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For more information

Call our Provider Service Centerat 800-557-9933

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In This Issue:

• Convenience Care Clinics ExpandsMember Services . . . . . . . . . . . . . . . . . 1

• Physician Satisfaction SurveyUnderway . . . . . . . . . . . . . . . . . . . . . . . 2

• Prompt Responses to MedicarePart D Prescription Appeals InquiriesEnsure Continuity of Care . . . . . . . . . 2

• New Clinical Guidelinesfor UnitedHealthcare CommunityPlan . . . . . . . . . . . . . . . . . . . . . . . . . . . 2

• National Institute for MentalHealth Resources: Focus onMedications . . . . . . . . . . . . . . . . . . . . . 3

• When Forces Collide: TraumaticBrain Injury Masquerading asADHD in Adolescents . . . . . . . . . . . . 3

• UnitedHealthcare CommunityPlan Provider Portal Online-Authorizations and NotificationProcess . . . . . . . . . . . . . . . . . . . . . . . . . 6

• Getting Started with EDI is simple . . 7

Important information from UnitedHealthcare for physicians and other health careprofessionals and facilities serving UnitedHealthcare Medicaid members

Convenience Care Clinics Expands MemberServicesUnitedHealthcare Community Plan has recently expanded ourprovider network to include walk-in clinics at various TakeCareHealth Clinics (Walgreens) and Minute Clinics (CVS) stores inOhio, Texas, New York,Wisconsin, Mississippi and Delaware.When provided with primary care physician information, theconvenience care clinic will make every attempt to submitnotification to that primary care physician to ensure continuityand quality of care. Convenience care clinic staff do not assistpatients with referrals for specialty care services. Convenience careclinics treat patients over the age of 19 months and will not beoffering immunizations for the vaccine for children (VFC)program in this setting. Convenience Care Clinics offer extendedhours, and in most cases are open until 8:00 pm.

Some common conditions that can be treated in the conveniencecare clinics:

Vaccines• Flu (seasonal)• Hepatitis A (adult)• Hepatitis (adult)• Meningitis• Pneumonia• Td (Tetanus, Diphtheria)

Fall 2012

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Mississippi | Winter 2012


Inside the Star Rating Initiative With James Carney, MD, MBAAs UnitedHealthcare’s National Medical Director for Physician Engagement for Medicare Solutions, Dr. Carney plays a lead role with others in developing and communicating strategies to aid physicians in supporting their patients to live healthier lives and manage chronic conditions by obtaining recommended preventive care screenings.

Why Star Ratings Matter for Quality of Care “UnitedHealthcare’s mission is to help people live healthier lives. The Centers for Disease Control and Prevention (CDC) report that screenings and preventive care services continue to be under-utilized. Star ratings emphasize patient care and satisfaction, using national clinical quality measures – including screenings and preventive care and service quality measures – as well as patient feedback, so that health plans, physicians and members can work together to improve individual and total population quality of care and experiences,” said Dr. Carney.

In This Issue:• Inside the Star Rating

Initiative With James Carney, MD, MBA ......................................1

• Getting Started With EDI is Simple ..........................................2

• Quality Improvement Program .......3

• Global Days Policy Reminder .........4

• Updated Information About 17 Alpha-Hydroxyprogesterone Caproate (17P) Injection .................5

• Recovery and Adherence .................8

BREAKING NEWS: As of Dec.1, 2012 UnitedHealthcare Community Plan CAN Product Claims Payer ID will change to 87726. UnitedHealthcare Community Plan CHIP Product Claims Payer ID will remain 95378. Our ERA Payer ID will remain 95378 for both CAN and CHIP plans.

For more information

Call our Provider Service Center at 800-557-9933

Visit UHCCommunityPlan.com

http://uhccommunityplan.com

UnitedHealthcare Approach According to Dr. Carney: “UnitedHealthcare has dedicated enterprise-wide resources and personnel to work together to create a proactive member engagement, physician engagement and operational excellence approach to support Star Ratings improvement.

This initiative promotes transparency about Star Ratings and is intended to provide physicians with information, tools such as View 360, and incentives that support the additional time and resources they need to strengthen the physician-patient relationship and to help them deliver high quality, comprehensive, affordable health care services.

Our approach is patient-centered and focuses on coordinated care for members to help them understand their benefits and receive the care they need to live healthier lives.”

About Dr. CarneyDr. Carney began his career in the National Health Service Corps as an Internist working in under-served communities in Kentucky and Maryland. Later, he practiced in a staff model HMO, and then a small group practice in Delaware and Pennsylvania. He lives in Richmond, Virginia with his wife and is the father of two adult daughters.

To live a healthier life, Dr. Carney plays golf and tennis. His personal health goals include: maintaining a healthy body weight and an acceptable cholesterol profile to lower the risk for coronary artery disease; eating a well-balanced diet; and promoting overall physical mobility in order to stay active.

Did you know by converting 10,000 paper claims, remittance advice, and reimbursements to electronic transmittal (EDI, EFT, and ERA) we could:

• Save 3729 pounds of paper• Eliminate 148,389 pounds of greenhouse

emissions (Equivalent to 1726 new trees grown for 10 years or 20,451 square feet of forest conserved)

• The average practice can save thousands of dollars per year by converting to electronic transmission.Source: payitgreen.org

Getting Started With EDI is Simple To submit claims electronically simply contact your clearinghouse or software vendor and request that Primary and Secondary UnitedHealthcare Community Plan Claims be sent electronically.

UnitedHealthcare Community Plan CAN Claims Payer ID prior to Nov. 31, 2012 is 95378 after Dec. 1, 2012 the CAN Plan Claims Payer ID will change to 87726. The UnitedHealthcare Community Plan CHIP Plan Claims Payer ID will remain 95378.

Submit Claims Directly to UnitedHealthcare Community Plan You can access our Secure Provider Portal by visiting the claims and member section of your state’s home page located on UHCCommunityPlan.com. There is no cost for this service.

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MS - Winter 2012 Provider Service Center: 800-557-9933

Important information for health care professionals and facilities

I Fall 2012 2 Provider Service Center: 800-557-9933

Illnesses• Bladder infection treatment (females 12-65)• Bronchitis (ages 10-65)• Laryngitis• Ear infections• Pinkeye and styes• Sinus infections (ages five and up)• Strep throat• Swimmer’s ear

Skin Conditions• Athlete’s foot• Acne• Cold sores (ages 12 and up)• Deer tick bites (ages 12 and up)• Impetigo• Minor burns and rashes• Minor sunburn• Poison ivy (ages three and up)• Scabies• Shingles• Ringworm• Swimmer’s itch (ages three and up)

Other servicesFlu diagnosis (ages 10-64)• Mononucleosis• Pregnancy testing

Physician Satisfaction SurveyUnderway

The annual PhysicianSatisfaction Survey processhas begun, and you shouldhave received your first faxnotification. There willbe two more invitations toparticipate before thesurvey closes in October.

Your response letsUnitedHealthcareCommunity Plan know

how we can improve our working relationshipand better meet the needs of your practice. Welook forward to your participation in the surveyprocess.

Prompt Responses to Medicare Part DPrescription Appeals Inquiries EnsureContinuity of Care

When you or your patient, files an appeal withUnitedHealthcare, we will contact your office viafax or phone to request certain key informationneeded as part of the appeal process.

By federal law, UnitedHealthcare must render anappeal decision within 72 hours for an expeditedrequest and seven calendar days for a standardrequest.

Your assistance in responding to these requestspromptly helps ensure continuity of themember’s treatment plan.

New Clinical GuidelinesUnitedHealthcare Community Plan

UnitedHealthcare Community Plan Pharmacyand Therapeutic Committee has approved a newclinical guideline for Antiemetic ContinuousPump Therapy for the Treatment of Nausea andVomiting in Pregnancy.

Notification - Effective Oct. 1, 2012, the use ofAntiemetic Medication through a continuoussubcutaneous pump in the treatment of nauseaand vomiting in pregnancy will no longer becovered under UnitedHealthcare CommunityPlan.

Providers may request clinical review criteria bycontacting the Pharmacy Prior Notificationdepartment at 800-310-6826.



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http://payitgreen.org/


COB (Secondary) EDI Claims Submissions are Preferred Electronically

• Please visit the EDI Section of your state’s home page and reference the 837 Companion Guide located on UHCCommunityPlan.com. Share the setup guidelines with your clearinghouse or software vendor.

• Do not send paper claim backup for claims that have already been submitted electronically.

Receive Payment for Claims Electronically (EFT)EFT is safe, secure, efficient, and more cost effective than paper claim payments.

If you would like to save money and time, enroll today! Enrollment forms can be found within the EDI Section of your state’s home page located on UHCCommunityPlan.com.

Receive Remittance Advice Electronically (ERA)To enroll in ERA contact your software vendor and/or clearinghouse. UnitedHealthcare Community Plan ERA Payer ID is 95378 for both the CAN and CHIP Plans.

United Healthcare Community Plan now offers Real-time 270/271 Electronic Health Care Eligibility Inquiry and Response Transactions and Real-time 276/277 Electronic Health Care Claim Status Inquiry and Response Transactions as a quick and easy way to streamline administrative tasks.

This information is also available through the Secure Provider Portal and by phone, however real time transactions save your office that added step.

Please see the Companion Guides located within the EDI Section on your state’s home page on UHCCommunityPlan.com for setup guidelines.

For additional information please contact OptumInsight HIN sales team at 800-341-6141 option three.

Electronic Claim Submission Tips• Include your tax identification number

(TIN) along with your NPI number. • Member ID numbers are required. • The Payer ID number indicates where

clearinghouses should direct their claims.

Quality Improvement ProgramTo continuously improve the care and services provided to members, UnitedHealthcare Community Plan uses Healthcare Effectiveness Data and Information Set (HEDIS) reporting to measure our health care performance. HEDIS is a set of standardized performance measures that are related to many significant public health issues. Nationwide, our HEDIS 2012 scores demonstrated improvements in the number of our adult members who had their body mass index (BMI) screened, an increase in follow-up visits following hospitalizations for mental illness, and an increase in diabetic HBA1c and LDL testing.

UnitedHealthcare Community Plan will continue to target multiple areas for improvement in 2012 through national initiatives including, the number of yearly well visits received by children ages three to six, the number of timely prenatal and postpartum visits, and proper patient use of asthma medications.

We also conduct annual member surveys to see how well we are meeting our member’s needs.























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Our 2011 Consumer Assessment of Healthcare Providers and Systems (CAHPS) surveys showed improvement in how our members rate their personal doctor, the specialists they see most often, and their overall health care. Members told us that they want it to be easy to get approvals for the tests and treatments they need through their health plan. We listened and in 2012 are working to improve processes in our prior authorization center.

If you would like further information about our Quality Improvement Program, our annual goals or our progress towards meeting our goals, please call 800-557-9933 for MS CHIP or 877-743-8734 for MS CAN.

Cultural NeedsAt UnitedHealthcare Community Plan we believe our members have the right to receive care that is culturally competent and respects their cultural and ethnic background and origins. Primary language information is obtained from members when they enroll and they are assisted in choosing a Primary Care Physician (PCP) who will meet their cultural needs. United HealthCare provides access to a language line for translation of communication between UnitedHealthcare staff and non-English speaking members. The language line use is tracked by the Customer Service Center and reported regularly to the health plan. Each health plan then assesses its practitioner availability to insure that the cultural, ethnic, racial, and linguistic needs of its members are being met.

The Provider Directory is available at UHCCommunityPlan.com and lists the languages spoken in provider offices.

Pharmacy UpdatesPharmacy Updates are available at UHCCommunityPlan.com. The pharmacy hotline is 800-922-1557.

Global Days Policy Reminder If you have received a denial for ‘Payment Being Included in Allowance for Another Service’ before filing an appeal, please reference the Global Days Policy. The full plan is available on-line at UHCCommunityPlan.com/assets/Global-Days-Policy-(R0005)-1-1-11.pdf.

A few reminders follow:

• Pre-operative visits are not separately reimbursable services when performed within the assigned global period.

• Major Procedures: 90-day global value begins with the day before surgery.

• Minor Procedures (global value other than 90 days): Global period begins the day of surgery.

• Complications following a procedure, including all additional medical and/or surgical services required of the physician (not resulting in a return trip to the operating room) that occur within the designated global period are included in the Global Package.

• Procedures having a zero-, 10- or 90-day global value that are performed during the post-operative period of a procedure having a 10- or 90-day global value are considered to be included in the Global Package of the initial procedure unless an appropriate modifier is appended.

• 58 – Staged or related procedure or service by the same physician during the post-operative period.























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http://www.uhccommunityplan.com/assets/Global-Days-Policy-(R0005)-1-1-11.pdf

http://www.uhccommunityplan.com/assets/Global-Days-Policy-(R0005)-1-1-11.pdf

• 78 – Unplanned return to the operating/procedure room by the same physician or other qualified health care professional following initial procedure for a related procedure during the post-operative period.

• 79 – Unrelated procedure or service by the same physician during the post-operative period.

• Services of physicians and other health care professionals of the same specialty within and using the same federal tax identification number are deemed as performed by the same physician providing global period services.

UnitedHealthcare Community Plan Evaluation & Management Services included in the global period are listed within policy as well as the global day values. If you have any questions, please contact Provider Services at 800-445-1638 or your local Provider Advocate.

Updated Information About 17 Alpha Hydroxyprogesterone Caproate (17P) InjectionUnitedHealthcare Community Plan has updated its drug policy for use of 17 alpha-hydroxyprogesterone caproate (17P)

injection, encompassing both the compounded drug and Makena, effective Oct. 1, 2012.

UnitedHealthcare’s Policy Regarding Compounded 17P and MakenaUnitedHealthcare understands the importance of access to 17P and we continue to support the

physician’s discretion to use either compounded preservative-free 17P if the prescribing practitioner has determined that a compounded product is necessary for the particular patient and would provide a significant difference for the patient as compared to the FDA-approved commercially available drug product, or Makena.

Relying on evidenced-based medicine and outcomes-based research, UnitedHealthcare has updated its drug policy for use of 17 alpha-hydroxyprogesterone caproate (17P) injection, both the compounded drug and Makena, effective Oct. 1, 2012. This policy applies to Commercial, Medicare and Community Plan business.

Options for Providing 17P to Your Patients Who Are UnitedHealthcare Community Plan Members

• State Fee-for-Service Pharmacy Program Some members of UnitedHealthcare Community Plan have pharmacy benefits that are not processed through UnitedHealthcare Community Plan, but through the state’s fee-for-service program. Providers in Louisiana, Tennessee and Wisconsin should contact your State Medicaid Agency to determine the state’s requirements, preferred pharmacy vendor and process for ordering 17P or Makena.

• Home Health Services UnitedHealthcare has a preferred relationship with the Women’s and Children’s Health division of Alere Health. This home health service offers a compounded, preservative-free 17P administration program, which includes in-home obstetric nurse administration, education about the risk factors and signs and symptoms of preterm labor, weekly assessments and 24/7 nurse-line support. For more information please contact Alere at 800-950-3963 or alere.com.























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http://www.uhccommunityplan.com/assets/Makena-17p.pdf


http://www.alere.com/us/en.html





















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• Buy-and-Bill for Compounded 17P Compounded, preservative-free 17P can be located in your area by calling or visiting the International Academy of Compounding Pharmacist Locator Service at 800-927-4227 or iacprx.org. Compounding pharmacies will continue to compound 17P as long as the prescribing practitioner has determined and documented that a compounded product is necessary for the particular patient and would provide a significant difference for the patient as compared to Makena.

• Reimbursement for Buy and Bill for Compounded 17PFor providers who administer compounded, preservative-free 17P in their office through the buy-and-bill process, reimbursement is achieved by submitting a medical claim for the medication HCPCS code-J2675 progesterone injection, per 50 mg (bill 5 units per injection-250 mg/injection) with the CPT code-96372 for therapeutic, prophylactic, or diagnostic injection (specify substance or drug); subcutaneous or intramuscular, and the diagnostic code V23.41- supervision of pregnancy with history of preterm labor. Please contact your local provider relations representative or call provider customer service if you have questions about reimbursement.

• Pharmacy Direct Bill UnitedHealthcare Community Plan for MakenaMakena can be obtained from either Prescription Solutions by OptumRx, or CVS Caremark Specialty Pharmacy, depending upon the state. Please refer to the table.



Makena Vendors – UnitedHealthcare Community PlanPlease consult the table below to determine which pharmacy is the designated UnitedHealthcare Community Plan vendor for Makena in your state.

Contact informationCVS Caremark Specialty Pharmacy phone: 800-237-2767 fax: 800-323-2445Prescription Solutions by OptumRx phone: 888-293-9309 fax: 800-853-3844

State VendorArizona OptumRx

Delaware CVS Caremark Specialty Pharmacy

District of Columbia CVS Caremark Specialty Pharmacy

Florida CVS Caremark Specialty Pharmacy

Hawaii CVS Caremark Specialty Pharmacy

Iowa OptumRx

Kansas OptumRx Effective Jan. 1, 2013

Louisiana Contact State Medicaid Agency

Maryland OptumRx

Michigan OptumRx

Mississippi CVS Caremark Specialty Pharmacy

Nebraska CVS Caremark Specialty Pharmacy

New Jersey OptumRx

New Mexico OptumRx

New York CVS Caremark Specialty Pharmacy

Ohio CVS Caremark Specialty Pharmacy

Pennsylvania CVS Caremark Specialty Pharmacy

Rhode Island OptumRx

South Carolina CVS Caremark Specialty Pharmacy

Tennessee Contact State Medicaid Agency

Texas CVS Caremark Specialty Pharmacy

Washington OptumRx

Wisconsin Contact State Medicaid Agency

http://iacprx.org

Prior AuthorizationUnitedHealthcare Community Plan requires prior authorization for compounded 17P or Makena whether administered in the office or by a home health service.

• Prior Authorization for Compounded 17P Please submit the UnitedHealthcare Community Plan’s standard medical prior authorization form with supporting documentation (documents regarding prior premature deliveries [e.g., delivery notes, discharge summaries that state gestational age at time of delivery, the reason for the premature birth], current gestational age) to the fax number listed on the form. If authorized, you will be issued an authorization number that you will need to provide to the pharmacy.

• Prior Authorization for MakenaPlease submit the UnitedHealthcare Community Plan’s standard medical prior authorization form with supporting documentation (documents regarding prior premature deliveries [e.g., delivery notes, discharge summaries that state gestational age at time of delivery, the reason for the premature birth], current gestational age) to the fax number listed on the form. If authorized, you will be issued an authorization number that you will need to provide to the pharmacy.

Upon completion of the manufacturer’s standard Makena Referral/Prescription form, place the authorization number on the top and submit via fax to the specialty pharmacy provider identified for your state (see table on page 6). These specialty pharmacy providers will bill UnitedHealthcare Community Plan directly.



Direct Billing For a complete list of pharmacies that will ship to you and bill UnitedHealthcare Community Plan directly and for more information on this policy go to UnitedHealthcare Community Plan 17P and Makena Drug Policy.

Recovery and AdherenceClinicians want individuals in their care to get better and believe that if the treatment plans they offer are followed their patient’s condition will improve. Yet treatment plans don’t work when patients don’t adhere to them. The connection between a lack of adherence and negative outcomes seems obvious, yet the World Health Organization (2003) states that for chronic illness, only 50 percent of patients adhere to their long-term therapy in developed countries.

Do the principles of recovery and resiliency offer any insights and support to approaching this problematic disconnect? There are several insights that can be adapted in most practices to help bridge this gap.

Focus on Strengths, Goals Spend time on where patients are going and not where they are stuck.A recovery-directed conversation with a patient focuses on individual strengths and personal goals rather than symptom severity or being sick. A conversation that focuses primarily on symptoms may further the negative self-image and sense hopelessness contributed to chronic illnesses. When a conversation includes a clear focus on the patient and their personal goals, and frames medication as one strategy toward meeting those goals, the individual is often more motivated and hopeful.





















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http://www.makena.com/media/PDFs/referral-prescription-form.pdf



Educate More, Direct LessA recovery oriented interaction in each appointment provides education on treatment — including addressing widely held, but inaccurate beliefs about medication. Of critical importance is putting written educational materials in patient’s hands. Written material supports different learning styles and affords an opportunity to easily share information with support networks.

Acknowledge Challenges and Invite ParticipationIt helps for patient’s to hear that many people find it very hard to take medicine regularly. Let them know that you want to hear the particular challenges they face in using medicine as a tool in their recovery plan. Inquiring about challenges lets patients know that you are committed to working with them toward solutions.

Support Engagement Through Tools and Community Resources Engagement is not synonymous with compliance. Compliance means an individual obeys a directive from a health care provider. Engagement signifies that a person is involved in a process through which he harmonizes robust information and professional advice with his own needs, preferences and abilities in order to prevent, manage and cure disease1.

Connecting members to local community resources can reduce isolation and increase treatment adherence. Links to reputable support groups can be found on our member portal. Tools like the Wellness Recovery Action Plan® (WRAP) have been shown to significantly enhance skills for coping with prodromal symptoms, use of wellness tools in their daily routines, and hope for recovery2. A free version of WRAP can be downloaded from the Substance Abuse and Mental Health


Action Plan® (WRAP) have been shown to significantly enhance skills for coping with prodromal symptoms, use of wellness tools in their daily routines, and hope for recovery2. A free version of WRAP can be downloaded from the Substance Abuse and Mental Health Services Administration (SAMHSA) web site.

SAMHSA recently issued this definition of recovery:

A process of change through which individuals improve their health and wellness, live a self-directed life and strive to reach their full potential.

SAMHSA further states:

Recovery involves individual, family, and community strengths and responsibility: Individuals, families, and communities have strengths and resources that serve as a foundation for recovery. In addition, individuals have a personal responsibility for their own self-care and journeys of recovery. The full article is available on the SAMHSA blog posting March 23, 2012.

These four simple tips reflect a recovery oriented way to support increased adherence while building a treatment plan that incorporates the patient’s own strengths and goals while providing them with the information and support they need to achieve those goals.

By Sue Bergeson, Vice President of Consumer Affairs

1 A New Definition of Patient Engagement: What is Engagement and Why is it Important?, Center for Advancing Health © 2010 http://www.cfah.org/pdfs/CFAH_Engagement_Behavior_Framework_current.pdf.

2 Cook, J. A., Copeland, M. E., Hamilton, M. M., Jonikas, J. A., Razzano, L. A., Floyd, C. B., et al. (2009). Initial outcomes of a mental illness self-management program based on Wellness Recovery Action Planning. Psychiatric Services, 60(2), 246-249.





















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Mississippi

Provider Service Center: 800-557-9933

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

M47507MS 8/12 © 2012 UnitedHealth Group, Inc. All Rights Reserved.

795 Woodlands ParkwaySuite 301Ridgeland, MS 39157


UnitedHealthcare Community Plan now offers Real-time 270/271 Electronic Health Care EligibilityInquiry and ResponseTransactions and Real-time276/277 Electronic Health Care Claim Status Inquiryand ResponseTransactions as a quick and easy way tostreamline administrative tasks..

This information is also available through the SecureProvider Portal and by phone, however real timetransactions save your office that added step.

Please see the Companion Guides located within theEDI Section on your State’s home page onUHCCommunityPlan.com for setup guidelines.

Electronic Claim SubmissionTips• Include your tax identification number (TIN) alongwith your NPI number.

• Member ID numbers are required.

• The Payer ID number indicates where clearinghousesshould direct their claims.

795 Woodlands ParkwaySuite 301Ridgeland, MS 39157

M47507MS 11/12 © 2013 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.

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