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Midwest Health Plan, Inc.
Provider Newsletter
January 2013
Medical Director’s Report
Dr. Mark Tucker
PHARMACY UPDATE
MIDWEST HEALTH PLAN HAS A NEW
PHARMACY BENEFIT MANAGER (PBM)
Effective January 1, 2013 Midwest Health Plan has engaged 4D-Pharmacy
Management, Inc. as our PBM for all lines of business. DO NOT contact or send PA
requests to CVS-Caremark. New Prior Authorization forms may be obtained from your
Provider Representative or on the Midwest Health Plan Web Site. New Contact
Numbers are:
FOR MEDICAID / CSHCS / COUNTY HEALTH PLANS / HEALTH CHOICE
Providers: 888–274–2031
Prior Authorization FAX: (248) 341-8133
Pharmacies: 888-378-4743
RxBin: 600428
RxPCN: 01990000
FOR MEDICARE ADVANTAGE
Argus Health Systems Help Desk: 888-445-5540
Customer Service: 888-445-5580
Prior Authorization FAX: (248) 341-8133
Pharmacies: 888-445-5540
RxBin: 012353
RxPCN: 06171000
MIDWEST HEALTH PLAN’S PHARMACY, BENEFITS AND NEW TECHNOLOGIES
SUBCOMMITTEE MEETING
Midwest Health Plan’s Pharmacy and Therapeutics Committee met on November 13, 2012. All
changes are effective on December 1, 2012.
The drug classes that were reviewed include:
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Glaucoma Agents
o No changes
Ophthalmic Anti-Infectives
o No changes
Ophthalmic Anti-Inflammatories
o No changes
CHARGING CO-PAYS FOR ABW AND HEALTH CHOICE PROGRAMS
Midwest pays Medicaid Fee for Service rates for both the well visit and sick visit when
conducted on the same day. Effective 10/1/12, Providers are to charge ONLY ONE copay to the member when both the sick and well visits are conducted on the same day.
If you have any questions, please contact your Provider Representative:
Nehya Ahmed #313-586-6055
Linda Chammout #313-586-60313
Brian Flemming #313-586-6069
FEDERAL REQUIREMENTS FOR ALL PROVIDERS TO CONDUCT FRAUD, WASTE
AND ABUSE TRAINING
In order to satisfy the regulatory requirements to establish and implement
an effective training and education program as part of measures to prevent,
detect, and correct Medicare fraud, waste and abuse (FWA) the Centers for
Medicare & Medicaid Services has developed a standardized FWA training
module. Instructions on how to access this module are included at the end
of this newsletter. It’s easy to do and the slides are easy to follow. After
reviewing the information, please complete the form that is included at the
end of the slides and fax it back to Kathy Harkness at 313-827-5694. Remember, this is
mandatory from the Federal Government as well as from Midwest. Section 2.2.2 of your
Provider contract with Midwest states “Rules and Regulations. Provider agrees to comply with
all federal, state and local laws, rules and regulations, medical laws, and CMS instructions
applicable to the provision of Covered Services and with all state laws requiring health
professionals to comply with reporting requirements for communicable diseases and other
health indicators. Provider agrees to comply with all applicable rules, regulations, policies and
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procedures as set forth in the PCP Provider Manual, and all requirements under any contracts
between Plan and any Program that are applicable to Plan’s subcontractors, including but not
limited to cooperating with and complying with quality improvement programs, grievance
procedures, appeal procedures and utilization management procedures.”
If you have any questions, please contact Kathy at #313-586-6063.
MIDWEST HEALTH PLAN’S WEBSITE
Be sure to visit MHP’s website at www.midwesthealthplan.com. On MHP’s website, providers
will find the following information:
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Member eligibility lists
“Quick Reference Guide” that tells you when you need referrals and authorizations
Which codes are included in capitation
How to request an appeal and the appeals process
Free educational programs for our members
Monthly provider newsletters
MHP’s QI program, QI plan and annual evaluation
Pharmacy information, including the formulary and preferred drug list
MHP’s entire Provider PCP Administrative manual, (this includes our preventive health
and clinical guidelines, policies and procedures on confidentiality, member’s rights and
responsibilities, medical record documentation, fraud/abuse/false claims, safety
information on area hospitals, our formulary, formulary updates and pharmacy
procedures, affirmative statement regarding UM decision making, etc.)
This web site also includes information for our members such as our free educational programs,
our policies and procedures and even the entire membership guide/handbook that tells the
members what their MHP benefits are! Hope you visit our website. If you would like a hard
copy of any of the information on our website, please contact me. Let us know what you think
about it. If you have any questions or comments, please call Kathy Harkness at #313-586-6063.
BALANCE BILLING MEMBERS
This serves as a reminder that Midwest Health Plan and Midwest Advantage beneficiaries
cannot be balance billed for services. For our Midwest Advantage members, you are required
to bill Midwest for the Medicare services and bill the State of Michigan for any co-pays,
coinsurance and deductible amounts (similar to how you bill the State for the Medicaid Fee For
Service patients). The member should not be balance billed. Please refer to our website of
www. Midwesthealthplan.com in the provider section under Administrative Manual for this
information as well as additional information on member benefits, rights and responsibilities.
MEDICAID AND MICHILD ACCESS
As a reminder, Medicaid and MIChild members may receive services at Federally Qualified
Health Centers (FQHC), Rural Health Centers (RHC), Tribal Health Centers (THC), and Child and
Adolescent Health Centers (CAHC). A list of these centers is available by calling your Provider
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Representative. Prior authorization is NOT required for in network FQHC, RHC, THC and CACH.
If a member wishes to visit one of these facilities that are out of network, they must receive a
prior authorization.
As a reminder, Women who want to see an OB/GYN doctor for a well woman check up or for
pregnancy can make an appointment with any OB/GYN in MHP’s network, without a PCP
referral. If you need help finding an OB/GYN for your member, call customer service at 888654-2200.
Your members under 18 years old may see any pediatrician in MHP’s network for well child
visits without a PCP referral. If you need help finding a Pediatrician for your member, call
Customer Service at 888-654-2200.
HEALTH SERVICES:
Member Appeals
Midwest Health Plan (MHP) recognizes that participating providers may choose to exercise
their right to appeal a utilization management decision. The appeals process is established to
facilitate this right. If a provider disagrees with a utilization management decision the provider
may file an appeal. The provider must make the appeal in writing to the Midwest Health Plan
Medical Director. Midwest Health Plan will accept verbal appeals only in emergent situations.
If the MHP Medical Director cannot reverse the adverse determination:
o A physician not involved in the initial denial will review the case.
o The physician reviewer will be of the same specialty of the requesting physician with
similar credentials and licensure.
o The appeal will be resolved within 15 calendar days (up to 30 calendar days total for all
levels of appeal) of the request for appeal.
When the request for urgent care is denied by the MHP Medical Director, MHP gives members
and practitioners confirmation of the decisions within 72 hours of receipt of the request.
Verbal notification is given within 72 hours of receipt of the appeal request, with written
notification within 3 calendar days.
Case Management
Midwest Health Plan has a telephonic case management program. Case Management Services
include:
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Education on current disease process
Coordination of services
Referral to community agencies
Support with adherence to plan of care
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Claims, utilization reports, discharge planners and utilization
review staff, disease management, providers and
member/caregiver self-referral, may identify members who
may benefit from case management services. The program is
voluntary and requires the involvement of the member or
caregiver.
The case manager will assess the needs of the member,
develop a plan of care with the member and health team,
establish mutual goals, and implement interventions designed
to reach Health Services Registered Nurse will set up a specific
care plan. The RN will contact members via phone to discuss
goals and the plan to attain the goal.
Please contact Midwest Health Plan Health Services Department (313) 586-6031 to initiate an
evaluation for case management services.
Community Resources: 2-1-1
2-1-1 is the health and human service equivalent of 9-1-1 to give or get help spearheaded by
United Way. 2-1-1 is a free, easy-to-remember telephone number that connects people with
resources that improve their lives. The 2-1-1 call specialists are available 24 hours a day, 7 a
days a week, and are ready to provide information about a wide range of community services –
including health care, job training, childcare, mortgage
foreclosure assistance and more. 2-1-1 is available in all of the
MHP service area, including Wayne, Washtenaw, Oakland,
Macomb, St. Clair, and Livingston counties.
Anyone can ask a 2-1-1 call specialist about resources for:
 Rent/Utility Assistance
 Food
 Legal Assistance
 Shelter
 Support Groups, and more
Help your patients get in touch with community resources by
telling them about 2-1-1! For more information go to:
http://www.uwsem.org/gethelp/index.html
InterQual
Criteria
The Health Services
Department of
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Midwest Health Plan utilizes InterQual Care Criteria® for making clinical decisions. The criteria
are evidence based and utilized as a guideline. The criteria ass ist with managing care processes
and resources in a way that fosters evidence-based practice and ensures patient safety while
controlling medically unnecessary care.
InterQual Care Planning Criteria helps Midwest Health Plan to evaluate the appropriateness of
care-related interventions including diagnostic testing and procedures.
InterQual Level of Care Criteria aid in recommending the right level of clinical care or setting for
patients—from acute through outpatient treatment.
Using information found in the medical record or supplied by healthcare providers, the
Midwest Health Plan reviewer determines whether a patient’s clinical status matches the
criteria for a specific intervention or placement at a specific level of care. When there isn’t a
match, a reviewer or physician advisor can work with the attending physician to decide on an
appropriate course of action.
If you would like to review or discuss the InterQual Criteria, please contact your Provider
Services representative or the Director of Health Services at 313-586-6031 or toll free at 888654-2200. As always you may discuss specific cases with the Midwest Health Plan Medical
Director. Copies of specific InterQual Criteria are available upon request.
Access to Health Services Staff
Members and Practitioners of Midwest Health Plan have a right to contact Midwest Health Plan
staff to discuss UM Issues. All Health Services staff is accessible for members or providers who
have questions regarding any UM process. Staff is available during normal business hours.
Midwest Health Plan has a toll free number (888)654-2200 for members or providers calling in
regards to UM Issues.
Midwest Health Plan (MHP) recognizes that participating providers may choose to exercise
their right to appeal a utilization management decision. The appeals process is established to
facilitate this right. The Midwest Health Plan Medical Director is available for providers who
need to discuss a denial. You may contact the Medical Director at (888)654-2200. See the online provider manual for additional information
Behavioral Health Care
By our contract with the State of Michigan, Midwest Health Plan members are allowed 20 outpatient mental health visits per calendar year. MHP members requiring Mental Health Services
may obtain these services by:
 Obtaining a referral from their Primary Care Physician to a contracted psychiatrist or
behavioral health provider.
 Direct contact of a behavioral health care provider. This may be a contracted or
non-contracted provider.
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 In a crisis, self-referring to the nearest emergency room that provides psychiatric
services.
Services for Substance Abuse
Services for substance abuse are not a covered benefit of MHP. Members seeking those
services should be referred to the Community Mental Health board of their county of
residence. The following is a listing of phone number that may be accessed by members when
requesting SA services:
City of Detroit – 800-467-2452
Washtenaw County - 800-440-7548
Wayne County – 800-686-6543
Macomb County – 586-541-2273
Oakland County - 248 858-5200
St. Clair County – 888-225-4447
Livingston County – 800-615-1245
QUALITY IMPROVEMENT
2012 HEDIS Survey
The 2012 HEDIS survey is officially complete. After the survey results are audited, MHP review
nurses will either hand deliver or mail the Performance Feedback Reports. These reports will
provide your personal HEDIS scores as compared to NCQA benchmarks and MHP’s reported
score (total of all providers).
In order to maintain our HEDIS scores, MHP will continue to perform medical record review
throughout the year. We appreciate your generosity in allowing our staff to perform this task.
If you have any questions or concerns, please contact Lynn Gregory at 313-827-5564 or
Kimberly Weaver at 313-586-6077.
Medicare QI Program and Evaluation
During the calendar year 2011, Midwest continued to make improvements in the quality and
safety of the care our members receive. MHP serves Dual Eligible Special Needs members in
Wayne and Oakland counties. We continually evaluate our internal structures and processes
and make changes based on results of surveys, audits, and feedback from our providers, office
staff and members. Information on the Annual Evaluation is placed in the Provider Newsletters
with the entire annual evaluation available by hard copy upon request. Hard copies of all
documents (QI Programs, Chronic Condition Improvement Projects, HEDIS results, Model of
Care, Medication Therapy Management Program, etc.) are available upon request please call
the QI Department at 313-586-6063.
Appropriate Testing for Children with Pharyngitis
For children, ages 2 to 18, diagnosed with pharyngitis and are prescribed an antibiotic,
Midwest Health Plan will reimburse PCP offices $20 for a strep test performed at the time of
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diagnosis. . This applies to Medicaid members only and claims/encounters submitted with
the following codes:
ICD-9-CM (any of the following diagnosis codes):
 462=acute pharyngitis
 463=acute tonsillitis
 034.0=streptococcal sore throat
CPT codes (any of the following CPT codes):
 87070
 87071
 87081
 87430
 87650-87652
 87880/87880QW
Lead Screening
Michigan State law states that all Medicaid-enrolled children, between the age of 12 and 24
months or 36 and 72 months if not tested previously, must have a blood lead test. NO
EXCEPTIONS OR WAIVERS EXIST! For more information, please go to the MDCH web site at
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http://www.bridges4kids.org/lead/MCDH8-03.html
Clinical and Preventive Health Guidelines
MHP’s Clinical and Preventive Health Guidelines include:
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Acute Bronchitis in Adults
Asthma
Cancer
Chronic Heart Failure
Chronic Kidney Disease
Deep Venous Thrombosis
Diabetes
Heart Failure
Hyperlipidemia
Hypertension
Low Back Pain
Major Depression
Obesity
Osteoarthritis
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Osteoporosis
Otitis Media
Pharyngitis
Prenatal & Postpartum Care
Prevention of Unintended
Pregnancy in Adults
Preventive Health Guidelines from
birth to over age 65
Stroke
Substance Use Disorders
Tobacco Control
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These guidelines are found on our website of www.midwesthealthplan.com. Please review
these guidelines. These guidelines are developed based on nationally recognized sources —
each guideline lists the sources. These guidelines were endorsed by the Medical Directors of
the Michigan Quality Improvement Consortium (MQIC) and/or the Michigan Association of
Health Plans Medical Directors. You can also find the guidelines along with physician tools on
the MQIC website at www.mqic.org.
If you would like a hard copy of these guidelines, or have any comments or suggestions for
revisions, please contact the Quality Improvement Department at #313-586-6077.
HEALTH MANAGEMENT
Effective Antibiotic Prescribing:
The power to prevent antibiotic resistance is in your hands
CDC has launched the program “Get Smart: Know When
Antibiotics Work.” Visit the website at
http://www.cdc.gov/getsmart Here you will have access
to educational tools for parents and children, along with
information for providers and pharmacists.
Antibiotics cure bacterial infections, NOT viral infections
such as:
• Colds or flu
• Most coughs and bronchitis
• Non-strep sore throats
• Runny noses
Midwest Health Plan educates members about antibiotics to reduce prescription requests for
colds, influenza or sore throats. We ask providers to support appropriate antibiotic testing by
performing strep tests and not prescribing antibiotics for viral infections. This supports clinical
guidelines and National CDC initiatives. To obtain URI and pharyngitis clinical practice
guidelines, visit www.midwesthealthplan.com or call the Health Management Department at
313-586-6071.
ROSEBUD® Pregnancy Education Program
Midwest Health Plan would like to remind you of our
telephonic case management and education
program for pregnant members and their infants.
ROSEBUD® is staffed by nurses who specialize in
perinatal care and case management.
The Perinatal Case Management program targets
women at risk for complications during pregnancy.
The program supports the healthcare provider’s plan of care as well as provides ongoing
education to the expectant mother and her family.
You may refer members to this program, by calling the Health Management Department at
313-586-6071. You may also fill out the Notification of Pregnancy form and fax it to 313-8275694, Attention: Health Management Department. Thank you for your assistance!
The Notification of Pregnancy form can be found on our website at
http://www.midwesthealthplan.com/MidwestHealthPlan/Providers/Forms.aspx
VaxtextSM Immunization Reminders
The VaxtextSM program is a mobile text program intended to help busy parents and caregivers
ensure that their infants receive vaccines according to the CDC-recommended vaccination
schedule for babies 0-24 months of age. The text messages include simple, timely reminders
about which vaccines are due next and information that supports the importance of vaccines.
VaxtextSM aims to help parents and caregivers stay on track with the recommended childhood
immunization schedule and understand why vaccines matter.
Patients can register by texting CARE to 38132 or visiting the website at www.vaxtext.com
It’s important to note that message and data rates associated with a participant’s calling plan
will apply.
The Centers for Disease Control (CDC) stresses the need for the supplemental dose of
Prevnar 13®
A CDC data review, published in November 2011, shows that children under 5 years of age who have
not had a dose of Prevnar 13® (PCV13) continue to develop invasive pneumococcal disease (IPD) that
results from the 6 serotypes unique to the vaccine. Therefore, the CDC is emphasizing the need to
administer the supplemental dose of Prevnar 13 ® to children 15 months to 5 years of age who have
received 4 doses of PCV7.
To help prevent IPD among children, the CDC and AAP are reminding health care professionals to
administer a single supplemental dose of Prevnar 13 ® to all children under 5 years of age who have
received 4 doses of PCV7 in order to provide additional protection against the 6 serotypes unique to
Prevnar 13®. Health care providers should take advantage of opportunities to provide the supplemental
dose of Prevnar 13® during any health care visit.
Due to the importance of the catch up vaccine, Midwest Health Plan has partnered with Pfizer
to notify our members ages 17 through 56 months who, according to our claims data, have not
had a Prevnar 13®. Members will receive a phone call followed by a postcard with a reminder
to schedule an appointment with their doctor for the vaccine. Reminder: As a Medicaid
provider, you are required to get your vaccines through the Vaccines for Children (VFC)
program. Contact your local health department if you have questions about the VFC program.
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If you have any questions about this project, please contact the Health Management
Department at (313) 586-6071. For more information on the supplemental dose of the vaccine,
please refer to the CDC. Thank you in advance for your efforts to have your members fully
immunized.
Screening for Depression
Primary Care practitioners play an important role in screening for
and treating depression. Midwest Health Plan recommends the
use of PHQ-9 Questionnaire as a depression screening tool. The
Tool is available online as part of the MacArthur Initiative on
Depression & Primary Care at Dartmouth and Duke at:
http://www.depressionprimarycare.org/clinicians/toolkits/materials/forms/phq9/.
You will find useful information and a Depression Management
Tool Kit on their website that includes the following:
 Recognition and Diagnostic Information
 Patient Education Materials
 Treatment Information
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Monitoring and Follow-up Information
Bibliography
Please remember to screen for depression in asthmatic, diabetic and post-partum patients and
refer patients for behavioral health services if needed. You can find behavioral health providers
in the Midwest Provider Directory which is online at www.midwesthealthplan.com . If you have
questions about the depression screening tool, please call the Health Management department
at 313-586-6071.
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FREE
GLUCOMETER PROGRAM
ATTENTION PROVIDERS:
Midwest Health Plan (MHP) provides glucometers FREE of charge to our diabetic members.
Below is the form that must be completed in order for members to receive the FREE
glucometer. You do not have to complete a MHP referral form, only the attached form. The
form is also available on the MHP website at:
http://www.midwesthealthplan.com/MidwestHealthPlan/Providers/Forms.aspx
There are two types of glucometers available, the Bayer Breeze 2 and Bayer Contour. The
glucometer can be shipped to your office for the member to pick up, or mailed directly to the
member’s home.
Because diabetic supplies (i.e. alcohol swabs, lancets, and test strips) are billed under the
prescription drug benefit, your patient will need a prescription to take to the pharmacy for
those items.
If you have questions regarding this program, please call Customer Service at
888-654-2200.
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Instructions for Accessing the FWA Medicare Learning Network® (MLN) Training Module
1. To take a web-based training course, go to http://www.cms.gov/Outreach-andEducation/Medicare-Learning-Network-MLN/MLNProducts/index.html?redirect=?MLNProducts
on the CMS website.
2. Under “Related Links”, at the bottom of the page, click on “Web-Based Training (WBT)
Courses”.
3. Click on Medicare Parts C and D Fraud, Waste and Abuse Training, not the icon next to it.
4. At the top of the Course Description Window, you will be able to click on either “Login” or
“Register”.
5. If you already have an MLN account, click “Login” and enter your User ID and Password.
6. If you do not have an MLN account, click “Register”.
You will be re-directed to a page with an e-mail address field stating “Please type
your E-mail address and press Submit”.
Enter an e-mail address and click “Submit”.
The next screen will read: “No account was found matching your search criteria.
Please click here to proceed with registration”.
Click the word “Here” to continue with registration.
7. After logging in or completing the registration, you will be re-directed to your home page.
8. Click on the “Web-Based Training Courses” link.
9. Click the Medicare Parts C and D Fraud, Waste and Abuse Training title, not the icon next
to it.
10. Scroll to the bottom of the page and click the “Please click here to access Provider
Compliance Web Page” not the “Take Course” button.
11. You will be re-directed to the Provider Compliance Web Page.
12. Under “Downloads” click on Medicare Parts C and D Fraud, Waste and Abuse Training.
13. You will be asked whether you would like to “Open” or “Save the File”. Choose which
option you prefer.
14. After you unzip the file, you will see two versions of the same training slides – one in PDF
format and the other in PPT format. Choose either version to access the training.
15. Once you have finished the training, go to slide 59 for a “Certificate of Completion”
template
that can be used to document course completion. If you choose to use this certificate, click
on slide 59 in the PowerPoint format, clear the existing fields - “Type Your Name Here”
and “Insert Today’s Date” - and replace the contents with your name and the date that you
completed the training. FAX THIS COMPLETED FORM TO KATHY HARKNESS AT
# 313-827-5694. This form will be used a proof you complied with Quality
Improvement as well as State and Federal requirements as stated in your
contract with Midwest. **
16. Congratulations! You have successfully accessed the Medicare Parts C and D Fraud, Waste
and Abuse Training!
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**Provider contract excerpt: Section 2.2.2 Rules and Regulations. Provider agrees to comply
with all federal, state and local laws, rules and regulations, medical laws, and CMS instructions
applicable to the provision of Covered Services and with all state laws requiring health
professionals to comply with reporting requirements for communicable diseases and other
health indicators. Provider agrees to comply with all applicable rules, regulations, policies and
procedures as set forth in the PCP Provider Manual, and all requirements under any contracts
between Plan and any Program that are applicable to Plan’s subcontractors, including but not
limited to cooperating with and complying with quality improvement programs, grievance
procedures, appeal procedures and utilization management procedure.
WIN CANDY:
Your office will have the chance each month to win a free box of candy. All you have to do is
answer the questions toward the last page of the newsletter and fax the page to us at 313-8275694. If your answers are correct, the candy will be mailed to your office. Please refer to our
website at www.midwesthealthplan.com for the list of winners. If you do not answer the
questions correctly, you will not receive the candy. So keep up the good work and keep
responding. If you’re not participating, you should. It’s quick and easy and all you have to do is
read the newsletter and answer the questions. Please try it. Congratulations to those offices
who responded correctly. We hope you are enjoying the candy! The December office winners
include:
Dr. Kamala Vanaharam, My Family Doctor, Dr. Rekha Shah, C A Murphy My Family Health
Center, Dr. Madan Gupta,Southfield.
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JANUARY CANDY CONTEST 2013
1. True or False (circle one) Medicaid and MIChild members may receive services at
Federally Qualified Health Centers (FQHC), Rural Health Centers (RHC), Tribal
Health Centers (THC), and Child and Adolescent Health Centers (CAHC). .
2. True or False (circle one) Midwest pays Medicaid Fee for Service rates for both the
well visit and sick visit when conducted on the same day. Effective 10/1/12,
Providers are to charge ONLY ONE co-pay to the member when both the sick and
well visits are conducted on the same day.
3. Midwest Health Plan’s Pharmacy and Therapeutics Committee met on November 13,
2012. All changes are effective on December 1, 2012.
The drug classes that were reviewed include:
___________________________
_________________________________________
______________________________
4. Members and Practitioners of Midwest Health Plan have a right to contact Midwest
Health Plan staff to discuss UM Issues. All Health Services staff is accessible for
members or providers who have questions regarding any UM process. Staff is
available during normal business hours. Midwest Health Plan has a toll free number
_____________________ for members or providers calling in regards to UM Issues.
Name: _________________________________
From the office of Doctor: ______________________ PIN _______
Office Site Name: ________________________________________
Phone Number: ____________________________
******************************************************
1.
2.
3.
4.
Answers for the December 2012 CANDY CONTEST
TRUE
TRUE
Colds Or Flu, most coughs & Bronchitis, non-strep sore throat, & runny nose
2-2-2
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Notification of Pregnancy Form
Phone number:
313-586-6071
Fax number:
313-827-5694
MEMBER DATA
Date
Date of Birth
Last Name
First Name
Address
Phone #
City
Alternate Phone #
ZIP
Recipient ID
HEALTHCARE PROVIDER DATA
PCP Name
Address
Zip
OB Provider
PCP ID #
Ste
Phone #
OB Phone #
PERINATAL INFORMATION
Maternal:
LMP
EDC
Date last Pap test
Date Chlamydia screen
RISK FACTORS / COMMENTS
Midwest Health Plan thanks you for notifying us of members who are pregnant.
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