new CPT codes are: Immunization administration through 18 years of age via any route of administration, with counseling by physician or other qualified health care professional; first vaccine/toxoid component Each additional vaccine/toxoid component. I Summer Provider Service Center:

16 These codes replace 90465, 90466, 90467, and Every vaccine administered has exactly one first component, and many vaccines have second and subsequent components (e.g., MMR, DTaP, and DTaP/IPV). Question: Given the VFC policy on the new CPT codes, what codes should providers use? Answer: Providers are encouraged to use the new code for the administration of a vaccine under the VFC program. If code is used for a vaccine with multiple antigens or components, it should be given a $0 value for a child covered under the VFC program. This applies to both Medicaid-enrolled VFC-entitled children as well as non-medicaid-enrolled VFC-entitled children. Question: How should I bill my VFC claims? Answer: Please refer to examples below: One single component serum: SL - $ $10.00 Multiple single component serums: SL - $ SL - $ SL - $ $30.00 (Quantity 3 units) Multi component serum: SL - $ $10.00 (Quantity 1 unit) $ 0.00 (Quantity 2 units Reminder to Use Network Laboratory Providers Encouraging the use of network laboratory providers will meet your contractual obligations and help support potentially lower out-of-pocket costs for your patients. Moreover, you and your patient may receive additional benefits from using network laboratory providers, such as automatic transmission of data to support care management programs, gaps in care analysis and physician performance assessment programs. To assist you, we offer the following resources and suggested actions: Physicians may access the current list of participating laboratories online at UnitedHealthcareOnline.com > Physician Directory> General Physician Directory > Search for Hospital or Other Facility > Search for a Laboratory. Discuss the importance of using our extensive network for covered laboratory services with your patients; if they have questions, direct them to myuhc.com to access their individual coverage information and directory of participating laboratories. Encourage the use of network laboratories to optimize your patient s health care benefits and possibly reduce the financial costs your patients may incur if their laboratory sample is sent to a non-network laboratory. UnitedHealthcare provides access to a broad network of more than 1,300 laboratories. In the unusual circumstance that you require a specific laboratory test for which you believe there is no network laboratory provider, we will work with you to ensure those tests are performed, even if that means the use of a non-network laboratory. I Summer Provider Service Center:

17 Did you know? Participating medical professionals can check member eligibility, benefits, or the status of their claims, plus much more - instantly. The best part - is our suite of tools offer real-time data accuracy and can be accessed at no cost, day or night. UnitedHealthcare Community Plan Online will save your office valuable time on the phone, improve your transaction efficiency and reduce errors caused by conventional claims submission practices. To register now, visit tion/register.jsp Talk to Your Patients Who Are UnitedHealthcare Members About the Cost of Smoking Most doctors routinely advise patients to quit smoking, but as we know most patients are not ready to change their behavior. This can be very frustrating for the clinicians. Warning patients about the health impact of continued smoking does not seem to have a great impact in this group. One way to have a constructive conversation with your patients is to calculate the cost of smoking. The average cost of a pack a day smoking habit in New York State is $9.20 per day. That comes out to $3,300 per year. In New York City, the cost is nearly $11.00 per day and $3,900 per year. Even your patient buys by the carton, the cost will still be more than $2,500 per year for the average smoker. It is useful to have the patient perform the calculation with you and then for you to ask, Have you ever wondered what you might do with that money if you quit smoking? Ask the patient to identify specific rewards and jot them down in the medical record for future reference. Remind the patient that the reward is available for each year that the patient remains smokefree. Remind your patient that there a fifty million former smokers in the United States, so if they were able to quit, so can they. Quitting smoking requires a good plan and when your patient is ready to quit, you and the New York State Quit Line can be of help to you in designing a complete plan to help you stop smoking and stay quit. You will find that the discussion that you have about smoking this time will be quite different from your previous conversations. When your patient returns for a follow-up, be sure to ask if they have been thinking of their reward. You have just transformed your relationship from adversaries to allies. For more information on how you can improve your effectiveness in smoking cessation interventions, obtain pamphlets and other useful information. Contact the Quit-line at 866-NYS-QUITS or log in to New Health Care Electronic Transactions Standards Versions 5010, D.0, and 3.0 The Health Insurance Portability and Accountability Act of 1996 (HIPAA) requires the Secretary of the Department of Health and Human Services (HHS) to adopt standards that covered entities (health plans, health care clearinghouses, and certain health care providers) must use when electronically conducting certain health care administrative transactions, such as claims, remittance, eligibility, and claims status requests and responses. Over 99 percent of Medicare Part A claims, and over 96 percent of Medicare Part B claims, transactions are received electronically. The current versions of the standards (the Accredited Standards Committee X12 Version I Summer Provider Service Center:

18 4010/4010A1 for health care transactions and the National Council for Prescription Drug Programs [NCPDP] Version 5.1 for pharmacy transactions) used in these health care transactions lack certain functionality required by the health care industry. Therefore, it is necessary for providers to prepare for new standards in order to continue submitting claims electronically. This fact sheet provides basic information about the new transactions standards for the following versions adopted by HHS: ASC X12 Version 5010, and NCPDP Versions D.0 and 3.0. What Regulatory Requirements are Responsible for the Transactions Standards? HIPAA mandated that the health care industry use standard formats for electronic claims and claims-related transactions. The Transactions and Code Sets Final Rule, published on August 17, 2000, adopted the International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) as a HIPAA standard for transactions. National Provider Identifier Information National Provider Identification (NPI) As you know, Federal Regulations and many state Medicaid agencies require providers to submit a claim with their unique national provider identifier (NPI) on all electronic and paper submissions. Clean Claim Billing Requirements In addition to including your NPI, you must continue to submit complete claims to comply with UnitedHealthcare Community Plan s clean claim billing requirements as published in the Administrative Guide. In addition to all of the information that UnitedHealthcare Community Plan expects to see when receiving a clean claim, it is mandatory that the claim include the following information: Servicing address with zip code Tax Identification Number (TIN) Failure to comply with all of UnitedHealthcare Community Plan s clean claim requirements as set forth in the Administrative Guide may result in the denial/rejection of the claim. If you have not yet applied for and received your NPI, please do so immediately by visiting or you can call the NPI Enumerator call center to request a paper application at If you have not yet provided your NPI to UnitedHealthcare Community Plan, please do so immediately by visiting then choose the National Provider Identifier Submission Information link under the Bulletins section. For your convenience, there are downloadable forms on the Web site for you to fill in the appropriate information. NPI information, provider name, TIN, and address can also be faxed to , ed to americhoice_dbm_npi@uhc.com, or mailed to: UnitedHealthcare Community Plan DBM Claims P.O. Box Phoenix, AZ Access and Availability This is a reminder about the importance of complying with Appointment Access and Availability standards. As you may be aware, the State Department of Health (SDOH), conducts secret shop calls to provider practices to confirm appointments can be made within the standards. When standards are not met, SDOH issues a Statement of Deficiency to the plan; which impacts our quality rating. Members have choices to select any managed care plan; together let's make UnitedHealthcare #1 in quality. In addition to the secret shop calls made by SDOH, the plan also conducts its own secret I Summer Provider Service Center: