Clinical Resources. Articles of Importance to Read: Spring 2012

Transcription

1 Spring 2012 Important information from UnitedHealthcare for physicians and other health care professionals and facilities serving UnitedHealthcare Medicaid members Clinical Resources Behavioral Health Adverse Occurrence Reporting Requirement Reminder An adverse occurrence (sentinel event) is an unexpected occurrence involving death or serious physical injury, or the risk thereof, that occurs during the course of a member receiving inpatient or outpatient behavioral health treatment, or that otherwise occurs while under the care of a behavioral health clinician. Examples of adverse occurrences include: Treatment complications (including medication errors and adverse medication reactions) Accidents or injuries to the member Morbidity Suicide attempts Death of the member Allegations of physical abuse, sexual abuse, neglect, and mistreatment, and/or verbal abuse Use of isolation, mechanical restraint, or physical holding restraint (if any injury results from the restraint e.g. bruising, scrapes, swelling) Providers must report adverse occurrences as soon as possible, or no later than one business day. The following steps outline the reporting process: For more information Call our Provider Service Center at Visit Articles of Importance to Read: Clinical Resources Behavioral Health Adverse Occurrence Reporting Requirement Reminder EPSDT/TENNderCare Screening Reminder The National Registry of Evidencebased Programs and Practices: A Clinical Resource Quality Care Updates The Use of Progesterone in the Prevention of Preterm Births Take Action Clinical Practice Guidelines Utilization Review Take Note New Research Reveals Sesame Street s Food for Thought Initiative is Helping Families Eat Healthy on a Budget New Year Reminders e-business Updates UnitedHealthcare Online Information Submitting Claims Electronically.. 12

2 1. Collect all pertinent information about the event 2. Complete an UnitedHealthcare Community Plan Adverse Occurrence Referral Form and fax to our secure number at ; Attention: Charles Nails, Jennifer Radcliffe, or Leigh Anne Dempsey 3. Have information readily available to assist in investigation, if warranted Should you have any questions regarding this process please contact the Behavioral Health Quality Specialists, Charles Nails ( ), Jennifer Radcliffe ( ), or (Leigh Anne Cunningham ( ). Additionally, please note that the referral form can also be accessed at the UnitedHealthcare Community Plan website UHCCommunityPlan.com/assets/TN- AdverseOccurrenceForm.pdf EPSDT/TENNderCare Screening Reminder UnitedHealthcare Community Plan recognizes that preventive care is an essential component of a child s well being. The American Academy of Pediatrics (AAP) and Bright Futures publish Recommendations for Preventive Pediatric Health. Since each child and family is unique; these recommendations are designed for the care of children who are receiving competent parenting, have no manifestations of any important health problems, and are growing and developing in satisfactory fashion. Additional TENNderCare visits are necessary if circumstances suggest variations from normal. Developmental, psychosocial, and chronic disease issues for children and adolescents may require frequent counseling and treatment visits separate from preventive care visits. These guidelines represent a consensus by the AAP and Bright Futures. The AAP continues to emphasize the great importance of continuity of care in comprehensive health supervision and the need to avoid fragmentation of care. United Healthcare Community Plan endorses the concept of the Medical Home as a model of care that greatly facilitates these concepts. Providing all seven of the components of the TENNderCare visit including vaccines takes full advantage of the member s presence in the clinic and eliminates another visit being needed in the office. These components include: Comprehensive health history Comprehensive unclothed physical examination Appropriate laboratory tests according to age and health history Health Education Vision Screening Hearing Screening Immunizations in accordance with The Center for Disease Controls Advisory Committee on Immunization Practices (ACIP) at As a best practice, all office staff including physicians, nurses, and front office personnel can ask members, with whom they have any contact, if they have had their well visit and vaccines. Please perform the EPSDT exam when the office workflow allows when members are already in the office for other reasons. These AAP/Bright Future guidelines can be found at brightfutures.aap.org/pdfs/aap%20bright%2 0Futures%20Periodicity%20Sched% pdf I Spri ng Provider Service Center:

3 The National Registry of Evidencebased Programs and Practices: A Clinical Resource As there is an increasing number of health homes and other opportunities for practitioners to prevent, identify, and treat (when appropriate) mental health and substance use conditions, resources to support clinicians to do that also grows. The Substance Abuse and Mental Health Services Administration s (SAMHSA) National Registry of Evidence-based Programs and Practices (NREPP) catalogues interventions used for prevention or treatment of mental health and substance use (MH/SU) conditions. This online searchable resource contains more than 200 interventions that are reviewed and rated by independent reviewers. This registry relies on a self nominating system and intervention summaries are added regularly. There is a current open call to researchers and intervention developers through February 2012 for submission of interventions. If you would like to learn more about submitting interventions on the NREPP s submission page, information is located at Treatment information you will find on the NREPP The NREPP lists an intervention summary for every treatment it reviews. Intervention summaries include: General intervention information The research outcomes reviewed Ratings on research quality Ratings on dissemination material Reviewed studies and materials Contact information to obtain more information about implementation or research How can the NREPP be useful to you in your practice? The NREPP promotes informed decision making. The summaries can help determine if an intervention meets client needs Contact information allows you to ask the intervention developer for more information The NREPP provides a list of potential questions to support a pre-implementation discussion The NREPP also rates the quality of research supporting outcomes and accessibility of training. SAMHSA cautions that these ratings do not reflect effectiveness of the interventions and advises users of the registry to carefully consider the Key Findings within the intervention summaries. Further, SAMHSA reminds users of the site that the registry is not exhaustive nor does inclusion carry any endorsement by SAMHSA. Wellness Recovery Action Plan One example of an intervention recently added to the registry is Wellness Recovery Action Plan or WRAP. This typically time-limited, group intervention strategy for adults, developed by Mary Ellen Copeland, Ph.D., has the following goals according to the NREPP registry: Teach participants how to implement the key concepts of recovery (hope, personal responsibility, education, self-advocacy, and support) in their day-to-day lives Help participants organize a list of their wellness tools--activities they can use to help themselves feel better when they are experiencing mental health difficulties and to prevent these difficulties from arising Assist each participant in creating a psychiatric advance directive that guides the involvement of family members or supporters when he or I Spri ng Provider Service Center:

4 she can no longer take appropriate actions on his or her own behalf Help each participant develop an individualized post-crisis plan for use as the mental health difficulty subsides, to promote a return to wellness. The full report covers more information about implementation, studies considered, availability of information and materials. This peer-based program helps consumers develop their own personalized plan for managing wellness and getting health needs met using individual strengths and accessing support available from significant others and within the mental health care system. Visit SAMHSA s NREPP web site for more information about WRAP. Quality Care Updates UnitedHealthcare Community Plan wants our members to get the best care and service. That is why we have a Quality Management (QM) Program. Our QM Program helps us learn what we can do better. Then we use it to improve. Our QM Program has several member health programs. These programs: help people with health conditions like asthma, diabetes, heart disease, depression, bipolar disorder, and schizophrenia help pregnant women have healthy babies improve patient safety make sure members are happy with the plan make sure doctors and other health care professionals meet our standards We use national standards to see how well our QM Program works. The National Committee for Quality Assurance (NCQA), writes the standards. NCQA is an independent agency. It compares the quality programs of health plans. We measure our progress meeting our goals using NCQA s: Healthcare Effectiveness Data and Information Set (HEDIS ) Consumer Assessment of Healthcare Providers & Systems (CAHPS ) If you would like to know more about our quality health programs go to UHCCommunityPlan.com/health-professionals. Choose Health Programs for your area. A paper copy of our QM Program Description is available upon request. Please call Customer Service at for a copy. HEDIS and CAHPS results are given in a national report card. Below you will find our 2011 TennCare HEDIS and CAHPS highlights. The box compares our results to national averages: help people stay healthy with shots, screenings, and tests I Spri ng Provider Service Center:

5 2011 Adult CAHPS Highlights MEASURE Middle TN East TN West TN National Average** Rating of Health Plan* 74% 71% 72% 73% Rating of Personal Doctor* 72% 75% 77% 76% Rating of all Health Care* 70% 67% 70% 69% Rating of Specialist* 78% 75% 79% 77% How Well Doctors Communicate 85% 85% 87% 88% 2011 Child + CAHPS Highlights-General Population Rating of Health Plan* 86% 84% 79% 83% Rating of Personal Doctor* 88% 84% 83% 85% Rating of all Health Care* 85% 85% 82% 82% Rating of Specialist* 85% 87% N/A 83% How Well Doctors Communicate 94% 92% 91% 92% 2011 HEDIS Measure Highlights Timeliness of Prenatal Care 81% 83% 65% 86% Postpartum Care 63% 58% 51% 65% Diabetes Care: A1C Level Testing 75% 78% 75% 82% Retinal Eye Exam Performed 34% 35% 30% 53% LDL-C Cholesterol Screening 73% 73% 71% 75% Monitoring for Kidney Disease 70% 71% 72% 78% Breast Cancer Screening 44% 41% 35% 52% Cervical Cancer Screening 68% 68% 60% 70% Behavioral Health Antidepressant Medication Management- Effective Continuation Phase Treatment 26% 32% 30% 33% +Population eligible members were 17 years of age and younger as of 12/31/2010 *Percentage reflects members who rated their plan/provider 8, 9, or 10 on a scale of 0-10, 10 being best. **National Average is based on the 2011 NCQA 50th percentile. NA - Not reportable by NCQA because plan did not achieve a minimum of 100 responses for the measure. HEDIS is a registered trademark of the National Committee for Quality Assurance (NCQA). CAHPS is a registered trademark of the Agency for Healthcare Research and Quality (AHRQ). I Spri ng Provider Service Center:

6 The Quality Improvement Program strives to continuously improve the care and services provided to members. Each year UnitedHealthcare health plans utilize HEDIS reporting to measure our health care performance. Healthcare Effectiveness Data and Information Set (HEDIS) is a set of standardized performance measures that are related to many significant public health issues. Below you will find highlights from our 2011 UnitedHealthcare Dual Complete Preferred SNP HEDIS and CAHPS results. HEDIS Measure Highlights Dual Complete Preferred 2011 Dual Complete Preferred 2010 Colorectal Cancer Screening 38% 38% Glaucoma Screening 39% 40% Controlling High Blood Pressure 60% 58% CAHPS Measure Highlights Dual Complete Preferred 2011 National Average Rating of Health Plan* Rating of Health Care* Getting Needed Care** How Well Doctors Communicate** N/A 3.71 * CAHPS overall scores are based on a 1-10 scale ** CAHPS composite scores are case-mix adjusted mean scores based on a 1-4 scale N/A- either too few beneficiaries answered the question to permit reporting or the score had very low reliability Scores in italics have low reliability (below 0.75 in a 0 to 1.0 range). HEDIS is a registered trademark of the National Committee for Quality Assurance (NCQA). CAHPS is a registered trademark of the Agency for Healthcare Research and Quality (AHRQ). We highly encourage regular use of UnitedHealthcare Community Plan Online as a service to help providers improve Preventive Health HEDIS rates. A report listing your members who are not up-to-date on their preventive health screenings can be found under the Patient Services Tab, by clinking on the Preventive Health Measure Report. If would like more information about UnitedHealthcare Community Plan Online, please contact your Physician Advocate or Customer Service at UnitedHealthcare would like to thank all of our providers for their dedication. Your hard work was clearly reflected in the HEDIS scores for For complete HEDIS & CAHPS reports, please visit our website at UHCCommunityPlan.com I Spri ng Provider Service Center:

7 The Use of Progesterone in the Prevention of Preterm Births Preterm birth is defined as birth occurring prior to 37 completed weeks of gestation. The burdens that commonly result from preterm births are emotional and financial, short-term and longterm. Preterm births may result in developmental delays, life long disabilities, and serious medical complications including cerebral palsy, sensory deficits, chronic lung disease, blindness, and hearing loss. More than one-third of deaths occurring within the first year of life are attributable to preterm-related causes. In 2005, the Institute of Medicine estimated that preterm births cost the U.S. at least $26.2 billion ($51,600 for every infant born prematurely). These costs include medical and educational expenses and associated loss of productivity. There are multiple causes for preterm births. Causes of preterm birth are both iatrogenic (appropriate and inappropriate) and spontaneous. By now most providers of obstetrical services are aware of the increased risks of delivering a baby prior to 39 weeks gestation without a medical maternal or fetal indication. Additionally, most caregivers are familiar with the use of progesterone injections for the prevention of spontaneous premature births. As with any condition, the appropriate choice of treatment is dependent on factors inherent in each patient. This appears true with progesterone and its use in two separate high risk populations: (1) those with a singleton pregnancy who have a short cervix and (2) those women with a singleton pregnancy who had a prior spontaneous singleton, live born, preterm delivery associated with preterm labor between 20.0 and 36.6 weeks with a normal cervical length in the current pregnancy. The two risks factors for spontaneous preterm births (SPB) respond differently to different forms and routes of administration of progesterone. Based on the current research (which is constantly evolving): Short Cervix: responds to the use of micronized progesterone vaginal gel, but does not respond to 17 Alpha-Hydroxyprogesterone Caproate (17P) injections. Micronized progesterone vaginal gel appears to benefit those pregnancies that are found to have a short cervix in individuals with no prior history of a SPB and those with a history of a SPB. A meta-analysis by Romero (see below) evaluated multiple gestations and revealed no benefit in reduction in PTBs or NICU admissions, but did see a benefit on composite neonatal morbidity and mortality. History of SPB with Normal Cervical Length: responds to the use of 17 Alpha- Hydroxyprogesterone Caproate (17P) injections for singletons and not multiples, but has so far not been shown to respond to micronized progesterone vaginal gel. Those with a prior history of a SPB and short cervix in the current pregnancy can benefit from only micronized progesterone vaginal gel without 17P injections. Short Cervix In an article accepted to be published in the American Journal of Obstetrics & Gynecology, Romero and colleagues, with funding from the NICHD, NIH, and DHHS, performed a systematic review and meta-analysis of individual patient data demonstrating that treatment with vaginal progesterone in women with asymptomatic sonographic short cervix (< 25mm) in the midtrimester (19 0/7-23 6/7 weeks gestation) results in a decrease in preterm delivery and neonatal morbidity. Five trials with I Spri ng Provider Service Center:

8 775 women and 825 infants were used. Singletons represented 93.3 % pregnancies and 6.7% were twin pregnancies. In 3 of the 5 studies cerclage was allowed after randomization. There was a significant reduction in the rate of PTB < 33 weeks (RR 0.58, 95% CI ), <35 weeks (RR 0.69, 95% CI ), and 28 weeks (RR 0.57, 95% CI ). There was also a significant reduction in composite neonatal morbidity and mortality (RR 0.50, 95% CI ) and admissions to the NICU (RR 0.75, 95% CI ). The number of patients with a short cervix who needed to be treated (NNT) to prevent one case of PTB < 33 weeks was 11 (95%, CI 8-23), <35 weeks 11, <34 weeks 9, and < 28 and 30 weeks 18. With regard to singleton and twins gestations, there were significant reductions in PTB < 33 weeks in only the singleton group, 44% reduction vs placebo (CI ). Additionally, NICU admission reductions, 33%, were statically significant only in the singleton pregnancies (CI ). However, both singletons and twins showed a statistical reduction in composite neonatal morbidity and mortality. Vaginal progesterone was associated with a significant reduction in PTB < 33 weeks in both women with a singleton gestation with no previous PTB (RR 0.60, 95% CI ) as well as those with a singleton pregnancy and at least one prior PTB between weeks (RR 0.54, 95% CI ). History of SPB From the time the Meis article was published in the New England Journal of Medicine in 2003, many other studies have confirmed the benefit in PTB reduction using 17 Alpha- Hydroxyprogesterone Caproate (17P). Several studies have looked at the use of vaginal progesterone in various delivery systems. There is now significant evidence that in those with a history of a PTB and a current singleton pregnancy with a short cervix may benefit from vaginal progesterone alone. There is clear evidence from the literature that 17P IM does not change outcomes when administered to women with multiple gestations. Indications for 17 Alpha-Hydroxyprogesterone Caproate (17P) IM Asymptomatic women with at least one prior spontaneous (without medical cause for delivery or due to cervical insufficiency), singleton, live born, with or without ruptured membranes, preterm delivery between 20.0 and 36.9 weeks associated with preterm labor and initiating the medication between 16.0 and 26.9 weeks. (UnitedHealthcare Drug Policy number 2011D0040A) Indications for 17 Micronized Progesterone Vaginal Gel Asymptomatic women with a singleton pregnancy and an ultrasound demonstrated short cervix (10-25mm) diagnosed between 19.0 and 23.9 weeks of gestation and initiating the medication between 20.0 and 23.9 weeks gestation. Take Home Message: 1. Short cervix alone and short cervix with a history of PTB both respond to a minimum of 90 mg of micronized progesterone vaginal gel daily. There are no studies to suggest better outcomes with the treatment of those with short cervix with a history of PTB with combined micronized progesterone vaginal gel and 17P. 2. History of PTB with a normal cervical length has been proven to respond to 250 mg of 17P IM weekly and not vaginal progesterone. 3. For those currently pregnant with twin gestations with or without short cervix treated with vaginal progesterone or 17P, there is no decrease in the rate of PTB or NICU admissions. I Spri ng Provider Service Center:

9 4. For those currently pregnant with twin gestations with a short cervix treated with vaginal progesterone there is a statistical reduction in composite neonatal morbidity and mortality. 5. There appears to be a benefit to the universal screening of all pregnant women with singleton pregnancies with transvaginal ultrasound measurement for cervical length performed by trained personnel between 19 and 24 weeks of gestations and treatment with 90 mg of micronized progesterone vaginal gel daily for those found to have a cervical length < 25 mm until 26 6/7 weeks of gestation. UnitedHealthcare supports the appropriate treatment for the appropriate patient. For those members that meet the criteria for 17P and do not have a State sponsored pharmacy benefit, UnitedHealthcare Community Plan has a preferred relationship with Walgreens Specialty Pharmacy. Walgreens Specialty Pharmacy will ship compounded, preservative-free 17P to a provider s office and bill UnitedHealthcare Community Plan directly. Walgreens Specialty Intake staff can be reached at Phone: , Fax: Additionally, UnitedHealthcare has a preferred relationship with the Women s and Children s Health division of Alere Health. This home health service offers a compounded, preservativefree 17P administration program, which includes in-home obstetric nurse administration, education about the risk factors and signs and symptoms of preterm labor, weekly assessments and 24/7 nurse-line support. For more information please contact Alere at UnitedHealthcare Community Plan requires prior authorization for compounded 17P whether administered in the office or by a home health service. Although 17P is a medication, it is covered under the medical and not pharmacy benefit because it is not a self-injectible medication. At this time micronized progesterone vaginal gel is covered by the pharmacy benefit and also requires prior authorization but through OptumRx. Authorizations are based on medical necessity, which is determined by the drug policy, evidence-based medicine, state benefits, regulations, contracts and medical judgment. For UnitedHealthcare Community Plan members who do not have a State Fee-for- Service Pharmacy Program, 17P and micronized progesterone vaginal gel will be covered under the patient s medical or pharmacy benefit, respectively, in accordance with their coverage. For more information please view the online provider bulletin at and select 17 Alpha-Hydroxyprogesterone Caproate (17P) Information Effective Oct. 1, 2011 with links to the UnitedHealthcare Drug Policy number 2011D0040A. Take Action Clinical Practice Guidelines Clinical Practice Guidelines (CPG) are available through UHCCommunityPlan.com. Click on your appropriate state and there will be a link to the currently approved CPG or you may call for a copy. UnitedHealthcare Community Plan 2012 HEDIS Medical Record Review The 2012 Healthcare Effectiveness Data and Information Set (HEDIS ) medical record reviews are set to begin in late February and continue through mid-june. UnitedHealthcare Community Plan in Tennessee will partner with I Spri ng Provider Service Center:

10 Outcomes Health Information Solutions to contact offices and collect data using a Health Insurance Portability and Accountability Act (HIPAA)-compliant process. Medical record data may be requested from you in order to document care provided to randomly selected members in conjunction with multiple HEDIS performance measures. Please remember, it is a contractual obligation that UnitedHealthcare Community Plan physicians, other health care professionals, and facilities participate in this important quality improvement activity. UnitedHealthcare Community Plan thanks you in advance for your cooperation with Outcomes Health Information Solutions and any record reviews and requests associated with this data collection event. If you have any questions regarding these upcoming reviews, please contact your Physician Advocate or Customer Service at Utilization Review UnitedHealthcare Community Plan staff performs concurrent review on inpatient stays in acute, rehabilitation and skilled nursing facilities, as well as prior authorization reviews of selected services. A listing of services requiring prior authorization is available in the Provider Manual. A physician reviews all cases in which the care does not appear to meet guidelines. Decisions regarding coverage are based on the appropriateness of care and service and existence of coverage. The decisions are in no way influenced by financial or incentives of any kind. The treating physician has the right to request a peer-to-peer review with the reviewing physician and to request a copy of the criteria used in the review. The denial letter contains information on how to request materials and how to contact the reviewer. Members and practitioners also have the right to appeal denial decisions. Appeals are reviewed by a physician who was not involved in the initial denial decision and who is of the same or similar specialty as the requesting physician. The appeal request must be submitted within 365 days of the original denial. Requests should be mailed to: UnitedHealthcare Community Plan P.O. Box 5220 Kingston, NY If you have questions about Utilization Management, you can talk to our staff by calling They are available 24 hrs a day, seven days a week. Take Note New Research Reveals Sesame Street s Food for Thought Initiative is Helping Families Eat Healthy on a Budget With the Healthy Habits for Life partnership, UnitedHealthcare and Sesame Workshop, the nonprofit educational organization behind Sesame Street, offer tools and resources to help parents and caregivers gain a greater understanding of the relationship between healthy habits and children s healthy growth. In 2010, UnitedHealthcare announced our partnership with Sesame Workshop to develop a bilingual educational outreach program titled Food for Thought: Eating Well on a Budget to help families make food choices that are affordable, nutritional, and set the foundation for lifelong healthy habits. Food for Thought program I Spri ng Provider Service Center:

11 outreach includes bilingual (English and Spanish) kits with an original DVD starring the Sesame Street Muppets, a parent/caregiver guide, child-friendly recipes and a children s storybook. Sesame Workshop recently unveiled compelling research illustrating how Food for Thought: Eating Well on a Budget has been successful in helping families increase their knowledge, beliefs and behaviors around nutrition. Launched in December 2010, the initiative was designed to help support families who have children, between the ages of two and eight, cope with uncertain or limited access to affordable and nutritious food. The study, conducted by The Field Research Corporation, was presented by a panel of experts moderated by Erica Hill, Co-Anchor of CBS News The Early Show, at the National Press Club in Washington, D.C. Highlights from the research include: 88% gave the kit an overall positive rating 88% found the materials educational with over 80% reporting that their child learned something new from the DVD and/or storybook Nearly all participants (99%) found the materials helpful About two-thirds found the kit relevant to their needs Nearly three in four families reported that they are now doing new things as a result of using the kit, including serving healthier meals More than one million Food for Thought kits have been distributed through Sesame Workshop, UnitedHealthcare, The Merck Foundation and other key organizations including National WIC association, Feeding America, the National Head Start Association, Witnesses to Hunger and other key organizations. All bilingual materials are available at Sesame Workshop, Sesame Street, and associated characters, trademarks, and design elements are owned and licensed by Sesame Workshop Sesame Workshop. All Rights Reserved. New Year Reminders A new year is upon us and below is a list of a few friendly reminders for providers claims submission requirements went into effect Jan. 1, 2012 TennCare Members are not permitted by law to be balance billed, please refrain from this practice Any changes to provider demographics should be changed through the provider portal or communicated to your provider advocate promptly All mid-level providers such as Nurse Practitioners, Physician Assistants, Mid-wives and Certified Registered Nurse Anesthetists need to be credentialed and bill under their own provider numbers ICD-10 is approaching quickly please prepare and obtain education for staff involved with diagnosis codes and coding If a provider leaves a group practice or the practice closes a satellite location please notify your network area manager or provider advocate immediately Verify eligibility of members Respond to Provider data validation surveys to ensure your provider demographics are correct for easier member access to your practice/facility Please contact your Physician or Hospital and Facility Advocate if you have any questions in regards to the reminders above. I Spri ng Provider Service Center:

12 e-business Updates UnitedHealthcare Online Information UnitedHealthcare's innovative online provider portal, UnitedHealthcare Online, UHCCommunityPlan.com (formerly AmeriChoiceOnline), has been updated with new features in To register for UnitedHealthcare Community Plan provider portal, go to UHCCommunityPlan.com/healthprofessionals/TN/members-information > Access secure provider website. Follow links to register. To access the non-secured portion of the website, go to UHCCommunityPlan.com > Health Professionals > Tennessee. Under Claims and Member Information, click UnitedHealthcare Community Plan for Families. This page brings you to the former AmeriChoice Online webpage. Here you can access our policies, Provider Administration Manual, handouts, forms and recent newsletters and e- Alert notices sent to providers. One new enhancement offers the provider the option to search by members by the TENNderCare EPSDT Screening Measures Report and the Preventive Health Screening Measures Report. Click on either the "TENNderCare EPSDT Report by Member" link or "PHM Report by Member" link to view an individual report for a member enrolled in your panel. Providers can search for an individual member by UnitedHealthcare Community Plan Member ID Number, Member Name, Last Name and Date of Birth. Searching by Member ID Number is the fastest and most accurate search method. Another enhancement of the website allows the provider to contact the health plan through the online portal, with questions regarding data on the TENNderCare EPSDT or Preventive Health Measures report. The goal is to facilitate communication about reports that are available for providers. To submit a query or comment to the health plan, providers will only have to click the notify plan link, enter and submit form information/comment relating to the TENNderCare EPSDT Screening or Preventive Health Screening Measures Report. An will be sent to the EPSDT/Preventive Health and Education Department, and providers will receive a reply within three to five business days. Submitting Claims Electronically Did you know by converting 10,000 paper claims, remittance advice and reimbursements to electronic transmittal (EDI, EFT, and ERA) we could: Save 3,729 pounds of paper Eliminate 148,389 pounds of greenhouse emissions (equivalent to 1,726 new trees grown for 10 years or 20,451 square feet of forest conserved) The average practice can save thousands of dollars per year by converting to electronic transmission *Source: Getting Started with EDI is Simple To submit claims electronically, have your office software vendor or clearinghouse make connection to UnitedHealthcare s clearinghouse OptumInsight. Website: Phone number: UnitedHealthcare Community Plan Payer ID for Tennessee: I Spri ng Provider Service Center:

13 Contact our EDI Department to Learn about No Cost Solutions for EDI UnitedHealthcare Community Plan EDI Support Services Phone number: Website: UHCCommunityPlan.com Receive Payment for Claims Electronically with Electronic Funds Transfer (EFT) EFT is safe, secure, efficient and more cost effective than paper claim payments. You can find the EFT enrollment form on our website, if you would like to save money and time, enroll today! Receive Electronic Remittance Advice (ERA) To enroll in ERA contact your software vendor and/or clearinghouse COB (Secondary) EDI Claims Submissions are preferred electronically Please refer to the 837 Companion Guide located on our website or simply call our EDI Support services at or us at we would be happy to assist with setup Do not send paper claim backup for claims that have already been submitted electronically Electronic Claim Submission Tips Include your tax identification number (TIN) along with your NPI number Member ID numbers are required The payer ID number indicates where clearinghouses should direct their claims Carrier Tables and Payer ID Set-up Set your computer system payer tables to generate electronic claims instead of paper claims Make sure that Payer spelling and setup are consistent. Set them as electronic vs. paper Confirm that new patient records and additional payer listings created by front desk staff are set to be sent electronically Contact your software vendor or clearinghouse with any questions you may have concerning the placement of information on your computer/practice management system Managing Your Clearinghouse Reports You should receive two sets of reports for every claim batch transmitted: Clearinghouse acknowledgement - claims accepted and/or rejected by the clearinghouse Payer acknowledgement- claims accepted and/or rejected by the payer Rejected claims must be corrected and retransmitted electronically. Do not resubmit these claims via paper. Claims will only be rejected if there is something incorrect on the claim. Resubmitting a claim via paper will not correct the issue and may delay processing time. How to Avoid Rejections The majority of rejected claims are the result of an eligibility issue such as: Subscriber/subscriber ID not found Coverage has been cancelled Conducting an eligibility check on the patient helps avoid most rejections Some Claims might be rejected due to a provider mismatch. To ensure correct matching of the provider, ensure that you are submitting with the Tax ID number as well as the NPI number only omitting the legacy/provider ID number I Spri ng Provider Service Center:

14 Rejected claims must be corrected and re-transmitted electronically. Do not resubmit these claims via paper. Claims will only be rejected if there is something incorrect on the claim. Resubmitting a claim via paper will not correct the issue and may delay processing time Effectively Manage Re-Bills Make sure you set your re-submissions/re-bills to be sent electronically. Most systems have automatic claim re-bill capabilities that resend claims every 30 to 60 days if payment has not been posted Do not send paper claim backup for claims that have already been sent electronically Practice Matters is a periodic publication for physicians and other health care professionals and facilities in the UnitedHealthcare network. UnitedHealthcare Plan of the River Valley, Inc. 8 Cadillac Dr., Ste. 100 Brentwood, TN M47507TN 2/12 Provider Service Center: