Important information for physicians and other health care professionals and facilities serving UnitedHealthcare Medicaid members Summer 2009 H1N1 (Swine Flu) Update UnitedHealthcare providers are directed to the Centers of Disease Control (CDC) Web site at http://www.cdc.gov/h1n1flu/guidance/ for the latest H1N1 (swine flu) updates. Providers can also download a Frequently Asked Questions (FAQ) document for their patients by accessing their state-specific physician Web site at www.uhcmedicaid.com. UnitedHealthcare Goes Live With 13th Edition of Milliman Care Guidelines UnitedHealthcare Medical Management continues to use the Milliman Care Guidelines in the utilization management of both inpatient and outpatient services for all plans except our Pennsylvania plans, and on May 1st went live with the use of the 13th Edition of the Care Guidelines. The Care Guidelines are nationally recognized evidence-based guidelines; and are more than just a tool used by the payer community to guide the authorization of care and services. The key aspects of the Care Guidelines: Clinical indications for decision-making for admission, procedures, testing and services; A guide for optimal recovery (the Milliman Care Guidelines Optimal Recovery Course) which is reflective of best practices in prescriptive care; Discharge planning guidelines; Patient education/teaching information; Clinical documentation requirements; Articles of Importance to Read: Page 1 H1N1 (Swine Flu) Update UnitedHealthcare Goes Live With 13th Edition of Milliman Care Guidelines Page 2 The Importance of Collaboration between Primary Physicians and Behavioral Health Clinicians Member ID Card Updates Page 3 Dental Benefit Changes for UnitedHealthcare s HealthChoice and Primary Adult Care (PAC) Members Page 4 Fraud and Abuse Health Education Program Notification Page 5 Provider Satisfaction Survey Provider Directories Case Management Programs Page 6 The Medical Technology Assessment Committee (MTAC) Extended Stay criteria; Common Complications and Conditions guidelines; Hospital Care Planning;
Quality Measures; Opportunity to use guidelines to guide collaboration and consultation between payers and providers regarding patient care and management. If you have questions or want to know more about the Milliman Care Guidelines, please contact your local UnitedHealthcare plan. The Importance of Collaboration between Primary Physicians and Behavioral Health Clinicians A substantial number of patients who have serious illnesses also have behavioral health conditions. For example, 20% of patients who have had a heart attack are likely to develop depression within 12 months of the event. Between 20% and 27% of patients with diabetes also have depression. It is important to determine if a behavioral health clinician is treating a patient with these and other illnesses. If so, it is helpful to coordinate care with the behavioral health clinician. Coordination of care takes on greater importance for enrollees with severe and persistent mental health and/or substance abuse problems. This is especially true when medications are prescribed, when there are co-existing medical/psychiatric symptoms and when patients have been hospitalized for a medical or psychiatric condition. Communication between clinicians can also maximize the efficiency of diagnosis and treatment, while minimizing the risk of adverse medication interactions for patients being prescribed psychotropic medication. It can also help reduce the risk of relapse for patients with substance abuse disorders or psychiatric conditions. Please discuss with your patients the benefits of sharing essential clinical information. We encourage you to obtain a signed release from each UnitedHealthcare patient that allows you to share appropriate treatment information with the patient s behavioral health clinician. Psychiatric Consults for Medical Patients If you would like to arrange a psychiatric consultation for a patient in a medical bed, are unclear whether a consultation is warranted, or need assistance with any needed authorization, please call the telephone number for behavioral health services on the back of the patient s medical insurance card. Member ID Card Updates UnitedHealthcare ID cards have been redesigned to incorporate the feedback we received from physicians and practice managers. We believe this is an important step in simplifying the administration of health care for you and our members. Beginning Fall 2009, the new ID card will be re-issued to all UnitedHealthcare HealthChoice (Medicaid) and Primary Adult Care (PAC) program members. You may continue to see the older ID cards for a period of time until the mass mailing is completed. Please continue to accept both versions of the ID cards from your patients. In addition, if you participate in both UnitedHealthcare s Medicaid and commercial networks, you may have already seen the ID page 2 Provider Service Center: 1-877-842-3210
card enhancements for your commercial patients. Some of the important changes which abide by the Workgroup for Electronic Data Interchange (WEDI) health care ID card standards include: Consistency layout based on WEDI standards for data fields, placement and size; personalization and variable information with labels printed on front of card and instructions on back of card Readability limited information on the card, machine readable formatting, and use of large font size Copying/Scanning ability to clearly copy or scan for patient health records with white background Compliance compliant with the National Council for Prescription Drug Programs (NCPDP) Please note: the following information has not changed: Claims process Member benefits Contact information If you have any questions, please contact Provider Services. Dental Benefit Changes for UnitedHealthcare s HealthChoice and Primary Adult Care (PAC) Members IMPORTANT DENTAL BENEFIT CHANGES: EFFECTIVE JULY 1, 2009 HealthChoice members Children under 21 and pregnant women: Dental Services will be provided by the Maryland Healthy Smiles Program and through Doral Dental Services of Maryland, LLC. Members eligible for dental coverage received a new dental card from Doral Dental. For any questions regarding dental benefits, call the Maryland Healthy Smiles Dental Program at: 1-888-696-9596 (members) and 1-888-696-9598 (providers). Adults 21 and over: Dental services will continue to be provided by UnitedHealthcare. These enhanced benefits are exams and cleanings twice a year. Health plan members can continue to use their UnitedHealthcare member identification card to receive dental services. For any questions regarding dental benefits, call UnitedHealthcare Dental Services Department at: 1-888-307-6544. Primary Adult Care Program (PAC) members Dental services will continue to be provided by UnitedHealthcare. These enhanced benefits are exams and cleanings twice a year. Health plan members can continue to use their UnitedHealthcare member identification card to receive dental services. For any questions regarding dental benefits, call UnitedHealthcare Dental Services Department at: 1-888-307-6544. page 3 Provider Service Center: 1-877-842-3210
Fraud and Abuse If you find out about a case of fraud and abuse in the program, you must tell us about it, but you may report the information confidentially. Fraud and abuse for members can be things like: Lying about facts to get or keep health coverage. Hiding any facts so that you can get or keep health coverage. Letting someone else use your health plan ID card. Selling or giving your prescription medicines to anyone else. Fraud and abuse for providers can be things like: Billing the health plan for services that were never given. Billing the health plan twice for the same service. To report fraud and abuse to UnitedHealthcare, call 877-842-3210 or Call the HealthChoice Fraud hotline at 866-654-4421 Report online via HealthChoice Web site at http://www.dhmh.state.md.us/index.html. Click on Report Fraud located under Hot Issues Write to the DHMH Medicaid Program Integrity, Recipient Fraud and Abuse Unit, 201 West Preston Street, Baltimore, Maryland 21201, FAX: 410-333-5326 Health Education Program Notification With UnitedHealthcare, every provider has access to health education programs and educational materials. UnitedHealthcare s health educators are a resource for enrollees and providers in need of assistance with locating or coordinating health education materials and services. Providers may contact the health plan at (800) 487-7391 or (410) 379-3455 to assist members in accessing health education programs and services. Upon request through telephone, fax: (866)567-7759, or mail from the member s primary care provider (PCP) or a participating specialty care provider, our health plan will provide health education support services to the member. If a member receives a related health education postcard, please instruct the member to mail the postcard to the following address: ATTN: HEDIS Department UnitedHealthcare of Mid-Atlantic, Inc. 6095 Marshalee Drive, Suite 200 Elkridge, MD 21075 UnitedHealthcare will make reasonable efforts to accommodate member and provider requests and schedule members to attend health education classes, as needed. The health education program is intended to improve or preserve the continuing health and quality of life for individuals with routine or special health care needs. page 4 Provider Service Center: 1-877-842-3210
You can find out more about the health education programs available to you or our members from one of the following UnitedHealthcare resources listed below: Provider Web Portal Health education/health plan HEDIS staff Provider Manual Special Mailings Case Managers UnitedHealthcare displays and education materials at community events Provider Satisfaction Survey Tell Us What You Think UnitedHealthcare is committed to making sure that our services support the ability of your practice to provide the safest and highest possible quality of health care to your patients who are our members. We value and seek administrative simplicity that takes the hassles out of clinical practice and reduces inefficiency and waste. For this reason, we periodically offer our network physicians the opportunity to comment on our services. You will be receiving a survey to evaluate the services UnitedHealthcare provides to our members and you in the near future. Your opinions are important to us and will help us assess the level of satisfaction with our health plan, as well as identify opportunities for improvements so that we may better meet the needs of your practice. We appreciate your time and cooperation. Provider Directories Just a reminder, updated Provider Directories are located at www.uhcmedicaid.com. A Provider Directory can be requested by contacting Provider Services at 877-842-3210. Case Management Programs UnitedHealthcare Case Management Programs (CM) serve to optimize the health and well-being of members with chronic illness or at high risk for adverse medical outcomes. To accomplish this, AmeriChoice has developed comprehensive CM Programs that are member-centered and facilitate collaboration between members and their health care teams, as well as promote selfmanagement, active decision-making, and participation in health care interventions and outcomes. UnitedHealthcare currently provides CM Programs for the following: Diabetes Asthma COPD Heart Failure Coronary Artery Disease Childhood Obesity Major Depression Schizophrenia Bipolar Disease Maternity Management (Healthy First Steps ) Case Management is based upon the premise that collaboration between the member, support systems, and health care professionals result in the development of partnerships that promote targeted interventions and health care goals and that contribute to improving health care outcomes. This coordination of care provides an opportunity for an improvement in the quality of care continuum. We strive to empower the member to become successful in managing their chronic disease or condition. page 5 Provider Service Center: 1-877-842-3210
UnitedHealthcare understands how difficult it can be to change behavior. We have developed proprietary strategies to maximize success for our members. Members in our CM Programs receive ongoing diseasespecific education and coaching regarding lifestyle changes, as well as holistic support to address situations that may impede the member from reaching health care goals. Moreover, designated clinical staff, social workers, or educators are assigned to these members. The one-on-one relationship built during regular contact between the member and the health professionals creates a strong bond that encourages compliance and active participation. Eligible members of UnitedHealthcare do not have to enroll; they are automatically screened when we identify them as pregnant or living with a chronic illness. We will inform you of their participation. If you would like to enroll a UnitedHealthcare member who is not currently enrolled in the program, please let us know. We will work collaboratively with you and your patients to identify and prevent complications, promote optimal health, and ensure quality health care. If you have any additional concerns or questions, please let us know. This will allow us to support your treatment plan for your patients. A Case Management Program representative can be reached by calling 410-540-4369. The Medical Technology Assessment Committee (MTAC) The Committee meets at least 10 times per year. Reports from the MTAC are reviewed by the EMPC (Executive Medical Policy Committee) and recommendations are forwarded to the health plans. MTAC is responsible for the development and management of: Evidence-based position statements on selected medical technologies Assessments of the evidence supporting new and emerging technologies Evaluation of new usage of existing technologies Maintenance of externally licensed guidelines The consideration and incorporation of nationally accepted consensus statements, clinical guidelines and expert opinions into the establishment of national standards for UnitedHealth Group Ensuring that clinical decisions about the safety and efficacy of medical care are consistent across all products and businesses 6095 Marshalee Drive Suite 200 Elkridge, MD 21075 Practice Matters is a periodic publication for physicians and other health care professionals and facilities in the UnitedHealthcare network. M44275 7/09