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Arizona | Spring 2015

Community Plan

Practice Matters: AZ - Spring 2015 Provider Services Center: 800-445-1638

Important information for health care professionals and facilities

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In This Issue...• From Russia, With a Love for Treating Patients

• Time to Test Lead Levels

• Staff Must Be Trained About Federal False Claims Act

• Added Coverage for Incontinence Briefs

• How To Use Optum Cloud Dashboard for Notifications/Prior Authorizations

• Where To Get Clinical Practice Guidelines

• Reviews Help Ensure Patients Get Proper Care

• Member Rights and Responsibilities

• Enhanced HIPAA Claim Edits

We hope you enjoy the spring edition of Practice Matters. In this issue, you can read about who should be screened for lead poisoning, training on the federal False Claims Act, how Optum Cloud Dashboard can help determine when a Notification/Prior Authorization request is required, and much more. Happy spring!

Practice Matters: TX - Summer 2013 Customer Service Center: 888-362-33681

Community Plan

Practice Matters: AZ - Spring 2015 Provider Services Center: 800-445-16381

Important information for health care professionals and facilities

From Russia, With a Love for Treating PatientsSvetlana Barbarash, MD, FACC, cherishes what one of her cardiology patients wrote to her: “Thank you for allowing me to stay in this world.”

The message from a patient who was referred for replacement of a heart valve is on a Christmas card that hangs in Dr. Barbarash’s office. It’s a reminder of the satisfaction she gets from treating people and changing their lives.

“It is extremely rewarding to make a difference in a person’s life, and cardiology offers countless possibilities for it,” said Dr. Barbarash, a cardiologist and director of echocardiography at Southwest Medical Associates (SMA) in Las Vegas, Nevada. SMA is part of the health care delivery services of Optum, which is owned by UnitedHealth Group.

Dr. Barbarash shared the patient’s grateful words during a heart health awareness webinar on Feb. 27 that was presented to more than 1,000 UnitedHealth Group employees. She discussed cardiovascular disease and heart procedures, and gave guidance on how to keep your heart healthy.

Raised in Kemerovo, Russia, she came from a family of doctors and loved to hear about health care and patients when stories were told at the dinner table. “Growing up, it was very easy for me to envision my future in cardiology,” she said.

Dr. Barbarash earned her medical degree at Kemerovo State Medical Academy, where her mother had been in the first graduating class. “I was 16 when I started medical school and I was 22 when I graduated,” said Dr. Barbarash, noting that students in Russia can start medical school after high school.

In 2004, Dr. Barbarash joined the UnitedHealth Group family, and she now treats patients at Southwest Medical Associates. When she is away from the office, she keeps busy raising three children, playing piano, violin and cello, and coaching tennis and volleyball.

She urges everyone to lead a healthy lifestyle and treat your body as something precious. “Each of us is responsible for who we are health-wise, and if we take important steps to prevent things in the future, we’ll all be better people in the end.”

Practice Matters: TX - Summer 2013 Customer Service Center: 888-362-33682

Community Plan

Practice Matters: AZ - Spring 2015 Provider Services Center: 800-445-16382

Important information for health care professionals and facilities

Some Head Start programs require a blood lead test for child care school entry

• Head Start programs usually require the results of blood lead testing. The PCP may be asked to complete a Head Start form at the well-child visit.

For more information, call 602-255-8108 or send an email to uzma_urooj@uhc.com.

Staff Must Be Trained About Federal False Claims ActThe federal False Claims Act prohibits knowingly submitting (or causing to be submitted) to the federal government a false or fraudulent claim for payment or approval. It also prohibits knowingly making or using (or causing to be made or used) a false record or statement to get a false or fraudulent claim paid or approved by the state Medicaid program, the federal government, or its agents, such as UnitedHealthcare Community Plan.

Civil penalties can be imposed on any person or entity that violates the False Claims Act, including penalties of $5,500 to $11,000 and damages of up to three times the federal government’s damages for each false claim.

UnitedHealthcare Community Plan participating providers must establish an effective training program for all staff on the following aspects of the False Claims Act provisions:

• The administrative remedies for false claims and statements

• Any state laws relating to civil or criminal penalties for false claims and statements

• The whistleblower protections under such laws

Time to Test Lead LevelsTesting lead levels is part of the Early and Periodic Screening, Diagnostic and Treatment (EPSDT) requirements. Here are answers to some frequently asked questions about blood lead testing:

Who must be screened for lead poisoning?

• Children must have blood lead testing at their 12-month and 24-month EPSDT well-child visits.

• Children 36 to 72 months must have a blood lead test if they have not had at least one previous test.

What follow up is used for children with elevated blood lead levels (EBLLs)?

• Blood lead test results of 10μ/deciliter or higher are reported to the Arizona Department of Health Services (ADHS). Depending on the EBLL, the cause of exposure may be investigated.

• UnitedHealthcare Community Plan coordinates follow-up care and treatment for children with EBLLs in partnership with care providers and regulators.

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Practice Matters: TX - Summer 2013 Customer Service Center: 888-362-33683

Community Plan

Practice Matters: AZ - Spring 2015 Provider Services Center: 800-445-16383

Important information for health care professionals and facilities

Any training must be appropriately documented and may be requested at any time by the Arizona Health Care Cost Containment System (AHCCCS) or UnitedHealthcare Community Plan.

If any such actions, activities or behaviors come to your attention, please mail your documentation to:

UnitedHealthcare Community PlanCompliance Officer1 East Washington, Suite 900Phoenix, AZ 85004Fraud Hotline: 877-401-9430

Director, Office of Inspector General701 E. Jefferson, Mail Drop 4500Phoenix, AZ 85034602-417-4193

Reports need to be filed immediately, within one business day, by completing and submitting the reporting form. The form is available under the Provider Forms section of UHCCommunityPlan.com or on the Office of Inspector General website.

It is important that you only report the facts and not assumptions. If a police report is mentioned in the description, it also must be submitted with the referral form. If it is not included, do not mention it in the description.

If you have questions, contact the UnitedHealthcare Fraud Hotline at 877-401-9430.

Added Coverage for Incontinence BriefsOn Dec. 15, 2014, AHCCCS expanded coverage of incontinence briefs for members in the Arizona Long Term Care System programs who are 21 and older. These members can receive incontinence briefs when all of the following conditions are met:

• The member is incontinent due to a documented medical condition that causes incontinence of bowel and/or bladder. Briefs may be covered for preventative purposes with the documented medical condition.

• The PCP or attending physician has issued a prescription ordering the incontinence briefs.

• Incontinence briefs do not exceed 180 briefs per month unless the prescribing physician presents evidence of medical necessity for more.

• The member obtains incontinence briefs from vendors within the UnitedHealthcare Community Plan network.

• Providers must submit the service request with supporting medical documentation to Preferred Homecare via fax at 480-505-5053.

AHCCCS also covers incontinence briefs for medical and preventative purposes for members younger than 21. Refer to the following links for more information as outlined in AHCCCS policy 310-P, AHCCCS policy 430 and AHCCCS rule R9-22-212:

azahcccs.gov/shared/Downloads/MedicalPolicyManual/Chap300.pdf

azahcccs.gov/shared/Downloads/MedicalPolicyManual/Chap400.pdf

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Practice Matters: TX - Summer 2013 Customer Service Center: 888-362-33684

Community Plan

Practice Matters: AZ - Spring 2015 Provider Services Center: 800-445-16384

Important information for health care professionals and facilities

How To Use Optum Cloud Dashboard for Notifications/ Prior AuthorizationsOptum Cloud Dashboard’s Eligibility & Benefits Center now can be used to determine if Notification/Prior Authorization is required. Submit the Notification/Prior Authorization request form via single sign-on to UnitedHealthcareOnline.com and upload supporting documentation (if prompted to do so). These functions are available for UnitedHealthcare Commercial, UnitedHealthcare Medicare Solutions and UnitedHealthcare Community Plan members. They also are available for UnitedHealthcare One members, but benefit information is not yet part of the Dashboard functions for these members.

Determining if Notification/Prior Authorization is RequiredWhen checking eligibility and benefits for a patient on Optum Cloud Dashboard, a field called “Able to Submit Prior Authorization/Notification Request” will be displayed on the results screen. If the field contains “Yes,” the “My Actions” dropdown will include a link to “Submit Prior Auth Request.” You can link to the page and fill in the required fields to see if a Notification/Prior Authorization is required for the planned procedure.

If it is required, an “Initiate Now” button will be available to begin the submission and take you to the “Case Information” screen on UnitedHealthcareOnline.com (pre-populated with the data entered into Optum Cloud Dashboard) to complete the Notification/Prior Authorization request.

Adding Attachments and Clinical NotesAfter a Notification/Prior Authorization request has been submitted, you may be prompted to supply additional information by fax or attachment. If prompted to upload an attachment, you can add as many as needed, one at a time. The system will accept bmp, doc, docx, gif, jpg, jpeg, pdf, png, tiff, and tx files up to 3.5 MB in size. Once a file is uploaded, it cannot be removed. Whether or not an attachment is uploaded, you can type in the “Clinical Notes” section.

For information on required clinical documentation, go to UnitedHealthcareOnline.com > Tools & Resources > Policies, Protocols and Guides > Protocols > Medical Records Requirement for Pre-Service.

Checking Notification/Prior Authorization Status

• If you initiated your submission on Optum Cloud Dashboard, you will see the Notification/Prior Authorization request status at the bottom of the home screen in the Eligibility & Benefits application. Click the applicable yellow arrow under “View Details” to:

• Check the status of each procedure code• See if additional documentation is required • View a list of your attachments and upload more• Update Clinical Notes

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Practice Matters: TX - Summer 2013 Customer Service Center: 888-362-33685

Community Plan

Practice Matters: AZ - Spring 2015 Provider Services Center: 800-445-16385

Important information for health care professionals and facilities

If you initiated your submission on UnitedHealthcareOnline.com, you must locate the Notification/Prior Authorization request by Service Reference Number in the “Search Cases by Case Number” tool in the middle of the Eligibility & Benefits home screen. You then will see the same details listed above and the Notification/Prior Authorization will automatically display on the bottom of the home screen on subsequent visits to the Eligibility & Benefits applications.

Updating Notifications/Prior AuthorizationsAll updates must be made in the Notification/Prior Authorization Status transaction on UnitedHealthcareOnline.com, regardless of where the submission was initiated. If an update results in a request for more information, either the Fax or Attachment window will open.

For more information, refer to the quick reference guides at UnitedHealthcareOnline.com > Help > Optum Cloud Dashboard.

Where To Get Updated Clinical Practice GuidelinesUnitedHealthcare promotes the use of nationally recognized evidence-based clinical guidelines to support practitioners in making decisions about health care. Guidelines include Diabetic Care, Depression and Attention Deficit Hyperactivity Disorder.

To view a complete list of the most current guidelines adopted by UnitedHealthcare, go online to UHCCommunityPlan.com > For Health Care Professionals > Arizona > Clinical Practice Guidelines.

Reviews Help Ensure Patients Receive Proper CareWe perform concurrent reviews on inpatient stays in acute, rehabilitation and skilled nursing facilities, as well as prior authorization reviews of selected services. A list of services requiring prior authorization is available in the Provider Manual.

A physician reviews all cases in which the care does not appear to meet guidelines. Decisions regarding coverage are based on benefit coverage as well as appropriateness of care and service.

The treating physician has the right to request a peer-to-peer review with the reviewing physician and ask for a copy of the review criteria. The denial letter contains information on how to request materials and contact the reviewer. Members and physicians also have the right to appeal denial decisions. Appeals are reviewed by a physician who was not involved in the initial denial decision and is of the same or similar specialty as the requesting physician.

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Practice Matters: TX - Summer 2013 Customer Service Center: 888-362-33686

Community Plan

Practice Matters: AZ - Spring 2015 Provider Services Center: 800-445-16386

Important information for health care professionals and facilities

Member Rights and ResponsibilitiesThe UnitedHealthcare Community Plan Member Rights and Responsibilities can be found in the Provider Manual. Member Rights and Responsibilities are distributed to new members upon enrollment and then annually.

Enhanced HIPAA Claim EditsEffective March 25, 2015, UnitedHealthcare applied additional Workgroup for Electronic Data Interchange Strategic National Implementation Process Health Insurance Portability and Accountability Act edits to professional (837p) and institutional (837i) claims submitted electronically to most UnitedHealthcare and affiliate payer IDs.* These are new edits that were not applied with the revisions released in 2014. For more information on current and previous edit releases, go to Enhanced Claim Edits.

Because the edits will be applied on a pre-adjudication basis, an increase in claim rejections may occur. But you will be able to identify and correct rejected information prior to our adjudicating and processing claims. The advantage will be fewer denied claims and less interruption to your revenue stream.

The primary impact will come from edits that will validate code sets, such as diagnosis, procedure and modifier codes, at a pre-adjudication level. The new list of edits has been distributed to clearinghouses and software vendors.

It’s important to check all claim submission reports regularly. Claims may be rejected by your clearinghouse or UnitedHealthcare Community Plan, so you may receive multiple reports per submission.

Rejections that may occur from the enhanced edits will appear at a clearinghouse level. For assistance regarding these edits or to resolve rejections, first contact your Electronic Data Interchange (EDI) vendor or clearinghouse.

For assistance from UnitedHealthcare Community Plan, please contact EDI Support at EDI Transaction Support form, send an email to ac_edi_ops@uhc.com or call 800-210-8315.

*Exceptions are: Harvard Pilgrim (04271), Medica HealthCare Plans (78857), Preferred Care Partners (65088), The Alliance (88461) and TRICARE West (99726).

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1 East Washington Suite 900Phoenix, AZ 85004Doc#: PCA16131_20150409 © 2015 UnitedHealth Group, Inc. All Rights Reserved.

Practice Matters is a quarterly publication for physicians and other health care professionals and facilities in the UnitedHealthcare network.

Community Plan

Arizona