2009 Informational Guide. for the State Health Benefit Plan

Transcription

1 2009 Informational Guide for the State Health Benefit Plan

2

3 unitedhealthcareonline.com Review a member's eligibility or benefits Provide inpatient facility notification Check claims status Submit claims Update facility/practice data Print EOBs Lookup your fee schedule Recredential View policies (866) UHC-FAST ( ) To register for Online, ask questions about online capabilities, for information about our EDI Connections or for a list of our clearinghouse options, or receive assistance. unitedhealthcare.com To review the online physician and health care professional directory if you are not a registered user of Online. Dedicated SHBP Provider Line Care Coordination/ Notification Pharmacy Services MEDCO Customer Care, Mental Health, Substance Abuse or Transplant Services Electronic Payments and Statements Laboratory Services call (866) unitedhealthcareonline.com or call customer service number on back of member's ID card myuhc.com/groups/gdch.com (800) Options PPO Choice High Deductible Plan Definity HRA Retiree/MedicareDirect (866) UHC-FAST or [email protected] Online.com Physician Directory To inquire about a member's eligibility or benefits, check claim status, update facility/practice data, check credentialing status or request for participation inquiries, appeal submission process information, claim project submission process information, care notification process information, and privacy practices information. To notify us of the procedures and services outlined in the notification requirements section of the Physician Health Care Professional, Facility and Ancillary Provider Administrative Guide. To view the Prescription Drug List (PDL) for State health benefit plan members When prescribing medications that require notifications Address for all products: P.O. Box Atlanta, GA To sign up for Electronic Payments and Statements Effective January 1, 2007, Quest Diagnostics is no longer a participant in the network. 1

4 MedicareDirect New plan offering for 2009! SHBP is offering a new plan for 2009 called MedicareDirect. MedicareDirect is a Medicare Advantage Private-Fee-For-Service (PFFS) plan offered by Insurance Company. Participation is easy! This plan does not require a contract, referral, authorization or pre-admission approval - you just need to accept the plan's Terms and Conditions. To learn more about this plan and how to become a deemed provider, contact us at (866) , 9:00 A.M. to 8:00 P.M. (Eastern), Monday through Friday. For more information you can also visit us online at > Tools & Resources > Products & Services > Medicare> Private-Fee-For-Service (PFFS) Plans. State Health Benefit Plan (SHBP) Products This table provides some information on the State Health Benefit Plan products. If a member presents and Identification card with a product name with you are not familiar with, please contact customer care. Attributes How do members access physicians and health care professionals? Is a referral from a primary physician* a requirement for coverage of a specialty service? If those requirements exist, they will be noted in our agreement s state regulatory appendix.) Is the treating physician and/or facility required to notify Care Coordination? Choice Members can choose any network physician or health care professional without a referral and without designating a primary physician.* No, a referral is not needed. Yes, on selected procedures. See guidelines in Provider Manual. Options PPO, High Deductible Health Plan, and Health Reimbursement Account** Members can choose any network physician or health care professional without a referral and without designating a primary physician.* No, a referral is not needed. No. Members are responsible for notifying Care Coordination at the phone number on their ID card. Please refer members to Customer Care for questions about their responsibilities. * Primary physician is defined as a physician or other health care professional whom a member has designated as his/her primary care physician. ** See Definity HRA (page 4) *** Physicians and health care professionals must be licensed for the health services provided and covered under the member's benefit contract. 2

5 Definity HRA State Health Benefit Plan Definity HRA is a consumer-driven health plan that offers members a high deductible medical coverage plan linked to a health reimbursement account. The core medical product offered with Definity is PPO. The Definity account is a Health reimbursement account (HRA). Funds in these accounts can be used to cover some out of pocket costs such as deductibles and coinsurance. Billing After covered Definity services are adjudicated on our medical claims system, you and your patient will receive an explanation of benefits (EOB). If there is an outstanding patient balance, in most cases, it will automatically transfer for payment from the health reimbursement account. If there are sufficient funds in the account, you will be paid directly. The EOB which you receive after the claim is processed through the HRA will clearly indicate any remaining patient responsibility. To promote accurate billing, we recommend that you collect applicable deductibles and coinsurance after receiving the EOB. Preventive Care Members enrolled in the Definity HRA plan are encouraged to seek preventive care. In 2009, employees and their spouses will each receive $125 in HRA credits if they get an annual wellness exam and take 's online health assessment. Members are encouraged to work with their doctor's office to ensure that the annual wellness exam is billed appropriately. Members will earn the HRA credits for the following codes: Wellness Exam 99385, 99395, 99386, 99396, 99387, 99397, 99402, 99403, 99404, V70.0, V72.31, V76.2, V76.31, V76.47 Personal Health Record In helping to promote consumerism, is encouraging members to use their online secure Personal Health Record. This tool automatically captures in network dates of provider services and lab values. encourages members to bring a summary report to physicians to provide a more complete picture of a member's health status. Members may also grant online access to healthcare providers. 3

6 Member ID Cards for State Health Benefit Plan 4

7 5

8 Standard Notification Requirements Information gathered about planned member care supports the care coordination process which is vital as we engage physicians, hospitals and other health care professionals. s notification requirements are designed to most effectively gather the pertinent information in a timely manner. Effective December 3, 2007*: Physicians, Health Care Professionals and Ancillary Providers are responsible for Advance Notification for certain planned services. Facilities are responsible for Admission Notification for inpatient admissions described below. Notify us at Online.com for any inpatient admission notification required under this Guide. Alternatively, we will accept daily composite census logs, with complete and relevant information, via fax. For outpatient notifications or if you do not have electronic access, please call Care Coordination at the number on the back of the member ID card. Advance Notification (applies to Physicians, Health Care Professionals and Ancillary Providers only) Notification is required for only those planned services on the Advance Notification List. Notification is required at least five (5) business days prior to the planned service date (unless otherwise specified within the Notification List). Note that notification for home health services is required within forty-eight (48) hours after the physician s order. If services are planned less than five (5) business days prior to the service date, notification is required as soon as the service is scheduled. Rendering physician or healthcare professional name and TIN or NPI ICD-9-CM diagnosis code for primary diagnosis Anticipated date/s of service Type of service (procedure code/s) and volume of service (when applicable) Facility name and TIN or NPI where service will be performed (when applicable) Physicians who have received the UnitedHealth Premium quality and efficiency of care designation are exempt from the Advance Notification requirement for certain services as indicated on the Advance Notification List. Advance Notifications must contain the following information associated with the planned service: Member/enrollee name and member ID Ordering physician or healthcare professional name and TIN or NPI 6

9 Admission Notification (applies to Facilities only) Admission Notification is required for the following admission types: All planned/elective admissions for acute care All unplanned admissions for acute care All SNF admissions All admissions following outpatient surgery All admissions converting from observation All newborns admitted to NICU or who remain hospitalized after the mother is discharged Admission Notification must be received within twenty-four (24) clock hours after actual admission In recognition and to assist/enable facilities to support Admission Notification for the period 12/3/2007-6/30/2008: Admission Notification for weekend and holiday admissions will be required by next business day prior to 5:00 P.M. local time (weekend admission is defined as admission to inpatient status between 5:00 P.M. local time on Friday to 11:59 P.M. local time on Sunday, and holiday admission is defined as any admission occurring between 5:00 P.M. local time on the business day preceding a federal holiday to 11:59 P.M. local time on a federal holiday). Admission Notification is required even if Advance Notification was supplied by the physician Admission Notifications must contain the following details regarding the admission: Member name and member ID Facility name and TIN or NPI Admitting/attending physician name and TIN or NPI Description for admitting diagnosis or ICD-9-CM diagnosis code For emergency admissions where a member is unstable and not capable of providing coverage information at the time of admission, the facility should notify as soon as the information is known and communicate the extenuating circumstances. We will flag the case for payment without any notification-related reimbursement adjustments. For weekday admissions after 12/3/2007, and weekend and holiday admissions after 6/30/2008: If admission notification is provided after 24 hours, but within 72 hours after admission, the reimbursement will be 50% of the average daily payment rate for each day preceding notification and 100% thereafter (not applicable to DRG/case rate contracts without outlier provisions). The average daily payment rate will be calculated by dividing the contracted rate for the admission by the admission length of stay. For all admissions: If admission notification is provided after 72 hours or not at all, the reimbursement will be 50% of the contracted rate for the entire admission (applicable to all contracts, regardless of payment methodology). will suspend any reimbursement adjustments associated with the Admission Notification Protocol for facilities that have signed the electronic interface agreement until the earliest of the following dates of service: July 1, 2008 (extended from April 1, 2008); or The date the facility discontinues its efforts to create the electronic interface. *For a list showing each state s status, please refer to Online.com and click on Tools and Resources, then on Policies and Protocols and to Advance and Admission Notification. If additional states are added, you will be sent a written notice if you participate in that state. This protocol was previously communicated to providers, so the effective date of this protocol supersedes the overall effective date of this Guide. Please refer to Online.com for state-specific variations of this protocol. Actual admission date 7

10 Advance Notification List Notification Requirements for Physician Services* Procedures and Services Explanation Congenital Heart Disease Congenital Heart Disease related services, including the following codes: For services listed in this ICD-9-CM section call Optum Health through directly at (888) CPT or the notification number on , , , , , the back of the member , , and ID card, rather than For additional details and code descriptions, see Protocols section of Care Coordination Online.com. Initiation of Cancer Treatment other than surgery. Call Cancer Resource Services (CRS)* at (866) Orthopaedic and Spine Surgeries Pregnancy, Healthy Pregnancy Notification + Initiation of Cancer Treatment for a diagnosis other than skin cancer or cervical cancer. This notification program is voluntary. The program will assist in identifying customers for outbound calls to explain benefits and other programs (for example, Employee Assistance Programs). Inpatient admissions for spinal surgeries, total knee replacements and total hip replacements. Upon confirmation of pregnancy, a notification is required by physicians or other health care professionals who provide obstetrical care to a pregnant member for: ICD-9-CM V72.42 or any other diagnosis code related to pregnancy. Notification is required only once per pregnancy. Notification is not required for ancillary services such as ultrasound and labwork. If, after you have notified us of a pregnancy, you obtain information that would cause you to conclude that your member is no longer appropriate for a Healthy Pregnancy Program, e.g., termination of pregnancy, we ask that you notify us of that fact. ***The notification requirements with this indicator are not applicable to physicians who have received the UnitedHealth Premium quality and efficiency of care designation, in recognition of their demonstration of adherence to nationally recognized evidence-based quality and efficiency of care standards. Additional information regarding the UnitedHealth Premium Designation Program is available at Online.com or by calling (866) This notification list may change from time to time. If there is such a change, we will provide you with information about the change before it takes effect. This list does not signify coverage for benefits. Coverage is determined by the member s benefit plan. If you have questions about a member's coverage, visit Online.com or call the United Voice Portal- UVP (formerly known as VETSS) at (877)

11 Reconstructive/Potentially Cosmetic Procedures Cosmetic Procedures are procedures or services that change or improve physical appearance, without significantly improving or restoring physiological function, as determined by us. Reconstructive Procedures are procedures or services that either treat a medical condition or improve or restore physiologic function. To confirm coverage, we require notification for such services, including but not limited to: Blepharoplasty, upper lid reconstructive procedures including repair of brow ptosis Breast Reconstruction reconstruction of the breast other than following mastectomy Breast Reduction removal of breast tissue in men or women other than mastectomy for cancer Ligation, Vein Stripping removal of varicose veins Sclerotherapy an alternative method for removing varicose veins and other vein abnormalities (including, but not limited to, CPT codes and 36471) In addition to the examples listed above, some self-funded members may have requirements for other reconstructive/potentially cosmetic procedures. Therefore, it is important that you contact us to determine if notification is required for any reconstructive/potentially cosmetic procedure. Referral for Non-Network Services *For commercial customers only. A referral from a network physician or health care professional to a facility, physician, or other health care professional who does not participate in, where a member's benefit plan permits out-of-network services. Please note that your agreement with us states that you will refer members only to other network physicians, facilities and professionals, except as permitted under a member's benefit plan or as otherwise authorized by us or the payer. ***The notification requirements with this indicator are not applicable to physicians who have received the UnitedHealth Premium quality and efficiency of care designation, in recognition of their demonstration of adherence to nationally recognized evidence-based quality and efficiency of care standards. Additional information regarding the UnitedHealth Premium Designation Program is available at Online.com or by calling (866) This notification list may change from time to time. If there is such a change, we will provide you with information about the change before it takes effect. This list does not signify coverage for benefits. Coverage is determined by the member's benefit plan. If you have questions about a member's coverage, visit Online.com or call the United Voice Portal- UVP (formerly known as VETSS) at (877)

12 Transplant Services: Request for transplant or transplant related services prior to pre-treatment For services listed in this or evaluation including the following CPT Procedure Codes for section call Optum Health Specifically Requested Transplantations: directly at (888) HEART / LUNG or the notification number Donor cardiectomy-pneumonectomy, with preparation on the back of the member and maintenance of allograft ID card, rather than Heart-lung transplant with recipient cardiectomy-pneumonectomy Care Coordination. HEART Donor cardiectomy, with preparation and maintenance of allograft Heart transplant, with or without recipient cardiectomy 0051T Implantation of a total replacement heart system (artificial heart) with recipient cardiectomy 0052T Replacement or repair of thoracic unit of a total replace ment heart system (artificial heart) 0053T Replacement or repair of implantable component or components of total replacement heart system (artificial heart), excluding thoracic unit LUNG Donor pneumonectomy(ies) with preparation and maintenance of allograft (cadaver) Lung transplant, single; without cardiopulmonary bypass with cardiopulmonary bypass Lung transplant, double (bilateral sequential or en bloc); without cardiopulmonary bypass with cardiopulmonary bypass KIDNEY Donor nephrectomy, with preparation and maintenance of allograft, from cadaver donor, unilateral or bilateral Donor nephrectomy, open from living donor (excluding preparation and maintenance of allograft) Recipient nephrectomy Renal allotransplantation, implantation of graft; excluding donor and recipient nephrectomy with recipient nephrectomy Removal of transplanted renal allograft Renal autotransplantation, reimplantation of kidney Laparoscopic donor nephrectomy from living donor (excluding preparation and maintenance of allograft) PANCREAS Pancreatectomy, total or subtotal, with autologous transplantation of pancreas or pancreatic islet cells Donor pancreatectomy, with preparation and maintenance of allograft from cadaver donor, with or without duodenal segment for transplantation Transplantation of pancreatic allograft Removal of transplanted pancreatic allograft ***The notification requirements with this indicator are not applicable to physicians who have received the UnitedHealth Premium quality and efficiency of care designation, in recognition of their demonstration of adherence to nationally recognized evidence-based quality and efficiency of care standards. Additional information regarding the UnitedHealth Premium Designation Program is available at Online.com or by calling (866) This notification list may change from time to time. If there is such a change, we will provide you with information about the change before it takes effect. This list does not signify coverage for benefits. Coverage is determined by the member's benefit plan. If you have questions about a member's coverage, visit Online.com or call the United Voice Portal- UVP (formerly known as VETSS) at (877)

13 LIVER Liver allotransplantation; orthotopic, partial or whole, from cadaver or living donor, any age heterotopic, partial or whole, from cadaver or living donor, any age INTESTINE Donor enterectomy, open, with preparation and maintenance of allograft; from cadaver donor partial, from living donor Intestinal allotransplantation; from cadaver donor from living donor Ancillary Provider and Other Health Care Professional Notification Requirements Accidental Dental Services Ambulance Transportation (Non-Urgent) Durable Medical Equipment (DME) Greater than $1,000 Dental services that meet the following criteria may be eligible for medical coverage depending on the member's benefit contract: Date of initial contact for dental evaluation is within plan limits following the accident. Initiation of definitive treatment services within guidelines. Estimated completion date of treatment services is known. Certification that the injured tooth was a sound natural tooth. Non-urgent ambulance transportation between specified locations for members who cannot travel by other forms of transportation. In general, we require notification for DME with a retail purchase cost or a cumulative retail rental cost over $1,000. Prosthetics are not DME. Some payer groups may have different DME notification requirements imposed upon the member through their benefit plan. For further information please call Customer Care. See the Medicare section of this Guide for additional requirements for Medicare members. ***The notification requirements with this indicator are not applicable to physicians who have received the UnitedHealth Premium quality and efficiency of care designation, in recognition of their demonstration of adherence to nationally recognized evidence-based quality and efficiency of care standards. Additional information regarding the UnitedHealth Premium Designation Program is available at Online.com or by calling (866) This notification list may change from time to time. If there is such a change, we will provide you with information about the change before it takes effect. This list does not signify coverage for benefits. Coverage is determined by the member's benefit plan. If you have questions about a member's coverage, visit Online.com or call the United Voice Portal- UVP (formerly known as VETSS) at (877)

14 End Stage Renal Disease Services Note: No notification is required for end stage renal disease when a Medicare member travels outside of the service area. Outpatient dialysis services (as defined by, but not limited to, the revenue and CPT codes below) require notification. We also require notification for all end stage renal dialysis (ESRD) services. Dialysis ESRD hemodialysis peritoneal peritoneal patient training, completed course patient training, per session unlisted dialysis procedure, inpatient or outpatient Revenue Codes: 0800 Renal Dialysis Hemo/op or home Peritoneal/op or home Capd/op or home Ccpd/op or home Dialysis / misc In an effort to maximize member benefit coverage, we ask that you refer to contracted dialysis facilities whenever possible. For the most current listing of contracted dialysis facilities, please refer to our online provider directory at Online.com or call us at (877) Home Health Care Services All services which are based in the home including, but not limited to: Home Infusion Therapy, Home Health Aid (HHA), Occupational Therapy (OT), Physical Therapy (PT), Private Duty Nursing, Respiratory Therapy (RT), Skilled Nursing (SNV), Social Worker (MSW) and Speech Therapy (ST). Hospice Inpatient Hospice services. Other Notification Requirements Specific Medications as Indicated on the PDL Behavioral Health Services Call (877) when prescribing medications that require notification. These medications are so designated on the Prescription Drug List (PDL). To view the Prescription Drug List (PDL), visit Many of our benefit plans only provide coverage for behavioral health services through a designated behavioral health network. Therefore, it is important for you to call the number on the member ID card when referring for any mental health or substance abuse services. ***The notification requirements with this indicator are not applicable to physicians who have received the UnitedHealth Premium quality and efficiency of care designation, in recognition of their demonstration of adherence to nationally recognized evidence-based quality and efficiency of care standards. Additional information regarding the UnitedHealth Premium Designation Program is available at Online.com or by calling (866) The notification requirements with this indicator are not applicable to Erickson Advantage members. This notification list may change from time to time. If there is such a change, we will provide you with information about the change before it takes effect. This list does not signify coverage for benefits. Coverage is determined by the member's benefit plan. If you have questions about a member's coverage, visit Online.com or call the United Voice Portal- UVP (formerly known as VETSS) at (877)

15 Coordination of Benefits (COB) has two different types of COB guidelines for medical claims and one COB type for pharmacy claims. The PPO/IND/Definity HRA are on the Come Out Whole COB concept, and the Choice HMO/HDHP are on the Non-Duplication COB plan. The pharmacy COB uses the Non-Duplication COB concept, but with a variance. Come Out Whole Concept Under COB, the primary plan pays its normal plan benefits without regard to existence of other coverage. The secondary plan pays the difference between the primary allowable benefit and the amount paid by the primary plan, provided this difference does not exceed the normal plan benefits which would have been payable had no other coverage existed. Non-Duplication COB Concept The intent of this type of COB plan is to maintain the member s same benefit level regardless of the existence of two carriers. The secondary plan pays only the difference between the plan s normal benefit and any amount payable by the primary plan. The member is responsible for any remaining balance. The Non-Duplication method has become the standard and is designed to provide a certain level of cost sharing by leaving some member liability. Medco/Pharmacy COB uses the Non-Duplication COB Concept The intent of the Non-Duplication COB concept is to maintain the member s same benefit level regardless of the existence of two carriers. The secondary plan pays only the difference between the primary amount paid and the Medco allowable amount payable, less the SHBP copayment if was primary.

16 This Guide is for informational purposes only and is subject to change. Visit our website at M39708A 12/ United HealthCare Services, Inc.