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California | Spring 2019

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Practice Matters: CA – Spring 2019 Provider Services Center: 866-270-5785

Important information for health care professionals and facilities

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In This Issue…CMO Corner

Support for Your Practice and Patients

• Diabetes Prevention Program

• A Team Approach to the Management of a Patient with Diabetes

• Health Homes Program

• Transportation Health: More than Just a Ride to the Doctor

• Available Training

State Servicing Guidelines

• Blood Lead Screening

• Family Planning Services Policy for Self-Administered Hormonal Contraceptives

• Alcohol Misuse Screening Guidelines

Administrative Information to Help With Your Practice

• Get the Power of Self-Service – Get Link

• Verification of Provider Information

• Claim Updates

Community Plan in Action

• San Diego Food Bank Grant

We hope you enjoy this issue of Practice Matters. In this issue, you can read about diabetes prevention, case management services for patients with chronic medical conditions, alcohol misuse screening guidelines, and much more.

Practice Matters: TX - Summer 2013 Customer Service Center: 888-362-33681 Practice Matters: CA – Spring 2019 Provider Services Center: 866-270-57851


CMO CornerJennifer Nuovo, MD, Chief Medical Officer, UnitedHealthcare Community Plan of CaliforniaWhat’s changing in Medi-Cal l for plans and care providers this year? Quite a lot! It’s a year of growth and change in California’s interest to bring a public health focus to the membership through the managed care plans. Two big programs kick off this year: the Diabetes Prevention Program (DPP) and the Health Homes Program. I like to think of the membership as occupying a pyramid, with care providers administering or connecting members to programs and support for every member within that pyramid – from the complex support for the top 1 percent highest risk to focusing on health and prevention for the majority of the members at the bottom of the pyramid.

UnitedHealthcare is partnering with Solera Health to bring DPP to your patients. This program will use an outreach to all potentially eligible members who are at risk for diabetes. These members complete a simple questionnaire to determine their appropriateness for the program, and then may choose to be enrolled in a free 22-week program that promotes healthy lifestyle and modest weight loss. Our program can be accessed in person through physical sites in San Diego or online in a virtual coaching program. The DPP has had exciting results in the Medicare population and is promoted by the Centers for Disease Control and Prevention (CDC) as an important step to maintain health for a sedentary high-risk population with poor eating habits. We’re excited to bring this to the Medi-Cal population, and it promises to bring support and structure in an easy-to-access manner.

Separately, for the highest risk population, the Health Homes Program is coming to San Diego in July 2019, with Community Based Case Management Entities (CB-CME’s) gearing up to provide support and navigation for members with complex medical problems who may also be homeless or using the ER and inpatient setting frequently for their health care. While complex case management has traditionally been provided by telephone by health plan programs or, during a time of acute illness, by hospital staff, this effort will bring case management to the practice setting or a community agency most adept at addressing social determinants of health. None of us has a complete solution for patients with severe and chronic medical conditions with frequent or long hospital stays or for addressing holistically the health needs of the homeless population. But this program has the potential to address real barriers at the right time and in the right setting.

We look forward to working on these initiatives and welcome your feedback. I’m grateful for your support and especially grateful for your commitment to serving this population.



UnitedHealthcare Community Plan of California has partnered with Solera Health to deliver the new DPP benefit to our members. Stay tuned as we will be sending future updates on how our members can participate.

A Team Approach to the Management of a Patient with DiabetesScott A. Edmonds, OD CMO, MARCH Vision Care

Caring for people with diabetes is a team effort for everyone involved with their care. The eye is a critical organ in the overall management. It can easily be examined in a non‑invasive way on a regular basis. It’s often the first place in the body to detect end-organ damage and thus is a subtle indicator of a progression of the disease.

Although the presence of diabetic retinopathy has been the gold standard to indicate inadequate glucose management, new high level optical coherence tomography can detect vascular changes before they’re visible with traditional ophthalmoscopic techniques. This and other subtle ocular changes are revising the standards of eye care for the diabetic population.

Diabetics suffer from a host of other eye and vision problems that affect their quality of life. These problems, revealed in a comprehensive annual eye examination, are often subtle, but affect the patient’s ability to perform everyday tasks. Some of these include dry eyes, refractive shifts, convergence problems, early cataracts and low-tension glaucoma.

Any of these diabetic eye changes can be a signal of inadequate blood sugar control but do not tell the whole story. Only in conjunction with fasting blood sugars, HA1c results and other clinical findings can diabetes be appropriately managed using the host of new treatment options that are now available.

Support for Your Practice and PatientsDiabetes Prevention Program The Diabetes Prevention Program (DPP) is a new Medi-Cal‑covered benefit offered to our members. The benefit is consistent with the Centers for Disease Control and Prevention’s (CDC) national diabetes prevention program and national standards and guidelines, also known as the CDC Diabetes Prevention Recognition Program (DPRP).

The DPP is an evidence-based, lifestyle change program designed to assist Medi-Cal members diagnosed with prediabetes in preventing or delaying the onset of Type 2 diabetes. Services are provided through trained peer coaches who use a CDC-approved curriculum.

The program includes a core benefit of at least 22 peer‑coaching sessions over 12 months, which are provided regardless of weight loss. In addition, members who achieve and maintain a required minimum weight loss of five percent from the first core session will also be eligible to receive ongoing maintenance sessions after the 12-month core services period to help them continue healthy lifestyle behaviors.

The CDC’s program curriculum promotes realistic lifestyle changes, emphasizing weight loss through exercise, healthy eating and behavior modification.

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Vision care and PCP coordination for patients with diabetesCoordination among all of care providers who care for a person with diabetes allows improved control of this complex disorder. MARCH® Vision Care supports this team approach by faxing a letter to the primary care provider (PCP) when any patient has an exam and the PCP is identified in the eligibility file MARCH receives. In addition to the procedure codes and some diagnosis codes, this letter includes the name and telephone number of the vision provider, so a complete medical record from the eye exam may be obtained from the vision provider. The Comprehensive Diabetes Care — Retinal Eye Exam (DRE) measure is a quality measure and is included in the 2019 Primary Care Practitioner Incentive (PCPi) program. Reports obtained from MARCH may be used by PCPs as evidence to document the DRE and earn incentive dollars.

Do you know the vision benefits for your Medi-Cal patients?

• Medi-Cal covers these vision services: – Eye tests and eyeglass tests to support a prescription

– Eye disease tests to confirm the need for contact lenses

– Exams to check eye health or low vision• Medi-Cal covers new eyeglasses once every

24 months and lenses for: – Children younger than 21 – Adults ages 21 and older who are pregnant or live in a nursing home

• MARCH Vision Care administers vision benefits.

For more information, call 844-336-2724 or visit the MARCH website at marchvisioncare.com.

Health Homes Program The Health Homes Program (HHP) is coming to San Diego County in July 2019. Certain community-based organizations and provider practice sites are becoming Community-Based Case Management Entities (CB-CMEs) to provide core case management services to the highest risk members with chronic medical conditions, frequent emergency department or inpatient use, or homelessness. When UnitedHealthcare gets approval from the California Department of Health Services (DHCS) for our HHP, we’ll work quickly to make sure the CB-CME’s are ready to start working with these members.

The goal of the HHP is to serve as a central point for coordinating patient-centered care. Each CB-CME is accountable for improving member outcomes by coordinating services for physical health, mental health, substance use disorder, long-term support, palliative care and social supports. This is anticipated to reduce avoidable health care costs, hospital admissions/readmissions, emergency department visits and, where possible, coordinate services to keep members in the home environment.

UnitedHealthcare will assign the designated HHP members to a CB-CME, provide support and oversight of the CB-CME to achieve goals, notify CB-CME’s of admissions and ER visits, and share data on each member’s health history. UnitedHealthcare will also pay the claims for these services and report to DHCS on a regular basis.

For more information, visit the Medi-Cal Health Homes Program page on the DHCS website at dhcs.ca.gov/services/Pages/HealthHomesProgram.aspx.

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http://marchvisioncare.com/

https://www.dhcs.ca.gov/services/Pages/HealthHomesProgram.aspx

https://www.dhcs.ca.gov/services/Pages/HealthHomesProgram.aspx



Organizations, such as National MedTrans, must take all of these factors into account. They must be aware of the needs of their members in every market and be well-informed about specific state requirements and the goals and mission of UnitedHealthcare. MedTrans strives to maintain close relationships with every partner in every market, so UnitedHealthcare members have consistent access to the highest levels of care possible.

California members can use their transportation service by calling 844-772-6623. Additionally, California facilities can schedule transportation for members by calling 833-217-4747.

For more information, visit nationalmedtrans.com.

Available TrainingCare providers can go to UHC on Air for training on topics such as:

• Introduction to UnitedHealthcare Community Plan of California/Medi-Cal The training includes an overview of UnitedHealthcare Community Plan of California. Learn how to check member eligibility and benefits submit notifications or request prior authorization, pharmacy services and other tools for doing business with UnitedHealthcare Community Plan of California.

• Cultural Competency and Americans with Disability Act This training discusses why cultural competency and the Americans with Disabilities Act (ADA) requirements are important to care providers, including information on their role in complying with these requirements. Cultural education for health care professionals is an important component of improving the quality of care delivered to diverse patient populations and can help address racial/ethnic disparities in health care.

Transportation and Health: More than Just a Ride to the DoctorEach year, millions of people in the United States miss important medical appointments because they don’t have a ride. We want to make sure our members don’t miss a visit to their primary care provider, a chemotherapy treatment or a trip to dialysis.

Research has shown that transportation is one of the most common barriers faced by low-income populations in accessing medical care because these families may lack funds to maintain a working vehicle or lack access to affordable public transit. Non-emergency Medical Transportation (NEMT) has been available through Medicaid since its inception in 1966, but many Americans are still unaware of how to use their transportation benefit or that it even exists.

It’s not enough to send a car to take someone to the doctor’s office when their condition may often necessitate certain accommodations. Riders may require a wheelchair, oxygen or assistance getting in and out of a vehicle. In many cases, they may not be able to travel alone or may not speak the same language as their driver. Transportation providers contracted to give rides to vulnerable populations are often required to receive additional training in dealing with unique populations and ensuring the safety of their passengers. But even in instances where patients have access to a transportation benefit, there are many reasons a trip can fail.

https://nationalmedtrans.com/

https://www.uhcprovider.com/en/resource-library/link-provider-self-service/uhc-on-air.html



State Servicing GuidelinesBlood Lead ScreeningCare providers who see Medi-Cal managed care members are required to conduct blood lead screening and provide oral or written anticipatory guidance to the parents(s) or guardian(s) of a child. UnitedHealthcare has developed a training course for care providers to review the blood lead screening guidelines and billing/coding requirements for reimbursement.

Go to UHCprovider.com/training and select the Blood Lead Screening of Young Children Training.

Family Planning Services Policy for Self-Administered Hormonal ContraceptivesProviders, pharmacists and locations licensed or authorized to dispense drugs or supplies may dispense or furnish members at one time with up to a 12-month supply of U.S. Food and Drug Administration-approved, self-administered hormonal contraceptives.

UnitedHealthcare will reimburse a 12-month supply of oral contraceptive pills, hormone-containing contraceptive transdermal patches or hormone-containing contraceptive vaginal rings when dispensed at one time at a member’s request by a qualified family planning provider or pharmacist, including out-of-network providers. A physician, physician assistant, certified nurse midwife, nurse practitioner and pharmacist are all authorized to dispense medication. When furnished by a pharmacist, self-administered hormonal contraceptives must be dispensed with a protocol approved by the California State Board of Pharmacy and the Medical Board of California. A registered nurse who has completed required training pursuant to BPC Section 2725.2(b) may also dispense contraceptives when evaluation and management procedures are billed accordingly.

Alcohol Misuse Screening GuidelinesThe United States Preventive Services Task Force (USPSTF) recommends that clinicians screen adults age 18 and older for alcohol misuse and provide people engaged in risky or hazardous drinking with brief behavioral counseling interventions to reduce alcohol misuse. Care providers must annually screen adult members age 18 and older for alcohol misuse. Although care providers must provide one alcohol misuse screening per year, additional screenings must be provided when medically necessary. Medical necessity must be documented by the member’s primary care provider or primary care team.

Care providers must maintain documentation of alcohol misuse screening. When a member transfers from another care provider, the new care provider must obtain the member’s prior medical records, including those pertaining to the provision of preventive services.

For clinician support, the National Institute on Alcohol Abuse and Alcoholism’s Clinical Guide “Helping Patients Who Drink Too Much” provides two methods for screening: a “single question” to use during a clinical interview and a written self-report instrument (AUDIT). For more information, visit niaaa.nih.gov/guide.

The AUDIT and Alcohol Use Disorder Identification Test — Consumption (AUDIT-C) screening instruments for alcohol misuse are available from the SAMHSA-HRSA Center for Integrated Health Solutions at integration.samhsa.gov/clinical-practice/screeningtools.

https://www.uhcprovider.com/en/resource-library/training.html?CID=none

https://www.niaaa.nih.gov/guide

https://www.integration.samhsa.gov/clinical-practice/screening-tools



Administrative Information to Help With Your PracticeGet the Power of Self-Service – Get Link Link’s self-service tools can quickly provide the comprehensive information you need for most UnitedHealthcare benefit plans — without the extra step of calling for information. Plus, you can print your activity or record reference numbers for better documentation and reduce paper costs by submitting your work online. On average, a practice will spend 6.5 minutes per call compared with 0.94 minutes a Link transaction takes.

Here are some of the transactions available through Link:

• ClaimsLink — View claims, access letters, remittance advice documents and reimbursement policies, submit additional information requested on pended claims, flag claims for future viewing, flag claims for future viewing, submit corrected claims and receive instant printable confirmation for your submissions.

• EligibilityLink — Search for covered members, check member cost share and/or copay,

• Prior Authorization and Notification Tool on Link — Determine if prior authorization or notification is required, complete your request for notification or prior authorization if required and online, upload medical notes or other attachments, and check the status of your notification and prior authorization requests

For more information on Link, visit UHCprovider.com/link or view the “Link Overview Video” on UHC on Air.

Verification of Provider InformationTo help ensure all Medi‑Cal beneficiaries have timely access to a comprehensive network of Primary Care Physicians (PCPs), specialists, hospitals, pharmacies, ancillary providers, facilities and other care providers, the Department of Health Care Services (DHCS) requires Medi-Cal plans to complete an annual provider network certification to comply with the All Plan Letter (APL) 19-002.

The process has three main components:

• Monthly submission of the plan’s network to DHCS using the industry standard 274 Healthcare Provider Information Transaction set.

• Annual certification of the plan’s network against the following standards:

– Network capacity and beneficiary ratio requirements

– Access to mandatory providers – Adherence to time and distance travel requirements

– Submission of alternative access request for DHCS approval in any zip codes not complying with time and distance travel requirements

• Monitoring and Oversight by DHCS including: – Direct provider survey calls conducted by DHCS’ External Quality Review Organization (EQRO) to assess timely access of all plans to help ensure compliance with network provider availability and appointment time standards for urgent and non-urgent appointments.

– Validation calls to a sample of each plan’s network of adult and pediatric PCPs, OB/GYNs primary and specialty care, core specialists, mental health outpatient providers, hospitals and pharmacies to confirm that network providers included in the plan’s 274 file submission are currently contracted with the plan.


https://www.uhcprovider.com/en/resource-library/link-provider-self-service.html?CID=none



What can your practice do to help?

• Review the address, specialty, panel status and other information on file for your practice through My Practice Profile on Link. You can access Link at UHCprovider.com/link.

• Update and correct your information using the processes outlined in the UHCprovider.com Demographic and Profile Updates Quick Link. Options include: 1. Signing on to Link to make direct online updates 2. Using the Care Provider Demographic

Information Update to document changes for submission by email to [email protected]

3. Calling our Provider Service Call Center at 866-270-5785

• Remind your front office staff and answering service that the DHCS may call to confirm that you are contracted and survey your appointment availability. Let your staff know that DHCS is making calls to contracted Medi-Cal care providers. As a reminder, appointments need to be available according to the following standards:

StandardsUrgent care with no prior authorization – within 48 hours

Urgent care with prior authorization – within 96 hours

Non-urgent PCP visits – within 10 business days

Non-urgent specialist – within 15 business days

Non-urgent mental health – within 10 business days

Non-urgent ancillary services – within 15 business days

Claim UpdatesWe’ve received questions about the billing of corrected claims and would like to provide details to help practices and facilities submit corrected claims.

Claim Resubmission or Correction Process

• A corrected claim is used to submit corrections to a previously paid or denied claim.

• A Care Provider Dispute Resolution (PDR) should be submitted for a claim outcome with which you do not agree. This could be an overpayment, underpayment or a payment denial of an original or corrected claim.

• Under the National Uniform Billing Committee (NUBC) claim frequency guidelines, the entire original or previous submission must be replaced or voided when sending a replacement or voided claim.

• Resubmit the entire claim as originally submitted (including line items that were previously paid correctly) with corrections.

– Check your UnitedHealthcare Community Plan Administrative Guide and reimbursement policies to reconfirm types of billing allowable for reconsideration.

Submitting Electronic Corrected Claims

• Online: To sign in to Link, go to UHCprovider.com/link and then select the claimsLink tool tile.

• Electronic Data Interchange (EDI) Submissions: – Corrected Claim Number: 5010 837 (I or P), Loop 2300, REF segment, REF02 element where REF01=F8

– Frequency: 5010 837 (I or P), Loop 2300, CLM segment, CLM05-3 element




mailto:hpdemo%40uhc.com?subject=





Community Plan in ActionSan Diego Food Bank GrantOne in seven San Diego residents faces food insecurity every day, meaning almost half a million people, including children and seniors, don’t have access to sufficient food. As part of its mission to help people live healthier lives and invest in the communities it serves, UnitedHealthcare has provided the Jacobs & Cushman San Diego Food Bank (Food Bank) with a $375,000 grant to address food insecurity. The partnership will improve the food bank’s capacity to provide nutritious food to vulnerable people and families.

The grant supports the expansion of the food bank’s Feeding Everyone with Dignity & Equity (FEED) database pilot program. Currently used at 82 food bank sites in San Diego County, the database was designed to modernize the food bank’s systems to reduce wait times and preserve the dignity of clients. Since the program’s implementation, clients have drastically reduced wait times from hours to as little as 20 minutes. Additionally, clients who use select food bank sites are provided a personalized food ID card during initial registration, streamlining the complicated intake process by eliminating repeat registration.

With UnitedHealthcare’s support, the database will expand to an additional 50 sites this year and connect people to services through the 2-1-1 Community Information Exchange (CIE). More than 114,000 additional food bank clients will be empowered with greater access to tools from CIE partners for housing, legal help and employment services.

The grant is expected to support the delivery of an additional 10 million pounds of food in 2019. Last year, the food bank distributed 28 million pounds of food and served about 370,000 people each month. UnitedHealthcare has enjoyed a longstanding partnership with the food bank through support of food distributions across San Diego County, as well as a new Diaper Bank program.

Submitting PDR by Mail or FaxPrint out the UnitedHealthcare PDR Form located on UHCprovider.com/cacommunityplan > Provider Dispute Resolution and Member Grievance and Appeals > Provider Dispute Resolution (PDR)

• Complete the PDR Form as instructed

Submit by Mail:

UnitedHealthcare Attention: Provider Dispute P.O. Box 31364 Salt Lake City, UT 84131-0364

Submit by Fax:

317-715-7648

When filling out CMS-1500:

• Enter the appropriate claim frequency code in Box 22 left justified in the left‑hand side of the field

• 7 – Replacement of prior claim• 8 – Void/cancel of prior claim• Original claim number under Original Reference No.

in Box 22

When filling out UB-04:

• Bill type in Box 4• Enter the appropriate claim frequency code in the

third position of the “type of bill”• 7 – Replacement of prior claim• 8 – Void/cancel of prior claim• Original Claim number in Remarks Box 64A

Resources

• Refer to UHCprovider.com for additional reference materials such as UnitedHealthcare policies, administrative information, important addresses and more.


https://www.uhcprovider.com/content/provider/en/viewer.html?file=%2Fcontent%2Fdam%2Fprovider%2Fdocs%2Fpublic%2Fcommplan%2Fca%2Fforms%2FCA-UHCCP-Provider-Dispute-Res-Form.pdf

https://www.uhcprovider.com/

© 2019 UnitedHealth Group, Inc. All Rights Reserved.CPT® is a registered trademark of the American Medical AssociationDoc#: PCA-1-015179-03162019_05202019

practicemattersPractice Matters is a quarterly publication for physicians and otherhealth care professionals and facilities in the UnitedHealthcare network.

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For more information, visit UHCprovider.com

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