Provider Manual hawk-i Community Plan
Community Plan 2014 UnitedHealthcare hawk-i Iowa Physician, Health Care Professional, Facility and Ancillary Provider Manual UHCCommunityPlan.com Table of Contents Welcome to UnitedHealthcare Community Plan.................................................................... 1 Key Contact Information........................................................................................................... 3 Identification Cards/Eligibility Verification............................................................................. 4 Administrative Functions.......................................................................................................... 5 Claims Billing Procedures....................................................................................................... 10 Reimbursement........................................................................................................................ 15 Member Cost Share Responsibility....................................................................................... 17 Provider e-Services.................................................................................................................. 19 Emergent and Urgent Services............................................................................................... 20 Credentialing............................................................................................................................. 23 Covered Benefits...................................................................................................................... 26 Coverage of Abortions............................................................................................................. 29 Member Rights and Responsibilities.................................................................................... 30 Care After Hours....................................................................................................................... 33 Health Services......................................................................................................................... 34 Prior Authorization Guidelines............................................................................................... 38 Referral Procedure................................................................................................................... 39 Medical Record Charting Standards...................................................................................... 40 Member Access and Availability............................................................................................ 42 Utilization Care Management Programs............................................................................... 45 Timing of Utilization Management Decisions...................................................................... 48 Medical Hospital Utilization Management........................................................................... 50 Care Management.................................................................................................................... 53 Disease Care Management..................................................................................................... 54 Preventive Health and Clinical Practice Guidelines............................................................ 55 Practitioner Education – Sanction Policy Summary............................................................ 58 Denied Payment Authorization Decisions............................................................................ 60 Quality Improvement................................................................................................................ 61 Member Complaint and Appeal Process.............................................................................. 65 Glossary of Terms..................................................................................................................... 66 Forms Appendix....................................................................................................................... 68 Welcome to UnitedHealthcare Community Plan UnitedHealthcare Community Plan (UnitedHealthcare), a division of UnitedHealth Group, provides services to the Healthy and Well Kids of Iowa hawk-i program under the brand “UnitedHealthcare Community Plan”. This Provider Manual contains information related to this specific program. If you are also a network provider for UnitedHealthcare commercial and Medicare products, you can access those Administrative Guides at UHCOnline.com. If you have any questions about the information or material in this manual or about any of our policies or procedures, please do not hesitate to contact Provider Services at 888-650-3462. This toll-free number is conveniently located at the footer of each page in this manual. Healthy and Well Kids in Iowa hawk-i offers free or low-cost health insurance for children under 19 years old. UnitedHealthcare Community Plan partners with the Iowa Department of Human Services to participate in the hawk-i program across the state. UnitedHealthcare is one of the participating health plans that families can choose. Important Information Regarding the Use of This Guide We greatly appreciate your participation in our program and the care you provide to our members. In the event of a conflict or inconsistency between your state Regulatory requirements and this manual, the provisions of the regulatory requirements will control, except with regard to benefit contracts outside the scope of that Regulatory requirement. This manual 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 periodic updates and some additional electronic tools, is available on our website at UHCCommunityPlan.com. Additionally, in the event of a conflict or inconsistency between your contract and this manual, the provisions of your contract will control except for State of Iowa or Centers for Medicare and Medicaid Services (CMS) required language for provider contracts. Communications to Providers Our goal is to ensure that 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. UnitedHealthcare Community Plan Provider Manual 2/14 From time to time, there may be important information about policies and protocols that must be communicated to all participating providers. These communications may be done through Network Bulletins or through the Practice Matters Provider Newsletter. If the information communicated through these methods is a change to any protocol set forth in this Manual, you will see the updated information in this Manual upon the next provider manual revision notification. 1 UnitedHealthcare hawk-i provider services: 888-650-3462 Network Bulletin – The Network Bulletin is a bimonthly publication (6 times a year) posted to UHCOnline.com. This bulletin contains information and updates as well as administrative changes for all providers, not just Medicare, Medicaid, and CHIP. Articles located in this bulletin that are specific to hawk-i providers will also be communicated through the Provider Newsletter called Practice Matters. Practice Matters – Practice Matters is the Provider Newsletter published quarterly specific to the hawk-i product within UnitedHealthcare Community Plan. This newsletter includes any policy changes and communicates any clinical topics or reminders. Articles regarding policy or administrative updates will be included in this publication but may also be found in the Network Bulletin as specified above. The Practice Matters newsletters are posted on the UHCCommunityPlan.com provider website. They can be found at: http://www.UHCCommunityPlan.com/ health-professionals/IA/provider-news. UnitedHealthcare Community Plan Provider Manual 2/14 2 UnitedHealthcare hawk-i provider services: 888-650-3462 Key Contact Information UnitedHealthcare hawk-i Provider Service 888-650-3462 (TDD 711) UnitedHealthcare hawk-i Member Services 800-464-9484 Inpatient Care Authorization 866-604-3267 Pharmacy Program (Pharmacist) 877-305-8952 Prescription Prior Authorization (Physician) 800-310-6826 Epic Hearing 866-956-5400 OptumHealth Behavioral Services 800-510-5145 Routine vision services are managed by Block Vision. Verification of eligibility and authorization for routine vision services are available online at www.blockvision.com or through Block Vision’s Voice Response Unit at 866-819-4298 800-428-8789 OptumHealth NurseLine 877-244-0408 State of Iowa hawk-i Customer Service (Member) 800-257-8563 Delta Dental Delta Dental contracts directly with the State of Iowa hawk-i program to cover routine dental services. 800-544-0718 UnitedHealthcare Community Plan Provider Manual 2/14 3 UnitedHealthcare hawk-i provider services: 888-650-3462 Identification Cards/Eligibility Verification the health plan’s website or by phone 24 hours a day. This procedure is essential because: Identification Cards - Eligibility Verification UnitedHealthcare hawk-i members should receive a new membership Identification (ID) card prior to his/her effective date. However, if a member does not receive an ID card prior to their effective date, using provider e-services, you can access member eligibility information on the health plan website at UHCCommunityPlan.com or contact Provider Services to verify eligibility. • Member may no longer be eligible. • Benefits may change. • Fraudulent use may occur. Steps to Verify Eligibility • Ask members to present their UnitedHealthcare hawk-i ID card. The ID card does not guarantee eligibility. It is for identification purposes only. Eligibility must be verified every time services are received. The most recent member eligibility information can be accessed on • If unable to determine eligibility using the provider website eligibility tool, contact Provider Services. Sample Plan ID Card - Information is subject to change, therefore you should check the member ID card at every appointment. Note: hawk-i is located in the lower right hand side on the front of the ID card, so members can be identified as UnitedHealthcare hawk-i. Printed: 04/23/12 Printed: 04/23/12 Health Plan (80840) 911-95378-08 Health Plan (80840) 911-95378-08 Member ID: 999999999 Member ID: 999999999 Member: Member: SUBSCRIBER M BROWN SUBSCRIBER M BROWN DHS11 DHS11 Payer ID 87726 95378 Payer ID 95378 Group Number: Group Number: Rx Bin: Grp: Rx Bin: PCN: Rx Grp: Rx PCN: 0APU 0APU Unauthorized use of non-plan providers may result in benefits denial. www.uhccommunityplan.com. Unauthorized use of non-plan providers may result in benefits denial. TDD 711 800-464-9484 For Members: www.uhccommunityplan.com. 877-244-0408 NurseLine: TDD 711 800-464-9484 For Members: 800-510-5145 Mental Health: TDD 800-486-7914 877-244-0408 NurseLine: 711 800-510-5145 Mental Health: TDD 800-486-7914 For Providers: www.uhccommunityplan.com 888-650-3462 P.O. Box 5220, Kingston, NY 12402-5220 Medical Claim Address: www.uhccommunityplan.com For Providers: 888-650-3462 Medical Claim Address: P.O. Box 5220, Kingston, NY 12402-5220 610494 hawki 610494 9999 hawki 9999 hawk-i Administered by UnitedHealthcare Plan of the River Valley, Inc. hawk-i Administered by UnitedHealthcare Plan of the River Valley, Inc. UnitedHealthcare Community Plan Provider Manual 2/14 Pharmacy Claims: OptumRx, PO Box 29044, Hot Springs, AR 71903 For Pharmacist: 877-305-8952 Pharmacy Claims: OptumRx, PO Box 29044, Hot Springs, AR 71903 For Pharmacist: 877-305-8952 4 UnitedHealthcare hawk-i provider services: 888-650-3462 Administrative Functions Regulatory Compliance for compliance with the obligations that govern our federal and state programs. Introduction As a business segment of UnitedHealth Group, UnitedHealthcare implements and is governed by the UnitedHealth Group Ethics and Integrity Program. UnitedHealthcare is dedicated to conducting business honestly and ethically with members, providers, suppliers and governmental officials and agencies. The need to make sound, ethical decisions as we interact with physicians, other health care providers, regulators and others has never been greater. It’s not only the right thing to do, it is necessary for our continued success and that of our business associates. Ethics and Integrity Program activities support the following seven key elements that facilitate prevention, early detection and remediation of violations of law and UnitedHealthcare policies. 1. Written Standards, Policies and Procedures 2. High Level Oversight – Governance 3. Effective Training and Education 4. Effective Lines of Communication/Reporting Mechanisms 5. Enforcement and Disciplinary Guidelines The Ethics and Integrity Program promotes compliance with applicable legal requirements, fosters ethical conduct within UnitedHealthcare and provides guidance to its employees and contractors. Additionally, the Ethics and Integrity Program focuses on increasing the likelihood of preventing, detecting, and correcting violations of law or UnitedHealthcare policy. The implementation of such a program, however, cannot guarantee the total elimination of improper employee or agent conduct. If misconduct occurs, UnitedHealthcare will investigate the matter, take disciplinary action, if necessary, and implement corrective measures to prevent future violations. Preventing, detecting and correcting misconduct safeguards UnitedHealthcare’s reputation, assets and the reputation of its employees. 6. Auditing and Monitoring 7. Response to Identified Issues Examples of applicable regulations and requirements include but are not limited to – Medicaid: Title 42 CFR Part 438 Managed Care, and executed state contracts. Federal Health Insurance Portability and Accountability Act of 1996 (“HIPAA”) and state health information privacy laws; Federal and State False Claims Acts. UnitedHealthcare has compliance program staff, led by the Chief Medicaid Compliance Officer, which is responsible for oversight and management of the Ethics and Integrity Program. A compliance committee, consisting of senior managers from each of our key organizational functions provides direction and oversight for the Program. UnitedHealthcare also has compliance officers or compliance contacts located in each health plan or business unit who report to the senior management of their assigned entity. Ethics and Integrity Program The Ethics and Integrity Program incorporates recommended compliance program guidance from the Department of Health and Human Services Office of the Inspector General (“OIG”), the Centers for Medicare and Medicaid Services (“CMS”), and the Federal Sentencing Guidelines for Organizations (revised and amended, 2010). The purpose of the Ethics and Integrity Program is to ensure operational accountability and to provide standards of conduct UnitedHealthcare Community Plan Provider Manual 2/14 5 UnitedHealthcare hawk-i provider services: 888-650-3462 Reporting and Auditing investigate and recover money it has paid for fraudulent, wasteful or abusive claims through evolving policies and initiatives to detect, prevent and combat fraud, waste and abuse. Any unethical, unlawful or otherwise inappropriate activity by a UnitedHealthcare employee which comes to the attention of a provider should be reported to a UnitedHealthcare senior manager in the health plan or directly to the Ethics and Compliance Help Center at 800-455-4521. UnitedHealthcare will also appropriately refer suspected fraud, waste and abuse (FWA) cases to law enforcement, regulatory, and administrative agencies pursuant to state and federal law. UnitedHealthcare seeks to protect the ethical and fiscal integrity of the company and its employees, members, providers, government programs, and the public, as well as safeguard the health and wellbeing of its members. An important aspect of the Ethics and Integrity Program is assessing high-risk areas of UnitedHealthcare operations and implementing periodic reviews and audits to ensure compliance with law, regulations, and contracts. When informed of potentially irregular, inappropriate or fraudulent practices within the plan or by our providers, UnitedHealthcare will conduct an appropriate investigation. Providers are expected to cooperate with the company and government authorities in any such inquiry, both by providing access to pertinent records (as required by the Participating Provider Contract) and access to provider office staff. If activity in violation of law or regulation is established, appropriate governmental authorities will be advised. UnitedHealthcare is committed to compliance with its Anti-fraud, Waste and Abuse Program and all applicable federal and state regulatory requirements governing its Anti-fraud, Waste and Abuse Program. UnitedHealthcare recognizes that state and federal health plans are particularly vulnerable to fraud, waste and abuse and strives to tailor its efforts to the unique needs of its members and Medicaid, Medicare and other government partners. If a provider becomes the subject of a governmental inquiry or investigation, or a government agency requests or subpoenas documents relating to the provider’s operations (other than a routine request for documentation from a regulatory agency), the provider must advise UnitedHealthcare of the details of this and of the factual situation which gave rise to the inquiry. All suspected instances of Fraud, Waste and Abuse in any way and in any form is thoroughly investigated. In appropriate cases, the matter is reported to law enforcement and/or regulatory authorities, in accordance with federal and state requirements. UnitedHealthcare cooperates with law enforcement and regulatory agencies in the investigation or prevention of Fraud, Waste and Abuse. Fraud, Waste and Abuse The Deficit Reduction Act of 2005 (DRA) contains many provisions reforming Medicare and Medicaid that are aimed at reducing fraud within the health care programs funded by the federal government. Under Section 6032 of The DRA, every entity that receives at least $5 million in Medicaid payments annually must establish written policies for all employees of the entity, and for all employees of any contractor or agent of the entity, providing detailed information about false claims, false statements and whistleblower protections under applicable federal and state fraud and abuse laws. UnitedHealthcare’s Anti-fraud, Waste and Abuse Program focuses on proactive prevention, detection, and investigation of potentially fraudulent and abusive acts committed by providers and plan members. A toll-free Fraud, Waste and Abuse Hotline (866-242-7727) has been set up to facilitate the reporting process of any questionable incidents involving plan members or providers. Through the Anti-fraud, Waste and Abuse Program, UnitedHealthcare’s mission is to prevent paying fraudulent, wasteful and abusive health care claims, as well as identify, UnitedHealthcare Community Plan Provider Manual 2/14 6 UnitedHealthcare hawk-i provider services: 888-650-3462 conduct business electronically are required to do so utilizing the standard formats adopted under HIPAA or to utilize a clearinghouse to translate proprietary formats into the standard formats for submission to UnitedHealthcare. As a contracted provider with UnitedHealthcare, you and your staff are subject to this provision. The UnitedHealth Group policy, titled “Integrity of Claims, Reports and Representations to Government Entities” can be found at UHCCommunityPlan.com. This policy details our commitment to compliance with the federal and state false claims acts, provides a detailed description of these acts and of the mechanisms in place within our organization to detect and prevent fraud, waste and abuse, as well as the rights of employees to be protected as whistleblowers. 2. Unique Identifiers HIPAA also required the development of unique identifiers for health care providers for use in standard transactions. Providers The National Provider Identifier (NPI) is the standard unique identifier for health care providers. The NPI is a 10-digit number with no embedded intelligence which covered entities must accept and use in standard transactions. While the HIPAA regulation only requires that the NPI be used in electronic transactions, many state agencies require the identifier on fee-for-service claims and on encounter submissions. For this reason, UnitedHealthcare requires the NPI on paper transactions. HIPAA and Compliance/ Provider Responsibilities Health Insurance Portability and Accountability Act The Health Insurance Portability and Accountability Act (HIPAA) of 1996 is aimed at improving the efficiency and effectiveness of the health care system in the United States. While the portability and continuity of insurance coverage for workers and greater ability to fight health care fraud and abuse were the core goals of the Act, the Administrative Simplification provisions of HIPAA have had the greatest impact on the operations of the health care industry. UnitedHealthcare is a “covered entity” under the regulations as are all health care providers who conduct business electronically. The NPI number is issued by the National Plan and Provider Enumeration System (NPPES) and should be shared by the provider with all impacted trading partners, such as providers to whom you refer patients, billing companies, and health plans. 3. Privacy of Individually Identifiable Health Information The privacy regulations ensure a national floor of privacy protections for patients by limiting the ways that health plans, pharmacies, hospitals and other covered entities can use patients’ personal medical information. The regulations protect medical records and other individually identifiable health information, whether it is on paper, in computers or communicated orally. 1. Transactions and Code Sets These provisions were originally added because of the need for national standardization of formats and codes for electronic health care claims to facilitate electronic data interchange (EDI). From the many hundreds of formats in use prior to the regulation, nine standard formats were adopted in the final Transactions and Codesets Rule. All providers who UnitedHealthcare Community Plan Provider Manual 2/14 7 UnitedHealthcare hawk-i provider services: 888-650-3462 The major purposes of the regulation are to protect and enhance the rights of consumers by providing them access to their health information and controlling the inappropriate use of that information. In addition, the regulation is designed to improve the efficiency and effectiveness of health care delivery by creating a national framework for health privacy protection that builds on efforts by states, health systems, and individual organizations and individuals. CFR, Part 455, Subpart B. This disclosure of criminal convictions related to the Medicare and Medicaid programs is required by CMS. These requirements hold that individual physicians and other health care professionals must disclose criminal convictions, while facilities and businesses must additionally disclose ownership and control interest. Medical Review Hours The health plan staff is available for medical review Monday through Friday, 8 a.m. to 5 p.m. 4. Security The Security Regulations required that covered entities meet basic security objectives. Medical review is available during standard business hours. Emergency medical services do not require prior authorization. 1. Ensure the confidentiality, integrity and availability of all electronic PHI the covered entity creates, receives, maintains and transmits; **The health plan offices are closed on the following holidays: New Year’s Day, Martin Luther King, Jr. Day, Memorial Day, Independence Day, Labor Day, Thanksgiving Day, Day after Thanksgiving Day and Christmas Day. Refer to the website for additional holiday observances. 2. Protect against any reasonably anticipated threats or hazards to the security or integrity of such information; 3. Protect against any reasonably anticipated uses or disclosures of such information that are not permitted or required under the Privacy Regulations; and Change Notification Any change in your provider information should be reported as soon as possible. Some examples of these changes are practice location, Tax Identification Number or practice status regarding acceptance of new patients. Please call the UHG VETSS line at 877-842-3210 or Provider Service at 888-650-3462 to communicate any changes. 4. Ensure compliance with the Security Regulations by the covered entity’s workforce. UnitedHealthcare expects all network providers to be in compliance with the HIPAA regulations that apply to their practice or facility within the established deadlines. Additional information on the HIPAA regulations can be obtained from the website: www.cms.hhs.gov. If terminating your participation, you must submit a termination notification to us in the time frames stated in your provider contract. All notices must be in writing and delivered either personally or sent by certified mail with postage prepaid. If mailed, such notice shall be deemed to be delivered when deposited in the United States mail, at the UnitedHealthcare respective address as it appears on the signature sheet of your provider contract. Disclosure of Criminal Conviction, Ownership, and Control Interest Prior to payment for any services rendered to UnitedHealthcare members, the provider must have completed and filed with the health plan disclosure information in accordance with requirements in 42 UnitedHealthcare Community Plan Provider Manual 2/14 8 UnitedHealthcare hawk-i provider services: 888-650-3462 If services covered by the contract agreement are added or discontinued, the provider is responsible for notifying the health plan prior to such discontinuation or addition. The health plan will review the changes requested to ensure adequacy of member access for service. If the need for additional service exists, the provider must comply with health plan credentialing requirements for that new service. A current provider contract will not automatically include a new location. Each request will be evaluated on an individual basis. for claims payment or medical management. The provider may charge the member for records provided at the member’s request. Providers are not allowed to charge the health plan or the member for records provided when a member moves from one primary care provider to another. Pro-Children Act The Plan must comply with Public Law 103-227, Part C Environmental Tobacco Smoke, also known as the Pro-Children Act of 1994 (Act). This Act requires that smoking not be permitted in any portion of any indoor facility owned or leased or contracted by an entity and used routinely or regularly for the provision of health, day care, education, or library services to children under the age of 18, if the services are funded by federal programs either directly or through State or local governments. Federal programs include grants, cooperative agreements, loans or loan guarantees, and contracts. The law also applies to children’s services that are provided in indoor facilities that are constructed, operated, or maintained with such federal funds. The law does not apply to children’s services provided in private residences; portions of facilities used for inpatient drug or alcohol treatment; service providers whose sole source of applicable federal funds is Medicare or Medicaid; or facilities (other than clinics) where WIC coupons are redeemed. Locum Tenens In instances when a network physician has a locum tenens covering for a short period of time (less than 60 days), it will be the network provider’s responsibility to ensure appropriate licensure, malpractice insurance and other pertinent information is validated prior to allowing the locum tenens to treat patients. Claims should be submitted under the network physician’s name and NPI. Allied Health Professional Billing If your office employs an “Allied Health Professional” (e.g., Nurse Practitioner, Physician Assistant) who is providing services to members, the claim must be submitted to the health plan with the NP/PA’s assigned provider identification number. These claims should not be filed under the supervising physician’s number. The Plan further agrees that the above language will be included in any subawards that contain provisions for children’s services and that are subgrantees shall certify compliance accordingly. Failure to comply with the provisions of this law may result in the imposition of a civil monetary penalty of up to $1000 per day. Records and Patient Information for Claims and Medical Management Medical records and patient information shall be supplied at the request of the health plan or appropriate regulatory agencies as required for claims payment and medical management. The provider is not allowed to charge the health plan or the member for copies of medical records provided UnitedHealthcare Community Plan Provider Manual 2/14 9 UnitedHealthcare hawk-i provider services: 888-650-3462 Claims Billing Procedures Electronic Data Interchange (EDI) Contact your software vendor or clearinghouse with any questions regarding placement of information on your system. EDI is our preferred choice for conducting business transactions with contracting/participating physicians and healthcare industry partners. Electronic Funds Transfer (EFT) EFT can reduce administrative costs, simplify bookeeping, and offer greater security. EFT can significantly reduce reimbursement turnaround time and funds are available as soon as they are posted to your account. To enroll in EFT for UnitedHealthcare Community Plan, please visit the EDI section of your state home page on UHCCommunityplan.com. EDI tools We offer an array of EDI tools designed to help you save time and money by automating several of your daily office administrative and reimbursement functions. Please refer to the UnitedHealthcare Community Plan published Companion Guides for the required data elements. Companion guides are available for viewing or download within the EDI section of your state home page at UHCCommunityplan.com. Electronic Remittance Advice (ERA) ERA allows a provider to obtain an electronic version of the Explanation of Payment (EOP). Depending on your system’s capability, the data may be uploaded directly to the ledger of your practice computer system. ERA can potentially replace the tedious process of Guide EOP reconciliation, posting and data entry. This transaction is available only in the HIPAA ANSI X1 2 835 format. EDI claims/encounters EDI claim is the preferred method of submission for contracted physicians and health care providers. You may submit all professional claims and/or encounters electronically for UnitedHealthcare Community Plan. The HIPAA ANS1 X1 2 837 format is the only acceptable format for submitting claims/ encounter data. Electronic eligibility inquiry/response One of the primary reasons for claims rejection is incomplete or inaccurate eligibility information. This EDI transaction is a powerful productivity tool that allows providers to instantly obtain Customers’ eligibility and benefit information in “real-time,” using a computer instead of the phone, prior to scheduling and confirming the patient’s appointment. The HIPAA ANSI X1 2 270/271 format is the only acceptable format for this EDI transaction. Claims requiring medical record attachments will require paper submission. However, do not submit medical record attachments unless instructed to do so by UnitedHealthcare Community Plan. Secondary Claims Please refer to the 837 Companion Guide located within the EDI Section of UHCCommunityPlan.com for technical requirements. Do not send paper claim backup for claims that have already been submitted electronically. Electronic claims status inquiry/response This EDI transaction allows a provider to send and receive in “real-time” an electronic status of a previously submitted claim using a computer. Claims with missing or inaccurate information can be resubmitted, which greatly enhances the provider’s receivables and cash flow cycle. The HIPAA ANSI X1 276/277 format is the only acceptable format for this To set up Carrier Tables within your Software Set your system payer tables for UnitedHealthcare Community Plan to generate electronic claims instead of paper claims. Make sure the Payer ID for the plan is spelled correctly and setup is consistent. UnitedHealthcare Community Plan Provider Manual 2/14 10 UnitedHealthcare hawk-i provider services: 888-650-3462 EDI transaction. Some software vendors and/or clearinghouses, may also offer Electronic Claims Status and Inquiry transaction services. The following claims may be submitted electronically without specific rules: • 59 Modifier. Please refer to the UnitedHealthcare Community Plan Companion Guides for the data elements required for these transactions. Companion guides are available for viewing or download at UHCCommunityplan.com. Paper claim specific rules include: Claims Format • Corrected claims may be submitted electronically; however the words “corrected claims” must be in the notes field. Your software vendor can instruct you on correct placement of all notes. All claims for medical or hospital services must be submitted using the standard CMS 1500 (formerly known as HCFA 1500), UB-04, or respective HIPAA-compliant format. The health plan recommends the use of black ink when completing a CMS 1500. Black ink on a red CMS 1500 form will allow for optimal scanning into the claims processing system. • Unlisted procedure codes may be submitted with a sufficient description in the notes field. Your software vendor can instruct you on correct placement of all notes. If sufficient information cannot be submitted in the notes field, paper must be submitted. X-ray, lab and drug claims with unlisted procedure codes should be submitted electronically with notes. No matter which format you use to submit the claim, ensure that all appropriate secondary diagnosis codes are captured and indicated for line items. This allows for proper reporting on encounter data. • Occupational Therapy, Speech Therapy, Physical Therapy, Mental Health/Substance Abuse and dialysis claims require the date of service by line item. The health plan does not accept span dates for these types of claims. Claim Processing Time • Secondary COB claims may be submitted if the following “required” fields are included on the electronic submission: Please allow 30 days before inquiring about claims status. The standard turn-around time for clean claims is 10 business days, measured from date of receipt. – Institutional: Payer Prior Payment, Medicare Total Paid Amount, Total Non-Covered Amount, Total Denied Amount. Claims Submission Rules – Professional: Payer Paid Amount, Line Level Allowed Amount, Patient Responsibility, Line Level Discount Amount (Contractual Discount Amount of Other Payer), Patient Paid Amount (Amount that the payer paid to the member not the provider). The following claims MUST be submitted on paper due to required attachments: • Timely filing reconsideration requests. • CCI edit reconsideration. • Unlisted procedure codes if sufficient information is not sent in the notes field. – Dental: Payer Paid Amount, Patient Responsibility Amount, Discount Amount (Contractual Discount Amount of Other Payer), Patient Paid Amount (Amount that the payer paid to the member not the provider). Please do not send claims on paper or with attachments unless requested by the health plan. UnitedHealthcare Community Plan Provider Manual 2/14 11 UnitedHealthcare hawk-i provider services: 888-650-3462 Balance Billing Effective Date / Termination Date The balance billing amount is the difference between the allowed charge and the provider’s actual charge to the patient. UnitedHealthcare members cannot be balance billed for covered services in accordance with the federal law prohibition found at 42 U.S.C.A. § 1395cc and 42 U.S.C.A § 1396a(p). Coverage will be effective on the date the member is effective with the health plan. Coverage will terminate on the date the member’s benefit plan terminates with the health plan. If a portion of the services or confinement take place prior to the effective date, or after the termination date, an itemized split bill will be required. Services to members cannot be denied for failure to pay copayments. If a member requests a service that is not covered by UnitedHealthcare, providers should have the member sign a release form indicating understanding that the service is not covered by UnitedHealthcare and the member is financially responsible for all applicable charges. Please be aware that effective dates for members can be revised. You should verify eligibility at each visit, to assure coverage for services. Overpayments The best way to handle a potential overpayment is to call Provider Service. Be sure to have the Claim Number or Member ID and Date of Service available. The health plan’s claim processing system will automatically deduct any overpayment made from the next remittance advice. Federal and State law prohibit a provider who participates in the Medicaid program from billing members for covered services. Additionally, section 403 of the Children’s Health Insurance Program Reauthorization Act of 2009 (CHIPRA) applies Medicaid-managed care requirements to CHIP, which includes the Iowa hawk-i program. This section further explains that providers are prohibited from balance billing a member for service(s) in excess of the contracted amount, other than approved copayments and/or deductibles. If an overpayment is identified, contact Provider Service to submit an overpayment request. Checks should not be sent to the health plan for overpayment related issues unless specifically requested. Subrogation Span Dates The health plan will not override timely filing denials based on decisions received from third-party carriers on subrogation claims. At the time of service, please submit all claims to the health plan for processing. Through recovery efforts, we will work to recoup dollars related to subrogation. In addition, if your office receives a third-party payment, notify the health plan’s Customer Service and the overpayment will be recouped. Exact dates of service are required when the claim spans a period of time. Please indicate the specific dates of service in Box 24 of the CMS 1500, Box 45 of the UB-04, or the Remarks field. This will eliminate the need for an itemized bill and allow electronic submission. UnitedHealthcare Community Plan Provider Manual 2/14 12 UnitedHealthcare hawk-i provider services: 888-650-3462 Timely Filing and Late Bill Criteria The following are not acceptable forms of documentation for timely filing payment reconsideration: Timely filing improves cash flow for your office. It enables the health plan to settle fund accounts accurately and to intervene earlier in cases requiring case management to improve patient outcomes. Claims must be submitted and received by us in accordance with the time frames outlined in your provider contract. Claims that are filed untimely will be denied. The claims filing deadline is based on the date services were rendered, or the date when the provider identifies us as the primary health payer, or receives a claim response from the primary payer. Secondary claim submissions can be submitted electronically or with a copy of the primary health payer’s remittance. If we receive a claim and return it to the provider for additional information, the provider must resubmit the claim within the time frame outlined in the provider’s contract. • Screen prints showing dates of a claim previously submitted to the health plan. • Electronic reports stating vendor or clearinghouse has accepted the claim. • CMS or UB form with “print” date located in Box 31 or Box 86, respectively. • Electronic report stating the health plan has rejected the claim. Provider Claim Reconsideration Requests Step 1: Claim Reconsideration. You must submit your Claim Reconsideration within 12 months from the date of the Explanation of Benefits (EOB) or Provider Remittance Advice (PRA). A Claim Reconsideration request is typically the quickest way to address any concern you have with how we processed your claim. With a Claim Reconsideration request, we review whether a claim was paid correctly, including if your provider information and/or contract are set up incorrectly in our system, which could result in the original claim being denied or reduced. Claims submitted after the claims filing period will be denied as NOT ALLOWED – DO NOT BILL THE PATIENT. If a claim has been denied for timely filing, the following are acceptable forms of documentation for payment reconsideration: • EOB or EOMB from primary health payer dated within the claims filing period of claim submission to the health plan. UnitedHealthcare acknowledges that providers remain eligible to file claims reconsiderations, resubmissions, disputes or appeals as permitted under the terms of their participation agreement or this manual. A request for claims reconsideration is intended solely for convenience and administrative ease. In the event this claims reconsideration process conflicts in any way with your participation agreement or this manual, the terms and conditions of the participation agreement or this manual shall govern. Providers are encouraged to review their participation agreement and this manual to understand all other available claims reconsideration, resubmission or appeals remedies. • Confirmation of denial from believed health payer within the claims filing period of claims submission to the health plan. • Copy of billing statement to patient showing dates of bills or provision of patient’s health plan insurance information. • Documentation proving the health plan contributed to the filing delay. • Electronic report states the health plan has accepted the claim. UnitedHealthcare Community Plan Provider Manual 2/14 13 UnitedHealthcare hawk-i provider services: 888-650-3462 Below is the method for submitting Claim Reconsideration Requests. Paper Claim Reconsideration Request The paper Claim Reconsideration Request form can be downloaded from: • UnitedHealthcareonline.com Claim Reconsideration – Paper Claim Reconsideration instructions Where to send Claim Reconsideration Requests: UnitedHealthcare P.O. Box 5220 Kingston NY 12402-5220 Claim Dispute If you do not agree with the outcome of the Claim Reconsideration decision in Step 1, you may submit a formal claim dispute. You must submit your appeal to us within 12 months (or as required by law or your participation agreement), from the date of the Explanation of Benefits (EOB) or Provider Remittance Advice (PRA). The provider dispute form can be found on UHCCommunityPlan.com. Forms should be mailed to: UnitedHealthcare Community Plan P.O. Box 31364 SALT LAKE CITY UT 84131 Or the form can be faxed to (801) 994-1082. A copy of the claim and supporting documentation will be required for review. UnitedHealthcare Community Plan Provider Manual 2/14 14 UnitedHealthcare hawk-i provider services: 888-650-3462 Reimbursement To align with federal mandates regarding enforcement of Correct Coding Initiatives (CCI) and Fraud, Waste and Abuse Prevention tools, the health plan performs coding edit procedures. These Program Integrity activities are referred to as reimbursement policies. contract documents, the enrollee’s benefit coverage documents, and the Provider Manual all may supplement or in some cases supersede these policies. Reimbursement policies are based on external sourcing including: Provider Claim Editing Tools iCES Clearinghouse from Ingenix: UnitedHealthcare Community Plan utilizes a customized version of the Ingenix Claim Edit System known as iCES Clearinghouse (v2.5.1) iCES-CH is a clinical edit system application that analyzes health care claims based on business rules designed to automate UnitedHealthcare Community Plan reimbursement policy and industry standard coding practices. Claims are analyzed prior to payment to validate billings in order to minimize inaccurate claim payments. • CMS National Correct Coding Initiative. • CMS National/Local Coverage Determinations (NCDs/LCDs). • Current Procedural Terminology (CPT). • Specialty Societies including, but not limited to: – American Society of Anesthesiologists (AMA). – American College of Cardiologists (ACC). – American College of Obstetrics and Gynecology (ACOG). Facility Claim Editing: UnitedHealthcare Community Plan utilizes an edited system application for claims for outpatient and inpatient services provided to Medicaid/CHIP beneficiaries. The Facility Editor is a rules-based software application that evaluates claims data for validity and reasonableness. The edits are based on CCI guidelines and other CMS rules established for government programs. • National Physician Fee Schedule (NPFS)/Relative Value File. Reimbursement policies are available online at UHCCommunityPlan.com. Reimbursement policies may be referred to in your agreement with UnitedHealthcare Community Plan as “payment policies.” UnitedHealthcare Community Plan may revise/update or add to these policies on occasion. As a participating provider, you agree to abide by these policies. UnitedHealthcare Community Plan is committed to notifying providers who are impacted by policy changes/additions. Outpatient Code Edits These reasonableness tests incorporate the Outpatient Code Edits (OCE) developed by the CMS for hospital outpatient claims. The Facility Editor will be used to examine outpatient facility-based claims prior to payment to validate billings in order to minimize inaccurate claim payments. Payment of a claim is subject to our payment policies (reimbursement policies) and medical policies, which are available to you online or upon request to your Network Management contact. The CMS OCE edits that will be applied by the Facility Editor include: NOTE: Policies do not cover all issues related to reimbursement for services rendered to UnitedHealthcare Community Plan enrollees as legislative mandates, the physician or other provider UnitedHealthcare Community Plan Provider Manual 2/14 1. Basic field validity screens for patient demographic and clinical data elements on each claim. 15 UnitedHealthcare hawk-i provider services: 888-650-3462 2. Effective-dated ICD-9-CM, CPT-4 and HCPCS Level II code validation, based on service dates and patient clinical data. The inpatient edits are sourced to: Medicare Code Editor (MCE) which include (but are not limited to) the following edit rules: 3. Facility-specific National Correct Coding Initiative edits. The NCCI edits identify pairs of codes that are not separately payable, except under certain circumstances. NCCI edits were developed for use by all health care providers; the Facility Editor incorporates those NCCI edits that are applicable to facility claims. The NCCI edits in the Facility Editor are applied to services billed by the same hospital for the same beneficiary on the same date of service. There are two categories of NCCI edits: • Data Validation Edits. Multiple Services on Same Visit: In certain situations, providers can bill for both evaluation and management (E&M) and preventive medicine (PM) on the same office visit. PM codes must be billed with one of the following E&M codes: 99211, 99212, or 99213 for an unrelated diagnosis. If the PM code is billed in any other combination of E&M codes, it will not be payable. The E&M code must be filed with a –25 modifier in these circumstances. a. Comprehensive code edits, which identify individual codes, known as component codes, which are considered part of another code and which are designed to prevent unbundling; and Immunization Administration The health plan will pay for immunization administration in conjunction with an E&M or P&M visit. Providers should use code 90471 for the first injection and 90472 for subsequent injections. b. Mutually exclusive code edits, which identify procedures or services that could not reasonably be performed at the same session by the same provider on the same beneficiary. 4. Other OCE edits for inappropriate coding, including incorrect coding of bilateral services, evaluation and management services, incorrect use of certain modifiers, and inadequate coding of services in specific revenue centers are also included in the Facility Editor. Note: the hawk-i program does not participate in the Vaccines for Children (VFC) program. Vaccinations are reimbursed according to your provider contract fee schedule. Inpatient Code Edits The inpatient editing rule sets are also developed by the CMS for hospital inpatient claims. As with the outpatient edits, the claims editing tool will review claims prior to payment to validate billings to minimize inaccurate claims payments. UnitedHealthcare Community Plan Provider Manual 2/14 16 UnitedHealthcare hawk-i provider services: 888-650-3462 Member Cost Share Responsibility Cost-Sharing for Members • Non-plan services when not a result of an emergency or in absence of a prior authorization – member is responsible for the costs of those service(s). hawk-i members are only responsible for the costs allowed under the Rules and Regulations as valid cost sharing responsibilities. A contracted provider cannot refuse to provide Medically Necessary Services for a member’s failure to pay. • Services without prior authorization where one is required – member is responsible for the cost of those service(s). • Services outside of their benefit plan. A network provider shall collect from the member any applicable costs. Reasonable efforts to collect should include, but are not limited to, referral to a collection agency and, where appropriate, court action. Documentation of the collection efforts must be maintained and made available to the health plan upon request. • For questions, please contact Provider Services. For more information about hawk-i benefits, refer to the Covered Benefits section in this manual. Non-payment of Copayment hawk-i Copayments When a member does not pay the applicable copayment at the time services are rendered, the physician has the following options: hawk-i members have no copayments for most services, exceptions include but not limited to: • Render the service, and pursue member payment of cost sharing at a future time. • Dental – member must use dental carrier’s schedule of benefits, contact Delta Dental for details. • Reschedule the appointment (unless the visit is for urgent/emergent care). • Non-emergent – member will have a $25 copayment for any non-emergent visits to an emergency room. Contact Provider Service for assistance if the member refuses to pay copayments. • Hearing – member can have one audiometric exam, one hearing aid evaluation, and one hearing aid per ear every 36 consecutive months. Costs for services above these benefits are the responsibility of the member. Coordination of Benefits Coordination of Benefits (COB) is designed to avoid duplicate payment for covered services. COB is applied whenever the Member covered by the health plan is also eligible for health insurance benefits through another policy. The health plan recommends the copayment not be collected until the second payer has paid the claim in order to prevent a possible overpayment. • Prescription – member will pay the full contracted price of any brand prescription filled when an equivalent generic is available on the Preferred Drug List (PDL). • Vision – member may receive 1 eye exam every 12 consecutive months and has a $100 material allowance per calendar year, they are responsible for any amount in excess of these limits. UnitedHealthcare Community Plan Provider Manual 2/14 17 UnitedHealthcare hawk-i provider services: 888-650-3462 As a network provider you agree to cooperate with the health plan toward the effective implementation of COB procedures, including identification of services and individuals for which there may be a financially responsible party other than the health plan, and assist in efforts to coordinate payments with those parties. How to file: • When the health plan is primary, submit directly to us. • When the health plan is secondary, submit to primary carrier first, then, submit the EOB with the claim to the health plan for consideration. EOBs can be submitted to the health plan electronically. Refer to “Claims Submission Rules” in this manual. Reminder: The Contract Agreement between UnitedHealthcare and the State of Iowa states: “in the event a hawk-i child is enrolled with other health insurance coverage, the other insurance plan shall be the primary payer and hawk-i shall be the payer of last resort.” Therefore, if the member is eligible for services or benefits under another policy, including Medicare, coverage under that plan will be primary. The only exception is in rare instances that the member also has Medicaid coverage. In these cases, Medicaid is the payer of last resort. UnitedHealthcare Community Plan Provider Manual 2/14 18 UnitedHealthcare hawk-i provider services: 888-650-3462 Provider e-Services Provider e-Services can be accessed from the health plan website at UHCCommunityPlan.com. Offering online features is just another way the health plan is working to strengthen our relationships with providers. • Reduce the number of claims rejected due to inaccurate eligibility information. Provider Registration • Determine if your claims have been received by the health plan. How to Obtain a Username and Password • To register for e-Services provider portal, go to UHCCommunityPlan.com. Then click on Health Professionals and select the state of Iowa under “Already Part of Our Network”. Choose “Claims and Member Information” from the navigation buttons on the left side of the screen, under UnitedHealthcare hawk-i, click “Access secure provider website”. This will bring you to the log in page for the online provider portal. • Know if your claim is pended, denied or paid within seconds. Claim Status/Review Allows you to locate specific claims and obtain claim summary and line item detail information. • Reduce your cost of duplicate claims submission and reduce administration cost. • Submit online request for claim review and receive answer within 48 hours. • From the Community Plan Online Provider Portal log in page, you will see a prompt to register for an account. Once you click on “register”, it will direct you to a page to set up your log in information. • To access the non-secured portion of the provider website, go to UHCCommunityPlan.com and click on Health Professionals and select the state of Iowa under “Already Part of Our Network”. This brings you to the general home page. Here you can access our policies (including the Reimbursement Policies), Provider Manual, handouts, forms, and recent newsletters. e-Services Verify Patient Eligibility • Verify the eligibility of your patients before you see them. • Know patients’ copayments that you can collect at time of service. • View deductibles, out-of-pocket maximums and co-insurance of patients. UnitedHealthcare Community Plan Provider Manual 2/14 19 UnitedHealthcare hawk-i provider services: 888-650-3462 Emergent and Urgent Services Post-stabilization Care Services are: Members are encouraged to receive Emergency Services from their Primary Care Provider (PCP) or a network hospital or facility. Covered services, related to a medical emergency that are provided after a member is stabilized in order to maintain the stabilized condition to improve or resolve the member’s condition. The health plan covers Emergency, Post-stabilization, and Urgently Needed Services without prior approval whether the member is in or out of the service area or if the care is provided by network or nonnetwork providers. All non-emergency services must be provided or coordinated by network providers. Members who are present at an emergency room should be screened to determine whether a medical emergency exists. Prior authorization is not required for the medical screening. Claim coverage decisions are based upon the severity of symptoms at the time of presentation. Post-stabilization services, including all medical health services that are necessary to assure there is no likely material deterioration of the member’s condition after discharge or during transport to another facility, are also covered based upon the prudent layperson standard. If either the member’s PCP or the health plan directs the member to the emergency room, emergency screening services and other medically necessary emergency services will be reimbursed, whether or not the member’s condition meets the prudent layperson definition of a medical emergency. A member is encouraged to contact their PCP as soon as possible, preferably within 24 hours after an Emergent/Urgent Service Procedure. The member’s PCP is expected to work with the member to coordinate any followup care. As a participant in a managed care health plan, the PCP is responsible for the emergency medical direction of members 24 hours a day, 7 days a week. Urgently Needed Services Urgently Needed Services are Covered Services that are not emergency services provided when: A Medical Emergency is defined as—A physical or behavioral condition manifesting itself by acute symptoms of sufficient severity (including severe pain) that a prudent layperson, who possesses an average knowledge of health and medicine, could reasonably expect the absence of immediate medical attention to result in the following: • The Member is temporarily absent from the UnitedHealthcare hawk-i Service Area, and • When such services are Medically Necessary and immediately required: 1. As a result of an unforeseen illness, injury, or condition; and • Placing the health of the individual (or, with respect to pregnant women, the health of the woman or her unborn child) in serious jeopardy; 2. It is not reasonable given the circumstances to obtain the services through a UnitedHealthcare network provider. • Serious impairment of bodily functions; or • Serious dysfunction of any bodily organ or part. UnitedHealthcare Community Plan Provider Manual 2/14 Under unusual and extraordinary circumstances, services may be considered urgently needed services when the Member is in the service area, but the UnitedHealthcare hawk-i provider network is temporarily unavailable or inaccessible. 20 UnitedHealthcare hawk-i provider services: 888-650-3462 After Hours/Provider Availability Emergency Inpatient Admission PCPs shall provide coverage 24 hours a day, 7 days a week. When a network provider is unavailable to provide services, he or she must ensure that another network provider is available. Should the attending physician proceed and admit the member, the health plan must be notified no later than the end of the next working day. Once the member’s condition is stabilized, the health plan requires notification for hospital admission and follow up care. Should the hospital fail to notify the health plan within 10 calendar days following a member’s presentation for emergency services, charges deemed not medically necessary by the health plan’s Medical Director, could become the financial responsibility of the hospital. The Member should normally be seen within 30 minutes of a scheduled appointment or be informed of the reason for delay (e.g., emergency cases) and be provided with an alternative appointment. After-hours access shall be provided to assure a response to urgent and emergency phone calls occur within 15 minutes. Individuals who believe they have an emergency medical condition should be directed to immediately seek emergency services. Billing for Hospital Observation Beds Used for the purpose of determining whether a patient requires admission or other treatment. Emergency Services in the Emergency Room • Outpatient observation is limited to up to 24 hours for medical observation. The health plan covers all emergent services necessary to stabilize members, without pre-certification of the services, where a prudent layperson, acting reasonably, would believe that a medical emergency existed. Screening services to determine whether a medical emergency exists are covered services. • When a member is admitted after an outpatient observation, the health plan will consider the date the member entered outpatient observation as the first day of the inpatient admission. Coverage Updates The health plan routinely meets to review changes and advances in health care treatment as they occur. Changes in the health plan’s coverage and payment are posted online. These changes are also maintained in the online version of the provider manual that can be accessed using the health plan provider website at UHCCommunityPlan.com. If there is disagreement regarding the member’s stabilized condition at the expected time of discharge or transfer, the decision of the attending physician will prevail. The health plan may arrange for a network physician with appropriate emergency room privileges to assume the attending provider’s responsibilities to stabilize, treat and transfer the member. This situation can only occur when the arrangement does not delay the provision of emergency services. UnitedHealthcare Community Plan Provider Manual 2/14 You may also contact Provider Services with any questions related to coverage and payment guidelines. 21 UnitedHealthcare hawk-i provider services: 888-650-3462 Encounter Data Element Collection All data required for Encounter collection and reporting is drawn from submitted claims. Should your office have a capitation arrangement with the health plan, encounters must be submitted with the same level of required information as fee-for-service claims. UnitedHealthcare Community Plan Provider Manual 2/14 22 UnitedHealthcare hawk-i provider services: 888-650-3462 Credentialing Provider Credentialing certified nurse midwives. When an office site check is required, a health plan representative will contact the provider’s office to schedule the site visit. Providers wanting to participate in the health plan must contact the National Credentialing Center by calling 877-842-3210 and provide specific information regarding their credentials and practice arrangements. When a decision is made to offer a provider an opportunity to be considered for participation, the provider will receive application submission instructions via fax. The application process includes submission of a completed signed application and supporting documents to the UnitedHealthcare National Credentialing Center by utilizing the Council for Affordable Quality Healthcare’s (CAQH) Universal Credentialing Datasource. Nondiscrimination in Network Participation The health plan does not deny or limit the participation of any clinician or facility in the health plan network, and/or otherwise discriminate against any clinician or facility based solely on any characteristic protected under state, federal, or local law. The health plan wishes to assure its provider(s) and facilities that it has never had a policy of terminating a clinician or facility because he or she: Provider Recredentialing Process 1. Advocated on behalf of a member; All providers are recredentialed at least every 36 months. At the time of recredentialing, the UnitedHealthcare National Credentialing Center will notify the provider to access the CAQH Universal Credentialing Datasource to update and re-attest to the validity of credentialing data. The provider’s professional license, DEA license (if applicable) and professional liability insurance are verified prior to the Credentialing Committee review. Each provider’s file is also reviewed for any sanctions (the health plan and/or state/federal) and quality of care or quality of service issues. This triennial cycle does not preclude recredentialing for shorter time frames due to quality issues and/or per the direction of the Corporate Credentialing Committee. 2. Filed a complaint against the health plan; 3. Appealed a decision of the health plan; or 4. Requested a review or challenged a termination decision. The health plan has not, and will not, terminate any clinician or facility from its network based on any of the four grounds enumerated above. Nothing in the health plan’s clinician or facility contracts should be read to contradict or in any way modify this longstanding practice. Public Release of Physician/ Clinician Specific Information The health plan does not release any individual clinician-specific utilization management information to entities outside of the health plan except as permitted or required by law. Office Site Review Office site checks are required as a part of the credentialing process for primary care, obstetrician/ gynecology providers. Office site checks are also required for physician assistants and nurse practitioners, who practice primary care, as well as UnitedHealthcare Community Plan Provider Manual 2/14 23 UnitedHealthcare hawk-i provider services: 888-650-3462 Written Notification and Correction of Information A request for arbitration must be in writing. At any time a provider’s participation status changes with the health plan, the provider shall provide all necessary information in a timely manner to ensure continuity of care for the members. If, during the process of credentialing or recredentialing, the health plan discovers information that varies substantially from that which was initially provided, the health plan will notify the clinician or facility and offer an opportunity to correct the information. Provider(s) and facilities are given 10 business days to respond. Responses must be made in writing to the health plan. Once the corrected information is verified, it becomes part of the clinician’s or facility’s file and is maintained in the same manner as all other credentialing and recredentialing material. Provider(s) or facilities have the right to review information submitted to support their credentialing application; the right to correct erroneous information; the right to be informed of their credentialing or recredentialing status, upon request; and the right to be informed of their rights. Please note that it is essential that you provide updated demographic information as changes occur. The Health Care Quality Improvement Act of 1986, as amended, requires that health care entities (e.g., hospitals, health maintenance organizations, group medical practices) report to the National Practitioner Data Bank/Health Integrity and Protection Data Bank and State Medical and Dental Boards specific information when adverse actions occur. Member Notification of Provider Suspension/Termination The health plan’s members will be notified when a provider’s participation status has been suspended or terminated regardless of cause. The health plan will notify members affected by the termination of providers. Altering Participation Status Organizational Provider Credentialing Program When a provider is identified with performance, license or sanction issues, the health plan has the right to restrict, suspend or terminate the provider’s participation status. Providers who are subject to an adverse action will be offered an appeal of the health plan’s decision. The Organizational Provider Credentialing Program includes the credentialing of network hospitals, ambulatory surgery centers, home health/infusion agencies, and skilled care facilities according to company and external review standards. The process follows established policies and procedures approved annually by the health plan’s Corporate Quality Improvement Committee. The purpose of the program is to select and monitor organizational providers. Appeals will be presented to a credentialing appeals panel. The network provider will be given the opportunity to present evidence and discuss the adverse decision with the credentialing appeals panel by telephone or in person. The panel’s decision will be by majority vote. The network provider will be notified by certified mail of the panel’s decision. If the network provider disagrees with the decision of the credentialing appeals panel, he/she has days from the date of the decision to request arbitration. UnitedHealthcare Community Plan Provider Manual 2/14 24 UnitedHealthcare hawk-i provider services: 888-650-3462 Facility In some instances the health plan may elect to delegate organizational provider credentialing. In these instances the delegate must comply with the health plan’s organizational provider credentialing standards. Application Process A Provider must submit a complete, signed application and supporting documentation for review by the UnitedHealthcare National Credentialing Center. This includes copies of the following as applicable: Ambulatory Record Review Standard Guidelines • Accreditation certificate/letter. Provider’s office medical records will be reviewed against the health plan, NCQA and regulatory guidelines relating to structure and content. It is expected that all medical records be in substantial (≥85%) compliance with these standards. • State license. • Certificate of professional liability insurance. • Laboratory certification. • Information regarding any license sanctions and/or insurance denials. Medical record standards for physical health providers are located in the Medical Record section of the manual. • A listing of all subcontracted patient care services (required in order to confirm the use of plan, accredited providers). It is the policy of the health plan to contract with only accredited facilities unless otherwise determined by business need. If the need is so determined the health plan may conduct an on-site facility audit. At the request of the health plan, an organizational provider must provide evidence of license for any personnel employed that are legally required to be licensed in the state in which they practice and that each is practicing within the scope of the license. Organizational providers are recredentialed on a 36-month basis; facilities are triennial (3-year) basis. The recredentialing process includes the collection of an updated application and supporting documents. Utilization and quality issues are also reviewed at the time of recredentialing. Between credentialing and recredentialing, providers are required to notify the health plan within 15 days of any material changes in their Network Applications and supporting documentation. UnitedHealthcare Community Plan Provider Manual 2/14 25 UnitedHealthcare hawk-i provider services: 888-650-3462 Covered Benefits UnitedHealthcare hawk-i Covered Benefits Benefits Chart The following benefit information is a summary. Some procedures, including certain medical services or benefits provided, require prior authorization by UnitedHealthcare before rendering services. Call Provider Services to check benefit coverage for hawk-i members. Service Benefit Limit Preventive Care Services Includes, but is not limited to, initial and periodic evaluations, family planning services, prenatal care, laboratory services and immunizations in accordance with rules and regulations. EPSDT Screenings Covered as medically necessary, except that the screenings do not have to be medically necessary. Children may also receive screenings in-between regular checkups if a parent or caregiver believes there is a problem. Screening, interperiodic screening, diagostic and follow-up treatment services as medically necessary in accordance with federal and state requirements. Inpatient Hospital Services As medically necessary, including rehabilitation hospital facility. Outpatient Hospital Services As medically necessary. Physician Inpatient Services As medically necessary. Physician Outpatient Services/ Community Health Clinic Services/ Other Clinic Services As medically necessary. Lab and X-ray Services As medically necessary. Hospice Care As medically necessary with a prior authorization. Must be provided by a Medicare-certified hospice. Dental Services Dental Services are provided by the Dental Benefits Manager. Benefits available through State Dental Plan with Delta Dental. Delta can be contacted at 800-544-0718 or visit their website at www.deltadentalia.com. Routine Vision Services Routine Vision Services are provided by Block Vision. Routine annual assessment, evaluation, or screening of normal eyes and examinations for the purpose of prescribing fitting or changing eyeglass and/or contact lenses are covered through Block Vision. Medical eye care, meaning evaluation and management of abnormal conditions, diseases, and disorders of the eye (not including evaluation and treatment of refractive state), are covered as medically necessary as a medical benefit through UnitedHealthcare. Home Health Care UnitedHealthcare Community Plan Provider Manual 2/14 As medically necessary. Must have approved prior authorization by UnitedHealthcare. 26 UnitedHealthcare hawk-i provider services: 888-650-3462 Service Benefit Limit Pharmacy Services Pharmacy services shall be provided by the Pharmacy Benefits Manager (PBM), unless otherwise described below. • Outpatient Prescription Drugs: The health plan covers medications when ordered by a network physician and supplied by a network pharmacy. The pharmacy will not dispense more than a 30-day supply for each prescription and drugs must be on the preferred drug list (PDL). Members do not have a copayment for generic medications or brand medications if a generic equivalent is not available. Members will pay the full health plan contracted rate if they choose a brand drug that does have a generic equivalent. If members have a prescription filled at a non-network pharmacy, they must pay for the prescription at the time it is filled and submit request for reimbursement. The health plan will consider payment up to the contracted rate for that drug. • Injectable Drugs provided in an office/clinic setting: The health plan shall be responsible for reimbursement of injectable drugs obtained in an office/clinic setting and to providers providing both home infusion services and the drugs and biologics. The health plan shall require that all professional claims contain NDC coding and unit information to be paid for home infusion and J codes. Services reimbursed by the health plan shall not be included in any pharmacy benefit limits established for pharmacy services. The PDL and Prescription look-up tool can be found at UHCCommunityPlan.com. Durable Medical Equipment As medically necessary. Specified DME services shall be covered/non-covered in accordance with rules and regulations. Medical Supplies As medically necessary. Specified medical supplies shall be covered/noncovered in accordance with rules and regulations. Emergency Air and Ground Ambulance Transportation As medically necessary. Speech Therapy* Covered as medically necessary by a Licensed Speech Therapist to restore speech (as long as there is continued medical progress) after a loss or impairment. The loss or impairment must be the results of a stroke, accidental injury, or surgery to the head or neck. Occupational Therapy* Covered as medically necessary when provided by a Licensed Occupational Therapist to restore, improve, or stabilize impaired functions. Physical Therapy* Covered as medically necessary when provided by a Licensed Physical Therapist to restore, improve, or stabilize impaired functions. UnitedHealthcare Community Plan Provider Manual 2/14 27 UnitedHealthcare hawk-i provider services: 888-650-3462 Service Benefit Limit Organ and Tissue Transplant and Donor Organ Procurement All medically necessary and non-investigational/experimental organ and tissue transplants, as covered by Medicare, are covered. Unless noted below, the services of United Resource Network (URN) must be used and a prior authorization is required, please contact Provider Service for assistance. Example of transplants include: • Bone marrow/Stem cell; • Cornea; (Do not require a prior authorization or the services of URN) • Heart; • Heart/Lung; • Kidney; • Kidney/Pancreas; • Liver; • Liver/Small bowel; • Lung; • Pancreas; and • Small bowel Reconstructive Breast Surgery Coverage of all stages of reconstructive breast surgery on a diseased breast as a result of a mastectomy, as well as surgical procedures on the non-diseased breast to establish symmetry between the two breasts in the manner chosen by the physician. Chiropractic Services Allowed with a UnitedHealthcare prior authorization. A network provider must contact UnitedHealthcare in advance to request the prior authorization to a chiropractor. Benefits are covered for therapeutic application of chiropractic manipulative treatment rendered to restore/improve motion, reduce pain and improve function in the management of an identifiable neuromusculoskeletal condition. Coverage is not available for health-related services which do not seek to cure, or which are provided during periods when the medical condition of the patient who requires the service is not changing. *Maximum 60 combined outpatient treatment days per calendar year per disability. Exclusions and Limitations guidelines, to assist clinicians in making informed decisions in many health care settings, including acute and sub-acute medical, rehabilitation, skilled nursing facilities, home health care and ambulatory facilities. There are exclusions and limitations to the UnitedHealthcare hawk-i covered services. Contact provider service to verify coverage. The Coverage Policy Library can be located online at UHCCommunityPlan.com. Select Billing and Reference Guides from the left navigation buttons, then click on Coverage Policy Library. In addition and when appropriate, UnitedHealthcare uses Milliman® Care Guidelines®, which are nationally recognized clinical UnitedHealthcare Community Plan Provider Manual 2/14 Emergency Transportation UnitedHealthcare hawk-i benefits provide for emergency transportation. Non-emergent (routine) transportation is not a covered benefit. 28 UnitedHealthcare hawk-i provider services: 888-650-3462 Coverage of Abortions Documentation Required for Claim Payment The health plan covers abortions pursuant to applicable federal and state laws and regulations. Please submit medical records detailing the procedure with the claim. This will facilitate faster claims payment. When coverage requires the completion of a specific form, the form must be properly completed as described in the instructions with the original form maintained in the member’s medical file and a copy submitted to the health plan. Abortions Absolute • State medical necessity form • Documentation (police report statement from rape crisis centers) to support necessity form Abortions, Suspect or Missed • Ultrasound report or physician’s documentation report Required forms for abortions are available online at UHCCommunityPlan.com. • History and physical (documentation of ultrasound, history of bleeding, open os, etc.) Under the Hyde Amendment, the health plan is permitted to provide reimbursement for abortions only when one of the following circumstances is present: • Operative report • Pathology report • There is credible evidence to believe the pregnancy is the result of rape or incest. • The abortion is medically necessary because the mother suffers from a physical disorder, physical injury, or physical illness, including a lifeendangering physical condition caused or arising from the pregnancy itself, that would place the woman in danger of death unless an abortion is performed. A “Certification of Medical Necessity for Abortion” form must be completed by the physician. This form along with supporting documentation must be attached to the claim form. UnitedHealthcare Community Plan Provider Manual 2/14 29 UnitedHealthcare hawk-i provider services: 888-650-3462 Member Rights and Responsibilities Member Rights and Responsibilities • Be free from any form of restraint or seclusion used as a means of coercion, discipline, convenience or retaliation. UnitedHealthcare hawk-i Members have the right to timely, high quality care, and treatment with dignity and respect. Network providers must respect the rights of all UnitedHealthcare hawk-i Members. Following are the member rights and responsibilities, as provided in the Member Handbook. • Get a copy of your child’s medical record, talk about it with your child’s doctor, and to ask, if needed, that your child’s medical record be amended or corrected. • Have your child’s medical record be kept private, shared only when required by law or contract or with your approval. You and your child have the right to: • Receive information about UnitedHealthcare, its services, the doctors providing the care, and member rights and responsibilities in a manner and format that is easily understood. • Receive respectful care in a clean and safe environment free of unnecessary restraints. • Receive information about physician incentives. • Participate in decisions regarding your child’s health care. • Make an advance directive. • Be told by your child’s doctor what is wrong, what can be done and what the likely result will be in a language you understand. You and your child have a responsibility to: • Learn about available options and alternatives to treat your child. • Give information that UnitedHealthcare and your child’s doctor need to give proper care to your child. • Voice complaints or appeals about UnitedHealthcare and the care we provide. • Listen to the doctor’s advice, follow instructions and ask questions. • Suggest changes to UnitedHealthcare’s member rights and responsibilities. • Understand your child’s health problems and work with your child’s doctor to develop treatment goals. • Be cared for with respect and dignity, without regard for health status, physical or mental handicap, sex, race, color, religion, national origin, age, marital status, or sexual orientation. • Work with your child’s doctor to guard and improve your child’s health. • Find out how your child’s health care system works by reading this member handbook and other member materials. • Be told where, when and how to get the services you need from UnitedHealthcare. • Go back to your child’s doctor or ask for a second opinion if your child does not get better. • Get a second opinion about your child’s care. • Give your OK to any treatment or plan for your child’s care after that plan has been fully explained to you. • Treat health care staff with respect you expect yourself. • Tell us if you have problems with any health care staff. • Refuse care for your child and be told what you may risk if you do. UnitedHealthcare Community Plan Provider Manual 2/14 30 UnitedHealthcare hawk-i provider services: 888-650-3462 • Keep your child’s appointments. If you must cancel or reschedule, call the doctor as soon as you can. and ethnic backgrounds. Network providers must cooperate with UnitedHealthcare in meeting this obligation. • Use the emergency room only for real emergencies. UnitedHealthcare does not reimburse for translation services for hawk-i members in the provider office setting. Providers are responsible for offering these services without charge to the member and should not be billed to UnitedHealthcare. This is a requirement under Title VI of the federal regulations. • Call your doctor when your child needs medical care, even if it is after office hours. • Follow the rules and limitations that are explained in this member handbook and the Evidence of Coverage. • Contact only UnitedHealthcare hawk-i network providers to arrange medical care when needed. Disease Management Member Rights and Responsibilities As a member of the health plan, members also have certain rights and responsibilities specific to disease management services they receive. • Get a prior authorization for referral services, when needed, as explained in your member handbook. • Comply with the limits of the prior authorization. • Carry and use your child’s member ID card. Always identify your child as a UnitedHealthcare hawk-i member before receiving medical care. Disease Management Member Rights 1. Upon request, have access to information about the organization’s disease management programs and services, including those provided by a vendor, its staff and its staff ’s qualifications and any contractual relationships. One of the most important responsibilities you have is to use network providers. The only exceptions to this rule are: • When your child received a prior authorization from UnitedHealthcare after working closely with their network provider on needed care. 2. Members may decline participation or disenroll (opt out) from disease management programs by contacting the health plan’s disease management department. • When the situation is a medical emergency. 3. Members have the right to know which staff members are responsible for managing disease management services for the individual patient. Remember that not all network providers in your community are contracted with UnitedHealthcare hawk-i. You can call the customer service number listed on your child’s member ID card or go to UHCCommunityPlan.com to find out if a doctor is in the UnitedHealthcare hawk-i network. 4. Members will receive support from the health plan in making decisions with their treating providers regarding health care. 5. Members have the right to information, in an understandable form, about all disease management-related treatment options included in provider practice guidelines, whether or not they are covered under the member’s benefit plan, and are encouraged to discuss treatment options with their treating providers. Services Provided in a Culturally Competent Manner UnitedHealthcare is obligated to ensure that services are provided in a culturally competent manner to all Members, including those with limited English proficiency or reading skills, and diverse cultural UnitedHealthcare Community Plan Provider Manual 2/14 31 UnitedHealthcare hawk-i provider services: 888-650-3462 e. Obtain recommended screenings according to the disease-specific standards of care. 6. Member’s personal identifiable data and medical information will be kept confidential in accordance with applicable law. f. Have a primary care provider that plans and coordinates your care. 7. Members will be treated privately, with courtesy and respect. g. Know the goals and targets you have agreed to with your physician; know your current status in order to make lifestyle modifications to meet those goals and targets. 8. Members have the right to file a complaint according to the procedure as set forth in the appropriate benefit plan documents if they experience a problem with any service, provider, or with the organization. h. Actively participate in your disease management program by following prescribed treatments and recommendations, reading and applying written and verbal information provided to you, and giving feedback to the disease management staff and your treating provider regarding your progress. 9. Members may have the organization act as a patient advocate. Disease Management Member Responsibilities 1. Provide, to the extent possible, information needed by professional staff in order to provide disease management services for the member. 3. Inform all providers providing your care of treatments and recommendations you are receiving from other providers. 2. Following instructions, advice and guidelines agreed upon with those providing your health care and disease management services. The instructions may include but are not limited to the following: a. Follow exercise and dietary prescriptions b. Daily monitoring (e.g., blood glucose monitoring, peak flow readings, blood pressure) as prescribed. c. Consistent use of prescribed medications. d. Schedule and keep follow-up appointments. UnitedHealthcare Community Plan Provider Manual 2/14 32 UnitedHealthcare hawk-i provider services: 888-650-3462 Care After Hours In the event of a medical emergency, a member should seek care from the nearest doctor or hospital. If the member has questions or needs medical advice, they may contact OptumHealth NurseLine. OptumHealth NurseLine Services OptumHealth NurseLine is a service that gives medical facts and access to health information. NurseLine can be accessed 24 hours a day by calling 877-244-0408 and TDD (Hearing-Impaired) 711. OptumHealth NurseLine can provide: • Help to avoid unnecessary emergency room visits. • Guidance to callers on appropriate treatment settings. • Education about the importance of healthy lifestyle choices. UnitedHealthcare Community Plan Provider Manual 2/14 33 UnitedHealthcare hawk-i provider services: 888-650-3462 Health Services Treatment Philosophy If you need to recommend a member to a specialist for medically necessary services, and UnitedHealthcare does not have the needed specialist in-network, or, should the member feel that an in-network specialist does not meet their needs; you must first receive approval from UnitedHealthcare to recommend an out-of-network specialist. Emergency services never require prior authorization. The health plan encourages prevention and early treatment of illness for its members and is committed to creating and maintaining relationships with its network providers. The health plan has established and made available assessment, treatment planning, and documentation guidelines and has adopted practice guidelines to assist the providers. These assessment guidelines recognize the importance of a thorough assessment to screen for medical and behavioral disorders. Women can choose any of our network OB/GYN or midwives to deal with women’s health issues. Women can have routine check ups, follow-up care if there is a problem, and regular care during pregnancy. Primary Care Provider (PCP) Responsibilities UnitedHealthcare works with members and providers to ensure that all participants understand, support, and benefit from the primary care case management system. The PCP acts as the medical home for members. PCPs coordinate members’ medical care with all other health care professionals and services. Responsibilities of the PCP Role of the PCP In addition to the requirements applicable to all providers (see Network Provider Requirements), the responsibilities of the PCP include: The PCP plays a vital role as a physician case manager in the UnitedHealthcare system by improving health care delivery in four critical areas—access, coordination, continuity, and prevention. The PCP is responsible for the provision of initial and basic care to members, makes recommendations for specialty and ancillary care, and coordinates all care delivered to members. The PCP must provide 24/7 coverage and backup coverage when he or she is not available. The PCP is the point of entry into the delivery system, except for emergencies and out-of-area urgent care services. UnitedHealthcare expects PCPs to communicate with specialists the reason for the necessity of specialty services by way of a prescription or note on their letterhead. UnitedHealthcare also expects PCPs to note the reason for the recommendation in the patient’s medical record. UnitedHealthcare expects a specialist to communicate to the PCP significant findings and recommendations for continuing care. UnitedHealthcare Community Plan Provider Manual 2/14 • Offer access to office visits on a timely basis, in conformance with the standards outlined in the Timeliness Standards for Appointment Scheduling section in this manual. • Conduct a baseline examination during the member’s first appointment. • Treat general health care needs of members. Use nationally recognized clinical practice guidelines as a guide for treatment of important medical conditions. Guidelines can be found in the Preventive Health & Clinical Practice Guidelines section of this manual. 34 UnitedHealthcare hawk-i provider services: 888-650-3462 • Coordinate each member’s overall course of care. • Take steps to encourage all members to receive all necessary and recommended preventive health procedures in accordance with the Agency for Healthcare Research and Quality, US Preventive Services Task Force Guide to Clinical Preventive Services, http://www.ahrq.gov/clinic/uspstfix.htm. • Be available to members by telephone 24 hours a day, 7 days a week, or have arrangements for telephone coverage by another UnitedHealthcare network PCP. No recorded messages are permitted. • Make use of any member lists supplied by the health plan indicating which members appear to be due preventive health procedures or testing. • Respond to after-hour patient calls within 30–45 minutes for non-emergent symptomatic conditions and within 15 minutes for emergency situations. • Be sure to timely submit all accurately coded claims or encounters to ensure member preventive health lists or the PCP personal provider profile reports are as accurate as possible. • Educate members about appropriate use of emergency services. • Discuss available treatment options and alternative courses of care with members. • Understand PCP Provider Profiling reports and use them to help determine what areas of practice may need to be strengthened as compared to peers. Profiles are already risk adjusted for the age, sex and patient health. • Refer services requiring prior authorization to the Pre-Certification Department, Behavioral Health, or Pharmacy as appropriate. • Inform UnitedHealthcare Care Management of any member showing signs of End Stage Renal Disease. • For questions related to profiles, member lists, practice guidelines, medical records, government quality reporting, HEDIS, etc., call Provider Services. • Admit UnitedHealthcare members to the hospital when necessary and coordinate the medical care of the member while hospitalized. • Provide all EPSDT services to members up to 21 years. • Respect the Advance Directives of the patient and document in a prominent place in the medical record whether or not a member has executed an advance directive form. • Screen UnitedHealthcare members for behavioral health problems, using the Screening Tool for Chemical Dependency (a.k.a. Substance Abuse) and Mental Health. File the completed screening tool in the patient’s medical record. • Provide covered benefits in a manner consistent with professionally recognized standards of health care and in accordance with standards established by UnitedHealthcare. • Make recommendations to network specialists for health problems not managed by the PCP. The PCP completes a prescription or a note on a letterhead indicating the reason for the recommendation and assists the member in making an appointment. No formal referral form is required. The prescription note will suffice. • Document procedures for monitoring patients’ missed appointments as well as outreach attempts to reschedule missed appointments. • Transfer medical records upon request. Copies of members’ medical records must be provided to members upon request at no charge. • Document the reason for a specialist recommendation and the outcome of the specialist intervention in the member’s medical record. UnitedHealthcare Community Plan Provider Manual 2/14 35 UnitedHealthcare hawk-i provider services: 888-650-3462 Communication With PCPs and Other Health Care Professionals - Behavioral Health • Allow timely access to UnitedHealthcare member medical records as per contract requirements for purposes such as: medical record keeping audits, HEDIS or other quality measure reporting, and quality of care investigations. Such access does not violate HIPAA regulations. To appropriately coordinate and manage care between behavioral health care clinicians and medical professionals, the health plans asks that clinicians attempt to obtain the member’s consent to exchange treatment information with medical care professionals (e.g., primary providers, medical specialists) and/or other behavioral health care clinicians (psychiatrists, therapists). Coordination and communication should take place at: the time of intake, during treatment, the time of discharge or termination of care, and between levels of care. • Maintain staff privileges at a minimum of one UnitedHealthcare network hospital. • Report infectious diseases, lead toxicity, and other conditions as required by state and local laws and regulations. Coordination With Other Service Providers/Contractors The coordination of care between behavioral health care clinicians and medical care professionals improves the quality of care to our plan participants in several ways: Your office may contact dental, vision, pharmacy, and mental health/substance abuse services directly on behalf of the member, or you may contact Provider Services for assistance with coordination, as needed. Contact information for other covered services is located in the front of this manual. • Communication can confirm for a primary physician that his or her patient followed through on a referral to a behavioral health professional. Coordination of care between physical, mental health, and substance abuse providers is important for improved outcomes in treatment. Providers should evaluate individuals in their care for other health care needs and refer as appropriate. If referral information to other providers is needed, providers may contact Provider Service. Referrals to other providers should include, at a minimum, the individual’s identifying information, the reason(s) for the referral, medication(s) the individual is currently being prescribed, diagnosis(es), current course of treatment, and any other pertinent information deemed appropriate by the referring provider. All referrals should be documented in the member’s chart. UnitedHealthcare Community Plan Provider Manual 2/14 • Coordination minimizes potential adverse medication interactions for member’s prescribed psychotropic medication. • Coordination allows for better management of treatment and follow up for members with coexisting behavioral and medical disorders. • Continuity of care across all levels of care and between behavioral and medical treatment modalities is enhanced. • For members with substance abuse disorders, coordination can reduce the risk of relapse. 36 UnitedHealthcare hawk-i provider services: 888-650-3462 The following guidelines are intended to facilitate effective communication: During the diagnostic assessment session, request the patient’s written consent to exchange information with all appropriate treatment professionals. Following the initial assessment, provide other treating professionals with the following information within two weeks: • Summary of patient’s evaluation. • Diagnosis. • Treatment plan summary (including any medications prescribed). • Primary clinician treating the patient. • Update other behavioral health clinicians and/or primary or referring physicians when the patient’s condition or medications change. At the completion of the treatment, send a copy of the termination summary to the other treating professionals. • Attempt to obtain all relevant clinical information that other treating professionals may have pertaining to the patient’s mental health or substance abuse problems. Some members may refuse to allow for release of this information and this decision must be noted in the clinical record. Both accreditation bodies and the health plan expect all clinicians to make a “good faith” effort at communicating with other behavioral health clinicians and any medical care professionals who are treating the plan participant. UnitedHealthcare Community Plan Provider Manual 2/14 37 UnitedHealthcare hawk-i provider services: 888-650-3462 Prior Authorization Guidelines Services That Require Prior Authorization and Contact Information Non-urgent prior authorization requests must contain the documentation required for each particular procedure or device. Once all documentation has been received, notification of the decision will be made to the Provider within 14 calendar days. Urgent pre-service requests will be decided and communicated within 72 hours. You may also contact Provider Services to request a current list of services that require prior authorization and a list of codes. Prior Authorization forms can be found online at UHCCommunityPlan.com. In the event of an adverse decision, the Provider may discuss the case with the Medical Director, and the member has the right to appeal as outlined in their member handbook. For any benefit question, please contact Provider Service at 888-650-3462. Service Needed Behavioral Health and Substance Abuse Go to www.liveandworkwell.com for information about Behavioral Health services Call 800-510-5145 Medical Services Call 888-650-3462 Go to www.UHCCommunityPlan.com for the Coverage Policy Library, which includes services that require prior authorization. • Chiropractic • Cosmetic and Reconstructive Surgery • Durable Medical Equipment and Supplies • Home Health – Medication or Infusion – All other • Hospice • Hospital Inpatient – Acute – Sub-acute • Abortion • Non-Contracted Provider Services (Hospital and Professional) • Prosthetics and Orthotics • Skilled Nursing Facility • Transplant • Medical Injectables Including but not Limited to – Acthar HP – Botulinum Toxins – Immune Globulins – Makena Call 800-310-6826 or fax requests to 866-940-7328 Pharmacy The PDL can be found at UHCCommunityPlan.com UnitedHealthcare Community Plan Provider Manual 2/14 38 UnitedHealthcare hawk-i provider services: 888-650-3462 Referral Procedure **A referral does not guarantee payment of a claim. Certain procedures and DME equipment require prior authorization and benefit determination as outlined in the member’s Plan Document. Out-of-Network Procedures for Referral to Non-Network Providers When services are not available from a network physician, prior authorization for a referral to non-network physicians or facilities is required. The health plan must be advised of all requests for prior authorizations (except emergencies). In the case of emergencies, the health plan must be notified the first working day following referral. Prior authorization for extensions must also occur as described above. Prior authorization is required for each follow up visit unless otherwise indicated. Network physicians must arrange for care by non-network physicians or facilities prior to the service, except in emergencies or accidents. If a member requests authorization after the fact, please advise them that this is against policy and refer them to the health plan if they have further questions. UnitedHealthcare Community Plan Provider Manual 2/14 39 UnitedHealthcare hawk-i provider services: 888-650-3462 Medical Record Charting Standards Medical Record Charting Standards • Working diagnosis(es) must be documented and must be consistent with findings. • All pages of the record must contain patient identification (name and identifying number). • Plans of action/treatment must be consistent with diagnosis(es). • The record must contain biographical/personal data, such as age, date of birth, sex, race/ethnicity, and marital status/social supports as well as a notation of cultural/linguistic needs. • Episodes of emergency care, hospitalizations and discharge summaries must be documented, including follow-up care, such as home health visits, physical therapy reports, etc. • Each entry must have provider name, initials, or other identification (even for solo practitioner sites). • Each encounter must include documentation of clinical findings and evaluation, as well as a followup plan, such as date for return visit. • Each entry must be dated and signed. • The record must be legible, as judged by the auditor (illegibility of records may result in the need for provider assistance in completing the audit). • Each encounter must present evidence that unresolved problems from previous visits have been addressed. • The record must contain a completed, up-to-date, problem list and a list of all prescribed medications. • Consultations documented in the record must be appropriate given patient characteristics, history, and presenting problems. • Allergies and adverse reactions to medications must be prominently displayed for patients of all ages. Document even if no allergies exist. • The record must document appropriate coordination of care between the PCP and authorized specialty physicians. • The record must contain an appropriate and organized medical history and physical exam. • Consultant summaries, lab reports, imaging study reports, operative procedures, and tissue excisions must be noted in the chart or otherwise reflect physician review. • Preventive services/risk screenings must be appropriately used and documented. • Pediatric charting must contain a completed immunization record and BMI charting and anticipatory guidance documentation. • Care must be medically appropriate. • The record must document efforts to educate patients, including lifestyle counseling, and disease specific education. • Adolescents should be screened for and counseled on depression, substance abuse, tobacco use, sexual activity, exercise and nutrition. • Records should reflect the patient’s advance directives. • The record must document smoking habits and history of alcohol and substance use: negative histories also must be noted. If the history is positive for any of these habits, document advice to quit. • Providers are to maintain an organized medical record keeping system and standards for the availability of medical records and medical record retention. • Lab and other studies must be signed and documented. • Providers are to maintain the confidentiality of all medical records in accordance with any applicable statutes and regulations. • Notes must be appropriate in presenting a problem or complaint. UnitedHealthcare Community Plan Provider Manual 2/14 40 UnitedHealthcare hawk-i provider services: 888-650-3462 • All medical records are to be stored securely. Only authorized personnel are to have access to the records and all staff should receive periodic training on maintaining confidentiality of member information. • Treatment involving the care of more than one member of a family should have separate treatment records for each identified and diagnosed member and billing records should reflect the plan participant who was treated and the modality of care. • Problem list. • Medication list. • Policy for monitoring and addressing missed appointments. • Clinical tools for flow sheets for patients with chronic conditions. Does the record contain practice guidelines, prescription printouts with safety warnings, flow sheets for monitoring diabetic labs, etc. for patients with chronic conditions. UnitedHealthcare Community Plan Provider Manual 2/14 41 UnitedHealthcare hawk-i provider services: 888-650-3462 Member Access and Availability that could seriously jeopardize the life or health of the member or the member’s ability to regain maximum function, based on a prudent layperson’s judgment, or in the opinion of a practitioner with knowledge of the member’s medical condition, would subject the member to severe pain that cannot be adequately managed without the care or treatment that is the subject of the request. The health plan has established standards for the access and availability of network primary care, designated specialty care practitioners and provider services, as necessary to meet the health care needs of the member population or demographically significant sub-populations. Health plan members expect, and should receive, reasonable and timely access to health care from network practitioners irrespective of physical, mental, language, or cultural barriers. The health plan’s goal is to select and retain practitioners and providers to meet the medical health care needs of members. • Emergency: A physical or behavioral condition manifesting itself by an acute symptoms of sufficient severity (including severe pain) that a prudent layperson, who possesses an average knowledge of health and medicine, could reasonably expect the absence of immediate medical attention to result in the following: These standards allow for evaluation of practitioners’ performance in the area concerning accessibility of appointments and scheduling times. These standards allow for evaluation of the health plan’s performance in the area concerning an adequate availability of practicing practitioners and providers. 1. Placing the health of the individual (or with respect to a pregnant woman, the health of the woman or her unborn child) in serious jeopardy; 2. Serious impairment to bodily functions; or 3. Serious dysfunction of any bodily organ or part. Access Medical Appointment Scheduling Guidelines Accessibility guidelines are established to ensure that members are provided with access to timely, urgent, routine, and consult appointments, telephone procedures, and after hours or emergent care. • Preventive physical exam appointments on patients with no acute problems should be scheduled within 3 weeks. Each network practitioner/provider will provide or will arrange to provide all necessary services to members on a 24 hours a day, 7 days a week basis. Access will be provided after hours through on-call coverage. – Well childcare appointments within 3 weeks. – General medical exams (including pelvic exams with PAP smears) should be scheduled within 3 weeks. • Preventive: Covered services for well exams for adults and children and scheduled follow-up exams. Patients are normally free of symptoms or no acute symptoms. – Mammograms should be scheduled within 3 weeks. – Preventive Dental and Optometry care within 3 weeks. • Routine: Non-urgent, non-emergent, medical or behavioral health care. – Lab and X-ray appointments within three 3 weeks. • Urgent: Covered service for an illness or injury manifesting itself by acute symptoms that are of medical care or treatment for an illness or injury UnitedHealthcare Community Plan Provider Manual 2/14 42 UnitedHealthcare hawk-i provider services: 888-650-3462 • Appointments for urgent complaints that can be handled in the office should be seen within 48 hours. Patient phones calls for urgent complaints may result in either an appointment to be seen within 48 hours or referral for telephone follow-up. • Patients scheduled for procedures (lab, X-rays) are to be seen within 45 minutes of their scheduled procedure. • Emergencies are seen immediately, at the nearest available facility, regardless of the contract. Availability guidelines are established to meet the health care needs of the member population or demographically significant sub-populations. Availability • Referral appointments to specialty care (specialty care includes, but not limited to: specialty practitioner, specialty facilities, hospice care, home health care, rehabilitation/skilled) shall not exceed 30 days for routine care or 48 hours for urgent care. Availability Standards are: • PCP and/or Extender: – Not to exceed 30 miles (one way) or 30 minutes. • Specialty care: • Routine care (non-urgent, non-emergent, symptomatic conditions) appointments with PCP should be scheduled within three 3 weeks. – Travel distance does not exceed 60 miles. • 1 Hospital: – Not to exceed 30 minutes. • Access will be provided after hours through on-call coverage. • General Optometry Services: – Not to exceed 30 minutes. Waiting Time Guidelines • Lab and X-ray: – Not to exceed 30 minutes. • A practitioner or his/her designee should be available 24 hours a day, 7 days a week for emergency care. • Pharmacy within 30 minutes. Continuity and Coordination of Care • After-hours calls to the answering service for urgent problems are to be returned within 15 minutes or as soon as possible. Continuity and Coordination of Care is monitored in the following areas: • Non-urgent phone calls to the practitioner during regular office hours are to be returned the same day by the practitioner or designee. The practitioner office staff should set an expectation with the caller as to when the call will be returned. • Mental health and substance abuse. • Specialty care. • Hospital. • Home health and other ancillary providers. • Urgent phone calls to the practitioner during regular office hours are to be returned by the practitioner or his staff designee as soon as possible. • Transplant services. • Health departments that provide care to members. • Patients with scheduled appointments are to be seen by the practitioner within 45 minutes of their scheduled appointments. UnitedHealthcare Community Plan Provider Manual 2/14 • ER use review. 43 UnitedHealthcare hawk-i provider services: 888-650-3462 The PCP has the overall responsibility for the continuity of patient care and should receive treatment information and regular care updates from specialty providers, including mental health and substance abuse providers. • Medical Record Review. • Referral and prior authorization process. • Disease management process. • Access and availability process. • Cultural/linguistics process. Specialty providers have the responsibility to provide regular care updates to the members PCP within the guidelines of member’s confidentiality. Continuity and coordination of care between members and providers delivering specialty services such as home health, health departments, Centers of Excellence for transplants, tertiary care hospitals and sub-acute facilities are monitored by the case managers and regional Care Management (CM) staff. Continuity of care is also monitored by ambulatory medical record review, inpatient concurrent review, and pharmacy claims data analysis. Member complaint information, customer service logs, network physician input, practitioner satisfaction surveys, concurrent review, and case management includes some element to monitor continuity of care, and when opportunities for improvement occur, the health plan staff work to create interventions to improve processes. The CM staff work closely with providers to ensure there is the integration of physical, mental health, and substance abuse care. Should providers encounter difficulties in securing medically necessary, covered services for health plan members, the CM and Customer Service staff are able to assist. These individuals can be reached by contacting Provider Services. Providers of physical health care are encouraged to assess patients for mental health and substance abuse problems and refer as appropriate. Providers of mental health services should evaluate members in their care for physical health and substance abuse problems. Substance abuse providers should evaluate for physical health and mental health problems. All providers should refer members for services as appropriate and acceptable to the member. UnitedHealthcare Community Plan Provider Manual 2/14 44 UnitedHealthcare hawk-i provider services: 888-650-3462 Utilization Care Management Programs Goal: The goal of the Utilization Management (UM) Program is to assure that: payment authorization for medications that require prior authorization. • Care provided is the right care, for the right patient, at the right time. UM decisions are based on the appropriateness of the care and services as determined by national guidelines for best practice taking into consideration individual patient needs as appropriate. The health plan does not compensate or reward UM reviewers for denials of coverage. Nor do reviewers receive financial incentives to influence UM decisions. • Care is provided in the most appropriate setting. • Care is provided is by the most appropriate provider. • To accomplish this goal, the processes must be sound and the application of the processes must be consistent. Some services, which providers may recommend, are not covered as part of the benefit package. If you have questions about what services or treatments are covered, contact Provider Services. The health plan: • Uses CM and continuums of care principles. • Uses guidelines for care. • Tracks medical utilization data. Components of UM Program • Follows guidelines as established by all applicable regulatory and accrediting bodies including NCQA and CMS. Prior Authorization – A documented process for authorizing out-of-network care at an in-network level of benefits as determined by the member’s benefit plan. • Evaluates annually the effectiveness of the health care management programs. Inpatient Review – A process for reviewing the appropriateness of admission to the hospital and ongoing inpatient care. • The health plan reports outcomes and customer satisfaction using the standard measures of Medicare, Healthcare Effectiveness Data and Information Set (HEDIS) and Consumer Assessment of Health care Providers (CAHPS) and Systems. Ambulatory Review – A process for evaluating the appropriateness of services performed in the ambulatory setting. Confidentiality of Physician-Specific Information – Physician-specific information gathered during the UM processes is confidential and will not be released to the public or the member without written consent of the physician. Network providers agree to comply with the health plan’s medical policies, QI and Medical Management programs, and ongoing Utilization Review Program. Our philosophy is that medically appropriate care is cost-effective care. Inappropriate denials of coverage is more costly to the plan than coverage for appropriate care. The health plan seeks to avoid under and over utilization of medical services. Organization and Responsibility – The development and continued improvement of the UM Program is the responsibility of the Health Services Process. Responsibility for ongoing monitoring of the application of the UM Program lies with the Chief Medical Officer. Only qualified physicians may issue UM denials. Only registered pharmacists or physicians may deny UnitedHealthcare Community Plan Provider Manual 2/14 45 UnitedHealthcare hawk-i provider services: 888-650-3462 Authority for Medical Management Decisions Advance Directive The patient Self-Determination Act requires that HMO patient records (charts) note whether or not an advance directive has been made. If the patient has given the physician a copy, it should be filed in the patient’s chart. A notation that the physician has addressed advance directives should be present on adult (age 18 and older) patient charts. Criteria exist which may allow a Utilization Care Manager (UCM) to approve payment for a treatment, physician or location of treatment. The ultimate authority, however, for any denial of a request for payment lies with the Physician Advisor. The attending physician has the ultimate authority for the medical care of the patient. The medical management process does not override this responsibility. If there is disagreement regarding the appropriate intensity or location of care, the attending physician shall be allowed to care for the patient without any encumbrances from the medical management process. Advance directives are also available for members to specify their desires for behavioral health services. These directives are called Declarations for Mental Health Treatment. Services Out of Network Members must receive routine, preventive, and scheduled care within the UnitedHealthcare hawk-i provider network. Peer Review Process Peer review is an integral part of the CM Program. The Medical Director reviews issues relating to quality of care and patient safety. These issues are reviewed on a case-by-case basis and takes into consideration individual patient circumstances. The peer review process recognizes best practice, community standards of care, and the local health care systems. Out-of-network services are only covered if: an emergency condition exists, or an approved prior authorization has been granted. • Notification from network providers pertaining to such services received by the health plan must be directed to Health Services. • The health plan processes service requests for treatment authorizations under the direction of the network provider and out-of-network attending physician. Technology Review Process The health plan has a Technology Assessment Process in which to evaluate and address the safety, efficacy, and appropriateness of emerging and new medical/behavioral technologies, as well as keep pace with changes to existing medical/behavioral health technologies and to make recommendations regarding their use for potential inclusion in the benefit plan. This includes medical/behavior health procedures, devices and selected pharmaceuticals. If you have a technology that you would like to have reviewed, please contact Provider Services. UnitedHealthcare Community Plan Provider Manual 2/14 • The health plan, in conjunction with the network provider and the out-of-network doctor, coordinates the member’s transfer back to the UnitedHealthcare hawk-i network when medically feasible as appropriate. • The health plan provides coverage out-of-network for urgent or emergent stabilization services. This will include the time he/she is stabilized in the emergency room, prior to admission as an inpatient or discharge from the facility. 46 UnitedHealthcare hawk-i provider services: 888-650-3462 • The health plan also provides coverage for poststabilization care services. Post-stabilization care services are those that are provided after an enrollee is stabilized in order to maintain the stabilized condition. • Coverage from out-of-area inpatient services continues only as long as the member’s condition prevents transfer to a network hospital. Transfers should occur within 48 hours of determination of member’s transferability. UnitedHealthcare Community Plan Provider Manual 2/14 47 UnitedHealthcare hawk-i provider services: 888-650-3462 Timing of UM Decisions Medical management decisions must be made in a timely manner. The health plan’s turnaround times are in compliance with federal and state regulations as well as NCQA standards. Concurrent Review – services requiring approval for continued authorization of a previously approved, ongoing course of treatment over a period of time or number of treatments. Example: concurrent inpatient, skilled, or rehabilitation review. Every attempt will be made to insure that all pre-service, concurrent, and post-service authorization decisions are made with practitioners and members notified according to the health plan’s policy, regulatory, and external requirements. Post-Service-Review – for services already incurred. Urgent Care – request for medical service in which application of the non-urgent review time frames may in the opinion of a practitioner with knowledge of the member’s medical condition result in severe pain or loss of function. The final decision concerning admission, referral, and the continued medical management of the patient will be solely the responsibility of the attending practitioner. Medical Necessity Health Services Physician Responsibility for Adequate Provider Information To be medically necessary the service or treatment must meet the following criteria: Adequate provider information must be provided by the requesting provider’s office when making UM requests. 1. Recommended by a licensed practitioner who is treating the member or other licensed health care provider practicing within the scope of his or her license who is treating the member. Provider information provided by the requesting physician is the supporting documentation for whether medical necessity can be justified. The absence of complete and adequate provider information at the time of request and review results in increased administrative time and work for both the physician office staff as well as for health plan staff and reviewing physicians. 2. Required in order to diagnose or treat a member’s medical condition. 3. Safe and effective. 4. Not experimental or investigational. 5. The least costly alternative course of diagnosis or treatment that is adequate for the member’s medical condition. Service Definitions The requesting physician may seek the opportunity to discuss decisions with the physician reviewer by calling the number listed on the coverage decision letter. For additional information, see the Medical Necessity section of this manual. ** The health plan has adopted the NCQA service definitions. Pre-Service – services requiring approval for payment, either in whole or part, by the health plan prior to the member receiving services. Example: out-of-network referrals and prior authorization. UnitedHealthcare Community Plan Provider Manual 2/14 48 UnitedHealthcare hawk-i provider services: 888-650-3462 Criteria Used for Medical Management Decisions Reviewers for the health plan are allowed to make decisions to approve care based on specific criteria. These criteria are of two types: Externally Developed Criteria Nationally recognized review criterion is used to guide the Utilization Care Manager in approving inpatient care. Review criteria will be reviewed and approved annually by the Chief Medical Officer. Updates occur annually or as necessary or when provided. Other criteria may be substituted when there is published peer reviewed literature support for admission or continued stay criteria. All criteria are subject to the review and approval process. Internally Developed Approval Criteria The health plan may develop standards for medical appropriateness (approval criteria) e.g., Level of Care Guidelines. These guidelines are reviewed and revised annually utilizing a literature review search of new articles pertaining to levels of care as well as input solicited from providers. Medical necessity criteria are available to network physicians upon request by contacting Provider Services. UnitedHealthcare Community Plan Provider Manual 2/14 49 UnitedHealthcare hawk-i provider services: 888-650-3462 Medical Hospital UM Admissions are usually reviewed on the first working day following admission, using Milliman Care Guidelines and taking the individual enrollee circumstance into consideration. If admission or continued stay does not meet criteria outlined in the guidelines and the individual enrollee circumstance, the nurse reviewer will refer the case to the Medical Director. documented quality of care or service or patient safety issues as well as any system issues with care. Individual patient or physician issues are reviewed on case-by-case basis with the Medical Director. System issues identified by Health Services staff or the Medical Director are addressed with the individual facilities as needed. The Provider Contracting Department will consider this information during the contracting process. The role of the Medical Director is to review for appropriateness of admissions and need for continued stay, as well as the quality of care being provided for those cases referred by a nurse reviewer. Inpatient Review Program The inpatient review program is a review process in which admissions and hospital stays are reviewed to assure that inpatient care is medically appropriate; to identify quality of care concerns and opportunities for improvement; to detect and better manage over and underutilization. Nurse reviewers also review certain care aspects as they relate to disease management programs and practice guidelines. Discharge planning and care management identification also occurs at this time. The nurse should call the attending physician for further information concerning the management/ treatment plan prior to review with the Medical Director. If the Medical Director cannot justify the care, the attending practitioner will be notified. If the attending wants to speak with the Medical Director, they will be afforded that opportunity within one business day of the request. External Independent Review will be obtained as determined by the health plan or by member request according to applicable State laws. The health plan uses Milliman Care Guidelines for review of inpatient confinements directed by network and out-of-network physicians. The ultimate decision regarding medical management of a member is solely the responsibility of the attending physician. An attending physician is never told he/she must discharge a patient, only that the admission/continued stay is not determined to be medically necessary by the health plan. If an admission or continued stay is determined to be medically unnecessary, coverage for those services will not be eligible for authorization and payment, and the physician education/sanction process may be applied. Notice of Termination of Hospital Benefits Hospital Review Process Include but not limited to the following: Concurrent hospital review addresses many aspects of a patient’s medical care in the hospital. Nurses review the hospital record for documentation related to: medical necessity supporting the acute inpatient level of care, potential quality of care concerns, UnitedHealthcare Community Plan Provider Manual 2/14 • Continued hospitalization is determined to be medically unnecessary. 50 UnitedHealthcare hawk-i provider services: 888-650-3462 skilled rehabilitation services would meet the daily basis requirement when he/she needs and receives those services at least 5 days a week. Skilled services, however, are required and provided at least 3 times per day. Although, the frequency with which a service must be performed does not by itself, make it a skilled service. • Treatment occurs that is considered experimental/ investigational and is a non-covered benefit. If any of the situations listed above occur, the following procedures should be followed: • Notify health plan UM immediately. The health plan and hospital representatives will deliver Notice of Termination of Benefits to the member. The nature and complexity of a service and the skills required for safe and effective delivery of that service is considered in determining whether a service is skilled. Skilled care requires frequent patient assessment and review of the provider course and treatment plan for a limited time period, until a condition is stabilized or a predetermined treatment course is completed. Skilled care is goal-oriented to progress the patient toward functional independence, and requires the continuing attention of trained medical personnel. Admission to Skilled Nursing Units **Inpatient hospitalization is not required for a member to be admitted to a Skilled Level of Care. An individual that may require inpatient skilled nursing care is defined as having had an acute illness, injury, surgery, or exacerbation of a disease process. Skilled nursing care is rendered immediately after, or instead of, acute hospitalization to treat one or more specific, active, medical conditions or to administer treatments that must be performed by licensed professional health personnel. In addition, services must be ordered by a physician and be reasonable and necessary for the treatment of the patient’s illness or injury, (i.e., be consistent with the nature and severity of the individual’s illness or injury, his/her particular medical needs, and accepted standards of medical practice.) The services must also be reasonable in terms of duration and quantity. The patient must be clinically stable with provider and lab findings improving/unchanged for the last 24 hours; and diagnosis and initial treatment plan established prior to admission to the skilled nursing facility. • Prior authorization must occur on all admissions to the skilled facility (or skilled level of care within an acute facility). Initial certification for admissions will be authorized based upon level of care required based upon anticipated treatment plan. The facility must submit documented plan of care including treatment goals, summary of services provided, expected length of stay (LOS), and initial discharge plan. • Concurrent review is conducted at least weekly, or more often if indicated. The provider (skilled facility) is responsible for providing appropriate/adequate documentation including changes in the level of care. Approval for additional days of authorized coverage must be obtained prior to the expiration of the authorization. The patient must require skilled services on a daily basis (i.e., available on a 24-hour basis, 7 days a week). If skilled rehabilitation services are not available on a 7 day a week basis, a patient whose inpatient stay is based solely on the need for UnitedHealthcare Community Plan Provider Manual 2/14 51 UnitedHealthcare hawk-i provider services: 888-650-3462 • Determinations regarding levels of care must consider not only level of service but also medical stability of the patient. Disagreements regarding the level of care required are discussed by the health plan Chief Medical Officer or Medical Director in consultation with the attending physician (managing the patient in the skilled facility, not the transferring attending physician). The appeal procedure can be initiated as desired by the patient and/or authorized representative when coverage is not authorized by the health plan. UnitedHealthcare Community Plan Provider Manual 2/14 52 UnitedHealthcare hawk-i provider services: 888-650-3462 Care Management Transplant The Care Management Program provides coordination of care for patients with complex, chronic, or critical health care needs. EPSDT services are also a focus of the Care Management program. The program assists families, patients, and doctors in planning care and services. This is part of a team plan, which looks at individual health care needs. Care Managers assist members and their families by analyzing all options/choices available to them within the health care delivery system. Care management uses a proactive approach in assisting patients and families with coordination of transplant services. This approach supports screening assessment and development of an individualized treatment plan. The primary objective is to ensure quality care in a costeffective manner through our Centers of Excellence. These Centers of Excellence have been evaluated for quality of care. The criteria addressed includes, but is not limited to, volume, rejection protocols, survival rates, and Quality Management Programs. Each program is reviewed annually to assess continuing compliance with criteria. Care Managers contact these members by phone to work cooperatively and effectively with patients for whom some form of behavioral change and motivational interviewing might result in better health outcomes. The intended outcome is to empower members to better manage their chronic conditions and improve their use of clinical, caregiver/family and community resources to improve their health outcome. The role of the Care Manager is intended to support the care prescribed for the member by the attending physician. Their health problems can cut them off from family, co-workers and friends. A cycle of isolation, depression, and a deterioration of their health frequently sends them into a downward trend. In a combined effort of the Care Manager, and in collaboration with the member’s PCPs, members are supported in ways that make the most difference to their health. All home services must be ordered by a physician and prior authorized before services are rendered. UnitedHealthcare Community Plan Provider Manual 2/14 53 UnitedHealthcare hawk-i provider services: 888-650-3462 Disease Care Management The health plan has developed several Disease Care Management Programs which include a coordinated system of health care interventions and communications for populations with specific health care needs. These programs help our members better understand their conditions, provide self-care tips, and give updates on new information about certain diseases and preventive care. Physicians provide input into our health management programs to ensure that they are based on current medical practices. Nurses manage the programs and work with members by providing educational mailings, newsletters, and reminder cards. Physicians also receive information about their patients and the services they are receiving. Participation in health programs is voluntary. Disease Care Management Programs include: • Asthma. • Diabetes. • Pregnancy Management (Healthy First Steps). • Weight Management. For more information, go to UHCCommunityPlan.com. UnitedHealthcare Community Plan Provider Manual 2/14 54 UnitedHealthcare hawk-i provider services: 888-650-3462 Preventive Health and Clinical Practice Guidelines Preventive Health Care Standards (EPDST): Early and Periodic Screening, Diagnosis, and Treatment of Children Under Age 21 UnitedHealthcare’s goal is to partner with providers to ensure that members receive preventive care. Screening, diagnostic and follow-up treatment services are covered when medically necessary in agreement with federal regulations, including rules and regulations, policies and procedures, and federal requirements as described in 42 CRF Part 441, Subpart B, and the Omnibus Budget Reconciliation Act of 1989 for members under 21. 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 or can be viewed at www.ahrq.gov/. UnitedHealthcare monitors the provision of these services through chart reviews and also through a provider profiling system highly dependent on the accuracy of the PCP’s submissions of claims and encounters. Such things as: well child, adolescent and adult visits, childhood and adolescent immunizations, lead screening, and cervical and breast cancer screening are included. The profile is risk adjusted for the members’ comorbidities in order to also profile on hospital, emergency room, specialist and pharmacy utilization. All children and teens under 21 should receive regular checkups. These checkups help find health, speech, hearing, vision, dental, mental health, and drug or alcohol problems. UnitedHealthcare pays for medicine and treatments needed. Members under the age of 21 may be referred for behavioral health services as a result of the EPSDT screening by a health care professional. Behavioral health providers will provide diagnostic and treatment services in accord with the EPSDT screening or diagnosis findings. Clinical Practice Guidelines for Chronic Conditions In the event that a member under 16 years of age is seeking behavioral health services and the member’s parent(s), or legally appointed representative is unable to accompany the member to the assessment, the provider shall contact the member’s parent(s), or legally appointed representative to discuss the findings and inform the family of any other necessary behavioral health treatment recommended for the member. If the provider is unsuccessful in contacting the parent(s) or legal representative, the provider must inform the health plan to contact the parent(s) or legal representative. UnitedHealthcare strongly supports evidence-based medicine and we have identified sources that have received national recognition both from the government and the health care community. We have vetted these sources within the UnitedHealth Group and our own network advisory committees. Providers are encouraged to visit the following websites for clinical practice guidelines as they are intended as an important resource to support and guide your clinical decision making. Clinical Practice Guidelines can be viewed at UHCCommunityPlan.com. UnitedHealthcare Community Plan Provider Manual 2/14 55 UnitedHealthcare hawk-i provider services: 888-650-3462 Periodicity Schedule for Check-ups and Screenings No prior authorization is required for screenings, members must receive services from a network provider, for completion of the exam or for treatment of problems discovered during the exam. Any time a member is in your office, you should ask if they have had their age-appropriate physical for that year. If they have not, this examination should be performed, including any necessary immunizations. A Women, Infants, Children (WIC) visit is not considered a Care for Kids visit. It is also very important that delivery of these services is documented in the patient’s medical record. The health plan sends each eligible member reminders to schedule an exam. Please help us assist our members in obtaining their well-visit exams. Infancy Early Childhood Middle Childhood Adolescence At birth 15 months old 5 years old 12 years old 2-4 days 18 months old 6 years old 14 years old 1 month old 24 months old 8 years old 16 years old 2 months old 3 years old 10 years old 18 years old 4 months old 4 years old 20 years old 6 months old 9 months old 12 months old Recommended Childhood Immunization Schedules Government Quick Reference Guide: http://www.cdc.gov/vaccines/recs/schedules/childschedule.htm#printable The childhood and adolescent immunization schedule for 2013 have been approved by Advisory Committee on Immunization Practices (ACIP), American Academy of Family Physicians (AAFP), and the American Academy of Pediatrics (AAP). Source: AAFP, CDC and Advisory Committee on Immunization Practices Medical Record Requirements Government Childhood and Adolescent Immunizations Guide: There are specific components of screening examinations that must be documented in the medical record. Details regarding these components are listed in the Medical Record Review section of this provider manual. www.cdc.gov/vaccines/recs/schedules/childschedule.htm http://www.aafp.org/online/en/home/clinical/ immunizationres.html?navid=immunizations UnitedHealthcare Community Plan Provider Manual 2/14 56 UnitedHealthcare hawk-i provider services: 888-650-3462 Network practitioner’s office medical records will be reviewed against the recommended components of EPSDT exams. The health plan will utilize the Audit Form for the office medical record review. Offices are selected for audit based upon the services billed by the Provider under defined service codes. These codes are listed in the Billing section of this provider manual. Developmental Screening Component Documentation of a visit should include a description of the developmental behavioral screening method used. When validated developmental screening tests are performed in addition to the preventative medicine service or other services, providers can report CPT code 96110 in addition to the Preventive Medicine Service. Examples listed in CPT include the Denver II and the Early Language Milestones Survey. This service is reported in addition to the Preventive Medicine and other evaluation and management or screening services (hearing, vision, and laboratory) performed during the same visit. Informal developmental checklists are considered part of the history of the preventive medicine visit and not reported and billed separately. You must have a process for documenting services declined by a parent, guardian, or mature competent child. This documentation must include the particular service declined, a notation of the reason why it was declined, and whether another appointment was offered to get the service. If you are unable to complete all components of a exam, or if additional questions or concerns remain after a screening, please schedule a follow-up appointment for the child. Children may receive immunizations at the local health department rather than in a provider’s office. Administration of the immunization must be included in the chart. The documentation should be a print-out from the health department. This information should include the vaccine administered, site, date, lot number, and any reactions noted. NOTE: Verbal reporting from a parent or guardian is not adequate confirmation of administered immunizations. UnitedHealthcare Community Plan Provider Manual 2/14 57 UnitedHealthcare hawk-i provider services: 888-650-3462 Practitioner Education – Sanction Policy Summary be referred to the Provider Advisory Committee between recredentialing cycles. Practitioner issues are taken into consideration when deciding on continued participation. Any issues warranting restricting privileges will be referred to the Credentialing Committee. The Practitioner Education/Sanction Policy has been developed to ensure physical health practitioner compliance with utilization and quality management policies and procedures. Practitioners not in compliance with standards of care or policies and procedures will be advised of the areas of noncompliance and will be notified of their right to appeal. Following is a list of potential actions that may be exercised in the issuance of a sanction in any of the aforementioned categories: Administrative, Utilization, Quality of Practitioner Service, Quality of Care and Professional Conduct. The categories subject to sanctions include: • Administrative. • Utilization. Appropriate education/sanction actions may include but are not limited the following: • Quality of Practitioner Service. • Quality of Care. • Notification and education regarding the occurrence(s); • Professional Conduct. • Educational material from other providers, or literature references; The Chief Medical Officer and Medical Director have the authority to recommend: monetary and non-monetary sanctions and/or to place a practitioner on focused review. • A documented plan for improvement from the practitioner; • Focused review of the practitioner’s practice; If there is a recommendation to terminate a practitioner for conduct falling within the scope of this policy, it must be issued by the Chief Medical Officer or Medical Director. • Additional training and/or mandatory Category 1 CME. All expenses associated with training and CME will be the responsibility of the practitioner; • External, professional review of relevant documentation; When a sanction is issued, practitioners will receive a sanction letter describing the occurrence and notifying them of the sanction action and the consequences that may result from additional incidences. The physician will also be notified in writing of any sanction issued to a mid-level practitioner that they supervise. All practitioners are notified in writing of their right to appeal a sanction via the Participating Practitioner Appeal Process for Sanctions, including the opportunity to have a discussion with the physician reviewer. • Summary suspension; • Establishing a range of actions altering practitioner participation; • Initiation of the termination process; • Monetary sanction. When appropriate, sanctions will be reported to the appropriate regulatory or licensing agency as required. The final decision for imposing sanctions rests with the CEO and Chief Medical Officer or their designee. As necessary, sanction information may UnitedHealthcare Community Plan Provider Manual 2/14 58 UnitedHealthcare hawk-i provider services: 888-650-3462 Professional Conduct Sanctions Arbitration concerning recredentialing and termination shall be conducted in accordance with the Commercial Arbitration Rules of the American Arbitration Association. If arbitration is utilized, the parties must waive their right to seek remedies in court, including their right to jury trial, except for enforcement of the decision of the arbitrator. Professional misconduct will be handled on a case-by-case basis in collaboration with Chief Medical Officer, Medical Director, legal and other appropriate individuals. Suspension and/or termination may result. Appeals of Sanctions If you elect to appeal a sanction, you must notify the issuer of the sanction in writing within 30 days of the date of notification of the sanction. If the initial reviewer does not approve the appeal request, it will be presented to another reviewer of same or similar specialty for the decision. A decision will be made within 30 days of receipt of all information you submit. You will be notified in writing of the appeal decision. Should you disagree with the appeal decision, you will have 60 days from the date of the decision on the appeal to request binding arbitration. The request should be submitted in writing to the issuer of the sanction. The health plan legal department will send the practitioner information regarding how to initiate arbitration with American Arbitration Association (AAA). The practitioner’s request for arbitration must be made to the AAA within 180 days of the decision on the appeal. The question before the arbitrator will be whether the decision being arbitrated should be set aside because the decision was arbitrary and capricious. Judgment upon the decision by the arbitrator may be entered in any court having jurisdiction. Each party will bear its own costs and attorney fees. Both parties will share expenses associated with the arbitration equally. Arbitration shall be final and binding on all parties. UnitedHealthcare Community Plan Provider Manual 2/14 59 UnitedHealthcare hawk-i provider services: 888-650-3462 Denied Payment Authorization Decisions As a network practitioner, you have the right to submit additional information following an initial payment authorization denial, speak to the physician reviewer regarding medical necessity issues involved in the denied payment authorization. As the network practitioner, you make the final provider decision concerning admission, referrals, and the continued medical care of your patients. The health plan makes the final determination concerning payment. If the original decision is not reversed, the provider may then pursue the denied payment authorization through the appropriate Claim Reconsideration or Provider Dispute Process. For denied services that have not been rendered, the member may initiate an appeal by contacting Customer Service at the number on the back of their ID card. Physicians may assist members in the Member Appeal Process. Appeals may be expedited when the member’s medical condition warrants, and the treating physician signs the member’s appeal request for expedited review. UnitedHealthcare Community Plan Provider Manual 2/14 60 UnitedHealthcare hawk-i provider services: 888-650-3462 Quality Improvement The Health Plan’s Quality Management (QM) Department monitors the performance in the following areas: • Cooperation with the member complaint process. • Access to Care. • Participation in health plan Quality Improvement studies related to enhancing provider care or service for health plan members. • Response to inquiries by the health plan QM Committee staff or health plan QM staff. • Member Satisfaction. • Quality Improvement/Management. • Assisting the health plan in maintaining various accreditations as appropriate and as requested by the health plan. • PCP and BH Practitioner Coordination. • Patient Safety. UnitedHealthcare strives to continuously improve the quality of care and service provided by our health care delivery system both from the clinical and non-clinical perspective. The Quality Improvement (QI) Program establishes goals and objectives that encompass the quality improvement activities across the markets we serve. Health promotion, health management and patient safety activities are also an integral part of the QI Program. Upon request, the health plan makes available to provider(s) information about its QM program, including a description of the QM program and a report on the health plan’s progress in meeting its goals. The health plan examines the effect of treatment programs using measures such as, but not limited to, outcome measurement, re-hospitalization rates and drug utilization reviews. Some of the activities involving provider(s) are described in more detail below. Provider Participation in QM Program Service Initiatives Providers are encouraged to participate with the health plan in QM activities. Our committees that address concerns related to members, provider(s) and the health plan are enhanced by the ongoing participation of contracted provider(s). Our committees include the Provider Affairs Committee and QM Committee. Providers are encouraged to offer feedback to the health plan on our various QM projects and processes. In addition, health plan network providers have agreed contractually to comply with the health plan QM Program. The program includes, but is not limited to: Information gathered from a variety of sources is used to identify service initiatives for the health plan. These include but are not limited to complaint information, appeals and directives information customer service logs, member satisfaction surveys, and information obtained in the provider satisfaction surveys. Network Providers must participate in Quality Improvement activities, including service initiatives as they are identified. • Ensuring that care is appropriately coordinated and managed between provider(s) and the member’s primary physician. • On-site audits and requests for treatment records as described below. UnitedHealthcare Community Plan Provider Manual 2/14 61 UnitedHealthcare hawk-i provider services: 888-650-3462 Member Satisfaction Prospective Drug Safety Review – Patient Safety The health plan monitors the FDA Center for Drug Evaluation and Review (CDER) for announcements of drug product recalls or drug product safety warnings. The Pharmacy Director and Chief Medical Officer will evaluate the need for action. In general, a need for action exists when: The health plan utilizes multiple sources for obtaining member feedback. This includes administration of the annual CAHPS® member satisfaction survey, member complaints/appeals, member/provider feedback, and information obtained from member service logs. The information is gathered, sorted, and aggregated. Every attempt is made to address the customer’s issue/problem at the time of the occurrence (1st call resolution). In addition, the information is aggregated for tracking and trending. • A significant safety concern is identified about a pharmaceutical in common use. • The likelihood exists that without intervention from the health plan members will continue to use a pharmaceutical with significant risks to their health. Opportunities, typically service initiatives, are identified and become part of the annual Health Services Work Plan. • The safety warning involves information not previously known to members or providers prior to the issuing of the warning. Quality of Care/Quality of Service Issues When such a situation is determined to exist, an immediate plan of action will be determined. This generally involves a review of claims to identify members currently established on the medication with a high likelihood for continued therapy and their prescribing physician. Depending on the urgency of the situation, a decision will be made to notify the members and/or their physician. Notification may take place through direct mail or scheduled publications (Member Newsletter, Network Bulletin and/or Pharmacy Update), again depending on the urgency and publication schedules. Quality of Care and Quality of Service concerns are member reported or discovered by health plan staff and are investigated in collaboration with the Chief Medical Officer or Medical Director. If a quality issue has occurred, corrective action may include notifying the provider, education, and request for additional CME education for the provider, probation, summary suspension, or termination. The health plan has processes in place to report serious deficiencies to the appropriate agencies and/or National Practitioner Data Bank. Patient Safety Quality medical care is the core of the health plan’s mission and Health Services program. As part of that commitment, the health plan integrates patient safety into the various aspects of the annual Health Services program. The comprehensive focus on patient safety is seen in multiple aspects of the health plan as described below: UnitedHealthcare Community Plan Provider Manual 2/14 62 UnitedHealthcare hawk-i provider services: 888-650-3462 Provider Cooperation With Complaint Investigation and Resolution Pharmacy Programs - Patient Safety The health plan works together to review patient provider information, which it can use to optimize each member’s care. Instances may exist whereby pharmacy utilization patterns may require either immediate intervention or detailed investigation and analysis to determine whether provider issues exist requiring intervention. These may be but are not limited to: Provider(s) are expected to cooperate with the health plan in the quality improvement complaint investigation and resolution process. If the health plan requests written records for the purpose of investigating a member complaint, provider(s) should use their best efforts to submit these to the health plan within 14 business days. Complaints filed by the health plan members should not interfere with the professional relationship between the clinician and member. • Potential drug disease interactions. • Multiple prescriptions within the same pharmaceutical class (polypharmacy). QM staff in conjunction with Network Management staff, will monitor complaints filed against all network provider(s), and solicit information from network provider(s) in order to address the member complaints. The health plan will develop and implement appropriate action plans to correct legitimate problems discovered in the course of investigating member complaints. Such action plans may include the following: • Under-utilization of medications to treat a specific disease process. • Over-utilization of medications to treat a specific disease process. • Utilization of medications in excess of established guidelines. • Suspected uncoordinated health care by multiple practitioners. • Suspected inappropriate/excessive controlled substance usage. • Require the clinician to submit and adhere to a corrective action plan. • Suspected fraudulent and/or illegal acquisition of prescription medications. • Monitor the clinician for a specified period, followed by a determination about whether substandard performance or noncompliance with the health plan requirements is continuing. Health Services monitors the above issues and intervenes as appropriate with either the physician or member. Members who display drug-seeking behavior may be placed in a “restricted access” situation. • Require the clinician to use peer consultation for specified types of care. • Require the clinician to obtain training in specified types of care. We encourage your feedback on all guidelines and welcome any suggestions on new guidelines to be considered for adoption. • Limit the clinician’s scope of practice in treating health plan members. • Cease enrolling or referring any new or existing health plan members to the care of the clinician, or reassign members to the care of another network clinician. UnitedHealthcare Community Plan Provider Manual 2/14 63 UnitedHealthcare hawk-i provider services: 888-650-3462 Chart review measures include: • Temporarily suspend the clinician’s participation status with the health plan. • Childhood Immunization Status. • Terminate the clinician’s participation status with the health plan. • Adolescent Immunization Status. • Cervical Cancer Screening. HEDIS® • Prenatal and Postpartum Care. • Controlling High Blood Pressure. HEDIS, the Healthcare Effectiveness Data and Information Set, is a set of standardized measures collected to show a health plan’s performance in member care. HEDIS is developed (and updated annually) with the knowledge of clinical and technical experts and the representation of purchasers, members, managed care organizations, providers, and policy makers. • Cholesterol Management for Patients with Cardiovascular Conditions. • Comprehensive Diabetes Care. • Beta Blocker Treatment After a Heart Attack. The health plan greatly appreciates providers’ efforts in supporting the HEDIS chart review process each year. HEDIS is compiled and submitted to NCQA each June. Following the completion of HEDIS for NCQA, the health plan publishes a “Report Card” reflecting the scores we’ve reached on the HEDIS measures. HEDIS focuses much of its attention on the major health issues affecting Americans today. The health plan analyzes and applies the results from HEDIS measures when considering disease management strategies in the areas of asthma, diabetes, cardiovascular disease, women’s care, childhood immunizations, and more. Members and providers may use the health plan annual HEDIS results to compare quality across health plans and regions. HEDIS is a part of NCQA’s accreditation program, accounting for 33 percent of the accreditation ranking. Accredited plans are required to submit audited HEDIS data annually. NCQA reassesses a health plan’s accreditation status with each year’s HEDIS, and may raise or lower the standing accordingly. Measures like Beta Blocker Treatment After a Heart Attack, Comprehensive Diabetes Care, Use of Appropriate Medications for People with Asthma, and many others are important tools in care. The focus of the health plan is to improve care to our members, which is reflected by continuously improved HEDIS scores. To reflect the most accurate score HEDIS allows for health plans to conduct “Hybrid Data Collection”. Furthermore, NCQA is very interested in seeing improvement in quality of care on an annual basis. The health plan holds accreditation status from NCQA. For more information about HEDIS, or for a copy of the health plan’s latest HEDIS® report card, contact your local provider service representative. HEDIS® is a registered trademark of the National Committee for Quality Assurance (NCQA) www.ncqa.org. Hybrid data collection is a combination of administrative data and data found manually by medical record review. A sample of members for each measure is randomly selected from the health plan’s population for chart review. HEDIS data collectors review providers’ charts looking for evidence of procedures related to specific care to count in the HEDIS report. UnitedHealthcare Community Plan Provider Manual 2/14 64 UnitedHealthcare hawk-i provider services: 888-650-3462 Member Complaint and Appeal Process member service and request the form. The form must be signed by the member and the person acting on the member’s behalf, then returned to UnitedHealthcare. UnitedHealthcare hawk-i members can voice a complaint or submit a formal appeal about a service or care their child received. If the problem or concern is about their child’s benefits, coverage or payments of services to a provider, they can file an Appeal. • The member also has the right to hire a lawyer to act on their behalf. If the complaint is about the quality of care they received, waiting times or customer service at their child’s doctor’s office, they can file a Complaint. Complaint Process The complaint process is used for problems related to quality and/or service the member receives from their child’s doctor. The following are types of complaints: Appeal Process If UnitedHealthcare makes a decision and the member is not satisfied with this decision, they can “appeal” the decision. An appeal is a formal way of asking UnitedHealthcare to review and change a decision we made. This is called a Level 1 appeal. • Quality of care The appeal request must be within 180 calendar days of the decision. When the member makes an appeal, UnitedHealthcare reviews the decision made. Once the review is complete, the decision is communicated. • Cleanliness • Respecting Privacy • Disrespect, poor customer service • Waiting times • Information you get from UnitedHealthcare The member can call member services to make a complaint. If the member does not wish to call member service, they can put their complaint in writing and send it to UnitedHealthcare at the following address: If the appeal is upheld, the member can request a Level 2 Appeal. The Level 2 Appeal is conducted by a UnitedHealthcare Reconsideration Committee. If the member is not satisfied with the decision at the Level 2 Appeal, the member may be able to continue through more levels of appeal. UnitedHealthcare Community Plan P.O. Box 31364 Salt Lake City, UT 84131 If the member needs help with the Appeal: • The child’s doctor can request an appeal on their behalf. For full details about the complaint and appeals process, refer to the member’s Evidence of Coverage. • The member may also ask someone to act on their behalf. The person may be someone who is already legally authorized to act on the member’s behalf under State Law. If the member wants a friend or relative to act on their behalf, they must call UnitedHealthcare UnitedHealthcare Community Plan Provider Manual 2/14 65 UnitedHealthcare hawk-i provider services: 888-650-3462 Glossary of Terms Adverse Action – Any action taken by the health plan to deny, reduce, terminate, delay or suspend a covered service as well as any other acts or omissions of the health plan which impair the quality, timeliness or availability of such benefits. Iowa Department of Human Services (DHS) – The Iowa governmental agency that administers the State Medicaid and hawk-i programs. For the purposes of this Agreement, Iowa DHS shall mean the State of Iowa DHS and its representatives. Appeal Procedure – The process to resolve a member’s right to contest verbally or in writing, any adverse action taken by the health plan to deny, reduce, terminate, delay, or suspend a covered service as well as any other acts or omissions of the health plan which impair the quality, timeliness or availability of such benefits. The appeal procedure shall be governed by hawk-i rules and regulations and any and all applicable court orders and consent decrees. Medical Emergency – A medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that a prudent layperson, who possesses an average knowledge of health and medicine, could reasonably expect the absence of immediate medical attention to result in: • placing the health of the individual (or with respect to pregnant women, the health of the woman or her unborn child) in serious jeopardy; or • serious impairment of bodily functions; or Behavioral Health Services – Mental health and substance abuse services. • serious dysfunction of any bodily organ or part. Medically Necessary Services – Covered services that are determined through utilization management to be: EPSDT – The Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) service is Medicaid’s comprehensive and preventive child health program for individuals under the age of 21. EPSDT was defined by law as part of the Omnibus Budget Reconciliation Act of 1989 (OBRA ‘89) legislation and includes periodic screening, vision, dental, and hearing services. In addition, Section 1905(r)(5) of the Social Security Act (the Act) requires that any medically necessary health care service listed at Section 1905(a) of the Act be provided to an EPSDT recipient even if the service is not available under the State’s Medicaid plan to the rest of the Medicaid population. The federal regulations for EPSDT are in 42 CFR Part 441, Subpart B. 1. Appropriate and necessary for the symptoms, diagnosis, and treatment of the condition of the member. 2. Provided for the diagnosis or direct care and treatment of the condition of the member enabling the member to make reasonable progress in treatment. 3. Within standards of professional practice and given at the appropriate time and in the appropriate setting. 4. Not primarily for the convenience of the member, the member’s physician or other provider, and Exclusions – Specific conditions or circumstances listed in the Standard Rules for which the hawk-i plan will not provide coverage reimbursement. UnitedHealthcare Community Plan Provider Manual 2/14 5. The most appropriate level of covered services, which can safely be provided. 66 UnitedHealthcare hawk-i provider services: 888-650-3462 Not Allowed Charges – Medical charges for which the network provider is not permitted to receive payment from the health plan and cannot bill the member. Examples are: 1. the difference between billed charges and contracted rates and 2. charges for services that are bundled or unbundled as detected by Correct Coding Initiative edits. Not Covered Services – Services for which the benefits are not payable under a Member’s Evidence of Coverage (EOC) and for which the Member is financially responsible. Post-stabilization Care Services – Covered services, related to a medical emergency that are provided after a member is stabilized in order to maintain the stabilized condition to improve or resolve the member’s condition. Prior Authorization – Approval in advance of services being rendered. Certain covered services need prior authorization. Additional information can be found in the Prior Authorization Guidelines section of this manual. UnitedHealthcare Community Plan Provider Manual 2/14 67 UnitedHealthcare hawk-i provider services: 888-650-3462 Forms Appendix The following forms can be found online at UHCCommunityPlan.com. Click on “For Health Professionals” and select the state of Iowa. Choose “Provider Forms” from the navigation buttons on the left side of the screen. • Disclosure of Ownership • Member Appeal Form • Provider Claim Dispute Form • Demographic Change • Medical Prior Authorization • Proscription Drug Prior Authorization • Utilization Management Determination UnitedHealthcare Community Plan Provider Manual 2/14 68 UnitedHealthcare hawk-i provider services: 888-650-3462 Insurance coverage provided by or through UnitedHealthcare Insurance Company, Inc., UnitedHealthcare Plan of the River Valley, Inc., or their affiliates. Administrative services to self-funded benefits provided by UnitedHealthcare Insurance Company, Inc. UHC1169b_20140305 © 2014 United HealthCare Services, Inc. Community Plan A proud partner in Iowa’s hawk-i program
© Copyright 2024