H7833_150304MO01. Information for Care Providers about UnitedHealthcare Connected (Medicare- Medicaid Plan) in Harris County, Texas
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1 H7833_150304MO01 Information for Care Providers about UnitedHealthcare Connected (Medicare- Medicaid Plan) in Harris County, Texas
2 Agenda Connecting Medicare and Medicaid Eligible Members Service Coordination Covered Services Claims and Billing Requirements for Member Access to Care Protected Health Information (PHI) Americans With Disabilities Act (ADA) Regulations Cultural Competency Care Provider Support and Resources Behavioral Health Pharmacy
3 Connecting Medicare and Medicaid To better serve individuals eligible for both Medicare and Medicaid, the Centers for Medicare & Medicaid Services (CMS) and the State of Texas Health and Human Services Commission (HHSC) have established a federalstate partnership to implement the Texas Dual-Eligible Integrated Care Demonstration. The initiative aims to integrate the current, fragmented model of care for Medicare-Medicaid beneficiaries by creating a single point of accountability for the delivery, coordination, claims payment and management of Medicare and Medicaid services. Services include primary, preventive, acute, specialty, behavioral health services, nursing facilities, long-term services and supports, and pharmacy products. UnitedHealthcare Connected (Medicare-Medicaid Plan) is a federal-state partnership in Harris County, Texas to offer integrated benefits for Medicare- Medicaid members beginning March 1, 2015.
4 Eligible Members Participating members must meet all of the following criteria: Age 21 or older at the time of enrollment Entitled to benefits under Medicare Part A and enrolled under Medicare Parts B and D, and receiving full Medicaid benefits Required to receive their Medicaid benefits through the STAR+PLUS program Generally, these individuals reside in Harris County, Texas and: o Have a physical disability or a mental disability and qualify for Supplemental Security Income OR o Qualify for Medicaid because they receive home- and communitybased services as STAR+PLUS waiver members
5 Service Coordination Service Coordination is a specialized care management service. It includes: Use of assessment tools available at UHCCommunityPlan.com to identify member needs, including physical and behavioral health services, and long term services and supports (LTSS) A plan of care to address identified needs plan is developed with the member, member representatives, the primary care provider and other applicable health care providers involved with the member s care Timely and coordinated access to an array of care providers and covered services, including LTSS and behavioral health Coordination of covered services with non-capitated services (e.g. non-emergency transportation) according to the plan of care, including necessary authorizations A virtual community care service center that allows primary care physician connection to service coordinators and other care providers, along with active participation from members and member representatives regarding their health care
6 Service Coordination UnitedHealthcare Connected (Medicare-Medicaid Plan) covers service coordination for chronic diseases and conditions, such as heart disease, stroke, cancer, diabetes, obesity and arthritis. Many members in this plan face exceptional challenges while attempting to access health care, including: Speech and/or hearing impairment Limited mobility Cognitive challenges Negative social prejudices and stereotypes Changes in the member s condition and/or circumstances must be shared with the service coordinator so they are able to review and update the member s care plan. The secure section of UnitedHealthcareOnline.com includes service coordinator contact information in the member s online record. Or contact us at
7 Covered Services Visit UHCCommunityPlan.com for a complete list of benefits. Here is a sample of some covered services: Acute Preventive screening and testing Long Term Services and Support Adaptive aids Primary care providers and specialists, both in and out-patient care Behavioral Health Minor home modifications Emergency response system Chiropractic Home-delivered meals Durable Medical Equipment Personal attendant assistant services Emergency care Temporary assistance services Inpatient treatment Pharmacy Vision Adult day care Assisted living Respite
8 Claims and Billing Submit claims at UnitedHealthcareOnline.com UnitedHealthcare Community Plan Claims Payer ID: Electronic Remittance Advice Payer ID: TEX01 UnitedHealthcareOnline.com help desk: , option 2 Submit claims with attachments online through Optum Cloud* Dashboard To access the Optum Cloud Dashboard, contact your password owner (the person who approved your access to UnitedHealthcareOnline.com) or ID administrator to register Registration assistance is available at , Monday through Friday, 7 a.m. to 9 p.m. CST. *Cloud computing is defined as a wealth of shared resources that live in a cloud on the Internet. A web browser enables you to securely access the information and capabilities you need from any Internet connection.
9 Claims and Billing Member Billing Protections Members are responsible for pre-specified co-payments and may not be balanced-billed. A member may decide to pursue services that are not covered by the Medicaid program. In this event, the member must sign an acknowledgement statement that they understand the services will not be paid by UnitedHealthcare Connected (Medicare- Medicaid Plan) or the Texas Health and Human Services Commission. The statement must be signed prior to service, dated and filed in the member s medical record. A Medicaid enrollee, including a Medicaid managed care enrollee, must not be referred to a collection agency for unpaid medical bills or billed for anything beyond applicable Medicaid co-payments. Emergency Medical Care A hospital that accepts a UnitedHealthcare Connected (Medicare-Medicaid Plan) member as a patient accepts the responsibility of making sure that the member receives all medically necessary care and agrees to bill UnitedHealthcare directly. This applies to all medically necessary inpatient services provided in the hospital-based emergency room, regardless of whether the treating care provider is enrolled in a Medicaid program.
10 Requirements for Member Access to Care Description Condition Timeframe Requirements for Scheduling Appointments Primary Care (including specialists such as Routine Within 14 days behavioral health) Specialty Care Referrals Routine Within 30 days Adults Preventative Health Within 90 days Services Adults Behavioral Health Post Within 7 days from date of discharge Hospitalization Routine Prenatal Care (High risk or new members in 3rd trimester should be seen within 5 days or immediately if it is an emergency) First Prenatal Care As soon as practical but in no case longer than 14 days of request, or within 5 days if in the 3rd trimester Postpartum Routine Checkup Within 60 days Including urgent specialty care Urgent Care Within 24 hours Including non-network and out-of-area facilities Emergency Upon member presentation
11 Protected Health Information What is Protected Health Information (PHI)? PHI is information recorded electronically, on paper, or transmitted orally about an individual. PHI must be protected from unauthorized use or disclosure by the Covered Entity and its Business Associates under HIPAA regulations. HIPAA Privacy Rules define PHI as individually identifiable health information about the past, present, or future physical health, mental health or condition of an individual that is held or transmitted by a covered entity or its business associate, in any form. PHI includes the provision of an individual s care, insurance, payment status, etc. For additional guidance on PHI, please see the HIPAA Privacy Rule at:
12 Americans with Disabilities Act Regulations Care providers have a legal obligation to adhere to Americans with Disabilities Act (ADA) standards, which governs access and usability of facilities by individuals with disabilities. The ADA outlines reasonable accommodations for those with hearing, vision, cognitive, and psychiatric disabilities when requested. This commitment includes: Waiting room and exam room furniture that meet needs of all members, including those with physical and non-physical disabilities Accessibility along public transportation routes and/or provide enough parking Clear signage throughout facilities (e.g., color and symbols signage) For information about ADA regulations, visit ADA.gov or call (Voice) or (TTY) ADA definitions are located in the UnitedHealthcare Connected (Medicare and Medicaid Plan) Texas Administrative Guide and can be downloaded at UHCCommunityPlan.com
13 Cultural Competency For many patients for whom English-language competency is an issue, it is important for physicians and other health professionals to be aware of cultural needs and subtleties. Although a health care professional may not have experience with growing up or living in diverse cultures, it is possible to enhance their knowledge of, and sensitivity to, cultural issues that will impact the way patients share their medical needs, and the ways that physicians and nurses can enhance communication, diagnosis and treatment.
14 Cultural Competency Cultural competency is the ability of individuals and systems to provide services effectively to people of various backgrounds in a manner that respects individuals and preserves their dignity. Studies show that patients respond better when care instructions are delivered in their own language and their cultural background is taken into account. Improved communication between care providers and patients is possible through sensitivity to cultural issues which can aid communication, diagnosis and treatment.
15 Cultural Competency UnitedHealthcare offers resources to support diverse patient populations and accommodate competent care for a growing number of patients. Member materials are available in prevalent languages. You can access interpreter services through our Customer Services by calling Hearing Impaired Services are available at TDD/TTY. For person-to-person interpretation services in your practice, contact Alliance at This services is available Monday through Friday, 8 a.m. to 5 p.m. If you are unable to provide treatment, counseling or referral services to a member due to an awareness of personal prejudices, religious grounds or a moral conflict, contact customer service at so we can secure alternate care for the member.
16 Cultural Competency Learn more about cultural competency at UnitedHealthcareOnline.com > Tools & Resources > Health Literacy and Cultural Competency > Cultural Competency Register to explore cultural competency in health care while earning credit: Physicians up to 9 CME credits Nurses 9 CNE credits Pharmacists 9 contact hours (0.9 CEU's) Care providers can complete the training from anywhere, any time. CME/CEU certificates will be issued once each of the three themes of the course are successfully completed.
17 Care Provider Support and Resources UnitedHealthcareOnline.com Care provider Administrative Guide Complete Manual Quick Reference Guides Newsletters Network Bulletin Practice Matters
18 Care Provider Support and Resources Providers Our web portals allow for both access and training for all areas of services for our PCPs. UnitedHealthcare has developed extensive online training and education that allows us to document PCP participation and development. Provider Express: Optum Behavioral Solutions created this provider portal to help clinicians, facilities and their staff better manage patient care and their practices. It provides easy online access to a variety of self-service transactions, including, claims submission and inquiry, EPS and administrative resources.. UBHonline.com
19 Care Provider Support and Resources Clinical practice guidelines point providers to evidence-based information to diagnose and treat many conditions, both medical and behavioral-health related. Each guideline covers a specific condition and includes references, links to journal articles and links to third-party websites. The service coordinator will work with clinical and quality teams who analyze and review care provider quality outcomes. Please work with the service coordinator to identify LTSS needs. A description of LTSS services is available at UHCCommunityPlan.com > Provider Training. Primary care providers may find additional assessment tools to identify behavioral health at UHCCommunityPlan.com > Provider Reference Guides.
20 Behavioral Health ProviderExpress.com is an online tool to help clinicians, facilities and their staff better manage patient care at their practices. ProviderExpress.com offers information for complex issues related to symptoms, treatment options and community support groups. Our care managers have access to this resource both for their own use and to reference specific member needs. Educational materials can be downloaded for sharing with members as related to their areas of concern.
21 Behavioral Health ProviderExpress.com > Training
22 Behavioral Health ProviderExpress.com > Clinical Resources > Clinical Tools and Quality Initiatives
23 Pharmacy A formulary is located at UHCCommunityPlan.com > For Health Care Professionals > Texas > Pharmacy > UnitedHealthcare Connected Not all drugs are included. In some cases, the law prohibits coverage of certain types of drugs or we decided not to include a particular drug based on clinically accepted guidelines. We may also add or remove drugs from the formulary during the year. If we change the formulary, we will notify the member of the change at least 60 days before the effective date. Contact us with prior authorization requests for applicable pharmacy services at
24 Out-of-Network Pharmacy Prescriptions We will cover prescriptions that are filled at an out-of-network pharmacy if the prescriptions are related to care for a medical emergency or urgently needed care. UnitedHealthcare Connected (Medicare-Medicaid Plan) members are required to pay the full cost when they fill the prescription, rather than paying just the co-payment amount. If a member becomes ill, loses or runs out of their prescription drugs while traveling within the United States and outside of the benefit plan service area, we will cover prescriptions that are filled at an out-of-network pharmacy. UnitedHealthcare Connected (Medicare-Medicaid Plan) members can request reimbursement for their portion of the cost by submitting a paper claim form.
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