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 Michigan has approximately 200,000 “dual eligibles”: people who qualify for both Medicare

(by age and/or diagnosis) and Medicaid. In fact, duals represent the largest num-ber of Michigan’s Medicaid population. This population represents individuals with some of the most complex needs, yet they have been subject to episodic and fragmented care as they navigate two programs with distinctly different rules.

Earlier this year, the U.S. Depart-ment of Health and Human Services, Medicare and Medicaid Innovation Center awarded the Michigan Depart-ment of Community Health (MDCH) funds to improve coordination of care for duals while controlling costs. The

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NavigatorUnitedHealthcare Great Lakes. Great Coverage. Great Choice.

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Flu Vaccine Guidelines

Help Prevent Fraud, Waste, and Abuse

Initiatives to Improve Member Satisfaction

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Dual-Eligible Patients Benefit from Coordinated Care

result was MDCH’s integrated care model in which duals are enrolled into a Medicaid health plan (MHP) instead of fee-for-service Medicaid.

The Good NewsWhen your dual-eligible patient has Unit-edHealthcare Great Lakes Health Plan for both Medicare and Medicaid, you submit only one claim. We will process the claim under Medicare then Medicaid benefits following coordination of benefits rules.

Other important points:◆ Voluntary enrollment of duals into

an MHP plan is expected to begin later this year.

◆ It is expected that MHP enrollment will become mandatory in April 2012.

◆ Providers must participate in both products in order to enjoy all the advantages of integrated care!Duals often have multiple chronic con-

ditions and will greatly benefit from case management, disease management, and other services provided by UnitedHealth-care Great Lakes. For more information about integrated care for duals, please contact your Provider Relations Advocate.

As your partner in health care, we feel it is important for you to have access to the Medical outpatient prior authorization medical neces-sity guidelines used by United-Healthcare Great Lakes. View the guidelines at www.uhcgreatlakes.com/health-professionals/MI/reimbursement-policy.

It is important to note the outpatient prior authorization medical necessity determination clinical hierarchy is state/federal policies when applicable, followed by UnitedHealthcare Medical Policy guidelines, and lastly “Milliman” care guidelines are used when there is a need for further specific-ity. Further, if our medical policies conflict with provisions of the state contract or with state or federal law, the contractual/statutory/regulatory provisions shall prevail.

If you have any questions related to these medical necessity coverage guidelines, please contact the clinical personnel partnering with you on the specific matter or call Provider Relations at 248-331-4296 for general questions.

MEDICAl OuTPATIENT PrIOr AuTHOrIzATION MEDICAl NECESSITy uPDATE

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 The Advisory Committee on Immu-nization Practices (ACIP) recom-mends that certain people should

get vaccinated each year for the seasonal flu. They are either people who are at high risk of having serious flu complications or people who live with or care for those at high risk for serious complications.

During flu season when vaccine sup-plies are limited or delayed, ACIP makes recommendations regarding priority groups for vaccination. People who should get vaccinated each year are:◆ children ages 6 months to 19 years old◆ pregnant women◆ people 50 years of age and older

Flu Vaccine Guidelines

UnitedHealthcare Great Lakes Health Plan • www.uhcgreatlakes.com2

CAQH’s data-collection initiative, the Universal Provider DataSource® (UPD), is eliminating more than $44 million per year in costs or more than 1.5 million hours (the equivalent of 731 full-time employees) of provider and support staff time required to complete and send credentialing application forms.

UPD allows registered physicians and other health professionals to enter their credentialing information free of charge into a single, uniform online system that meets the credentialing needs of most health plans, hospitals, and other health care organizations. The provider data-collection service streamlines the 

initial application and re-credentialing processes, reduces provider administra-tive burdens and costs, and offers health organizations real-time access to reliable provider information for quality assur-ance and support services.

All data submitted by providers through UPD is maintained by CAQH in  a secure, state-of-the-art data center. Providers authorize health plans and other organizations access to the information. Periodic provider updates help ensure the information is always current; provider changes are automati-cally sent to participating health care organizations.

UnitedHealthcare Great Lakes is a participating health plan with CAQH. CAQH is a nonprofit alliance of the nation’s leading health plans and networks working to simplify health care administration. CAQH solutions help promote quality interactions between plans, providers, and other stakeholders, reduce costs and frustrations associated with health care administration, facilitate administrative health care information exchange, and encourage administrative and clinical data integration.

For more information about registering or completing the UPD application, please visit www.caqh.org/cred/.

UnITeDHeALTHCARe GReAT LAkeS CALLS on PRoVIDeRS To CReDenTIAL THRoUGH UPD

◆ people of any age with certain chronic medical conditions

◆ people who live in nursing homes and other long-term care facilities

◆ people who live with or care for those at high risk for complications from flu, including:

• health care workers

• household contacts of persons at high risk for complications from the flu

• household contacts and out-of-home caregivers of children younger than 6 months of age (these children are too young to be vaccinated).

UnitedHealthcare Great Lakes is making flu shot reminder calls to par-ents, members older than age 50, and members with chronic illness. The health plan is also sending reminder postcards to adults at risk. Look for 2011-12 flu billing guidelines on our website at www.uhcgreatlakes.com/health-professionals/MI/provider-bulletin.

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UnitedHealthcare Great Lakes Health Plan • www.uhcgreatlakes.com3

 UnitedHealthcare Great Lakes Com-munity Outreach team is responsi-ble for developing and maintaining

relationships with organizations and non-profit agencies across the counties we serve. Our mission is “Helping Our Mem-bers Live Healthier Lives,” a value shared by our partner organizations: Great Start and Head Start early childhood pro-grams, senior centers, community and youth centers, faith-based organizations, and subsidized living facilities.

The team provides the community with education surrounding Medicaid, Medicare Special Needs Plans, and MIChild. We also attend community events that are related to healthy living or are located in underserved areas where people need health education the most. The star of these events is our mascot, Dr. Health E. Hound, who has partici-pated in parades, planted new trees, and led the pack in community walks.

Our unique partnership between UnitedHealthcare and Sesame Workshop teaches parents healthy affordable eating habits through “Food for Thought: Eating

Making a Difference in Your Community

Well on a Budget.” This program was introduced to grocery stores in “food deserts”—inner-city areas with little access to fresh produce.

The team was also very excited to donate 200 brand-new pairs of shoes to the Vista Nuevas Head Start in Detroit, which oversees 1,472 children between ages 3 and 6 across 13 locations. UnitedHealth-care Great Lakes was chosen for this cor-porate donation because we achieved the highest HEDIS® scores for well-child visits for children ages 0 to 15 months across the entire UnitedHealthcare Community and State health plans.

If you would like UnitedHealthcare Great Lakes to attend any of your events or you know of an organization that could use our help, please contact Andrea Bell at abell24@uhc.com or 248-331-4291 or Tori Johnson at tojohnson@uhc.com or 269-552-3044 (West Michigan). Our team would love to hear from you!

HEDIS is a registered trademark of the National Committee for Quality Assurance®.

MICHIGAN DEPArTMENT OF COMMuNITy HEAlTH HIPAA 5010 TESTING

Instructions for HIPAA version 5010 testing are posted on the Michigan Department of Commu-nity Health (MDCH) website: www.michigan.gov/5010ICD10.

All providers that currently send 4010A1 transactions to MDCH must test with MDCH before submitting version 5010 transactions on January 1, 2012. 

Testing is essential to ensure that you are ready. If you have not begun testing, please start now. Information about 5010 and helpful links are also found on the MDCH website. Testing questions may be sent to MDCH at MDCH-B2B-Testing@michigan.gov. other 5010 questions should be sent to MDCH at www.michigan.gov/5010ICD10.

Find FAQs and more informa-tion about HIPAA 5010 on UnitedHealthcare Great Lakes’ website at www.uhcgreatlakes.com/health-professionals/MI/provider-information.

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 As a managed care organization serving Medicaid and Medicare members in Michigan, UnitedHealthcare Great Lakes is responsible for ensuring that funds are

used in an ethical manner. Therefore, we have processes in place to prevent, identify, and address fraud, waste, and abuse within our membership, our provider network, and our internal operations.

Examples of Fraud, Waste, and Abuse May Be When:◆ a member shares his or her health plan ID card, shares his

or her Medicaid ID card, alters a prescription or gets medi-cation to resell it, alters a referral or medical record, or uses transportation services for something other than getting medical care

◆ a provider bills for services never provided; bills for the same services twice or uses improper coding; overstates a member’s illness or condition, receives payment for making patient referrals; or gives false information about creden-tials, such as a college degree

◆ an employee obtains funds that should go to a provider or the health plan.

We Need you to Help Prevent Fraud, Waste, and Abuse

UnitedHealthcare Great Lakes Health Plan • www.uhcgreatlakes.com4

you Can report Fraud, Waste, and AbuseYou may choose to remain anonymous when reporting potential fraud, waste, and abuse. If you suspect fraud, waste, and abuse with a member or provider, you may report to the following:◆ Compliance Officer

UnitedHealthcare Great Lakes Health Plan 26957 Northwestern Highway, Suite 400 Southfield, MI 48033 800-903-8253 (ask for Compliance)OR

◆ The State of MichiganMedicaid Integrity Program Section Capitol Commons Center Building 400 South Pine, 6th Floor Lansing, MI 48909 517-335-5239 or 866-428-0005You will need to identify what you observed, when you

observed it, who was present, and any further information that may be of assistance.

A number of federal and state regulations govern informa-tion provided to the government, including the federal False Claims Act, state False Claims Act, and other regulations and protections. The UnitedHealthcare Great Lakes “Integ-rity of Claims Reports and Representations to Government Entities” policy provides information about these regulations. Providers, contractors, and agents who contract with UnitedHealthcare Great Lakes or submit claims to govern-ment agencies should review this policy.

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UnitedHealthcare Great Lakes Health Plan • www.uhcgreatlakes.com5

Our relationship with Physicians Drives Member Satisfaction

CoDInG IS THe keY To CoMPLIAnCe: DIAbeTIC SCReenInGIn 2010, approximately 20% or 1,100 of our members 

diagnosed as being a diabetic were not taking any diabetic medications or filling prescriptions for testing supplies.

We need your help to prevent the incorrect marking of members as diabetics, when they in fact may not be. We have noticed via claims that a diabetic diagnosis code is being used inappropriately for diabetic screening purposes.This information is used in various studies, reports, and 

audits, so we are asking that in instances when you are ordering various lab work to check for / confirm / rule out diabetes, please use V77.1 as your diagnosis code.

In those instances when you are ordering lab work for those members who have a confirmed diagnosis of diabetes, please continue to use the regular Diabetes 250.XX diagnosis coding.

Questions? Please contact a Quality Improvement nurse at 800-903-5253.

 In 2004, UnitedHealthcare Great Lakes was a “one star” health plan as rated by our members and reported in the State of Michigan Consumer Guide. UnitedHealthcare Great

Lakes recognized that the relationship between primary care physicians and UnitedHealthcare Great Lakes was the key to member satisfaction.

Recognizing this link, UnitedHealthcare Great Lakes began an odyssey to improve its relationship with its practitioner net-work. The following provides a list of initiatives designed and implemented to positively impact perceptions of practitioners, who could then recommend UnitedHealthcare Great Lakes to their patients:◆ Revise the reimbursement methodology. Medicaid reim-

bursement does not compare with commercial products, but UnitedHealthcare Great Lakes was determined to make its physician reimbursement rates as competitive as possible in Michigan.

◆ View practitioners as partners. Remove such barriers as in-network referrals and many prior authorization requirements.

◆ Pay claims timely and accurately. Revise payment edits, con-duct root cause analysis, redesign processes, and establish and enforce performance standards.

◆ Make performance data readily available. Create an online portal that allows physician offices to check claims status, patient eligibility, preventive health, and clinical services needed.

◆ Shift perspective. Change the focus from provider service to provider advocacy.

◆ Employ a “high-touch” approach. Implement frequent, in-person provider office visits by Provider Advocates to answer questions, address concerns, educate, and assist offices.

◆ Use unique approaches to educate providers on best prac-tices, clinical guidelines, and measurement success.

resultsMember satisfaction with UnitedHealthcare Great Lakes has improved 7.9 percentage points since 2007 and 23.9 percentage points since 2004. The UnitedHealthcare Great Lakes’ 2011 final rate is in the 2010 national 90th percentile among Medicaid plans reporting. UnitedHealthcare Great Lakes’ rating was the highest among Michigan Medicaid health plans in 2011.

MEMBEr SATISFACTION with unitedHealthcare Great lakes

  10  20  30  40  50  60  70  80  90

  2011

  2010

  2009

  2008

  2007

  2006

  2005

  2004

81.9%

77.0%

79.2%

72.7%

74.0%

77.0%

74.0%

58.0%

     2010      national 90th Percentile   79.3%

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Visit our website! www.uhcgreatlakes.com

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Navigator

PO Box 2127 Southfield, MI 48037-9955

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PAIDUnitedHealthcare Great

Lakes Health Plan

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UnitedHealthcare Great Lakes Health Plan Is Committed to Quality Care

David K. Livingston President

Steven Stein, MD, MHS Medical Director

Melanie Osment Editor

The Navigator is published by UnitedHealthcare Great Lakes, a Michigan for-profit corporation, to provide general information. It is not intended to provide personal medical advice, which should be obtained directly from a physician. © 2011 All rights reserved. Printed in the U.S.A.

 T he purpose of the Quality Improve-

ment (QI) Program is to achieve

desired performance outcomes.

Health Management, behavioral health

management, medical management,

pharmacy management, clinical perfor-

mance management, and benefit manage-

ment programs, as well as the

credentialing program, fall under its

framework.

QI Program components include,

but are not limited to, the following:

◆ children’s and women’s preventive

health initiatives and outcomes

◆ chronic health care improvement

initiatives and outcomes

◆ service improvement initiatives and

outcomes

◆ utilization management program

◆ health care practitioner and organiza-

tional credentialing

◆ complex case management program

◆ disease management programs

◆ health plan accreditation

◆ credentialing

◆ member safety.

The UnitedHealthcare Great Lakes

QI Program operates on a yearly cycle,

beginning January 1 and ending December

31. The QI Program is guided by impor-

tant objectives:

◆ Improve the health status of the

Health Plan’s members.

◆ Provide for an effective monitoring

and evaluation process that ensures

care and services provided to the

Health Plan’s members meets accept-

able medical practice standards and

contractual performance expectations

and is positively perceived by mem-

bers, Michigan Department of Com-

munity Health, and health care

professionals.

◆ Ensure prompt identification and

analysis of barriers to desired perfor-

mance, improvement opportunities,

subsequent improvement interven-

tions, and follow-up.

◆ Encourage patient safety.

The UnitedHealthcare Great Lakes

Board of Directors (BOD) has the ulti-

mate responsibility for the quality of care

and services provided to Health Plan

members. The BOD receives reports from

the Quality Management Committee

(QMC) and is responsible for reviewing

and approving the QI Program, annual QI

implementation plan, and annual QI Pro-

gram evaluation. The BOD has delegated

certain responsibilities to the QMC,

the Medical Director, and the Quality

Management Department.

If you would like more information

about the QI Program or program results,

please contact your Provider Relations

Advocate.