Community Plan

practicematters

For More Information

Call our Provider Services Center at 877-651-6677Visit UHCCommunityPlan.com

Wisconsin | Summer 2015

Community Plan

Practice Matters: WI - Summer 2015 Provider Services Center: 877-651-6677

Important information for health care professionals and facilities

p.1

In This Issue...• A Message from Wisconsin’s Chief Medical Officer

• Claims Adjudication Platform To Be Upgraded

• Introducing the ICD-10 Coding Practice Tool

• Tips on the Claim Resubmission and Correction Process

• Reviews Help Ensure Patients Receive Proper Care

• Coordination of Care among Primary Care Physicians and Specialists

• New Information Needed for Institutional Claims Submissions

• Summertime is the Time for Satisfaction Survey

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

Community Plan

Practice Matters: WI - Spring 2015 Provider Services Center: 877-651-66771

Important information for health care professionals and facilities

A Message from Wisconsin’s Chief Medical Officer Dr. Donna Davidoff, UnitedHealthcare Community Plan of WisconsinLet’s face it, we are in a society where everything gets measured, rated and reported. And all of this measurement is moving toward public reporting, the goal being transparency. The practice of medicine and care of patients/members is no different.

HEDIS (Healthcare Effectiveness Data and Information Set) is one of those measurement tools. HEDIS was developed by the National Committee for Quality Assurance (NCQA) in 1991. HEDIS has five domains of care:

• Effectiveness of Care• Access/Availability of Care• Experience of Care

• Utilization and Relative Resource Use• Health Plan Descriptive Information

We collect information each year for each of these categories through surveys, medical chart reviews and claims data. Administrative data are collected from claims while hybrid data are clinical in nature and generally require chart review. Once the data are collected, the information must be audited by an NCQA-approved auditing firm for public reporting.

The various HEDIS measures change yearly. You can get more information about HEDIS and NCQA at ncqa.org/HEDISQualityMeasurement/HEDISMeasures/HEDIS2015.aspx.

As I write this, we are just finishing our annual “chart chase,” which generally ends in the middle of May each year. We try very hard to identify all potential sources to collect the needed information related to our members. This is a labor-intensive effort and we take it very seriously. In the future, we are hoping to move toward more contemporary year-round data collection.

When all of this measurement began, it was highly process-oriented, and we looked at things like whether diabetics had their HgB A1C checked or did eligible women have a mammogram. As HEDIS continues to develop, the focus is becoming more outcome-oriented, and we look at things like what the HgB A1C result was or what the last recorded blood pressure was in a member with hypertension.

And outcome orientation leads to more chart reviews...

So why all this HEDIS talk? We want to improve our data collection and minimize the interference to your clinical practice. If you have an Electronic Medical Record system (EMR), we’d like to discuss getting remote view only access to your charts. This would greatly improve the data flow and reduce the impact on your practice.

We also would like to work more closely with you to identify members who have preventive care opportunities as reflected by the HEDIS measures. We can provide you with practice-specific/member-specific reports and have a variety of programs available to help get members into your office to close those gaps in care.

If you would like more information, please contact me at donna_davidoff@uhc.com. As always, thank you for all you do to take good care of our members.

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

Community Plan

Practice Matters: WI - Summer 2015 Provider Services Center: 877-651-66772

Important information for health care professionals and facilities

FeaturesThe Physician ICD-10 Coding Practice Tool allows providers to practice selecting ICD-10 codes for various clinical scenarios across 35 medical specialties. Each clinical scenario for commonly used diagnosis codes includes a medical example, medical history and office notes; and users can compare codes used by peer physicians within each specialty. Clinical ScenariosThe clinical scenarios included in the tool were chosen based on the number of claims submitted by the most common clinical specialties including:Allergy/Immunology OphthalmologyAudiology OptometryCardiology Orthopedic SurgeryChiropractic Care OtolaryngologyDermatology Pediatric Medicine

Emergency Medicine Physical Medicine and Rehabilitation

Endocrinology Physical Therapy

Family Medicine Plastic and Reconstructive Surgery

Gastroenterology PodiatryGeneral Practice PsychiatryGeneral Surgery Psychology, ClinicalHematology PsychologyHematology-Oncology Pulmonary MedicineInfectious Disease Radiation OncologyInternal Medicine RheumatologyNephrology Thoracic SurgeryNeurology UrologyObstetrics & Gynecology Vascular SurgeryOccupational Therapy

Claims Adjudication Platform To Be UpgradedUnitedHealthcare is upgrading the Claims Adjudication platform (the Facets Application) to improve performance and enhance security between UnitedHealthcare and the states we serve. The upgrade will occur Nov. 25 to Nov. 29, 2015. No action is required on your part.

The upgraded platform will provide analytics faster. The Facets application will be updated from version 4.7 to 5.2. You and our members will benefit from this upgrade with a better online performance experience.

We are implementing features with this upgrade to improve the provider and member experience, including integration of customer service enquiries into claims and enhancement of claims display to include other claims with the same reason.

Introducing the ICD-10 Coding Practice ToolOct.1, 2015 signals the effective date for transition to ICD-10 coding to replace ICD-9 - the coding system used by physicians and health care professionals to record and identify diagnoses and procedures for claims payments.

ICD-10 affects diagnosis and inpatient procedure coding only. It does not affect current procedural terminology (CPT) coding for outpatient procedures.

To assist physicians with the transition to ICD-10, we developed the Physician ICD-10 Coding Practice Tool, an online self-service tool available as of July 29 at UnitedHealthcareOnline.com under Quick Links. Click ICD-10 and Regulatory Outreach. The tool is specific to physicians and their office staff to practice the new coding. It is not intended for facilities.

(continued on next page)

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

Community Plan

Practice Matters: WI - Summer 2015 Provider Services Center: 877-651-66773

Important information for health care professionals and facilities

Example scenarioScenario (aligned with Medical History and Office Visits Notes)Patient in for weekly B12 injection Medical History Member is currently under treatment for severe B12 deficiency; no other medical history. Office Visit Notes Member was given 1000 mcg. Vitamin B 12 Intramuscular in her left deltoid for severe B12 deficiency. Patient tolerated injection without complications; Patient to return to office in one week. Access and RegistrationTo access the tool, please register at UnitedHeatlthcareOnline.com > Tools & Resources > Health Information Technology > ICD-10. When you register, you’ll get a username and password for secure access to the tool. You can then access the tool as often as you would like. If needed, you also can pick-up where you left off from a previous session the next time you access the tool.

ResourcesFor assistance using the Physician ICD-10 Coding Practice Tool, a link to the How to Guide will be available and accessible via the Services & Support page of the tool. If you need technical assistance, call 855-819-5909 during the following hours:

Monday-Friday, 6 a.m. to 10 p.m. CTSaturday, 6 a.m. to 6 p.m. CTSunday, 9 a.m. to 6 p.m. CT

Tips on the Claim Resubmission and Correction ProcessHealth care professionals can resubmit or correct professional (CMS 1500) and institutional claims (UB-04) by making the necessary changes in their practice management system for the corrected claim to be printed or submitted electronically or by making the necessary corrections to the original submitted paper claim. Please check your UnitedHealthcare Community Plan Provider Manual and reimbursement policies to reconfirm bill types allowed for reconsideration.

Please resubmit the entire claim as originally submitted – even line items that were previously paid correctly. Under the National Uniform Billing Committee (NUBC) claim frequency guidelines, when sending a replacement or voided claim, the entire original or previous submission must be replaced or voided.

(continued on next page)

(continued from previous page)

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

Community Plan

Practice Matters: WI - Summer 2015 Provider Services Center: 877-651-66774

Important information for health care professionals and facilities

How to make a resubmission or corrected claim request:

• Online: Visit UnitedHealthcareOnline.com or access OptumCloud Dashboard. (Resubmissions with attachments can only be done via OptumCloud Dashboard).

• Mail: Print the UnitedHealthcare Claim Reconsideration form available at UnitedHealthcareOnline.com > Tools & Resources > Forms > Claim Reconsideration Request Guide.

– Complete the Claim Reconsideration Request form as instructed and mark the box on Line 4 for Corrected Claims. Continue to the comments section and list the specific changes made and rationale or other supporting information.

– Enter the words “Corrected Claim” in the comments field on the claim form.

– Filling in CMS 1500:• Original claim number in Box 22• Enter the appropriate claim frequency code left-

justified in the field.7 – Replacement of prior claim8 – Void/cancel of prior claim

– Filling in UB 04:• Bill type in Box 4• Enter the appropriate claim frequency code in

the third position of the Type of Bill7 – Replacement of prior claim8 – Void/cancel of prior claim

Please double check claims for errors prior to submitting the first time and make sure to send your claims directly to the UnitedHealthcare Community Plan address on the back of the members’ identification card or as outlined in your state’s Provider Manual.

For more information on completing your claim, go to:• nucc.org or nubc.org• CMS Claims Processing Manual at

cms.hhs.gov/Manuals/IOM/list.asp and refer to the CMS-1450 and CMS-1500 data sets

• For electronic claim submissions, refer to the Health Insurance Portability and Accountability Act Implementation Guides at wpc-edi.com.

Reviews Help Ensure Patients Receive Proper CareUnitedHealthcare Community Plan staff performs 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 the appropriateness of care and service and existence of coverage. We do not provide financial or other rewards to our physicians for issuing denials of coverage or for underutilizing services.

(continued from previous page)

(continued on next page)

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

Community Plan

Practice Matters: WI - Summer 2015 Provider Services Center: 877-651-66775

Important information for health care professionals and facilities

The treating physician has the right to request a peer-to-peer review with the reviewing physician and ask for a copy of the criteria used in the review. The denial letter contains information on how to request materials and contact the reviewer. Members and practitioners also have the right to appeal denial decisions. Information on requesting an appeal is included in the denial letter.

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.

If you have questions about the reviews, please contact our staff at 877-651-6677 during normal business hours.

Coordination of Care among Primary Care Physicians and SpecialistsPrimary care physicians (PCPs) and specialists share responsibility for communicating essential patient information with each other regarding consultations and referrals. Non-communication affects quality of care and can negatively affect health outcomes.

Relevant information that the PCP should provide to the specialist includes the patient’s history, diagnostic tests and results, and the reason for the consultation. The specialist is responsible for timely communication to the PCP of the results of the consultation, and ongoing recommendations and treatment plans.

Information exchange among health care providers should be timely, relevant and accurate to facilitate ongoing patient care management. The partnership between the PCP and specialist is based on the consistent exchange of clinical information, and this communication is a key factor in providing quality patient care.

New Information Needed for Institutional Claims SubmissionsAll institutional claims (uniform billing) submitted by paper or electronic transactions must now include the individual attending physician’s first and last name with a valid National Provider Identifier (NPI).

This edit helps ensure that we maintain compliance with State Medicaid guidelines. Please continue to include the appropriate taxonomy code for billing and attending providers.

Summertime is the Time for Satisfaction SurveyEach year, we ask for your participation in our Physician Satisfaction Survey. The survey provides insights about your experiences working with us. Your opinions help identify opportunities to enhance our services to align with your practice’s needs.

The next survey will be fielded in August to a random sample of physicians. Invitations will be distributed by fax. Please complete the survey if you receive a request. Your feedback is important to us.

(continued from previous page)

10701 W. Research DriveMilwaukee, WI 53226Doc# PCA17224_20150630 © 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

Wisconsin

practicematters