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1 Summer 2011 Important information from UnitedHealthcare 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: Page 1 Important Information: Getting Ready for 5010/ICD-10 Page 2 UnitedHealth Group is First to Achieve CAQH Core Certification Using 5010 Testing Platform Page 3 Wellness Includes Emotional, Mental and Physical Health They All Work Together to Make Your Patients Feel Better Page 5 New Disease Management Program for 2011 Access to Care Page Provider Survey Immunization Code Information Medical Record Criteria Page 7 Prior Authorization Secure Fax Requirement Making Successful Claims Appeals Page 8 Important Contact Information

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 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 An important message to health care professionals and facilities New Disease Management Program for 2011 UnitedHealthcare Community Plan has issued a national Disease Management (DM) program for UnitedHealthcare DM programs are part of our innovative Care Management Program. Our DM program is guided by the principles of the UnitedHealthcare Personal Care ModelTM. We developed the Personal Care Model to address the needs of medically underserved and low-income populations. The Personal Care Model places emphasis on the individual as a whole, to include the environment, background and culture. We have placed extensive information regarding this program; including an explanation of how UnitedHealthcare members are identified to be placed in the DM program, the specific programs we offer, the plan of care, the goals we set, pharmacy information (if applicable), coordination of care, case management, stratification and clinical practice guidelines. We encourage you to read more information on this new program for 2011 by visiting: click here Access to Care Timely access is essential to the delivery of quality health care. That is why UnitedHealthcare Community Plan follows standards set by the State of Delaware and NCQA for its network of providers that encourage timely access in scheduling appointments and patient evaluation. These standards have been approved by our Quality Improvement/Utilization Management Committee. It is particularly important for sick patients to have access to a provider. If a delay in care occurs, patients with a routine symptomatic illness may end up seeking care in a hospital emergency room. Primary Care Physicians (PCPs) are better equipped for these types of non-emergency illnesses because of their I Summer familiarity with the patient s medical and social history, allergies, and compliance with prescribed treatments. Further, PCPs are better judges of the need for follow-up treatment. Please take the opportunity to review your appointment practices to ensure that adequate time is available for these sick visits. PCP Access Standards Emergency: Immediately Urgent: Within two (2) calendar days Routine: Within three (3) weeks Preventive: Within two (2) weeks Specialty Access Standards Emergency: Immediately at nearest facility Urgent: Within 48 hours of referral Routine: Within three weeks of referral Obstetrics Access Standards 1st trimester: Within three weeks of first request 2nd trimester: Within seven calendar days of first request 3rd trimester: Within three calendar days of first request High risk: Within three calendar days of identification of high risk Behavioral Health Care Access UnitedHealthcare Community Plan provides behavioral health benefits to all of our Medicaid members in our service area and we have established access standards for providers of these services. Life-threatening emergencies Immediately Care for non-life-threatening emergencies within 6 hours Provider Service Center:

6 Urgent care within 48 hours An appointment for a routine office visit within 7 calendar days Provider Survey UnitedHealthcare Community Plan conducts its provider survey in September each year. The 2010 Provider Survey was conducted by the Center for the Study of Services (CSS) in collaboration with Survey Research Solutions of Ingenix, Inc. The purpose of the Provider Survey is to guide the improvement of the quality of services to our provider network. Out of the completed surveys, 76% were Primary Care Providers. The following are a few areas identified as key strengths in the survey: Rating of Web site Utilization review process Accuracy of claims payment process Timeliness of claims payment process Assistance provided by the provider service center Assistance provided by care management staff in facilitating treatment coordination 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. 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. I Summer Provider Service Center:

7 Prior Authorization Secure Fax Requirement In order for us to reply back to you via fax, it is critical that you indicate that your fax line is dedicated to your business and it is secure. It is also critical that you certify that you will comply with all state and federal privacy laws as they relate to the transmission and use of Personal Health Information. If using the standard fax form, please answer the applicable question included on the form. If you do not use the standard fax form, please include a statement on future cover sheets certifying that the fax line used to receive a transaction is a secure fax line and that you will comply with both federal and state laws as they relate to the transmission and use of personal health information. For more information or to obtain a standard fax form, please contact your Provider Advocate. Making Successful Claims Appeals Many providers have asked about UnitedHealthcare Community Plan s appeal resolution timeframes. We d like to offer some advice/information on how to insure your appeal reaches the right person and receives a timely resolution. Timeframes Our published timeframes for a formal payment dispute/claim appeal are: We will make a decision within 30 calendar days from the time we receive the appeal We will send a written notice of any resulting denial within 5 business days from the date of the decision Please note: the notice timeframe listed above is for denials. If we approve a service, the remittance advice you receive from the adjustment of your claim is your notice of the approval. We adopted this practice as a way of doing our part for the environment we save trees by not sending duplicate notices. Timely filing of appeals Claim Appeals must be received by the plan within the filing limit designated in your provider agreement. This timeframe is expressed in terms of the number of days elapsed since the date of the most recent remittance advice issued on your claim. Please check your contract if you are unsure of your timeframe for filing claims appeals. Adequate documentation We like to make evidence-based decisions. If you send no evidence to support your statement, the only thing we can review is our own records. If you would like a complete review, please be sure to include the following with your appeal request: Member s name and plan ID number Claim number, and a copy of the claim or copy of remittance advice A detailed description of your dispute (example: If the dispute is over a specific procedure code, state the code and issue) Any documentation you can provide in support of your dispute A name, phone number and mailing address to contact your office if needed (this should be the address to which your response should be mailed) Medical records, if applicable If your denial is not clinical in nature, you will need to satisfy the reason for your denial (sending records does not automatically remedy a defect in your claim, authorization requirements, or a failure to meet contractual standards for timeliness) before review of records will proceed. Sending the right information helps UnitedHealthcare Community Plan respond to your appeal without delays. I Summer Provider Service Center:

8 Direct your issues to the appropriate venue Delays can also occur when issues are addressed to the wrong party. Here are two of the most common examples: Corrected claims are not appeals, and may be sent directly to the claims department Informal claims reconsiderations have a separate mailing address from that used for formal appeals Please consult you Provider Manual/Administrative Guide for further information about how to direct certain requests. If you are unsure where to send a request, please contact your Provider Advocate, or call our Provider Services line at Appeals should be mailed to: UnitedHealthcare Community Plan Attn: Grievance and Appeals Dept Brinton Road Pittsburgh, PA Claims and Reconsideration requests should be mailed to: UnitedHealthcare Community Plan P.O. Box 8207 Kingston, NY Important Contact Information Provider Services Phone: Interactive Voice Response Line (IVR) (verify member eligibility) Phone: Provider Relations Staff Wendy Alleyne Sr. Provider Advocate Kent/Sussex Counties Phone: wendy.alleyne@uhc.com Laura Geraci Sr. Provider Advocate New Castle County Phone: laura.geraci@uhc.com Valeria Jones Provider Advocate Phone: valeria.jones@uhc.com Member Advocate Erica Kearse Member Advocate Toll Free: Fax: erica.kearse@uhc.com HEDIS Health Educator Katie Sims Health Educator Phone: katie_j_sims@uhc.com Credentialing National Credentialing Center (NCC) Phone: Claim Forms and Correspondence Claims UnitedHealthcare Community Plan Delaware PO Box 8207 Kingston, NY Correspondence (including appeals) UnitedHealthcare Community Plan Delaware 1001 Brinton Road Pittsburgh, PA I Summer Provider Service Center:

9 Practice Matters is a periodic publication for physicians and other health care professionals and facilities in the UnitedHealthcare network. M47507DE 6/11 Unison Health Plan of Delaware Unison Plaza 1001 Brinton Road Pittsburgh, PA Provider Service Center: