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New Jersey | Spring 2015

Community Plan

Practice Matters: NJ - Spring 2015 Provider Services Center: 888-362-3368

Important information for health care professionals and facilities

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In This Issue...• Follow ups for Children on ADHD Medication

• HEDIS Measure Addresses Care After Hospitalizations for Mental Illness

• Get Updated Clinical Practice Guidelines

• State Designates 26 Measures as “Critical” To Focus On

• What’s in the Latest Provider Manual?

• Talking About the Importance of Screenings

• A Look at the Utilization Review Process

• Member Rights and Responsibilities

• Enhanced HIPAA Claim Edits

• Optum Cloud Dashboard Enhancements to Notifications/Prior Authorizations

We hope you enjoy the spring edition of Practice Matters. In this issue, you can read about follow ups for children who are taking medication for ADHD, 26 measures deemed “critical” by the state, 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: NJ - Spring 2015 Provider Services Center: 888-362-33681

Important information for health care professionals and facilities

For more information, contact your Physician Advocate. Physicians and other clinicians who treat ADHD can find guidelines in an article in a 2011 issue of Pediatrics. The National Institute of Mental Health also has ADHD information online.

HEDIS Measure Addresses Care After Hospitalizations for Mental IllnessTimely follow up after a patient’s hospitalization for mental illness promotes continuity of care and supports the patient’s return to baseline functioning. The HEDIS measure related to care after these hospitalizations requires that follow-up services be provided by behavioral health providers. Because some patients go to their primary care physician (PCP) after leaving psychiatric hospital programs, the PCP supports continuity of care by urging follow up by the patient with a social worker, counselor, family therapist, psychologist, psychiatrist or advanced practice psychiatric nurse, and providing referrals as needed.

This follow up measure has two different rates that are reported for all members age 6 and older:

• Follow up within seven days: A completed outpatient visit or partial hospitalization with a behavioral health clinician within seven days of hospital discharge.

• Follow up within 30 days: A completed outpatient visit or partial hospitalization with a behavioral health clinician within 30 days of discharge.

A follow-up within seven days is optimal and scheduling a timely post-discharge follow-up appointment with a behavioral health clinician is important, especially for patients who did not have a relationship with a behavioral health clinician prior to their hospital admission. Without this prior relationship, individuals often fail to follow up.

For more information, contact your Physician Advocate.

Follow Ups for Children on ADHD Medication The Healthcare Effectiveness Data and Information Set (HEDIS) has a measure regarding follow up and maintenance of medication treatment for children ages 6 to12 who have been prescribed a medication for Attention Deficit

Hyperactive Disorder (ADHD). The measure relates to new prescriptions for any of the following commonly prescribed ADHD medications:

• CNS stimulants: Amphetamine-dextroamphetamine, Dexmethylphenidate, Dextroamphetamine, Lisdexamfetamine, Methamphetamine or Methylphenidate

• Apha-2 receptor agonists: Clonidine or Guanfacine• Miscellaneous ADHD medications: Atomoxetine

During the annual HEDIS data collection, medical and pharmacy claims are reviewed in two phases to verify providers follow up with children on ADHD medications:

• Initiation Phase: Children with a face-to face follow-up visit with a practitioner with prescriptive authority within 30 days of filling an ADHD medication prescription.

• Continuation and Maintenance Phase: Of the children who remained on a medication for at least 210 days (including gaps of 90 days) this measure identifies children who stay on medication and have two additional practitioner visits within 270 days after the Initiation Phase ended.

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

Community Plan

Practice Matters: NJ - Spring 2015 Provider Services Center: 888-362-33682

Important information for health care professionals and facilities

Get Updated Clinical Practice GuidelinesUnitedHealthcare Community Plan promotes the use of nationally recognized evidence-based clinical guidelines to support your health care decisions. Guidelines include: Diabetic Care, Perinatal Care (we have recently added an additional guideline), Depression and Attention Deficit Hyperactivity Disorder.

A complete list of the most current guidelines is available online. Click on the appropriate link and the approved guidelines for the chosen topic will open.

Topics include:• Acute Myocardial Infarction• Asthma• Attention Deficit Hyperactivity Disorder• Bariatric Surgery• Bipolar Disorder – Adults, Children and Adolescents• Cardiovascular Disease• Cervical Cancer Screening• Cholesterol Management• Chronic Obstructive Lung Disease• Chronic Stable Angina• Diabetes• Depression (Major)• Heart Failure• Hypertension• HIV• Infertility• Oncology• Perinatal Care

• Preventive Service• Radiology• Sickle Cell Disease• Schizophrenia• Spinal Stenosis• Substance Abuse Disorders

State Designates 26 Measures as “Critical” to Focus OnEach spring, United Healthcare participates in medical record reviews for HEDIS. The National Committee for Quality Assurance has expanded the size and scope of HEDIS to include measures for physicians, preferred provider organizations and others. HEDIS 2015 includes 83 measures across five domains of care: Effectiveness of Care; Access/Availability of Care; Experience of Care; Utilization and Relative Resource Use; and Health Plan Descriptive Information. Under each domain are measures such as Childhood Immunizations, Well-Child Visits and Care for Older Adults.

The State of New Jersey has designated 26 measures as “critical” for 2015 and they will be the focus of special attention. They are:1. Adolescent Well-Care Visits annually2. Adult Access to Preventive Care3. Adult BMI4. Ambulatory Care/Emergency Department visits5. Annual Monitoring for Patients on Persistent

Medication6. Annual Preventive Oral Health and Preventive

Services for ages up to 21 7. Appropriate Testing for Children with Pharyngitis

annually8. Breast Cancer Screening annually9. Cervical Cancer Screening annually10. Child & Adolescent Access to PCP11. Childhood Immunization Status annually Combo 212. Chlamydia Screening annually

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

Community Plan

Practice Matters: NJ - Spring 2015 Provider Services Center: 888-362-33683

Important information for health care professionals and facilities

13. Comprehensive Diabetes Care annually, all sub measures

14. Controlling High Blood Pressure15. Follow-up after Hospitalization for Mental Illness

(Clients of Division of Development Disabilities only) 16. Follow-up Care for Children Prescribed ADHD

Medication17. Frequency of Ongoing Prenatal Care annually18. Human Papillomavirus Vaccine for female

adolescents19. Immunizations for Adolescents annually20. Lead Screening in Children annually21. Medication Management for people with Asthma22. Prenatal and Postpartum Care annually23. Use of Appropriate Medications for People with

Asthma 24. Weight Assessment and Counseling for Nutrition and

Physical Activity for Children/Adolescents25. Well-Child Visits in first 15 months of life annually26. Well-Child Visits in the 3rd, 4th, 5th and 6th year of

life annually

In addition, Early and Periodic Screening, Diagnostic and Treatment (EPSDT) is a program mandated by the State of New Jersey. The program covers screening and diagnostic services to determine physical and mental defects in patients up to age 21.

These exams need to include a comprehensive physical exam, vision services, hearing services, dental services, mental health and substance abuse treatment, nutritional assessment, appropriate immunizations, lead screenings, Hemoglobin/hematocrit, urinalysis, TB testing and additional lab tests if medically indicated.

For more information on HEDIS or EPSDT, contact your Physician Advocate.

What’s in the Latest Provider Manual?The latest version of the New Jersey Provider Manual is available online. The manual contains important topics such as:

• Timeliness standards for appointment scheduling• Allowable office waiting times• Compliance with Americans with Disabilities Act

standards• Medical record standards, including a copy of the

form used for record audits• Roles and responsibilities of the PCP• Telephone accessibility and call answer timeliness;

24 hours, 7 days a week coverage• Requirements concerning licenses and certifications• How to contact us

Talking About the Importance of ScreeningsWe encourage you to help our members focus on eliminating high-risk behaviors and discuss the importance of preventive health care screenings with them for chronic and/or life-threatening disease. Preventive care can help adults detect problems early and take an active role in maintaining good health.

We want to thank you for talking to our members about the importance of taking charge of their health by receiving timely preventive services and encouraging regular screenings.

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

Community Plan

Practice Matters: NJ - Spring 2015 Provider Services Center: 888-362-33684

Important information for health care professionals and facilities

A Look at the Utilization Review ProcessHere’s a friendly reminder about maximizing administrative efficiency for providers who participate in our networks. Please submit the clinical notes when requesting prior authorizations. A list of services requiring prior authorization is available in the provider administrative manual.

Decisions regarding coverage are based on the appropriateness of care and service and existence of coverage. 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 Medical Policies and Coverage Determination Guidelines used to make clinical determinations are available online.

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 (WEDI) Strategic National Implementation Process (SNIP) Health Insurance Portability and Accountability Act (HIPAA) 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).

Optum Cloud Dashboard Enhancements to 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

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

Community Plan

Practice Matters: NJ - Spring 2015 Provider Services Center: 888-362-33685

Important information for health care professionals and facilities

supporting documentation (if prompted to do so). These functions are available for UnitedHealthcare Commercial, UnitedHealthcare Medicare Solutions and UnitedHealthcare Community Plan members. They are also 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 StatusIf 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

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.

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1 River Front PlazaPO Box 200089Newark, NJ 07102-0304 © 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

New Jersey

practicematters

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