Release Notes December 08, 2011

Transcription

1 Release Notes December 08, 2011 UnitedHealthcareOnline.com Website Design Changes The look of UnitedHealthcareOnline.com has been updated to reflect UnitedHealthcare s new single brand. In many places the UnitedHealthcare logo, background colors and images have been changed. There are also a few minor navigational changes to the home page with this enhancement: Notifications is being changed to Notifications/Prior Authorizations in many areas, because the same function can be used for both. Most Visited has been renamed Quick Links. Bookmark This Site has been moved below the Login button. The top navigation has been re-ordered. December 08, 2011 UnitedHealthcareOnline.com/ EDI Gateway Release Notes Page 1 of 10

2 Oxford Medicare Solutions Moving to UnitedHealthcareOnline.com Effective Jan. 1, 2012 Starting January 1, 2012, providers who currently use OxfordHealth.com will use UnitedHealthcare Online for secure online medical claims administration*, benefits and eligibility information and notification/prior authorization requests for Medicare Solutions members. These members, located in New York, New Jersey and Connecticut, can be identified by the display of the product name AARP MedicareComplete, Evercare or SecureHorizons ** on their health care ID card. Migration of these products will allow for consistent administration of policies and processes for all UnitedHealthcare business. Registered UnitedHealthcareOnline.com users can log on with their existing User ID and Password. New users can register by clicking the New User link on the home page of UnitedHealthcareOnline.com. To gain immediate access to the site, the user must enter a physician date of birth or the number of a UnitedHealthcare commercial claim paid in the last 180 days (or an Oxford Medicare Solutions claim processed after Jan. 1, 2012). Additional information about registration can be found in the Accessing UnitedHealthcare Online Quick Reference Guide. Providers already enrolled in Electronic Payments and Statements (EPS) will automatically receive direct deposit for these patient s claims. Those not enrolled in EPS can find additional information on the EPS Overview page of UnitedHealthccareOnline.com Historical information will remain available at OxfordHealth.com where providers will be able to access pre-migration information. If you have questions about this transition, contact Oxford Medicare Solutions Provider Customer Service at , Option 1 to speak with a knowledgeable representative. *All claim functionality with the exception of Real-Time Adjudication. **Evercare and SecureHorizons plans will change to the UnitedHealthcare brand effective Jan. 1, December 08, 2011 UnitedHealthcareOnline.com/EDI Gateway Release Notes Page 2 of 10

3 New! Notification/Prior Authorization Required Inquiry Tool for Oxford Medicare Solutions Members in New York, New Jersey and Connecticut The new Notification/Prior Authorization Required Inquiry tool will support the migration of the Oxford Medicare Solutions members to UnitedHealthcare Online. The Notification/Prior Authorization Required Inquiry tool can only be used for the Oxford Medicare Solutions membership in New York, New Jersey and Connecticut to determine if a Notification/Prior Authorization is required. If the patient entered is not an Oxford Medicare Solutions member in the applicable states, the following message will display: This transaction is not available for the selected member. To determine which services require prior authorization for this member, please visit the Tools and Resources section for policy requirements, or call the number on the back of the member's Medical ID card. Differences from the OxfordHealth.com Precert Required Inquiry tool include the following: More patient search options plus ID card swipe/scan capability New Service Detail field with drop down choices, which are driven by the place of service. At least one diagnosis code is required and there is a Lookup Diagnosis Code by Keyword tool. Up to 10 procedure codes can be entered and there is a Lookup Procedure Code by Keyword tool. The Inquiry Tracking # is called the Decision ID. The Notification/Prior Authorization Required Inquiry page is initially displayed with only the Patient Information section expanded and the Service Details, Requesting Provider Information, Diagnosis Codes and Procedure Codes sections collapsed. December 08, 2011 UnitedHealthcareOnline.com/EDI Gateway Release Notes Page 3 of 10

4 After entering the required information, and clicking the Submit Inquiry button, users will be provided with information on whether a Prior Authorization is needed. A Stop response, with further instructions on how to proceed, will be returned if the Prior Authorization cannot be done on UnitedHealthcareOnline.com. If a decision as to the need for a Prior Authorization cannot be rendered by the tool, users can continue on and initiate the Notification/Prior Authorization. Please reference the Help section of the site for Quick Reference guides and other materials. Website Changes for New Navigate Products Navigate is a new Gated HMO product which will require a member to select a Primary Care Physician (PCP). The PCP is responsible for direction and management of a Navigate member s care. The member will be required to obtain a referral to see a specialist or another PCP within the Navigate network. The product names Navigate, Navigate Balanced and Navigate Plus will be displayed everywhere product names are displayed today. Details of the Navigate benefit designs: Navigate In network only benefits. There is no coverage if a network provider is accessed without a referral. Navigate Balanced A member will receive in network benefits if a Navigate network provider is accessed with a referral. A member will receive a lower in network benefit if a Navigate network provider is accessed without a referral. There is no coverage if a non network provider is accessed. Navigate Plus A member will receive the highest network benefit if a Navigate network provider is accessed with a referral. A member will receive a lower network benefit if a Navigate network provider is accessed without a referral. A member will receive the lowest level of benefit if a non network provider is accessed. When the user does an Eligibility Search for any Navigate product member, an information message will be displayed on the Eligibility Details page to alert the user that the member s PCP must refer the patient to a Navigate specialist. The member s PCP can submit a referral via UnitedHealthcare Online. A check will be performed to ensure the referring provider is the member s PCP or a PCP within the member s PCP s tax identification number (TIN). The following error message will be displayed if the referring physician is not the member s PCP: This Referral cannot be submitted. The Referring provider is not a Primary Physician (PCP) within the same Tax ID Number as the Primary Physician assigned to this Navigate member. Please check the Referral Submission guidelines ' The referred to provider selection list will display only other PCPs or Specialists that are part of the Navigate network. Referrals can be submitted for a member with a maximum of six visits for most services. A maximum of 99 visits will be available for service exceptions. The user will see an error message displayed if more than six visits are entered and the service is not on the exception list or when more than 99 visits are entered and the service is on the exception list. The Procedure code entry boxes have been removed as procedure codes are not required for Referral Submission. On the Referral Status screen, the number of visits remaining will be displayed. Note: the below screenshots display the changes for Navigate products but do not reflect the new color scheme. December 08, 2011 UnitedHealthcareOnline.com/EDI Gateway Release Notes Page 4 of 10

5 ID Cards will not be viewable online for any Navigate product members. When the View Patient s ID Card is clicked on any page that contains a Patient Search or Patient Information, an error message will be displayed. In the claim status function there are two newly created remark codes that may display on a claim for a Navigate product member. The two new remark codes are: FM: According to your plan, you have a lower benefit because you did not obtain a valid referral from your PCP (Primary Physician) prior to this service. FN: According to your plan, you have no benefit because you did not obtain a valid referral from your PCP (Primary Physician) prior to this service. December 08, 2011 UnitedHealthcareOnline.com/EDI Gateway Release Notes Page 5 of 10

6 NDC Claim Submission Enhancements In order to receive drug rebates from Manufacturers, states must now submit utilization data on a quarterly basis to each manufacturer as well as to the Centers for Medicare and Medicaid Services (CMS). The data submitted must identify the National Drug Code (NDC), the NDC quantity and the NDC unit of measure for each covered outpatient drug. To support these data utilization reporting requirements a change has been made to the NDC Claim Entry screen. In addition to the already required NDC code, the following fields have been added: NDC Quantity and NDC Unit, which identifies the type of drug measurement. HIPAA 5010 Changes for Online Claim Submission To make the online claim submission form 5010 complaint, on January 1, 2012, selections that are no longer valid will be removed from dropdown boxes on the form. The items to be removed include: Report Type Code: 77 (Support Data for Verification) Claim Note Reference Code: PMT (Payment) Line Note Reference Code: PMT (Payment, TPO (Third Party Organization Notes) These values are valid through December 31, 2011 and will remain on the website until then. When 5010 is implemented on January 1, 2012 they will no longer display. December 08, 2011 UnitedHealthcareOnline.com/EDI Gateway Release Notes Page 6 of 10

7 Changes to Notifications For all Lines of Business: Notification Changed to Notification/Prior Authorization In some locations the word Notification has been changed to Notification/Prior Authorization because the same functionality can be used for both transactions. The change is visible on the home page, the previously named Notification Submission and Status pages, the Patient Eligibility Other Transactions for this Patient as well as in the Quick Reference Guides, Step-by-Step Help and Tutorials in the Help section. Patient Not Found Message Enhanced The Patient Not Found message has been changed to: Patient Not Found. For further assistance please call the telephone number located on the back of the member s Medical ID card. The message may be returned during the member search functionality in Notification/Prior Authorization Submission / Status / Required Inquiry. December 08, 2011 UnitedHealthcareOnline.com/EDI Gateway Release Notes Page 7 of 10

8 Notification/Prior Authorization Automated Approvals Please note: automated decisions apply only to certain UnitedHealthcare Community Plan, UnitedHealthcare Medicare Solutions and Oxford Medicare Solutions membership and services at this time. Notification/Prior Authorization Submission: Automated decisions (when applicable) for Notifications/Prior Authorizations are no longer approved at the procedure code level; instead they will be approved at the case level. The list of procedure codes with the corresponding approval status has been removed from the top of the confirmation page and replaced with an overall approval status for the case. If the Notification/Prior Authorization entered has been approved, the following message will display: Your Notification/Prior Authorization submission has been Approved. Please note that it may take a few days for the procedure coverage status to be updated and viewable via the Notification/Prior Authorization Status transaction on UHC Online. Notification/Prior Authorization Status and Detail: The Auto-Approved fields have been removed from each Procedure Detail on the Notification/Prior Authorization Status and Detail screens. Updates to Previously Submitted Notification/Prior Authorization Requests Previously submitted Notification/Prior Authorizations for commercial and Medicare Solutions members can be updated except to add or change procedures when a decision has already been rendered for any included procedure. If a user attempts to update a Notification/Prior authorization request when a decision has already been rendered at the procedure code level, the following will occur on the Notification/Prior Authorization Update page: The Add more procedure codes button on the Notification Update Page will be disabled. None of the fields within the procedure lines can be edited by the user. A message will be displayed on top of the page: A decision has already been rendered on this case. To request an additional service for this member, please submit a new notification/prior authorization request for the member. If the member has already been admitted, please call the number on the back of the member's ID card." Enhancements to the Notification/Prior Authorization Submission and Status Case Information Pages Within the Procedure Code Details section the label Procedure Coverage has been changed to Procedure Coverage Status. The values for the Procedure Coverage Status have also been changed: Yes will now display as Covered/Approved No will now display as Not Covered/Not Approved Note: Pending and Cancelled remain unchanged. December 08, 2011 UnitedHealthcareOnline.com/EDI Gateway Release Notes Page 8 of 10

9 Other Enhancements: Provider Directory Update for Empire Plans With this release the Empire Plan providers will now be included in the Physician Provider Directory available on the website. Specialty Drug Prior Authorization Program This release will give users who are required to obtain pre-authorization for specialty type drugs a Single Sign-On to CareCore. To access CareCore, the Specialty Drug Prior Authorization Submission & Status (Medicare Part B) option should be selected on the Notification/Prior Authorization menu. Note: these specialty drug types are part of Medicare Part B and are administered by a physician in the office. These drugs are not part of Medicare Part D which is the pharmacy benefit for Medicare members. December 08, 2011 UnitedHealthcareOnline.com/EDI Gateway Release Notes Page 9 of 10

10 Electronic Data Interchange (EDI) Gateway Enhancements to Member Matching for Three EDI Transactions To comply with federal regulations, new versions of the Minnesota Uniform Companion Guides (MN AUC), Version ASC X12/ also referred to as Version 5010, have been adopted for use in advance of the Jan. 1, 2012 deadline. Note: while the regulations only apply to Minnesota and the Health Care Eligibility Benefit Inquiry (270) transaction, we have deployed this enhancement in all markets and for two additional transactions. The search scenarios used to match the submitted patient to a payer s member have been enhanced to increase the number of matches, by continuing to search even if some of the data elements submitted do not match the payer s system. The following search scenarios will be used when responding to 5010 versions of the Health Care Eligibility Benefit Inquiry (270), Health Care Claim Status Request (276), and Health Care Services Review Request for Review and Response (278) transactions: Scenario #1: 270 Request transaction contains the Subscriber ID, Last Name, First Name, and date of birth (DOB) Scenario #2: 270 Request transaction contains the Subscriber ID, Last Name, and DOB Scenario #3: 270 Request transaction contains the Subscriber ID, First Name and DOB Scenario #4: 270 Request transaction contains the Subscriber ID and DOB Scenario #5: 270 Request transaction contains the Subscriber ID, Last Name and First Name Scenario #6: 270 Request transaction contains the Last Name, First Name and DOB Please refer to the Companion Guides for more information. EDI Notifications/Prior Authorizations for Oxford Medicare Solutions Oxford Medicare Solutions notifications and prior authorizations can now be submitted electronically to payer ID via 278N (005010x216) and 278A (005010x217) transactions. Note: When submitting a discharge date in the 278N, the discharge disposition/location needs to be included in the MSG segment. Please see the Companion Guides for more information. December 08, 2011 UnitedHealthcareOnline.com/EDI Gateway Release Notes Page 10 of 10