new jersey hospital association meeting: what’s new in ... · for non-emergent emergency room...

New Jersey Hospital Association Meeting:What’s New in Managed Medicaid

UnitedHealthcareMarch 14, 2019

Proprietary information of UnitedHealth Group. Do not distribute or reproduce without express permission of UnitedHealth Group. PCA-1-012157-09042018_09212018© 2018 United HealthCare Services, Inc.

UHC Roles and Contact Information

Utilization Management / Medical Management (UM): 888-362-3368- MM/UM/UR is a consumer-focused health care program that facilitates member access to care

and services- UR activities are supported by evidence-based nationally recognized medical policies, clinical

guidelines and criteria- These policies, guidelines and criteria influence care decisions to promote delivery of appropriate

care in the most appropriate setting at the appropriate time- Medical Directors, nursing, pharmacy and behavioral health staff work closely with health care

practitioners and providers to optimize health care outcomes.Case Management / Whole Person Care (WPC): 877-704-8871

- Management of acute events as well as the reduction of future risk for members through integrated medical and behavioral Care Management/Care Coordination

- Members enrolled in WPC are provided a locally based integrated care team (ICT) to assist the member in achieving improved health outcomes

- The ICT includes Clinical (RN, Behavioral Health, Pharmacist, Medical Director) and Non-Clinical (Community Health Worker, Peer Support Specialist) staff

Network Management: NJ Dedicated Provider Service Center: 888 362 3368- Dedicated network managers for Medical and Behavioral Health escalated issues:o Medical Providers: [email protected] Behavioral Health Providers: [email protected]

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NJ ER Triage Rate Program

On Nov. 1, 2018, UnitedHealthcare Community Plan of New Jersey adopted the state-legislated ER Triage program to reimburse non-emergent services provided in the emergency room at a $140 triage rate.

This change only affects hospitals that are on a pay-as-the-state-pays contracted reimbursement methodology. This change doesn’t affect hospitals that are on negotiated contracts.

The policy does not include New Jersey Children’s Health Insurance Program (CHiP) members.

UnitedHealthcare notified the affected hospitals of these changes via email.

Here’s how we’ll determine the rate at which we’ll pay these claims. If the claim meets all of the following criteria, we’ll pay the state-legislated $140 triage rate:

• Revenue code 45X is present on the claim, and• Procedure codes 99281, 99282 are present on the claim, or• Procedure codes 99283, 99284 or 99285 are present on the claim and all of the first

three diagnosis codes on the claim are on the current State approved diagnosis code list published on the NJMMIS website

If the claim doesn’t meet all of the above criteria, we’ll pay the standard emergent rate.


NJ ER Triage Rate Program, Cont’d

The following are excluded from this policy change: • Pregnant women identified by the presence of condition code B3 (indicates patient is

pregnant)• Children ages 6 and younger• Seniors ages 65 and older• Claims certified as emergent by the care provider attaching an ER Certification form

You can find the state’s triage policy with diagnosis codes, titled Triage Fee Reimbursement for Non-Emergent Emergency Room Visits at NJmmis.com > Recent Newsletters > Choose “Newsletter Vol. 28, No. 20.”


Medication Assisted Treatment (MAT)Office-Based Addiction Treatment (OBAT)

UHC is increasing member access to MAT services through:• Identifying providers with the Data 2000 waiver and determining if they have

OBAT Navigator services• Recruiting new physicians to obtain the Data 2000 waiver• Provider training and education to increase OBAT engagement

- Webex training- Email communication- In-person socialization- UnitedOnAir recordings

• UHC staff education to maximize member engagement in MAT and OBAT• Removing prior authorization requirements for MAT and OBAT services and

prescriptions as of 4/1/19• Case Management services are available to assist PCP Navigators and

other providers with cases that have complex psychosocial barriers to care and/or complex SPMI

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Behavioral Health Updates: Care Management and Case Management


Behavioral Health Authorization Requirements

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Authorization is required for the following BH services:• All services rendered by Out-of-Network (OON) providers require prior authorization through 3/31/19. • Beginning 4/1/19, OON MAT services will not require prior authorization.• Emergent inpatient admissions require notification within 24 hours of admission• During inpatient utilization review, providers should actively discuss members with court-ordered

status and/or the eligibility for Administrative Days• In-Network providers are required to obtain prior authorization for the services below

Hospital based services • Inpatient (Non Emergent MH and SUD)• Mental Health Electroconvulsive therapy ECT ( Inpt/Outpt)• Mental Health Partial Hospitalization (PHP) Program• Substance Use Disorder (SUD) non hospital based detoxification – ASAM – 3.7WM

Outpatient services• Mental Health Intensive Outpatient Program • Substance Use Disorder (SUD) Intensive Outpatient Program – ASAM – 2.1• Ambulatory Withdrawal Management – ASAM 2-WM• Psychological Testing • Mental Health Partial Care• Substance Use Disorder (SUD) Partial Hospital – ASAM – 2.5

Residential services• Substance Use Disorder (SUD) Short Term Residential – ASAM – 3.7• Adult Mental Health Rehabilitation (AMHR)In order to obtain prior authorization you must call 866-362-3368. Please refer to your specific contract for your service codes.


Generally accepted standards of practice

• Based on credible scientific evidence

• Generally recognized by the relevant medical community

• Use evidenced-based outcomes to validate the practice

Clinically appropriate

• Type, frequency, extent, and duration of services

• Considered effective for the treatment of mental illness, substance use disorder, or associated symptoms

Determinations of medical necessity

• Informed by:• Unique aspects of

the case• Member’s benefit

plan• Available services:

• Ability of provider to meet the member’s immediate needs

• Alternatives that exist in the service area

Behavioral Health Medical Necessity

Behavioral Health Care Advocates use Optum Behavioral Health or ASAM SUD Level of Care Guidelines when making medical necessity determinations and as guidance when providing referral assistance.


• Optum Health is the services arm of United Health Group, serving United Healthcare members by:

• Offering the Case Management services program• Provide comprehensive assessments to identify gaps in care and barriers

to health• Engaging by telephone and field visits as needed• Creating important linkages between members and providers• Team of local and knowledgeable staff about community resources• Providing education about complex medical or healthcare information in

easy-to-understand language• Assisting members along a continuum of care, based on a comprehensive

Plan of Care, working to achieve better health outcomes for all

• Optum is seeking to improve patient health, access to care, and safe transitions by partnering with In-Network UHC providers and facilities, and lending the support of our clinicians wherever we can be of service

• Optum has several successful partnerships at the facility level and are eager to continue to expand those relationships to improve better patient outcomes

Partnerships in Case Management


• Field-Based Clinicians and Community Health Workers• Robust teams in the community to receive case management

“hand-off” and assist with safe transition• Comprehensive review of post-discharge instructions• Member may receive a post-discharge visit in the community if

needed• Linkage with resources to help with providers, medication

reconciliation, community resources, and housing services• Member may remain in Case Management until stable in the

community, with varying levels of care utilized as needed

• Focus on 7-day, 30-day and 90-day follow-up appointments

• Prevent unnecessary “rapid readmissions” that may result from gaps in care or other challenges

Post-Discharge Support

Care Provider ResourcesResources at your fingertips


UHCprovider.com

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UHCprovider.com is your home for the latest news, policy information and access to Linkself-service tools. • Access Link, your gateway to UnitedHealthcare’s online tools.• Instantly access the most used transactions and information including: Claims and Payments Eligibility and Benefits Policies and Protocols Prior Authorization and Notification

• Quickly find administrative guides, policies and protocols, our resource library and more.• Easily search for the information you need the most.• Stay current with the newest developments from UnitedHealthcare.

Provider Care Manual and Quick Reference Guides https://www.uhcprovider.com/en/health-plans-by-state/new-jersey-health-plans/nj-comm-

plan-home/nj-cp-forms-references.html

https://www.uhcprovider.com/en/health-plans-by-state/new-jersey-health-plans/nj-comm-plan-home/nj-cp-forms-references.html


UHCprovider.com – Cont’d

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UHCprovider.com can help simplify your daily UnitedHealthcare activities.


UHCprovider.com/NJcommunityplan

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Visit the UnitedHealthcare Community Plan of New Jersey state-specific page onUHCprovider.com/NJcommunityplan


UHCprovider.com/Njcommunityplan –Cont’d

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Current News, Bulletins and Alerts Bulletins and Newsletters UnitedHealthcare Community Plan of New Jersey Care Provider Manual UnitedHealthcare Dual Complete® ONE Managed Long-Term Care Services and Supports (MLTSS) Payment Policy Notifications Pharmacy Resources and Physicians Administered Drugs Policies and Clinical Guidelines Prior Authorization and Notification Care Provider Forms and References Contact Us Training and Education Credentialing and Attestation Join Our Network Member Information Medicaid Managed Care Rule Reporting Health Care Fraud, Waste and Abuse UHC On Air HIPAA


Care Provider Manual

We have a comprehensive UnitedHealthcare Community Plan of New Jersey Care Provider Manual for your reference, which you can find at:

UHCprovider.com→ Menu → Administrative Guides and Manuals → Community Plan Care Provider

Manuals→ New Jersey→ View the UnitedHealthcare

Community Plan of New Jersey Care Provider Manual

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Community Plan Policies

UnitedHealthcare Community Plan Medical & Drug Policies and Coverage Determination Guidelines, Clinical Guidelines as well as Reimbursement Policies can be referenced on UHCprovider.com > Menu > Policies and Protocols > Community Plan Policies

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• Public Pages include general information and other useful behavioral health resources:– Download standard forms– Provider Manual– Clinical Guidelines– Training/webinar offerings

• Private Pages:– Available only to In-Network Providers– Secure and require registration– Allows Providers to update information using the “My Practice Info” feature– To request a User ID, select the “First-time User” link in the upper right corer

of home page– For assistance or questions about the registration process, call Provider

Express Support Center toll free: 1-866-209-9320 from 7:00 am – 9:00 pm Central Time, or chat with tech support online

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Provider Express: providerexpress.comproviderexpress.com/content/ope-provexpr/us/en/our-network/welcomeNtwk/welcomeNJ.html

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Provider Manual Clinical Guideline (e.g.

level of care guidelines)

Forms • authorization forms,• sentinel events

reporting form Archived trainings and

webinars

Provider Express: Public Pages

providerexpress.com

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Provider Express: Log Into Private Pages

• Available to in-network providers, only

• Requires secure registration:

• Practice information –create, store and update

To set a UserID, select First Time User link at upper right corner of home page

Private Pages

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Technical Support1 866-209-9320 (toll-free)

Provider Express: Technical Assistance Support Center

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Provider Express: NJ State-Specific Provider Information


MLTSS Claims

• Claim submission rates and denial rates have remained consistent in the most recent 6 months.

• The top two denial reasons are:- Explanation of Benefits from the primary carrier is required- Confirmed duplicate submission

• The volume of these denials accounts for 45% of the top 10 reasons claims are denied.

• The UnitedHealthcare operations and clinical teams continue to collaborate to ensure that the services authorized in care plans are paid when billed.

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Questions?

Thank YouStephanie Mulfinger, LCSWDirector NJ Behavioral Health ServicesUnitedHealthcare Community [email protected]

new jersey hospital association meeting: what’s new in ... · for non-emergent emergency room...

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