Important information for physicians and other health care professionals and facilities serving UnitedHealthcare Medicaid members Summer 2009 UnitedHealthcare Goes Live With 13th Edition of Milliman Care Guidelines UnitedHealthcare Medical Management continues to use the Milliman Care Guidelines in the utilization management of both inpatient and outpatient services for all plans except our Pennsylvania plans, and on May 1st went live with the use of the 13th Edition of the Care Guidelines. The Care Guidelines are nationally recognized evidence-based guidelines; and are more than just a tool used by the payer community to guide the authorization of care and services. The key aspects of the Care Guidelines: Clinical indications for decision-making for admission, procedures, testing and services; A guide for optimal recovery (the Milliman Care Guidelines Optimal Recovery Course) which is reflective of best practices in prescriptive care; Discharge planning guidelines; Patient education/teaching information; Clinical documentation requirements; Extended Stay criteria; Common Complications and Conditions guidelines; Hospital Care Planning; Articles of Importance to Read: Page 1 UnitedHealthcare Goes Live With 13th Edition of Milliman Care Guidelines Page 2 H1N1 (Swine Flu) Update The Importance of Collaboration between Primary Physicians and Behavioral Health Clinicians Member ID Card Updates Page 3 Provider Satisfaction Survey Provider Directories Care Management and Disease Management Page 4 The Medical Technology Assessment Committee (MTAC) Quality Measures; Opportunity to use guidelines to guide collaboration and consultation between payers and providers regarding patient care and management. If you have questions or want to know more about the Milliman Care Guidelines, please contact your local UnitedHealthcare plan.
H1N1 (Swine Flu) Update UnitedHealthcare providers are directed to the Centers of Disease Control (CDC) Web site at http://www.cdc.gov/h1n1flu/guidance/ for the latest H1N1 (swine flu) updates. Providers can also download a Frequently Asked Questions (FAQ) document for their patients by accessing their state-specific physician Web site at www.uhcmedicaid.com. The Importance of Collaboration between Primary Physicians and Behavioral Health Clinicians A substantial number of patients who have serious illnesses also have behavioral health conditions. For example, 20% of patients who have had a heart attack are likely to develop depression within 12 months of the event. Between 20% and 27% of patients with diabetes also have depression. It is important to determine if a behavioral health clinician is treating a patient with these and other illnesses. If so, it is helpful to coordinate care with the behavioral health clinician. Coordination of care takes on greater importance for enrollees with severe and persistent mental health and/or substance abuse problems. This is especially true when medications are prescribed, when there are coexisting medical/psychiatric symptoms and when patients have been hospitalized for a medical or psychiatric condition. Communication between clinicians can also maximize the efficiency of diagnosis and treatment, while minimizing the risk of adverse medication interactions for patients being prescribed psychotropic medication. It can also help reduce the risk of relapse for patients with substance abuse disorders or psychiatric conditions. Please discuss with your patients the benefits of sharing essential clinical information. We encourage you to obtain a signed release from each UnitedHealthcare patient that allows you to share appropriate treatment information with the patient s behavioral health clinician. Psychiatric Consults for Medical Patients If you would like to arrange a psychiatric consultation for a patient in a medical bed, are unclear whether a consultation is warranted, or need assistance with any needed authorization, please call United Behavioral Health at (800) 582-8220. In addition, if a PCP or a non-psychiatrist prescribes an antipsychotic medication for a member, it is highly recommended that the prescribing physician contact United Behavioral Health to discuss the appropriateness for the utilization of this medication. Member ID Card Updates UnitedHealthcare ID cards have been redesigned to incorporate the feedback we received from physicians and practice managers. We believe this is an important step in simplifying the administration of health care for you and our members. Beginning Fall 2009, the new ID card will be reissued to all UnitedHealthcare Medicaid members. You may continue to see the older ID cards for a period of time until the mass mailing is completed. Please continue to accept both versions of the ID cards from your patients. In addition, if you participate in both UnitedHealthcare s Medicaid and commercial page 2 Provider Service Center: 1-877-842-3210
networks, you may have already seen the ID card enhancements for your commercial patients. Some of the important changes which abide by the Workgroup for Electronic Data Interchange (WEDI) health care ID card standards include: Consistency layout based on WEDI standards for data fields, placement and size; personalization and variable information with labels printed on front of card and instructions on back of card Readability limited information on the card, machine readable formatting, and use of large font size Copying/Scanning ability to clearly copy or scan for patient health records with white background Compliance compliant with the National Council for Prescription Drug Programs (NCPDP) Please note: the following information has not changed: Claims process Member benefits Contact information If you have any questions, please contact Provider Services. Provider Satisfaction Survey Tell Us What You Think UnitedHealthcare is committed to making sure that our services support the ability of your practice to provide the safest and highest possible quality of health care to your patients who are our members. We value and seek administrative simplicity that takes the hassles out of clinical practice and reduces inefficiency and waste. For this reason, we periodically offer our network physicians the opportunity to comment on our services. You will be receiving a survey to evaluate the services UnitedHealthcare provides to our members and you in the near future. Your opinions are important to us and will help us assess the level of satisfaction with our health plan, as well as identify opportunities for improvements so that we may better meet the needs of your practice. We appreciate your time and cooperation. Provider Directories Just a reminder, updated Provider Directories are located at www.uhcmedicaid.com. A Provider Directory can be requested by contacting Customer Service at 877-842-3210. Care Management and Disease Management The Personal Care Model is a holistic approach to care for members with complex needs, especially for those with chronic conditions. The goal is to keep our members in the community with the resources necessary to maintain the highest functional status possible. What can the UnitedHealthcare Case Manager provide for your patients? Telephonic contact with members and home visits as needed Disease management programs Health education and educational materials page 3 Provider Service Center: 1-877-842-3210
A health assessment with stratification of diagnosis and severity of condition and psychosocial needs Referrals to community resources as needed Assistance with medical transportation Arrangements for DME and ancillary services as needed or ordered by the physician Outreach to members to promote assistance with keeping doctors appointments Facilitation with members to identify and address barriers to seeking health care and to following their medical treatment plan of care Areas of Expertise Disease Management programs Diabetes CHF Asthma HIV COPD Sickle cell Special Needs Case Management (adults and children) Complex Needs Case Management Pediatrics/NICU Case Management Emergency Room Utilization Case Management Healthy First Steps Program for pregnant women (members do not have to be high risk to receive this service) How to refer For more information or to make a referral, call our referral line at 800-825-8792 ext. 84562. The Medical Technology Assessment Committee (MTAC) The Committee meets at least 10 times per year. Reports from the MTAC are reviewed by the EMPC (Executive Medical Policy Committee) and recommendations are forwarded to the health plans. MTAC is responsible for the development and management of: Evidence-based position statements on selected medical technologies Assessments of the evidence supporting new and emerging technologies Evaluation of new usage of existing technologies Maintenance of externally licensed guidelines The consideration and incorporation of nationally accepted consensus statements, clinical guidelines and expert opinions into the establishment of national standards for UnitedHealth Group Ensuring that clinical decisions about the safety and efficacy of medical care are consistent across all products and businesses page 4 Provider Service Center: 1-877-842-3210
13621 NW 12th Street Sunrise, FL 33323 Practice Matters is a periodic publication for physicians and other health care professionals and facilities in the UnitedHealthcare network. M44307 7/09 AHCA/FHK-B-N-025 07/09-08/12