Articles of Importance to Read:

Transcription

1 Spring 2011 Important information from UnitedHealthcare for physicians and other health care professionals and facilities serving UnitedHealthcare Medicaid members Antidepressant Medication Management: Improving Treatment Compliance While depression is the most common behavioral health condition affecting adults, it is also the most treatable. The National Committee for Quality Assurance (NCQA) has established two measures to monitor medication compliance for patients with depression that are prescribed antidepressant medication. Compliance is monitored for the percentage of patients that stay on their antidepressant medication for at least three months and those that stay on their antidepressant medication for at least six months. One way to increase patient medication compliance is with education at the beginning of the treatment episode. Patients should receive information related to the following key areas: How antidepressants work Benefits of antidepressant treatment Expectations regarding the remission of symptoms How long the medications should be used Coping with side effects of the medication Remind patients to: Speak to you often about the side effects of the medication. Tell you about all of their current medical conditions and all the medications they are taking, including nonprescription drugs, herbs, and supplements to support assessment of potential drug interactions. Schedule regular follow-up appointments so you can monitor their progress to determine whether a particular medication is working for them. Articles of Importance to Read: Page 1 Antidepressant Medication Management: Improving Treatment Compliance Page 2 Utilization Review Member Rights and Responsibilities Clinical Practice Guidelines Quality of Care Initiative: Screening for Common Behavioral Health Concerns Page 3 UnitedHealthcare Partners with Sesame Street to Tackle Food Insecurity Crisis Page 5 Getting Started with EDI Page 7 Clinical Administrative Support Unit Healthy First Steps Provider Incentive Opportunity For more information Call our Provider Service Center at Visit

2 Consider that they may need to try several different medications before finding the one that works best. Continue to take medication as prescribed for at least 6 months after they feel better in order to reduce the chances of feeling depressed again. Patients should understand that some people need to remain on medication for several months to years (maintenance therapy). Others need medication for the remainder of their lives, especially those who have had several episodes of major depression. 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 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. Information on requesting an appeal is included in the denial letter. 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 90 days of the denial. Unison Health Plan of the Capital Area, Inc., 1001 Brinton Rd Pittsburgh, PA Member Rights and Responsibilities Just a reminder, the UnitedHealthcare Community Plan Member Rights and Responsibilities can be found in the Provider Manual. The Provider Manual is located at or Member Rights and Responsibilities are distributed to new members upon enrollment and annually thereafter. Clinical Practice Guidelines Clinical Practice Guidelines (CPG) are available through Click on your appropriate state and there will be a link to the currently approved CPGs. Quality of Care Initiative: Screening for Common Behavioral Health Concerns The U.S. Preventive Services Task Force (USPSTF) recommends that primary physicians screen patients for depression and alcohol misuse. To support this national healthcare initiative, UHC-CS asks you to screen all patients, including adolescents, for alcohol misuse and depression. As you know, these common disorders often adversely affect family quality of life and clinical outcomes. Screening for these disorders is key to treatment, as it can contribute to readiness to change and appropriately focused treatment. Screening doesn t replace diagnosis, but it can illuminate issues that contribute to sound diagnosis. To support you in this quality of care initiative, UHC-CS has identified two sensitive and specific screens which are accurate and easy to use. For depression, we recommend the Whooley Depression Screen (Whooley et al., 1997), a two question screening tool, is both quick and sensitive and can be given to all patients. Other tools are also available, such as the PHQ-2, PHQ-9, the Beck Depression Inventory, the Zung depression scale, the HAM-D, the CES- I Spring Provider Service Center:

3 D, and the use of the DSM-IV-TR criteria in screening. For alcohol, the AUDIT-C screen for hazardous drinking and alcohol use disorders (Saunders, Aasland, Babor, de la Fuente, & Grant, 1993) is a reliable 3-question tool that can help you identify hazardous drinking or alcohol use disorders including alcohol abuse or dependence. Other screening tools include the NIAAA Two Question Screen, MAST/BMAST, CAGE, and use of the DSM-IV-TR criteria in screening. Patients who score positive for hazardous drinking can benefit from a simple Brief Intervention (BI). BI is a skill set defined by researchers and described more fully in the reference below. The essence of BI is four steps, taken over the course of one to four visits: 1. Express concern about the patient s drinking 2. Link the patient s drinking to his/her health concerns 3. Offer explicit advice to stay below recommended limits 4. Follow-up at the next visit To get a copy of the Whooley or the AUDIT-C, your request to BHInfo@uhc.com. For more information on these disorders, you and your patients may access our liveandworkwell.com Web site. For more information on screening and BI, visit this Web site: The Alcohol Clinical Training (ACT) Project, established by the Boston Medical Center and Boston University Schools of Medicine and Public Health, disseminates the latest research on alcohol and teaches pragmatic clinical skills to screen and conduct brief intervention for alcohol problems. References Fleming, M and Baier Manwell, L. Brief intervention in primary care settings: A primary treatment method for at-risk, problem, and dependant drinkers. Alcohol Research and Health 23: Saunders, J. B.; Aasland, O.G.; Babor, T.F.; de la Fuente, J.R.; and Grant, M. (1993). Development of the Alcohol Use Disorders Identification Test (AUDIT): WHO collaborative project on early detection of persons with harmful alcohol consumption. II. Addiction 88, Whooley, M, Avins, A, Miranda, J, Browner, W. (1997). Casefinding instruments for depression: Two questions are as good as many. J Gen Intern Med 12: UnitedHealthcare Partners with Sesame Street to Tackle Food Insecurity Crisis Previously we told you about UnitedHealthcare s national three-year collaboration with Sesame Workshop, the nonprofit educational organization behind Sesame Street, to promote healthy eating habits for children and families on limited incomes. We are excited to announce that the Sesame Street Food for Thought: Eating Well on a Budget outreach kits are now available. The outreach kit was developed especially for this initiative by Sesame Workshop in conjunction with a national advisory board of experts in health and social services. This kit is part of a bilingual (English/Spanish), multimedia program that guides parents and caregivers to better understand the relationship between healthy food habits and children s healthy growth, development and learning. We plan to partner with providers and community organizations to present the information to the general public in fun and engaging ways through community outreach I Spring Provider Service Center:

4 An important message to health care professionals and facilities events, cooking classes, nutritional counseling sessions, as well as printed and online materials. In addition to healthy eating, we ll emphasize the value of physical activity and encourage children to keep moving through exercise, sports, games and other fun activities. The program includes: An original Sesame Street DVD featuring the Sesame Street Muppets along with real families using various strategies to maintain healthy habits on a limited budget; Parent/Caregiver Guide providing tips, strategies and resources to assist food insecure families; Children s Storybook designed to reinforce how the routines of food shopping and cooking a family meal together are important ways to remain connected as a family; Recipe Cards with child-friendly and nutritional recipes to make as a family; and We are excited to make this national health initiative available to all Americans and especially to our members. They are most vulnerable to the detrimental effects of poor nutrition which often leads to obesity, hypertension, heart disease and diabetes. UnitedHealthcare is proud to collaborate with Sesame Workshop on this initiative that can make a positive and healthy difference in their lives. To learn more about this program, please contact (local provider relations rep name) at (phone number). Spring 2011 An invisible crisis exists in the United States: the impact of food insecurity on both children and adults. Food insecurity is defined as any household where there is limited or uncertain availability or accessibility to enough food to fully meet basic needs at all times due to a lack of financial resources. In 2008, an estimated 15 percent of U.S. households, or 49 million individuals, were identified as food insecure.1 It is estimated that 17 million children under the age of 18 are affected by issues of food insecurity; and 1 in 4, or 9 million, of these children are younger than 6 years old. For young children, food insecurity has lifelong consequences that affect their health and school readiness and performance, as well as their growth and development. 1 Mark Nord, Margaret Andrews, and Steven Carlson, Household Food Security in the United States, ERR83, U.S. Dept. of Agriculture, Econ. Res. Serv. November Online games for children and downloadable outreach materials for parents and caregivers. I Food Insecurity: An Invisible Crisis 4 UnitedHealthcare and Sesame Street have teamed up to make healthy eating and fitness fun for you and your kids. Look for tips on healthy foods and habits on Provider Service Center:

5 Getting Started with EDI To submit claims electronically: have your office software vendor or clearinghouse make connection to UnitedHealthcare s clearinghouse ICS - Ingenix Connectivity Solutions. Ingenix Connectivity Solutions (ENS) optimize@ingenix.com UnitedHealthcare Community and State EDI Department Support Services ac_edi_ops@uhc.com UnitedHealthcare Community Plan of Washington, DC s Payer ID: If you do not have office software and would like to submit directly, at no cost to you, submission can be done through a number of vendors that we work with such as Office Ally. Direct Connections for Healthcare Claims via Office Ally is a simple, secure, and HIPAA compliant solution offering you: Direct connectivity via the internet No cost to Providers...no installation, transaction, or support fees Free Setup and training Easy to use (Batch and Single Claims) 24/7 Customer Support Off ice Ally Enroll now at at: info@officeally.com or call COB (Secondary) EDI Claims Submissions General COB claims ARE ACCEPTED ELECTRONICALLY, we encourage you to explore this option Please refer to the 837 Companion Guide on Select your State and Plan Go to the For Providers section and select Provider Forms Go to the EDI Section and select the guide you wish to review or simply call our EDI Department Support services at: or us at ac_edi_ops@uhc.com 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 to help promote timely and accurate payments Member ID Numbers are required The Payer ID number indicates where clearinghouses should direct their claims. UnitedHealthcare Community Plan s Payer ID is: For additional assistance with electronic claim submission please contact our EDI Department Support services at: or us at ac_edi_ops@uhc.com 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 I Spring Provider Service Center:

6 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 Be sure you are working your reports! Reports show if a claim has been received by the clearinghouse and sent to the payer s system 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 and Denials The majority of rejected or denied 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 and denials. Rejected or denied claims must be corrected and re-transmitted electronically. Do not resubmit these claims via paper. Claims will only be rejected or denied 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 days if payment has not been posted. Do not send paper claim backup for claims that have already been sent electronically Receive Payment for claims electronically (EFT) EFT (Electronic Funds transfer) is the method of transferring money from one bank account directly to another without any paper money or checks actually changing hands. One of the most common EFT programs used is Direct Deposit for payroll. EFT is safe, secure, efficient, and more cost effective than paper claim payments. To Enroll in EFT: 1. Go to 2. Select your State and Plan 3. Go to the For Providers section 4. Under the Provider Forms section, select EFT Form, download, Complete and return to us at the address listed on the form. Receive Remittance Advice Electronically (ERA) ERA (Electronic Remittance advice) provides information for the payee regarding claims in their final status. The Content on the Electronic Remittance advice meets HIPAA requirements, containing nationally recognized HIPAAcompliant remark codes By receiving Remittance Advice and Claims Reimbursement electronically you will be eliminating the paperwork associated with manually posting Remittance Advice, you will also be reducing the cost associated with the time spent by your office staff manually posting I Spring Provider Service Center:

7 Remittance Advice and manual Reimbursement process. To enroll in ERA you will complete the applicable section of the EFT enrollment form. Clinical Administrative Support Unit Effective February 2010, the Clinical Administrative Support Unit (CASU) was formed. The scope of the unit is to perform administrative processes which support the Healthy First Steps Program. Below are Process Efficiencies that were implemented recently: Effective 12/10/10: Newborn well-baby authorizations are no longer required in the following states: PA, SC, DC, OH & DE. Effective 12/13/10: Providers no longer need to receive the global authorization # faxed back to them in PA, SC, OH & DE. Upon submitting the OB Risk Assessment Form (OB RAF), the provider will receive their provider incentive for submitting that form. Effective 1/1/11: The global authorizations were eliminated in NY & NJ. Upon submitting the OB RAF, the provider will receive their provider incentive for submitting that form. All Providers: Continue faxing your OB RAF s to: Any questions? Feel free to call your Provider Relations Representative at Healthy First Steps Provider Incentive Opportunity UnitedHealthcare Community Plan is pleased to announce implementation of a Healthy First Steps incentive program. We want to partner with you for early identification of pregnant members and the opportunity to enroll them in Healthy First Steps. We provide pregnancy related education, psychosocial support and referral to community resources as needed. You will receive an incentive payment of $25 for each completed Obstetrical Health Risk Assessment form faxed to , that are received within 5 days of the initial visit (this in addition to reporting this information to your local health department). The incentive check along with a list of members for whom we have received a completed Obstetrical Risk Assessment Form will be sent to you. Payment will only be issued for risk assessment forms that are legible and contain the following information. Physician name and plan provider ID number Current pregnancy information e.g. gestational diabetes, preterm labor, PROM, etc. Prior medical and obstetrical history e.g. hypertension, Diabetes Mellitus, Preterm delivery, infant birth weight of less than 4 pounds, Cerclage, etc. Current Medical conditions e. g. HIV+, Sickle Cell Disease, bleeding or clotting abnormalities, any other medical condition Hospitalizations related to pregnancy complications We appreciate the care you have provided to UnitedHealthcare Community Plan pregnant members and look forward to partnering with you with this incentive program. Questions and additional information related to Healthy First Steps may be directed to your provider advocate at Peggy Tate, I Spring Provider Service Center:

8 Practice Matters is a periodic publication for physicians and other health care professionals and facilities in the UnitedHealthcare network. M47507DC 2/11 Unison Health Plan of Delaware Unison Plaza 1001 Brinton Road Pittsburgh, PA Provider Service Center: