Administrative Guide

Transcription

1 Community Plan KanCare Program Physician, Health Care Professional, Facility and Ancillary Provider Administrative Guide Doc#: PCA15026_ UHCCommunityPlan.com

2 Welcome to UnitedHealthcare This administrative guide is designed as a comprehensive reference source for the information you and your staff need to conduct your interactions and transactions with us in the quickest and most efficient manner possible. Much of this material, as well as operational policy changes and additional electronic tools, are available on our website at UHCCommunityPlan.com. Our goal is to ensure our members have convenient access to high quality care provided according to the most current and efficacious treatment protocols available. We are committed to working with and supporting you and your staff to achieve the best possible health outcomes for our members. If you have any questions about the information or material in this administrative guide or about any of our policies or procedures, please do not hesitate to contact Provider Services at We greatly appreciate your participation in our program and the care you provide to our members. Important Information Regarding the Use of This Guide In the event of a conflict or inconsistency between your applicable Provider Agreement and this Guide, the terms of the Provider Agreement shall control. In the event of a conflict or inconsistency between your participation agreement, this Guide and applicable federal and state statutes and regulations, applicable federal and state statutes and regulations will control. UnitedHealthcare reserves the right to supplement this Guide to ensure that its terms and conditions remain in compliance with relevant federal and state statutes and regulations. This Guide will be amended as operational policies change.

3 Table of Contents Referral Guidelines Retro-Eligibility Emergency Care Resulting in Admissions Admission Authorization and Prior Authorization Guidelines The Patient-Centered Medical Home Determination of Medical Necessity Utilization Management Care Coordination/Management Coordination of Care with Providers Disease/Condition Management Programs Clinical Practice Guidelines Lock-in Program Family Planning Maternity Care Healthy First Steps (Maternity Case Management) Neonatal Resource Services (NICU Case Management) Delivery Admissions Newborn Admissions Abortion Hysterectomy Claims Sterilization Sterilization Consent Form Concurrent Review Discharge Planning and Continuing Care Preventive Health Care Standards Recommended Childhood Immunization Schedules Kan Be Healthy Periodicity Schedule

4 4.1 Referral Guidelines Providers caring for our members are generally responsible for initiating and coordinating referrals of members for medically necessary services beyond the scope of their practice. Providers are expected to monitor the progress of referred members care and ensure that members are returned to their care as soon as medically appropriate. 4.2 Retro-Eligibility Providers may request a retro-active prior authorization for a member if their eligibility was made retro-active by the state of Kansas. If the member has received services requiring a PA providers should request a retro-active prior authorization prior to submitting their claim. Provider MUST indicate on the request for PA RETRO-ACTIVE ELIGIBILIY or the retro-active prior-authorization will not be accepted. 4.3 Emergency Care Resulting in Admissions Prior authorization is not required for emergency services. Emergency care should be rendered at once. Please provide notification of any admissions by contacting the Prior Authorization Department at or by faxing in your Prior Authorization Form (see form below) by 5pm the following business day. Nurses in the Health Services Department review emergency admissions within one working day of notification. UnitedHealthcare uses evidence based, nationally accredited, clinical criteria for determinations of appropriateness of care. UnitedHealthcare Community Plan does not reward for denials or provide financial incentives that encourage under-utilization. The criteria is available in writing upon request or by calling Admission to inpatient starts at the time the order is written by a physician that a member s condition has been determined to meet an acute inpatient level of stay. Care in the Emergency Room UnitedHealthcare members who visit an emergency room should be screened to determine whether a medical emergency exists. Prior authorization is not required for the medical screening. UnitedHealthcare provides coverage for these services without regard to the emergency care provider s contractual relationship with UnitedHealthcare. Emergency services, i.e. physician and outpatient services furnished by a qualified provider necessary to treat an emergency condition, are covered both within and outside UnitedHealthcare s service area. An emergency is defined as a medical or behavioral condition, which manifests itself by acute symptoms of sufficient severity, including severe pain, that a prudent layperson possessing an average knowledge of medicine and health, could reasonably expect in the absence of immediate medical attention to result in: Placing the health of the person afflicted with such condition in serious jeopardy (or, with respect to a pregnant woman, the health of the woman or her unborn child), or in the case of a behavioral condition, perceived as placing the health of the person or others in serious jeopardy Serious impairment to such person s bodily functions Serious dysfunction of any bodily organ or part of such person Serious disfigurement of such person 2

5 4.4 Admission Authorization and Prior Authorization Guidelines All UnitedHealthcare Community Plan admission authorizations must contain the following information: Member name and ID number; Facility name and Tax Identification Number (TIN) or National Provider Identification (NPI); Admitting/attending physician name and TIN/NPI; Description for admitting diagnosis or ICD-9-CM, or its successor, diagnosis code; and Admission date. All UnitedHealthcare Community Plan prior authorizations must contain the following information: Member name and ID number; Ordering physician or health care professional name and TIN/NPI; Rendering physician or health care professional and TIN/NPI; ICD-9-CM, or its successor, diagnosis code for which the service is requested; Anticipated date(s) of service; Type of service (primary and secondary) procedure code(s) and volume of service, when applicable; Service setting; and Facility name and TIN/NPI, when applicable. For Behavioral Health and Substance Use Disorders authorizations, please see the current Network Manual and the KanCare Manual Addendum available on ubhonline.com. Providers who are non-participating with UnitedHealthcare are required to follow the same guidelines related to prior authorization as participating providers. Prior authorization is not required for all non-participating provider services, however it is required only for those services on the prior authorization list. Providers can obtain prior authorization in three ways: 1) Call the prior authorization number at ) Providers may complete the prior authorization request form online at UnitedHealthcareOnline.com. Quick reference guides are available to assist providers. To access the quick reference guides, go to UnitedHealthcareOnline.com > Help > Quick Reference Guides. 3) Providers may complete a PA request form and fax in. Form provided below. The prior authorization fax request form can be found below, and is posted at UHCCommunityplan.com. A copy of the form can also be found in Chapter 20 of the Provider Manual. If you have questions, please call the prior authorization intake line at

6 Kansas Acute and LTC/LTSS Prior Authorization Fax Request Form Acute Fax: LTC/LTSS Fax: Phone: Community Plan Please complete this form and fax it to the appropriate number listed above. Include all relevant clinical data such as progress notes, treatments rendered, tests, lab results, and radiology reports with this form to support the request for services and avoid a delay in the determination. If you have any questions, please call Medicaid Prior Authorization at Please go to UHCCommunityPlan.com for the list of services that require prior authorization and to see the Provider Administrative Guide for more information regarding prior authorization requirements. Thank you. Date: Contact person: Phone: Requesting provider: TIN/NPI: Fax number: Is this a HIPAA secure fax line? Yes No Member Information Member name: Member ID: Date of birth: Member phone number: Is member pregnant? Yes No Is request related to a motor vehicle accident/injury or work-related injury? Yes No Does the member have other insurance? Yes No If yes, Medicare Part A Part B Other insurance name and policy number: Is request due to member s retrospective eligibility? Yes No Type of Request Choose One: Inpatient Outpatient Home Care Choose One: Routine Expedited/Urgent* * Expedited/Urgent requests must include a physician order that indicates that waiting for a decision within the standard timeframe could endanger the member s life, health, ability to regain maximum functionality or cause serious pain. Servicing Provider and Facility Information Servicing provider: Address: TIN/NPI: Fax: Date of service: In-network Out-of-network Servicing facility: TIN/NPI: Address: In-network Out-of-network For out-of-network providers only: Do you accept Medicaid/Medicare default rate? Yes No 3/15 Doc#: KanCare Program Administrative Guide 5/14 Copyrighted PCA11360_ by UnitedHealthcare

7 Kansas Acute and LTC/LTSS Prior Authorization Fax Request Form Acute Fax: LTC/LTSS Fax: Phone: Community Plan Clinical Information Diagnoses: ICD-9 codes: Required CPT/HCPCS Code(s): Description required for miscellaneous and/or unlisted codes: Number of visits: Start date: End date: Frequency: DME Cost: $ Number of previous visits, service description and CPT/HCPCS codes: Confidentiality Notice: The documents in this correspondence may contain confidential health information that is privileged and subject to state and federal privacy laws, including the Health Insurance Portability and Accountability Act. This information is intended for the sole use of the addressee named above. If you are not the intended recipient, you are hereby notified that reading, disseminating, disclosing, distributing, copying, acting upon, or otherwise using the information contained in this correspondence is strictly prohibited. If you received this information in error, please notify UnitedHealthcare to arrange for the return of the documents to us or to verify their destruction 3/15 Doc#: KanCare Program Administrative Guide 5/14 Copyrighted PCA11360_ by UnitedHealthcare

8 Services Requiring Prior Authorization Service KS Medicaid 1/1/2014 Abortions Auth Not Required - Requires consent form at time of claims payment (unless state mandate) Chip (KBH) 1/1/2014 Auth Not Required - Requires consent form at time of claims payment (unless state mandate) KS LTC 1/1/2014 Auth Not Required - Requires consent form at time of claims payment (unless state mandate) Ambulance Services - Emergency Not Required Not Required Not Required Ambulance Services - Non emergency, Facility to Facility transports Ambulance Services - Non emergency, other than Facility to Facility Not Required Not Required Not Required Not Required Not Required Not Required Dental - Surgery provided in an Outpatient Hospital or Ambulatory Surgery Center Auth Required for Adults only CPT code only Auth Required for Adults only CPT code only Auth Required for Adults only CPT code only Drugs - Botox Auth Required Auth Required Auth Required Drugs - Synagis Auth Required Auth Required Auth Required Elective Inpatient Admissions Auth Required Auth Required Auth Required Home Health Care See Services Below See Services Below See Services Below Aide Auth Required Auth Required Auth Required Private Duty Nursing Auth Required Auth Required Auth Required PT/OT/ST Auth Required Auth Required Auth Required Skilled Nursing Auth Required Auth Required Auth Required Social Worker Auth Required Auth Required Auth Required Home Infusion Auth Required Auth Required Auth Required Hospice Services Not Required Not Required Not Required Hysterectomy Auth not Required - Requires consent form at time of claim payment Auth not Required - Requires consent form at time of claim payment Auth not Required - Requires consent form at time of claim payment This prior authorization list is subject to modifications. 6

9 Service KS Medicaid 1/1/2014 Chip (KBH) 1/1/2014 KS LTC 1/1/2014 Intensive Outpatient (IOP) Please see Optum Behavioral Health Manual Please see Optum Behavioral Health Manual Please see Optum Behavioral Health Manual Nursing Facilities, LTAC, SNF, Swing Bed and Extended Care Auth Required (Rev Code 120) Auth Required (Rev Code 120) Auth Required (Rev Code 120) Outpatient Drug and Alcohol Outpatient Mental Health No Auth for Nursing Facility Custodial (Residential) Stays (Rev Code 101) Please see Optum Behavioral Health Manual Please see Optum Behavioral Health Manual No Auth for Nursing Facility Custodial (Residential) Stays (Rev Code 101) Please see Optum Behavioral Health Manual Please see Optum Behavioral Health Manual No Auth for Nursing Facility Custodial (Residential) Stays (Rev Code 101) Please see Optum Behavioral Health Manual Please see Optum Behavioral Health Manual Outpatient Surgery - Gastric Bypass Surgery Auth Required Auth Required Auth Required Pain Management Services Not Required Not Required Not Required Partial/Day Hospitals for MH or Drug/Alcohol Please see Optum Behavioral Health Manual Please see Optum Behavioral Health Manual Please see Optum Behavioral Health Manual Cosmetic Surgery Covered when Medically Necessary Only - Auth Required Covered when Medically Necessary Only - Auth Required Covered when Medically Necessary Only - Auth Required Radiology (Imaging studies) See Services Below See Services Below See Services Below MRI (magnetic resonance imaging) Not Required Not Required Not Required MRA (magnetic resonance angiogram) Not Required Not Required Not Required PET (positron emission tomography) Not Covered Not Covered Not Covered SPECT MPI Not Required Not Required Not Required Sleep study Auth Required for Children Sleep Studies are now covered for adults as part of Pre- Bariatric Surgery work up. Prior Auth is required Auth Required for Children 0-20 Auth Required for Children Sleep Studies are now covered for adults as part of Pre- Bariatric Surgery work up. Prior Auth is required Sterilization See Services Below See Services Below See Services Below Tubal ligation Auth Not Required - Requires consent form at time of claims payment (unless state mandate) Vasectomy Auth Not Required - Requires consent form at time of claims payment (unless state mandate) This prior authorization list is subject to modifications. Auth Not Required - Requires consent form at time of claims payment (unless state mandate) Auth Not Required - Requires consent form at time of claims payment (unless state mandate) Auth Not Required - Requires consent form at time of claims payment (unless state mandate) Auth Not Required - Requires consent form at time of claims payment (unless state mandate) 7

10 Service KS Medicaid 1/1/2014 Chip (KBH) 1/1/2014 KS LTC 1/1/2014 Therapy/Rehab (OP/office setting) See Services Below See Services Below See Services Below Occupational Therapy Effective 5/2/14, NO Prior Authorization Required Effective 5/2/14, NO Prior Authorization Required Effective 5/2/14, NO Prior Authorization Required Physical Therapy Effective 5/2/14, NO Prior Authorization Required Effective 5/2/14, NO Prior Authorization Required Effective 5/2/14, NO Prior Authorization Required Speech Therapy Effective 5/2/14, NO Prior Authorization Required Effective 5/2/14, NO Prior Authorization Required Effective 5/2/14, NO Prior Authorization Required Transplant Services Auth Required Auth Required Auth Required This prior authorization list is subject to modifications. * Inpatient Acute, Sub-Acute, Rehab, and SNF (excluding Residential or Custodial) admissions require prior authorization. * Prior notification not required for emergency services however hospitals must provide notification within two business days of inpatient admission. If the charge (billed amount) for any DME line item exceeds $500, a prior authorization is required. Prior authorization is not required for any DME items for which the line item charge is less than $500 with the following exception: All wheelchairs and related parts require prior authorization regardless of the line item charge amount. 8

11 4.5 The Patient-Centered Medical Home The Patient-Centered Medical Home (PCMH) is an approach to providing comprehensive primary care to patients. The PCMH is a health care setting that facilitates relationships between individual patients, their physicians, and when appropriate, the patient s family. A medical home is defined as primary care that is accessible, continuous, comprehensive, family-centered, coordinated, compassionate, and culturally effective. This new clinical model is at the heart of Health Care Reform and delivery system transformation. Engaging patients in Communities of Care will improve the efficiency and effectiveness of the health care system. This model expands our relationship with providers from just payment model to clinical value-added services in delivering more efficient and effective care to our members. It also improves trust and satisfaction with our network community. UnitedHealthcare Community Plan is uniquely positioned with many existing tools and capabilities to support PCPs in this new process. UnitedHealthcare supports activities such as risk stratification, evidence-based interventions and advanced analytics. The core principal characteristics of a PCMH are based on the following: Personal physician Physician directed practice Whole person care orientation Coordinated care Quality and safety Enhanced care access Optimization through health information technology integration Each patient has a personal physician Practice operates as a team Scope of services is comprehensive Key Aspects of the PCMH Primary Care Practice Transformation: A practice team commits to: Expanding patient access and engagement the practice has a process for same-day appointments for routine and urgent care based on practice s triage of members. i. The practice can provide timely clinical advice by phone or during office hours and documents the phone or into the member s clinical record. ii. iii. iv. Members must have access after hours. Electronic access to information (e.g., clinical summaries, secure electronic medical records). Continuity of Care must have a process to assign members to personal clinician or team; maintain record of members; monitoring the proportion of member visits that occur with an assigned physician/team. v. Developing a member/pcp partnership in the care of the members condition(s); documents and explains what a medical home is and how if functions; how to use it the PCMH (e.g., patient self-management and support and how this is holistic approach). 9

12 vi. vii. viii. ix. Explain how to use the medical home (referrals hours of operation, how to seek help after hours). Explain the role of the member (e.g.,members sharing information about their medications, change in condition, symptoms, self-care needs, etc.). The practice must engage in activities that demonstrate an understanding of and meets cultural and linguistic needs of the members in their practice. The practice s care team manages the members in defining their roles internally, meets on members who are in their care and has a clear communication process, trainings. Improving chronic condition population management UnitedHealthcare will help participating practices to not only identify at risk members, but also develop strategies to achieve successful outcomes. Providing team-based care that focuses on care transitions & coordination. Monitoring performance on key quality/utilization measures and effectively. Utilizing available technologies including patient registries and e-prescribing where available. Primary Care Practice Support: UnitedHealthcare will commit to assisting participating PCMH practices in their transformation and acquisition of their NCQA PPC -PCMH certification by; Providing enabling technologies Providing timely/actionable patient clinical data Providing/supporting care coordination through Care Management services We also support the Medical Home in the tracking and monitoring of specific aspects of the members care and status of their condition in our clinical systems. This data provides the basis for alerting health care professionals if early intervention is warranted, reinforces members disease-specific education, and further promotes behavior change, compliance, and improved quality of care. The UnitedHealthcare Community Plan Care Management Program defines quality care as treatment that: Improves the member s physical and emotional status; Promotes health and healthy lifestyles and behaviors; Encourages early detection and treatment; Involves members in informed decision-making; Is provided by a health care team sensitive to illness-related issues; Is based on evidence-based medical principles; Uses technology and other resources effectively; Is accessible to members in a timely fashion; and, Is sufficiently documented in medical records. 10

13 In support of the PCMH we also provide consultative support by assigning a Medical Home Consultant who works directly with the leadership of their assigned physician practices. This committed roll is designed to support the practice transformation from a reactive model of patient care to a proactive Medical Home, using data to effectively measure, monitor and manage care of priority, high-risk members and present results and outcomes to the Practice s executive leadership. We have also integrated workflows across the entire continuum of care with special emphasis on Transition of Care, and integrate and leverage resources from UnitedHealthcare Community Plan to communicate on members who may be hospitalized. Upon launch of the Medical Home, UnitedHealthcare Community Plan will establish: a clear set of goals around the gaps to be addressed goal setting that needs to be done with the CEO, CMO and COO of the practices. On a monthly basis, UnitedHealthcare Community Plan assigned staff will jointly assess interventions to drive goals to results. Practices engaging in the PCMH model will be creating a comprehensive approach to managing care and a positive approach to better patient outcomes. 4.6 Determination of Medical Necessity UnitedHealthcare evaluates medical necessity according to the following standard. Medically necessary services or supplies are those necessary to: Prevent, diagnose, correct, prevent the worsening of, alleviate, ameliorate, or cure a physical or mental illness or condition; Maintain health; Prevent the onset of an illness, condition or disability; Prevent or treat a condition that endangers life or causes suffering or pain or results in illness or infirmity; Prevent the deterioration of a condition; Promote the development or maintenance of maximal functioning capacity in performing daily activities, taking into account both the functional capacity of the individual and those functional capabilities that are appropriate for individuals of the same age; Prevent or treat a condition that threatens to cause or aggravate a handicap or cause physical deformity or malfunction and there is no other equally effective, more conservative or substantially less costly course of treatment available or suitable for the member. 11

14 The services provided, as well as the type of provider and setting, must reflect the level of services that can be safely provided, must be consistent with the diagnosis of the condition and appropriate to the specific medical needs of the member and not solely for the convenience of the member or provider of service. In addition, the services must be in accordance with standards of good medical practice and generally recognized by the medical scientific community as effective. Experimental services or services generally regarded by the medical profession as unacceptable treatment are considered not medically necessary. These specific cases are determined on a case-by-case basis. The determination of medical necessity must be based on peer-reviewed publications, expert pediatric, psychiatric and medical opinion, and medical/pediatric community acceptance. In the case of pediatric members, the standard of medical necessity shall include the additional criteria that the services, including those found to be needed by a child as a result of a comprehensive screening visit or an inter-periodic encounter, whether or not they are ordinarily covered services for other members, are (a) appropriate for the age and health status of the individual, and (b) will aid the overall physical and mental growth and development of the individual and the service will assist in achieving or maintaining functional capacity. 4.7 Utilization Management Utilization Management decision making is based only on appropriateness of care and service and existence of coverage. The organization does not reward practitioners or other individuals for issuing denials of coverage or care. Financial incentives for Utilization Management decision makers do not encourage decisions that result in underutilization. A provider may call UnitedHealthcare Community Plan Utilization Management at to answer any questions about Utilization Management or denials. Someone is available to take your calls 24 hours a day, seven days a week. 4.8 Care Coordination/Management Our Care Management program is guided by the principles of the UnitedHealthcare Personal Care Model. We developed the Personal Care Model to address the needs of medically underserved and low-income populations. The Personal Care Model places emphasis on the individual as a whole, to include the environment, background and culture. If you need to directly refer a member who is not currently in the Care Management program, you may call Our model of Care Coordination/Care Management provides a platform for systematic, comprehensive care that closes the gap in the treatment of acute, chronic, co-morbid and other conditions that impact health and self-care. This model is founded upon best practices and principles for the care of children with special needs, the disabled, elderly, chronically ill, and frail individuals. We apply an individualized, holistic approach to help members navigate complex delivery systems, stabilize or delay progression of their illnesses or conditions, and promote independence and quality of life. We utilize advanced technology to improve communications and streamline day-to-day operations. 12

15 Specialty Programs for Care Management include but are not limited to: High Risk Care Management, Care Coordination for members receiving LTSS benefits, Disease Management, Maternity Care Management (Healthy First Steps), Neonatal Intensive Care Unit (NICU) Care Management,Transplant Programs, Obesity Management/Bariatric Surgery Programs. Our Care Coordination model: Integrates Primary, Acute, Behavioral, and Long-Term Services and Supports (LTSS) care services into one consumer-driven, seamless system of care Incorporates health risk screening, medical/social assessment, care planning, and ongoing care plan monitoring to identify and address member needs. Assigns highest risk members, members experiencing transitions, and members receiving LTSS to a dedicated Care Coordinator who assists the member and their families to plan & coordinate care, provide education for enhanced self management, and refer to appropriate community resources for additional support Provides members with timely, medically necessary health care services in the least restrictive and most appropriate setting Focuses on preventive, primary, and secondary care that slows illness progression and disability Involves members, caregivers, physicians, and other providers in the care planning process Works in collaboration with providers, caregivers, community resources, and others who are involved in the care of the member. If you need to directly refer a member who is not currently in the Care Management program, you may call Identification and Stratification All members who are enrolled in LTSS Waiver Programs - Frail Elderly (FE), Physical Disability (PD), Traumatic Brain Injury (TBI),Technology Assisted (TA), Serious Emotional Disturbance (SED), and Autism - are immediately assigned to a Care Coordinator for comprehensive assessment and coordination of physical/behavioral health needs and LTSS. The Health Risk Assessment and our predictive modeling and stratification system are the primary tools for identifying High Risk (Non LTSS/Waiver) members and those with other specialty needs for Care Management programs and/or assignment to a dedicated Care Coordinator. Health Risk Assessment The Health Risk Assessment is an initial assessment tool used for new and existing members, to identify a member s health risks. Based upon the member s response to a series of question, the tool will assign a score that corresponds to a level. These levels are as follows: Level 1: Low-risk members who are typically healthy, stable or only have one medical condition that is well managed. Level 2: Moderate-risk members who may have a severe single condition, or multiple conditions across multiple domains of Care Management. Level 3: High-risk members who are medically fragile, have multiple co-morbidities and need complex Care Management. 13

16 Stratification Our multi-dimensional, episode-based predictive modeling tool, compiles information from multiple sources including claims, laboratory and pharmacy data and uses it to predict future risk for intensive care services. On a monthly basis, the system uses algorithms to identify members for High Risk or Specialty Care Management Programs. The algorithm takes into consideration inpatient and emergency room (ER) use. An Overall Future Risk Score is assigned to each member and represents the degree to which the High Risk Care Management or Specialty Program has the opportunity to impact members health status and clinical outcomes. This assists Care Managers in identifying members who are most likely to benefit from interventions. Outreach and other Identification Processes While LongTerm Care/Waiver Program enrollment, Health Risk Assessments and retrospective data are the first line of identification of new members in the UnitedHealthcare Care Management Program, we have developed an extensive outreach program that supports real-time identification and referral for our Care Management services. Through community partnerships and relationships, our staff encourages and educates providers, ER staff, and hospital discharge planners, and other community-based providers to refer program members for a greater intensity and frequency of Care Management interventions when the situation requires it. Our Care Management staff is responsible for collaborating with other community partners such as program care managers, clinic staff, other health care team community partners, and fiduciary entities in order to identify members. Finally, in addition to claims and pharmacy data, we integrate authorization and pre-certification information into the Care Management software system. This data provides real-time identification of members experiencing health care barriers and self-care deficits. Care Management Interventions After a member has been identified, the Care Coordinator contacts the member, member s parent or caregiver by telephone to engage them in the Care Management Program. Program and health education materials targeted to the member s specific care opportunities and Care Management interventions are shared with the member. Members have the right to opt out of Care Management programs if they do not wish to participate, however to be eligible to receive LTSS, the member must consent to in-home assessment and ongoing reassessment by the Care Coordinator. Because our High Risk Care Management and Specialty Programs provide benefits and quality-of-life improvements that ultimately impact the overall costs in care, our enrollment staff makes every attempt to enroll members in the available programs. We employ a number of strategies to locate and contact the member s parents or caregivers, including after-hour calls; searching for updated member information by contacting the PCP/specialist office and reviewing prior authorization information; and sending written correspondence. We document and track contacts to ensure that all options have been exhausted prior to reporting failure to contact. 14

17 As part of full engagement in the Care Management Programs, the Care Coordinator performs a comprehensive health risk and needs assessment that identifies additional risk factors, current and past medical history, personal behaviors, family history, social history, functional capabilities, and environmental risk factors. This information is used to augment and validate the risk stratification of members. We also institute disease specific assessments to augment the Health Risk Assessment. We deploy evidence-based interventions for our Care Management Programs. The following general interventions have been structured to improve members health status: Health Risk Assessment; Health and Care Plan reviews via in home assessment or phone calls; Provide assigned Care Coordinator s contact information to the member/family; Ongoing monitoring of claims and other tools to re-assess risk and needs; Access to program websites for members; Post-hospitalization and emergency room assessment; Educational materials sent to the member for preventive care & other condition specific self-care reference; Communication with the PCP identifying the member s involvement, intervention and point of contact for Care Management Programs; and Additional and/or specific interventions conducted to individualize the plan of care. Plan of Care The Care Coordinator develops and implements an individualized plan of care for members requiring services, reviews the member s progress and adjusts the plan of care, as necessary, to ensure that the member continues to receive the appropriate care in the least restrictive setting. The Care Coordinator will involve the member, member s family and providers caring for our member in the plan of care development process. Care Coordinators assist providers when necessary to direct the course of treatment in accordance with the evidence-based clinical guidelines that support our Care Management Program. The plan of care addresses the following areas of care as relevant to the member s needs: LongTerm Services and Supports (for members enrolled in Waiver programs) based on functional ability and available community supports, Behavioral health, Nutrition, Medication, Preventive Care, Self-monitoring of symptoms, vital signs and early identification of potential complications, Emergency management/co-morbid condition action plan, Caregiver backup and/or disaster plans, Routine follow-up with PCP or specialty providers, and Other authorized services or treatments. 15

18 When the plan of care is implemented, our goals are: To ensure the member is leveraging personal, family, and community strengths when able and available; To ensure we are using evidence-based guidelines and best practices for education and self-management information while integrating interventions to address co-morbidities; To modify our approach or services based on the feedback from the member, family, and other health care team members; To document services and outcomes in a way that can be captured and modified in order to continually improve; To communicate effectively with the primary care provider/specialist and other providers involved in the member s care; To support member adherence to treatment plans and self-care best practices; and To monitor member satisfaction with services, adjusting as needed. The Plan of Care (POC) will address the following areas of care: Psychosocial adjustment, Nutrition, Complications, Pulmonary/cardiac rehab, Medication, Prevention, Self-monitoring of symptoms and vital signs, Emergency management/co-morbid condition action plan, Appropriate health care utilization. Our Care Management Program is supported by UnitedHealthcare s integrated clinical system, which includes basic and comprehensive supplemental assessments, facilitates the development of integrated care plans, and includes ongoing monitoring and evaluation tools. Pharmacy UnitedHealthcare s pharmacy management is integrated into our Care Management Program and, like the Care Management Program, is based on our Personal Care Model which emphasizes the whole individual, including environment, background and culture. UnitedHealthcare integrates pharmacy management for asthma into our regular Care Management Program. With the exceptions of the asthma component, pharmacy management services, UnitedHealthcare provides pharmacy management through OptumRx, our pharmacy benefit manager, and a United Health Group company. OptumRx administers Disease Therapy Management (DTM) programs that are clinical, patient-focused programs offered as part of Specialty Pharmacy Care Management services. The objective of our DTM programs is to improve patient quality of care through education and communication. 16

19 OptumRx Specialty Pharmacy offers DTM programs for the following disease states/conditions required by the Board for the Kansas Medicaid plan programs: Rheumatoid arthritis, Growth disorders, Hemophilia, Risk of respiratory syncytial virus due to prematurity. Additional programs to be provided to Kansas Medicaid plan program members include: Hepatitis C, Multiple sclerosis, Anemia related to chemotherapy. 4.9 Coordination of Care With Providers Each member is encouraged to select a medical home for community-based health and preventive services. Providers caring for our members receive reports regarding the health status of members participating in our Care Management Program. As this link is established, we involve the provider in the plan of care development process and assist them in directing the course of treatment in accordance with evidence-based clinical guidelines. The Care Manager collaborates with the member s provider on an ongoing basis to ensure integration of physical and behavioral health issues. In addition, the care manager will ensure the plan of care supports the member s/caregiver s preferences for psychosocial, educational, therapeutic and other non-medical services. The Care Manager ensures the plan of care supports providers clinical treatment goals and builds the plan of care to reflect personal, family and community strengths. The Care Manager and member will review the member s compliance with the treatment during each assessment cycle. Treatment, including medication compliance, is established as a health care goal with interventions and progress towards that goal documented in each assessment session. At any point that the care manager recognizes that the member is non-compliant with part or all of the treatment plan, the care manager will: Work to identify and understand the member s barriers to success; Problem solve for alternative solutions with the member; Report non-compliance to the treating provider/specialist, offer potential solutions and integrate provider feedback; Facilitate agreement for change between all parties and monitor progress of the change. 17

20 As the member s medical home, the provider caring for our member is continuously updated on the member s participation in the Care Management Program, the member s compliance with the plan of care and any unscheduled hospital admissions and emergency room visits. The provider receives notifications of when members are enrolled and disenrolled from the Care Management Program the assigned Care Manager for the Care Management Program, and how to contact the Care Manager. In addition, the provider receives notification of members who have generated care opportunities related to the Care Management Program. These evidence-based medical guidelines are generated from our multi-dimensional, episode-based predictive modeling tool. We also distribute clinical practice guidelines upon the provider s request and provide training for providers and their staff on how best to integrate practice guidelines into everyday physician practice. When a provider demonstrates a pattern of non-compliance with clinical practice guidelines, the Medical Director may contact the provider by phone or in person to review the guideline and identify any barriers that can be resolved Disease/Condition Management Programs Disease/Condition Management is a specialized component of our Care Coordination program. UnitedHealthcare Community Plan Disease Management focus is on conditions prevalent in our KanCare population and in which members self-care efforts have been shown to significantly impact health outcomes to the positive. 1. Coronary artery disease 2. Chronic obstructive pulmonary disease 3. Prenatal care especially for high risk pregnancies (Healthy First Steps program) 4. Diabetes mellitus 5. Asthma 6 Smoking cessation programs 7. Obesity (pediatric & adult) 8. Major depression The primary objectives of Disease/Condition Management are to support members in establishing and maintaining a stabilized, improved state of health. This is achieved by reducing risk factors and improving the overall health of members through encouragement of appropriate self-care, reinforcement of physician member relationship, member and provider education, improved monitoring, and targeted interventions. Care Coordinators assist members to understand what they can do to be good partners in their health care, help members find resources their healthcare providers feel will be of benefit to them, and reinforce the health care provider s treatment plan. 18

21 Upon the identification of members meeting the disease management program criteria, PCPs will receive a letter informing them of the member s inclusion in the Disease/Condition Management program, invites the PCP s partnership, informs how to use Disease Management services to augment the treatment plan, and provides disease-specific resources, e.g., clinical guidelines, patient education materials, etc. Care Coordinators communicate with providers regarding changes in a member s condition and/or needs for assistance (e.g., durable medical equipment needed, care issues, etc.). Members are assessed for the targeted health conditions and monitored against goals for: Disease specific education and interventions Medication and treatment adherence Symptom monitoring and self-care Nutrition and weight management Lifestyle changes such as physical activity or smoking cessation Education and assistance with advance directives and caregiver support Referrals to internal and community programs The Disease Management Program utilizes various sources and databases to track members satisfaction and effectiveness of interventions. Assessment of Disease/Condition management incorporates audited HEDIS or HEDIS-like results specifically relevant to the condition upon which there is focus. Assessment of members satisfaction with Programs follows the UnitedHealthcare Community Plan standards and processes but with specific focus for issues relevant to Condition Management Clinical Practice Guidelines UnitedHealthcare adopts clinical practice guidelines as the clinical basis for our Care Management program. Clinical guidelines are systematically developed, evidence-based statements that help providers make decisions about appropriate health care for specific clinical circumstances. We adopt clinical guidelines from recognized sources as defined by the National Committee on Quality Assurance (NCQA) and Utilization Review Accreditation Commission (URAC). UnitedHealthcare uses nationally recognized, evidence-based clinical criteria to guide our medical necessity decisions, including Milliman Healthcare Management Guidelines, Behavioral Health Level of Care Guidelines, and CMS policy guidelines. Milliman is widely regarded for its scientific approach, using comprehensive medical research to develop recommendations on optimal length of stay goals, best-practice care templates, and key milestones for the best possible treatment and recovery. Our Behavioral Health Level of Care Guidelines provide objective and evidence-based admission and continuing stay criteria for mental health and substance abuse services. These guidelines are integrated into our clinical system. 19

22 For specific state benefits or services not covered under national guidelines, we develop criteria through the review of current medical literature and peer reviewed publications, Medical Technology Assessment Reviews and consultation with specialists. The clinical practice guidelines are reviewed and revised annually. The UnitedHealthcare Executive Medical Policy Committee (EMPC) reviews and approves nationally recognized clinical practice guidelines. The guidelines are then distributed to the National Quality Management Oversight Committee (NQMOC) and the Health Plan Quality Management Committee. Medical guidelines are available and shared with providers upon request and are available on the provider website, UHCCommunityPlan.com. Policies and guideline updates are communicated through provider notices prior to implementation Lock-in Program The Lock-in Program ensures that members selected for enrollment in the program will use services appropriately and in accordance with department rules and policies. The program limits Lock-In members to one pharmacy, one hospital and one primary care physician for all non-emergent medical care. A member can be selected for the Lock-in Program review when any one or more of the following occur: 1. A utilization review report indicates the member has not utilized healthcare services appropriately; including, but not limited to: over-utilization, persistent non-compliance, or abusive/threatening conduct; 2. Medical providers, social service agencies, or other concerned parties have provided direct referrals to the State or to UnitedHealthcare Community Plan. 3. Member identified as committing fraud (reported and/or data analytics) or abuse of medical benefits. When a member is selected for Lock-in Program review, MCO staff (with clinical oversight) reviews their medical and/or billing history to determine if the member has utilized health care services and/or medications at a frequency or amount that is not medically necessary/abusive/excessive. As a result of the Lock-in Program review, UnitedHealthcare may take any of the following steps: 1. Determine that no action is needed and close the member s file; 2. Send the member and, if applicable, the member s authorized representative, a letter of concern with information on specific findings and notice of potential placement in the Lock-in Program; 3. Refer the member for education on appropriate use of health care services; 4. Refer the member to substance abuse or behavioral health treatment, or to other support services or agencies; or 5. Enroll the member in the Lock-in Program if education and referrals are not successful in changing the member s service utilization. 20

23 When a member is initially placed in the Lock-in Program: 1. UnitedHealthcare Community Plan will assist the member in selecting Lock-In providers: a. Primary care physician b. Pharmacy c. Hospital 2. The MCO will send the member and, if applicable, the member s authorized representative, a written notice containing at least the following components: a. Action MCO intends to take related to Lock-In. b. Reason for this action c. Instructions related to choosing a primary care physician, pharmacy and hospital. d. Effective date of the lock-in e. The duration of the enrollment and re-evaluation period f. Member s right to file an appeal g. Any other requirements under federal, state laws and regulations 3. The member will remain locked-in to the assigned providers for no less than 24 months unless: a. The member moves to a residence outside the provider s service area; or b. The provider moves outside the member s local geographic area and is no longer reasonably accessible to the member. c. The provider refuses to continue to serve the member. d. The provider was assigned to the member by the health plan, because the member failed to select a provider. In this case the member may request a change once within 30 calendar days of the initial assignment. e. The member s current provider no longer participates with the health plan. A member placed in the Lock-in Program must remain in the Lock-in Program for the initial 24-month period regardless of whether the member changes MCOs or becomes a Fee-for-Service member. The initial lock-in period is 24 months. Just prior to the end of the 24-month lock-in period, the member will be re-reviewed by United Healthcare Community Plan Lock-In Committee. If the member meets criteria for removal from the Lock-In Program the member will be removed from lock-in and notified in writing. If a member does not meet criteria for lock-in removal, the lock-in will continue and the member will be notified with an explanation regarding on-going lock-in placement. Provider Participation Providers participating in UnitedHealthcare Community Plan may opt out of the Lock-In Program by notifying the health plan. When a provider is selected for a Lock-in Program member, the PCP s office is contacted to confirm that the PCP is willing to accept a lock-in patient and that the PCP is accepting new patients. The provider s practice location and appointment availability is also verified. 21

24 Providers who participate in the Lock-in Program are expected to meet the following requirements: 1. Providers must be located in the member s local geographic area, and/or be reasonably accessible to the member. 2. The Lock-In PCP supervises and coordinates all Lock-in member s health care services, including continuity of care and referrals to specialists when necessary. a. The Lock-In PCP is expected to perform a thorough history and physical examination of the member prior to making referrals to other physicians or providers. b. The Lock-In PCP should document the rationale and medical necessity for all referrals in the member s medical record. c. A written referral is required for all non-emergent professional provider services and non-emergent outpatient physician services performed at a hospital using the UnitedHealthcare Lock-In Referral Form (see form instructions) d. Following inpatient hospitalization, the Lock-In PCP must authorize professional services and a referral is required. e. The Lock-In PCP is responsible for identifying the need for a referral and to which provider the member will be referred. Referrals to providers with the same specialty as the Lock-In PCP should be avoided. f. The Lock-In PCP should retain prescribing privileges when appropriate, based on the medications prescribed and provider s scope of practice. g. After the referral has been made, the Lock-In PCP is expected to provide ongoing management of the member s healthcare. h. The referred-to provider must receive the UnitedHealthcare Lock-In Referral Form prior to rendering services and agree to provide only the services requested by the Lock-In PCP. The referred-to provider must submit a copy of the Lock-In Referral Form with their initial claim for payment. Claims will be denied in the absence of a referral, and member will be responsible for payment. g. After the requested services are provided by the referred-to provider, a consultation report, including results of any diagnostic test, lab or x-ray, and follow-up or prescribing recommendations should be provided to the Lock-In PCP. h. A referral is NOT required for the following services: Non-ambulance medical transportation Home and community based services (HCBS) Community mental health (services only) Durable medical equipment Vision services (Routine eye exams only) Radiology and laboratory services 3. The pharmacy fills all Lock-in members prescriptions. 4. The hospital provides all Lock-in members non-emergent hospital services. For suspected Medicaid Fraud or Abuse, contact the Fraud and Abuse Hotline at

25 10895 Grandview, Suite 200 Overland Park, KS Primary Care Physician Lock-In Referral Date of referral This authorizes Provider to whom member is referred to only provide Description of service: office visit, consultation, surgery to ID # Patient name Medicaid 11-digit ID for symptoms and conditions of. Authorized date(s) of service to Referral should not be for more than a 30-day period. Mental health and on-going pain management should be for no more than six months. Please contact my office at - - to forward lab results, consultation information and to make prescribing recommendations. Lock-in provider signature Lock-in provider NPI number Date of signature Lock-In Physician: Retain this referral in the member s file and forward one copy to the provider that the member is being referred. Privacy statement: This correspondence and any attachments are intended solely for the addressee. The information contained herein is confidential, may be legally privileged or exempt from disclosure pursuant to applicable law. If the reader of this communication is not the intended recipient, you are hereby notified that you have received this communication in error and that any use, review, dissemination, distribution, forwarding or copying of this communication is strictly prohibited. If you have received this communication in error, please notify United Healthcare immediately. 23

26 Lock-In Referral Guidelines 1. A written referral is required for non-emergency medical services to be performed by another physician or health care professional. 2. The Lock-In PCP must complete the Referral Form and forward it to the referred-to provider via mail, fax or Referrals may be written for one day or subsequent days, but should not be written for more than 30 days per each Referral Form, unless a longer period of time is appropriate (i.e. mental health or on-going pain management). The maximum time allowed for any written referral is 6 months. 4. The Lock-In PCP should keep a copy of the Referral Form in the member s record. In addition, the PCP can provide a copy of the Referral Form to the member for purposes of communication and lock-in referral compliance. 5. The referred-to provider must receive the Lock-In Referral Form prior to rendering services and agree to provide only the services requested by the Lock-In PCP. Claims will be denied in the absence of a referral, and member will be responsible for payment. 6. After the requested services are provided by the referred-to provider, a consultation report, including results of any diagnostic test, lab or x-ray, and follow-up or prescribing recommendations should be forwarded to the Lock-In PCP. 7. The referred to provider must submit a copy of the Lock-In Referral Form with their claim for payment, and the Name and NPI number of the Lock-In PCP must be included on the provider claim. 8. A written referral is NOT required for the following services: a. Non-ambulance medical transportation b. Home and community based services (HCBS) c. Community mental health (services only) d. Durable medical equipment e. Vision services (Routine eye exams only) f. Radiology and laboratory services 9. Providers can find additional information regarding the Lock-In process, forms, claims and referrals at UnitedHealthcareOnline.com > Tools & Resources. You may also contact the Provider Services team for assistance regarding the Lock-in PCP referrals and verification of member enrollment by calling UnitedHealthcare at For suspected Medicaid Fraud or Abuse, providers should contact the Fraud and Abuse Hotline at

27 4.13 Family Planning Family planning services are covered when provided by physicians or practitioners to members who voluntarily choose to delay or prevent pregnancy. Covered services also include the provision of accurate information and counseling to allow members to make informed decisions about specific family planning methods available. Members have a choice to receive services from their UnitedHealthcare PCP/PCCM clinic or go directly to a local health department or family planning clinic. Members do not need a referral (permission) from the Health Plan for the services below: Family Planning services and birth control Immunizations HIV and AIDS testing TB screening and follow-up care Sexually transmitted disease treatment and follow-up care 4.14 Maternity Care Pregnant UnitedHealthcare members are encouraged to receive care from participating providers. Providers should notify UnitedHealthcare promptly of a member s confirmed pregnancy to ensure appropriate follow-up and coordination by the UnitedHealthcare Healthy First Steps coordinator. Providers need to contact Healthy First Steps by submitting an American College of Gynecology or any initial prenatal visit form to Healthy First Steps via fax Providers with questions regarding Healthy First Steps should call (See more information about Healthy First Steps below.) The following information must be provided to UnitedHealthcare within one business day of the visit when the pregnancy is confirmed: Member s name and member ID number Obstetrician s name, phone number, and member ID number Facility name Expected date of confinement (EDC) Planned vaginal or Cesarean delivery Any concomitant diagnoses that could affect pregnancy or delivery Obstetrical risk factors Gravida Parity Number of living children Previous care for this pregnancy 25

28 An obstetrician does not need approval from the member s primary care physician for prenatal care, testing or obstetrical procedures Healthy First Steps (Maternity Case Management) Designed to improve birth outcomes and reduce Neonatal Intensive Care Unit (NICU) admissions, the Healthy First Steps program uses early identification to: Help overcome common social and psychological barriers to prenatal care; Increase member understanding of the importance of early prenatal care; Increase the mother s self-efficacy by identifying and building the mother s support system; Ensure appropriate postpartum and newborn care; Develop the physician/member partnership and relationship before and after delivery Neonatal Resource Services (NICU Case Management) Our Neonatal Resource Services program manages NICU cases inpatient and post-discharge to reduce costs and improve outcomes. Our dedicated team of NICU nurse case managers, social workers and medical directors collaborate to provide both clinical care and psychological services. Neonatal Resource Services (NRS) Neonatal Resource Services (NRS) Program helps to ensure quality of care and efficiency in treatment of NICU babies. The NRS Program Eligible member is defined as a newborn who has been admitted to the NICU upon birth (including babies that get transferred from PICU to NICU) and/or any infants readmitted within the first 30 days of life. All babies admitted to the NICU will be followed by NRS. (Detained babies will also be eligible for the program for the initial inpatient hospitalization only). NRS Neonatologists and NICU nurses proactively manage NICU patients through evidence based medicine and the use of care plans. The NRS nurse case manager will: Collaborate with the family, physician, and Discharge Planner on a coordinated discharge to ensure timely provision of care and delivery of services Develop alternate strategies for care management interventions (as needed) Facilitate the discharge Coordinate services post-discharge as required if member is under NRS case management (The NRS Program also provides onsite nurses in many markets.) The NRS program includes a multidisciplinary approach to case management in the 30 day post discharge period. The NRS nurse case manager s role is comprehensive and includes: Discharge planning and facilitation of timely release Coordination of alternative care options, including home care, equipment and skilled nursing Post-discharge Support for 30 days, except detained babies 26

29 Educating parents and families on local community resources and support services available Case managers provide benefit solutions to families in order to ensure appropriate services for the neonate Home Health Services Home Health Services should be pre-certified by the home health provider or the hospital Discharge Planner ordering the home care by calling the Prior Authorization Department at or sending a fax to Delivery Admissions Authorization for delivery is not required, but delivery notification is requested. Please call or fax the following information for the newborn to UnitedHealthcare Intake at : Date of birth Birth weight Gender Delivery type Gestational age 4.18 Newborn Admissions The hospital must notify UnitedHealthcare prior to or upon the mother s discharge, if the baby stays in the hospital after the mother is discharged. Healthy First Steps will conduct concurrent review of the newborn s extended stay. The hospital should make available the following information: Date of birth Birth weight Gender Any congenital defect Name of attending neonatalogist 4.19 Abortion Indications and Limitations of Coverage Abortions are covered only under the following conditions: 1. If the pregnancy is the result of an act of rape or incest (use the G7 modifier); or 2. In the case where a woman suffers from a physical disorder, physical injury, or physical illness, including a life-endangering physical condition caused by or arising from the pregnancy itself. 27

30 The Abortion Necessity form (next page) must be completed in order for the claim to be processed. The Abortion Necessity Consent Form can also be found at the following web address: Prior Authorization is not required for Abortions. The Abortion Necessity Consent Form must be completed in its entirety and submitted with the claim. 28

31 Kansas Medical Assistance Program P.O. Box 3571 Provider Line: From the office of the fiscal agent Topeka, KS Beneficiary Line: Abortion Necessity I, (name of physician), certify on the basis of my professional judgment, the pregnancy of (name of patient) of (address), is suffering from a physical disorder, physical injury or physical illness, including a life-endangering physical condition, caused by or arising from the pregnancy itself. is a result of rape. is a result of incest. (Signature of Patient) (Date 00/00/0000) (Signature of Physician) (Date 00/00/0000) (Physician s Address) (Physician s NPI) This form must be completed in its entirety. Incomplete information may result in the claim being denied. Revied 07/2011 5/

32 4.20 Hysterectomy Claims Hysterectomies are covered only for medically indicated reasons. One of the following conditions must also be met and documented. If one of these three options does not apply to the situation for which you have provided service, you may not be reimbursed. The individual or her representative signs a document (similar to the Hysterectomy Necessity Form) acknowledging receipt of information that the surgery will make her permanently incapable of reproducing. The Sterilization Consent Form is not an acceptable substitute. The physician must certify in writing that the individual was already sterile and state the cause or reason for the sterility on an attachment to the claim. The signature in field 31 of the claim form will not suffice. The physician must certify in writing that the surgery was performed under a life-threatening situation and individual certification was not possible. Include a description of the nature of the emergency. The signature in field 31 of the claim form will not suffice. Refer to Section 4300 of the State s General Special Requirements Manual. A copy of the hysterectomy statement must be attached to the surgeon s claim at the time of submission. The Hysterectomy Consent Form, located on the next page, can be photocopied for your use. A copy of the hysterectomy statement is not required to be attached to related claims (anesthesia, assistant surgeon, hospital, or rural health clinic) at the time of submission. However, no related claim will be paid until the hysterectomy statement with the surgeon s claim has been reviewed and determined to be correct, unless the related claim has the correct hysterectomy statement attached. A total hysterectomy and the removal of tubes/ovaries cannot be billed as separate procedures when performed by the same provider. This applies to the following procedure codes: Total hysterectomy: 58150, 58152, 58180, and Removal of tubes/ovaries: 58700, 58720, 58920, 58925, 58940, and

33 Kansas Medical Assistance Program P.O. Box 3571 Provider Line: From the office of the fiscal agent Topeka, KS Beneficiary Line: Hysterectomy Necessity To be completed by the individual receiving the hysterectomy or her representative, if any:. (Please print name and relation to patient.) Please select one of the following choices and place your initials on the line next to the statement that best describes your situation. Prior to surgery, I received, orally and in writing, information stating that the hysterectomy would render me permanently incapable of reproducing. I understand that I will not be able to become pregnant or bear children. I am already sterile and incapable of bearing children. My physician and I have orally discussed my illness, and he or she has given me written information on my illness that has led to the decision for this surgery. The illness/disease/symptoms that I have is called:. (Signature of Patient or Representative) (Date 00/00/0000) (Signature of Physician ) (Date 00/00/0000) Revied 07/2011 5/

34 4.21 Sterilization Providers must comply with the procedures outlined below prior to performing the sterilization service. A completed Federal Consent Form must be submitted with claims for all voluntary sterilization procedures. Additionally, Federal consent requirements for voluntary sterilization require: The recipient to be at least 21 years of age at the time consent is signed. The recipient to be mentally competent. Consent is to be voluntary and obtained without duress. Thirty days, but not more than 180 days, must pass between the date of informed consent and the date of sterilization, except in the case of a premature delivery or emergency abdominal surgery. At least 72 hours must have passed since the recipient gave informed consent for the sterilization if the recipient is to be sterilized at the time of a premature delivery or emergency abdominal surgery. The informed consent must be given at least 30 days before the expected date of delivery in the case of premature delivery. The person securing the informed consent and the physician performing the sterilization procedure are required to sign and date the consent form. Copy of the signed Federal Consent Form must be submitted by each provider involved with the hospitalization and/or the sterilization procedure. That sterilization consents may not be obtained when an eligible recipient: is in labor or childbirth. is seeking to obtain or obtaining an abortion. is under the influence of alcohol or other substances that affect that recipient s state of awareness. In keeping with the Centers for Medicare and Medicaid Services (CMS) instructions on the form, one of the paragraphs under the Physician s Statement section must be used indicating the circumstance of the sterilization and the other paragraph must be crossed out. CMS guidelines The previous guidelines noted on this page can be found at the following web address: 32

35 4.22 Sterilization Consent Form If the provider is performing a sterilization procedure, which may only be performed on patients 21 years of age and older and who are mentally competent, the Federal Sterilization Consent Form must be completed and must accompany the claim form. Providers must ensure they are utilizing the most recent version of the Federal Sterilization Consent Form. The surgeon performing the sterilization procedure is responsible for obtaining a complete and accurate Sterilization Consent Form. However, it is recommended other providers billing services related to sterilizations, including hospitals, obtain a copy of the Sterilization Consent Form from the surgeon PRIOR to the service being performed to validate the form is completed and correct. Please note: If a hospital or provider (other than the surgeon performing the sterilization) files a claim prior to the surgeon, we will not have a valid sterilization consent form on file. As a result, the hospital or other provider claim will deny and the provider will be responsible for submitting a corrected claim once they have validated the surgeon s claim is on file with valid sterilization consent form. If the provider has obtained a copy of the complete and accurate Sterilization Consent Form from the surgeon, the provider may submit the form with their claim to facilitate payment. If the surgeon does not complete the sterilization consent form correctly making it invalid per federal regulation, we cannot accept it for the surgeon or any other provider. All sterilization related services will be denied. If the surgeon performs a sterilization procedure without obtaining the necessary sterilization consent form, no provider will be paid for any services related to the sterilization. As a result, it is recommended that all providers of services related to sterilization obtain a copy of a correct and complete Sterilization Consent Form from the surgeon PRIOR to the sterilization procedure to avoid claim issues. 33

36 NOTICE: CONSENT FOR STERILIZATION Form Approved: OMB No Expiration date: 12/31/2012 YOUR DECISION AT ANY TIME NOT TO BE STERILIZED WILL NOT RESULT IN THE WITHDRAWAL OR WITHHOLDING OF ANY BENEFITS PROVIDED BY PROGRAMS OR PROJECTS RECEIVING FEDERAL FUNDS. CONSENT TO STERILIZATION I have asked for and received information about sterilization from. When I first asked Doctor or Clinic for the information, I was told that the decision to be sterilized is completely up to me. I was told that I could decide not to be sterilized. If I decide not to be sterilized, my decision will not affect my right to future care or treatment. I will not lose any help or benefits from programs receiving Federal funds, such as Temporary Assistance for Needy Families (TANF) or Medicaid that I am now getting or for which I may become eligible. I UNDERSTAND THAT THE STERILIZATION MUST BE CONSIDERED PERMANENT AND NOT REVERSIBLE. I HAVE DECIDED THAT I DO NOT WANT TO BECOME PREGNANT, BEAR CHILDREN OR FATHER CHILDREN. I was told about those temporary methods of birth control that are available and could be provided to me which will allow me to bear or father a child in the future. I have rejected these alternatives and chosen to be sterilized. I understand that I will be sterilized by an operation known as a. The discomforts, risks Specify Type of Operation and benefits associated with the operation have been explained to me. All my questions have been answered to my satisfaction. I understand that the operation will not be done until at least thirty days after I sign this form. I understand that I can change my mind at any time and that my decision at any time not to be sterilized will not result in the withholding of any benefits or medical services provided by federally funded programs. I am at least 21 years of age and was born on: Date I,, hereby consent of my own free will to be sterilized by Doctor or Clinic by a method called. My Specify Type of Operation consent expires 180 days from the date of my signature below. I also consent to the release of this form and other medical records about the operation to: Representatives of the Department of Health and Human Services, or Employees of programs or projects funded by the Department but only for determining if Federal laws were observed. I have received a copy of this form. Signature Date You are requested to supply the following information, but it is not required: (Ethnicity and Race Designation) (please check) Ethnicity: Race (mark one or more): Hispanic or Latino American Indian or Alaska Native Not Hispanic or Latino Asian Black or African American Native Hawaiian or Other Pacific Islander White INTERPRETER'S STATEMENT If an interpreter is provided to assist the individual to be sterilized: I have translated the information and advice presented orally to the individual to be sterilized by the person obtaining this consent. I have also read him/her the consent form in language and explained its contents to him/her. To the best of my knowledge and belief he/she understood this explanation. STATEMENT OF PERSON OBTAINING CONSENT Before signed the Name of Individual consent form, I explained to him/her the nature of sterilization operation, the fact that it is Specify Type of Operation intended to be a final and irreversible procedure and the discomforts, risks and benefits associated with it. I counseled the individual to be sterilized that alternative methods of birth control are available which are temporary. I explained that sterilization is different because it is permanent. I informed the individual to be sterilized that his/her consent can be withdrawn at any time and that he/she will not lose any health services or any benefits provided by Federal funds. To the best of my knowledge and belief the individual to be sterilized is at least 21 years old and appears mentally competent. He/She knowingly and voluntarily requested to be sterilized and appears to understand the nature and consequences of the procedure. Signature of Person Obtaining Consent Facility Address PHYSICIAN'S STATEMENT Shortly before I performed a sterilization operation upon Date on Name of Individual Date of Sterilization I explained to him/her the nature of the sterilization operation, the fact that it is Specify Type of Operation intended to be a final and irreversible procedure and the discomforts, risks and benefits associated with it. I counseled the individual to be sterilized that alternative methods of birth control are available which are temporary. I explained that sterilization is different because it is permanent. I informed the individual to be sterilized that his/her consent can be withdrawn at any time and that he/she will not lose any health services or benefits provided by Federal funds. To the best of my knowledge and belief the individual to be sterilized is at least 21 years old and appears mentally competent. He/She knowingly and voluntarily requested to be sterilized and appeared to understand the nature and consequences of the procedure. (Instructions for use of alternative final paragraph: Use the first paragraph below except in the case of premature delivery or emergency abdominal surgery where the sterilization is performed less than 30 days after the date of the individual's signature on the consent form. In those cases, the second paragraph below must be used. Cross out the paragraph which is not used.) (1) At least thirty days have passed between the date of the individual's signature on this consent form and the date the sterilization was performed. (2) This sterilization was performed less than 30 days but more than 72 hours after the date of the individual's signature on this consent form because of the following circumstances (check applicable box and fill in information requested): Premature delivery Individual's expected date of delivery: Emergency abdominal surgery (describe circumstances): Interpreter's Signature HHS-687 (05/10) Date Physician's Signature Date 5/

37 4.23 Concurrent Review UnitedHealthcare performs concurrent review on all hospitalizations for the duration of the stay based on contractual arrangements with the hospital. UnitedHealthcare performs fax, telephonic or onsite utilization reviews at the facility. UnitedHealthcare uses evidence based, nationally accepted, clinical criteria guidelines for determinations of appropriateness of care. The Inpatient Care Manager may certify extension of the length of stay, but may not deny any portion of the stay. Only a medical director or physician advisor can deny an extension of the length of stay. UnitedHealthcare notifies the facility when the Inpatient Care Manager refers a hospital stay for review by a medical director or physician advisor. If a medical director or physician advisor determines that the extended stay is not justified, UnitedHealthcare notifies the facility by phone and fax within one working day. The attending physician, facility, or provider caring for the member may appeal any adverse decision, according to the procedures in the Complaints and Grievances section Discharge Planning and Continuing Care The Inpatient Care Manager contacts the provider caring for the member, the attending physician, the member, and member s family to assess needs and develop a plan for continuing care beyond discharge, if medically necessary. UnitedHealthcare Inpatient Care Managers facilitate of care across multiple sites of care. The Inpatient Care Managers work with the member, family members, physicians, hospital discharge planners, rehabilitation facilities, and home care agencies. They evaluate the appropriate use of benefits, oversee the transition of patients between various settings, and refer to community-based services as needed. Care Coordinators supporting members with LongTerm Services & Supports (LTSS) are actively engaged in discharge planning to assist with needed in-home assessments where post-discharge functional changes may require revision to Care Plans Preventive Health Care Standards UnitedHealthcare s goal is to partner with providers to ensure that members receive preventive care. UnitedHealthcare endorses and monitors the practice of preventive health standards recommended by recognized medical and professional organizations. Preventive health care standards and guidelines are available at UHCCommunityPlan.com. Standards such as well child, adolescent and adult visits, childhood and adolescent immunizations, lead screening, and cervical and breast cancer screening are included in the website. Education is provided to both members and providers related to preventive health services and members are offered assistance with gaining access to these services if needed. Members may self-refer to all public health agency facilities for medical conditions treated by those agencies. Following are charts that outline preventative care recommendations for both children and adults. 35

38 2014 HEDIS Measures at a Glance Adults ages 18 and older Preventive care Gender Ages 18 to to to and older M/F Adolescent Well-Care Visits One or more well-care visits each year M/F Children and Adolescent s Access to Primary Care Practitioners ages 18 and 19 Patients seen at least once annually M/F Annual Dental Visit Refer for dental care annually F Chlamydia Screening in Women up to age 24 Chlamydia test annually if patient is sexually active Chlamydia test annually if patient is sexually active M/F Access to Preventive/Ambulatory Health Services Ages 20 and Older Patients seen at least once annually (Commercial - at least every three years) Patients seen at least once annually (Commercial - at least every three years) Patients seen at least once annually (Commercial - at least every three years) Patients seen at least once annually (Commercial - at least every three years) M/F Body Mass Index (BMI) Assessment up to age 74 Document date and value of BMI and weight For age 18 members - document BMI percentile also Document date and value of BMI and weight Document date and value of BMI and weight Document date and value of BMI and weight M/F Controlling High Blood Pressure (BP) BP reading at each visit Monitor/treat to maintain control Document date hypertension (HTN) diagnosed BP reading at each visit Monitor/treat to maintain control Document date HTN diagnosed BP reading at each visit Monitor/treat to maintain control Document date HTN diagnosed BP reading at each visit Monitor/treat to maintain control Document date HTN diagnosed M/F Medical Assistance with Smoking and Tobacco Use Cessation Advise smokers and tobacco users to quit Discuss cessation products and strategies Advise smokers and tobacco users to quit Discuss cessation products and strategies Advise smokers and tobacco users to quit Discuss cessation products and strategies Advise smokers and tobacco users to quit Discuss cessation products and strategies M/F Annual Monitoring for Patients on Persistent Medications Annual serum potassium and serum creatinine/blood urea nitrogen test for patients on persistent ACE/ARBs, digoxin, or diuretics Annual serum concentration level test for patients on persistent anticonvulsants Annual serum potassium and serum creatinine/blood urea nitrogen test for patients on persistent ACE/ARBs, digoxin, or diuretics Annual serum concentration level test for patients on persistent anticonvulsants Annual serum potassium and serum creatinine/blood urea nitrogen test for patients on persistent ACE/ARBs, digoxin, or diuretics Annual serum concentration level test for patients on persistent anticonvulsants Annual serum potassium and serum creatinine/blood urea nitrogen test for patients on persistent ACE/ARBs, digoxin, or diuretics Annual serum concentration level test for patients on persistent anticonvulsants F Timeliness of Prenatal Care Initial prenatal visit in the first trimester (or within 42 days of enrollment in plan) Initial prenatal visit in the first trimester (or within 42 days of enrollment in plan) Initial prenatal visit in the first trimester (or within 42 days of enrollment in plan) F Postpartum Care Postpartum care visit between 21 and 56 days after delivery (not during the C-section suture removal appointment) Postpartum care visit between 21 and 56 days after delivery (not during the C-section suture removal appointment) Postpartum care visit between 21 and 56 days after delivery (not during the C-section suture removal appointment) F Frequency of Ongoing Prenatal Care Greater than or equal to 81 percent of expected prenatal visits* Greater than or equal to 81 percent of expected prenatal visits* Greater than or equal to 81 percent of expected prenatal visits* F Cervical Cancer Screening Pap test at least every three years Cervical Cytology performed every 3 years in women years of age and Cervical Cytology/HPV co-testing performed every 5 years in women years of age Pap test at least every three years Cervical Cytology performed every 3 years in women years of age and Cervical Cytology/HPV co-testing performed every 5 years in women years of age F Breast Cancer Screening years of age Mammogram at least every other year Mammogram at least every other year M/F Colorectal Cancer Screening Ages Fecal occult blood test (FOBT) every year (or) Flexible sigmoidoscopy every five years (or) Colonoscopy every 10 years Fecal occult blood test (FOBT) every year (or) Flexible sigmoidoscopy every five years (or) Colonoscopy every 10 years M/F Influenza Vaccination Commercial Ages 50-64; Medicare Ages 65 and Older Annual immunization for influenza Annual immunization for influenza M/F Aspirin Use and Discussion Discuss risks and benefits of using aspirin Discuss risks and benefits of using aspirin M/F Pneumonia Vaccination Pneumonia vaccination F Osteoporosis Testing Bone density test for women M/F Glaucoma Screening Refer for eye exams for glaucoma by an eye care professional M/F Fall Risk Management Discuss fall risk Manage fall risk M/F Physical Activity in Older Adults Discuss and advise physical activity M/F Potentially Harmful Drug-Disease Interactions Avoid prescription dispensing for: Tricyclic antidepressants, antipsychotics or sleep agents for patients with a history of falls Tricyclic antidepressants or anticholinergic agents for patients with dementia Nonaspirin NSAIDs (non-steroidal anti-inflammatory drug) or Cox-2 Selective NSAIDs for patients with chronic renal failure (CRF) M/F Use of High-Risk Medications Avoid prescribing high-risk medications M/F Care for Older Adults Ages 66 and Older Advance care planning Medication review Medication list Functional status assessment Pain screening Assessment of hearing, vision and speech *Refer to the American Academy of Pediatrics and The American College of Obstetricians and Gynecologists, Sixth Edition, Guidelines for Perinatal Care for recommended number of perinatal visits. 5/

39 2014 HEDIS Measures at a Glance Children/Adolescents ages Birth to 17 Preventive Care Ages Birth to Age 2 3 to 6 7 to to 17 Childhood Immunization Status before Age 2 Before Age 2: 4 Dtap 3 IPV 1 MMR 3 HiB 3 HepB 1 Varicella Zoster Virus 4 PCV 2 HepA 2 RV 2 flu vaccines Well-Child Visits in the First 15 Months - Six or more well-care visits by age 15 months 6 or more well care visits before 15 months of age Visits must be on different dates of service Lead Screening in Children Capillary or venous blood test for lead before age 2 (Many states require two capillary or venous tests by age 2). Annual Dental Visit Refer for dental care at age 2 Refer for dental care annually Refer for dental care annually Refer for dental care annually Children and Adolescents Access to Primary Care Practitioners Patients seen at least once annually after age 1 Patients seen at least once annually Patients seen at least once annually Patients seen at least once annually Well-Child Visits in the Third, Fourth, Fifth and Sixth Years of Life One or more well care visits each year Weight Assessment and Counseling for Nutrition and Physical Activity for Children/Adolescents Immunizations for Adolescents Ages Body Mass Index (BMI) percentile Counsel for nutrition BMI percentile Counsel for nutrition (must receive (must receive educational materials during face to face visit) educational materials during face to face visit) Counsel for physical activity Counsel for physical activity BMI percentile Counsel for nutrition (must receive educational materials during face to face visit) Counsel for physical activity Before Age 13: One Meningococcal One Tdap or Td (Tetanus and diphtheria) Adolescent Well-Care Visits One or more well-care visits each year Chlamydia Screening in Women Ages 16 or Older Chlamydia test annually if patient is sexually active Frequency of Ongoing Prenatal Care Greater than or equal to 81percent of expected prenatal visits* Postpartum Care Postpartum care visit between 21 and 56 days after delivery (not the C-section suture removal appointment) Timeliness of Prenatal Care Initial prenatal visit in the first trimester (or within 42 days of enrollment in plan) HPV vaccine Three doses of HPV before age 13 Appropriate Treatment for Children With Upper Respiratory Infection (URI) Ages 3 Months and Older 2012 HEDIS Measures at a Glance - Children/Adolescents ages Birth to 17 - Condition Management Avoid antibiotic medication prescription for URI Avoid antibiotic medication prescription for URI Avoid antibiotic medication prescription for URI Avoid antibiotic medication prescription for URI Appropriate Testing for Children With Pharyngitis Ages 2 and Older Group A streptococcus test with a diagnosis pharyngitis and a prescribed antibiotic Group A streptococcus test with a diagnosis pharyngitis and a prescribed antibiotic Group A streptococcus test with a diagnosis pharyngitis and a prescribed antibiotic Group A streptococcus test with a diagnosis pharyngitis and a prescribed antibiotic Use of Appropriate Medications for People With Asthma Ages 5 and Older One or more formulary prescriptions for a preferred therapy for patients with asthma One or more formulary prescriptions for a preferred therapy for patients with asthma One or more formulary prescriptions for a preferred therapy for patients with asthma Attention deficit hyperactivity disorder (ADHD) Medication Management Ages 6-12 Follow-up visit within 30 days of prescribing an ADHD medication Two follow-up visits within nine months Monitor medication compliance Follow-up visit within 30 days of prescribing an ADHD medication Two follow-up visits within nine months Monitor medication compliance Follow-up visit within 30 days of prescribing an ADHD medication Two follow-up visits within nine months Monitor medication compliance Medication Management for People with Asthma Ages 5 and Older Monitor asthma controller medication compliance Monitor asthma controller medication compliance Monitor asthma controller medication compliance Initiation and Engagenment of Alcohol and other drug dependence treatment Ages 13 and older Initiation of treatment within 14 days of diagnosis of alcohol or other drug dependence with two or more follow-up visits within 30 days of initial visit. * Refer to the American Academy of Pediatrics and The American College of Obstetricians and Gynecologists, Sixth Edition, Guidelines for Perinatal Care for recommended number of perinatal visits. 5/

40 2014 HEDIS recommended immunization schedule for children birth to age six (6) 2014 HEDIS recommended immunization schedule for children ages /

41 4.26 Recommended Childhood Immunization Schedules The childhood and adolescent immunization schedule and the catch-up immunization schedule have been approved by Advisory Committee on Immunization Practices (ACIP), American Academy of Family Physicians (AAFP), and the American Academy of Pediatrics (AAP). Bright Futures/American Academy of Pediatrics: brightfutures.aap.org/pdfs/aap%20bright%20futures%20periodicity%20sched% pdf Government Childhood and Adolescent Immunizations Guide: cdc.gov/vaccines/schedules/ Source: CDC and Advisory Committee on Immunization Practices 4.27 Kan Be Healthy Periodicity Schedule Screening frequencies are based on the 2007 American Academy of Pediatrics (AAP) Recommendations for Preventive Pediatric Health Care as published on the AAP website, as of November 5, The first screen may be performed at any age under 21 and repeated according to ideal timeframes listed in the Kan Be Healthy (KBH) Screening Frequencies table below. When the ideal schedule is not possible to follow, please note that KBH medical screens may be completed at any time. Note: Every KBH visit must have all components completed and documented. Medical Screenings (M) Medical screens follow the KBH minimum documentation requirements which include the hearing, vision, and dental screening. Dental Screenings (D) Dental screens are a required component of each KBH visit based on both the Kansas State and AAPD/ADA/AAP Periodicity Schedule. Vision Screenings (V) Vision screens are a required component of each KBH visit based on both the Kansas State and AAP Periodicity Schedule. School vision screenings are a separate and distinct process and follow their own periodicity schedule as outlined in the KDHE Vision Screening Guidelines. Hearing Screenings (H) Hearing screens are a required component of each KBH visit based on both the Kansas State and AAP Periodicity Schedule. School hearing screenings are a separate and distinct process and follow their own periodicity schedule as outlined in the KDHE Hearing Screening Guidelines and Resource Manual. 39

42 KBH Screening Frequencies Age with Type of Screens Due Birth: M, V, H Two months: M, V, H Nine months: M, V, H, D 18 months: M, V, H, D Yearly three - 20 years: M, V, H, D Two to five days after birth: M, V, H Four months: M, V, H 12 months: M, V, H, D 24 months: M, V, H, D One month: M, V, H Six months: M, V, H 15 months: M, V, H, D 30 months: M, V, H, D 40

43 Community Plan Doc#: PCA15026_ M / United HealthCare Services, Inc.