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August 2006 2—1

Univera Community HealthParticipating Provider Manual

2.0 Administrative Information

2.1 Obtaining Member Information from UCHThe privacy rights of members are very important to Univera Community Health (UCH), as is UCH’srelationship with participating physicians and other health care providers. UCH has procedures inplace to ensure that only properly authorized parties have appropriate access to members' protectedinformation. In addition, UCH has implemented a process that places extra emphasis on protectingconfidential patient information.

Note: For more information about UCH policies regarding privacy andconfidentiality, see Section 1 of this manual.

When a physician or other health care provider calls UCH requesting information about a member, theprovider will be required to answer a few questions before UCH will release the information.

First, the participating provider must confirm his/her identity by providing the Tax IdentificationNumber or Provider ID Number used for billing.

Next, the provider must confirm his/her relationship with the member by supplying the member’sfull name and ID number. If the provider is unable to provide the member ID number, the providermust supply at least one of the following, in addition to the member’s name:- Patient birth date- A claim number or authorization number- Patient address- Name of primary physician (when applicable)

If neither the provider’s identity nor the provider/patient relationship can be confirmed, UCH will notrelease the information.

2.2 Contact ListUCH employs individuals trained to perform specific services and support specific provider needs. TheContact List at the end of this section of the manual includes telephone numbers, fax numbers,addresses, Web page addresses and e-mail addresses of UCH departments and other agencies withwhich providers most often interact.

2.0 Administrative Information Univera Community Health

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2.3 Determining Member Eligibility for BenefitsBecause eligibility for government programs requires periodic recertification, it is important to verifythat the patient has coverage before providing services. See Section 1 of this manual for a generaloverview of each type of program covered by this manual.

2.3.1 Member ID CardsEach member is assigned an individual member identification (ID) number and sent an ID card.Sample ID cards are included at the end of this Section 2.

What to Look for on the ID CardIdentification cards carry vital information to assist providers in doing business with UniveraCommunity Health. Provider offices should copy the front and back of ID cards, as both sides containimportant information, including: Logo - The Univera Community Health logo is on all member identification cards. Product Name –PlusMed cards include the name of the health benefit program. Child Health Plus

and Family Health Plus cards do not name the program but rather include a “group” identifier of“C” or “F,” respectively.

Member Name Identification Number – The identification number is required on all claims. All members have a

member ID assigned by UCH. In addition, PlusMed and Family Health Plus member cards includethe patient’s CIN# (Medicaid client identification number).

Rx ID – Child Health Plus and Family Health Plus cards include a separate ID for members to usewhen obtaining prescription medicines. (PlusMed members obtain prescriptions via fee-for-serviceMedicaid.)

Primary Care Doctor Name and Telephone Number. Instructions for emergency care. Customer Service and other helpful telephone numbers.

2.3.2 Member Eligibility Internet Inquiry: WNY HealtheNetProviders may check member eligibility through the Internet-based system, WNY HealtheNet, butmust be registered to use the system. For registration information, see the paragraphs headedOnline Patient Information System: WNY HealtheNet.1. Log on to the Internet and go to the Web site www.wnyhealthenet.org. Select LOGIN. The system

will display the Disclaimer screen.2. Click on I AGREE. The system will display the login screen.

Participating Provider Manual 2.0 Administrative Information

August 2006 2—3

3. Enter USERNAME and PASSWORD. The system will display the WNY HealtheNet Introductionscreen, with a menu that includes the option, ELIGIBILITY AND BENEFITS. The system displays aninquiry screen.

4. a. In the field listing the participating plans, select UNIVERA HEALTHCARE. (Univera CommunityHealth information is stored with the information for its manager, Univera Healthcare.)

b. In the member information fields, supply two types of patient information, e.g., the patient’sname, birth date, Univera Community Health member ID number, or Social Security Number.

c. In the field, Eligibility Date, enter the date of the service that will be or has been provided tothe member.

5. The system displays a screen showing the benefits this member was eligible for on the given date.Note: For questions or problems while using WNY HealtheNet, contact the WNYHealtheNet System Administrator. (Telephone numbers are listed in the Contact Listat the end of this Section 2.)

2.3.3 Member Eligibility Telephone InquiryThe Member Eligibility Phone Line makes available to providers information about eligibility,copayments, and primary care physician assignments for members of selected Univera CommunityHealth benefit packages. An automated telephone system, the Member Eligibility Line is accessible 24hours a day, seven days a week. Information is updated daily.To access the Member Eligibility Phone Line:1. Using a touch-tone phone, dial the number of the Member Eligibility Phone Line (listed on the

Contact List at the end of this Section 2).2. Enter the 11-digit Provider ID number assigned by Univera Community Health. A provider must

have a Univera Community Health Provider ID number to provide care to or inquire about UniveraCommunity Health members.

3. Enter the four-digit Information Line PIN number assigned by Univera Community Health. Toobtain a four-digit PIN for the Information Line, contact Provider Service (listed on the Contact Listat the end of this Section 2).

4. Enter the member’s ID number. The system will list options for obtaining information about themember’s:- Primary Care Physician (PCP)- Pharmacy coverage- Out-of-network coverage

Note: Providers may obtain the same information by contacting the ProviderService Department (listed on the Contact List at the end of this Section 2). Be readyto provide the member’s ID number, name, date of birth, date of service/admission,and diagnosis.


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2.3.4 Checking Eligibility via the Medicaid Eligibility Verification SystemEligibility information for PlusMed and Family Health Plus members is available via the Medicaideligibility verification system, ePaces. The code for PlusMed membership is “MR.” Family Health Plusmembership will read “Family Health Plus.”http://www.emedny.org/HIPAA/SupportDocs/ePACES.html

Other options for checking eligibility are the Medicaid telephone system, or the PC Medicaid eligibilitysoftware. Providers should have the member’s name, date of birth and CIN number available beforecalling.

Note: Univera Community Health recommends providers check eligibility at everyvisit as members may lose eligibility for government programs from month to month.

2.3.5 PCP Change FormIf the member’s PCP is not listed correctly on the member’s ID card, the member may make a changeby calling the Customer Service number on the ID card at the time of the appointment. Another optionis for the provider to have the member complete the PCP Change Form and fax it to the number onthe form.For the convenience of providers, we have included a copy of the form at the end of this Section 2.Providers may have the member complete it in the office and fax it to UCH at the fax number listed onthe form.

2.4 UCH Connectivity

2.4.1 Web SiteThe Univera Community Health Web site univeracommunityhealth.org carries up-to-date informationfor members and providers. It includes: Detailed information about PlusMed, Child Health Plus and Family Health Plus A directory of providers who participate in Univera Community Health Provider pages that include:

- Practice guidelines recommended by UCH- Prescription drug formulary applicable to members of Child Health Plus and Family Health

Plus- Link to WNYHealtheNet, an online eligibility, referral and claims status system (see below)

News about Univera Community Health, including the most recent Univera Community Healthmember newsletter, and

Information about the organizations that sponsor Univera Community Health.The material presented on the UCH Web site is also available by calling Provider Service (see ContactList).


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Note: In case of a discrepancy between any material presented on the UCH Website and the up-to-date version of that material on file at UCH, the latter versioncontrols.

2.4.2 Online Patient Information System: WNY HealtheNetLocal physicians and other providers who access the Internet in the office may obtain membereligibility and benefit information about UCH health benefit packages through WNY HealtheNet.Providers must register to access this information.WNY HealtheNet is an online community health information network established through thecollaboration of Univera Healthcare, BlueCross BlueShield of Western New York, Independent Health,the Catholic Health System, ECMC, Kaleida Health, and Roswell Park Cancer Institute. The WNYHealtheNet Web site contains information about members of the three participating insurancecompanies.Providers who have registered for WNY HealtheNet can access information about PlusMed, ChildHealth Plus and Family Health Plus regarding: Member eligibility Claim status Referrals

Ultimately, providers also will be able to use WNY HealtheNet for remittance advice inquiry.

To RegisterTo register for WNY HealtheNet:1. On the Univera Community Health Web site, select the option For PROVIDERS.2. Select WNYHealthenet from the Quick Jump menu or scroll to the bottom of the page for a link.3. Click on the Sign-Up tab.4. Follow the instructions to access the online Request Form.5. Complete the form and submit it as instructed.6. A representative from one of the participating health insurance plans will contact an applicant

within five business days to provide further instructions and schedule training.

Note: For questions or problems while using WNY HealtheNet, call the WNYHealtheNet System Administrator. (Telephone numbers are listed in the Contact Listat the end of this Section 2.)


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2.4.3 Electronic BillingUCH is compliant with guidelines from the Centers for Medicare & Medicaid Services (CMS) regardingthe HIPAA EDI Transaction and Code Set regulation and is prepared to receive HIPAA-complianttransactions. For detailed information about electronic billing, see Section 8 of this manual.

2.5 Univera Community Health Publications

2.5.1 Participating Provider ManualThe Univera Community Health Participating Provider Manual is intended as a reference and sourcedocument for physicians and other providers who participate in Univera Community Health. Themanual is intended to clarify various provisions of a provider’s Univera Community Health ParticipationAgreement.

2.5.2 Provider NewsletterTwice a year, Univera Community Health distributes a newsletter to participating providers designed tokeep them apprised of developments in UCH policies and products. Copies of the newsletter also areavailable upon request from Provider Service. (The Provider Service telephone number is included inthe Contact List at the end of this Section 2.)

2.5.3 Ad Hoc CommunicationsAs needed, UCH sends written notifications to participating providers regarding new and revisedpolicies and procedures and other information of value. UCH issues bulletins, letters and other noticesin instances when notification is required outside the normal newsletter schedule, or when theinformation affects only a small, specific audience of providers.

2.6 Provider Office Environment

2.6.1 Minimum Office Hours for Primary Care PhysiciansMedicaid requires that Primary Care Physicians (PCPs) who participate in Univera Community Healthpractice a minimum of 16 hours a week at each primary care site.

2.6.2 Office Site ReviewUCH conducts site reviews of the office locations of physicians and other health care providers atinitial credentialing (see Section 3) and when a provider opens a new location.An office site review includes assessments of patient safety and privacy, office operations andconfidentiality, appointment and accessibility, security of pharmaceuticals and prescription pads, andoffice record maintenance. The Credentialing Site Visit Checklist (included at the end of this Section 2)lists the criteria UCH reviewers use during a site review.


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Wheelchair AccessibilityAs part of the Office Site Review, UCH reviewers gather information to better serve members withdisabilities. This information does not affect a provider’s credentialing status. Accessibility informationis included in provider directories.

2.6.3 HIPAA ComplianceNote: This section gives a general overview of HIPAA requirements. Forinformation about UCH compliance with HIPAA standards on privacy andconfidentiality, see Section 1 of this manual. For information regarding HIPAA-compliant availability of eligibility, claims, and referral information, see paragraphsabout Member Eligibility Remote Access Inquiry, Online Inquiry Systems, and referraland prior authorization information in Section 4 of this manual. For information aboutUCH compliance with HIPAA standards on electronic submission of claims, seeSection 8 of this manual.

HIPAA, the Health Insurance Portability and Accountability Act of 1996, Public Law 104-191, wasdesigned to improve the efficiency and effectiveness of the health care system. It includesadministration simplification provisions that required the U.S. Department of Health and HumanServices to adopt national standards for electronic health care transactions. Recognizing thatadvances in electronic technology could erode the privacy of health information, Congressincorporated into HIPAA provisions that mandate the adoption of federal privacy protections forindividually identifiable health information. This information is referred to as Protected HealthInformation or PHI.The HIPAA Privacy Rule provides standards for the protection of PHI in today’s world whereinformation is broadly held and transmitted electronically. HIPAA’s privacy rule requires that healthcare providers and other specified entities (“covered entities”) take certain actions to maintainconfidentiality. Some of these actions are: Notifying patients about their privacy rights and how their PHI can be used. Adopting and implementing privacy procedures. Training employees to understand privacy procedures. Designating a Privacy Officer responsible for seeing that privacy procedures are adopted and

followed. Securing patient records containing PHI so they are accessible only to specified individuals.

Who Must ComplyThe following individuals and organizations must comply with HIPAA transaction standards. They arereferred to as “covered entities.” Health care providers who electronically conduct the financial and administrative transactions

listed under Applicable Transactions, below.


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Health plans such as Univera Community Health, employer health plans under the EmployeeRetirement Income Security Act (ERISA), Indian Health plans, and self-administered plans (exceptthose with fewer than 50 participants).

Health care clearinghouses. Business associates of any of the covered entities, if the business associate has contracted to

comply with HIPAA.These covered entities are required to comply even if the specified transactions are conducted by athird party on their behalf.

Applicable TransactionsAll covered entities that conduct any of the following standard transactions are required to use HIPAA-compliant electronic language and codes: Health care claims or equivalent encounter information. Health care payment and remittance advice. Coordination of benefits. Health care claim status. Enrollment and disenrollment in a health plan. Eligibility for a health plan. Health plan premium payments. Referral certification and authorization.

Compliance DatesCovered entities had until April 14, 2003 to comply with the act’s privacy regulations. Covered entitieshad to comply with HIPAA standards for electronic submission (ANSI 837) by October 16, 2003,subject to fine, although a one-year delay was granted to “small” organizations. On September 23,2003, the federal government announced a contingency plan whereby the Centers for Medicare &Medicaid Services (CMS, formerly the Health Care Financing Association, or HCFA) would continue toaccept noncompliant electronic transmissions until further notice. Since then, CMS has instructedMedicare carriers and intermediaries to slow payment of electronic claims that are not compliant withthe ANSI 837 standards as an incentive to increase compliance. This incentive plan took effect July 1,2004.


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2.6.4 Updating Practice InformationUCH requires that providers submit updated information whenever there are any changes to aprovider or his/her practice. This is necessary to keep directory and claims systems informationcurrent. This includes changes in: Provider Name Provider Tax ID Payment Address Directory Listing: that is, provider address, phone number, fax number and, for primary care

providers who participate in managed care products, whether the practice is accepting newpatients

Service Addresses Change in coverage arrangements When one or more practitioners join the group practice When one or more practitioners leave the group practice

To notify UCH of such changes, complete a Provider Information Update Form, indicating whatinformation has changed. A sample form is provided at the end of this section. The form is alsoavailable from the Provider Service or Provider Relations. Address and fax number are included on theform.Note: Providers also may notifyUCH of changes in practice information by e-mailing

([email protected]) or by submitting a letter on office letterhead specifyingwhat the changes are. Letters also should be faxed or mailed to Provider File Maintenance.

2.6.5 Closing/Opening a PracticeIn signing a participation agreement with UCH, a participating physician agrees to accept as patientsthose members who elect to receive care from the physician, or those whom UCH assigns to thephysician. If the physician’s practice is at capacity, the physician may close his/her practice to newmanaged care patients.However, a participating physician shall not close or reopen his/her practice to new patients withoutgiving UCH 90 days prior written notice. For purposes of continuity of care, a participating physicianshall continue to permit a current patient to designate the physician as his/her PCP when the patientchooses to enroll as a member of PlusMed, Child Health Plus or Family Health Plus.

2.6.6 Access to CareUCH has established appointment availability standards to provide reasonable patient access to care.In addition, physicians are required to advise UCH in writing of covering participating physicianarrangements or changes to those arrangements, including situations in which physicians in the same


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office are covering for each other. Physicians should also communicate coverage arrangements totheir patients.See Section 9 (Quality Management) for additional information about UCH’s requirements foraccessibility, including access to after hours care.

2.6.7 Member Payments – Medicaid (PlusMed and Family Health Plus)The following sections are a direct reprint from the April 2006 DOH Medicaid Update. The update is areminder to all hospitals, free-standing clinics and individual practitioners about requirements of theMedicaid program related to requesting compensation from Medicaid recipients, including Medicaidrecipients who are enrolled in a Medicaid managed care plan such as PlusMed or in Family HealthPlus (FHPlus).

Acceptance and AgreementWhen a provider accepts a Medicaid recipient as a patient, the provider agrees to bill Medicaid forservices provided or, in the case of a Medicaid managed care or FHPlus enrollee, the recipient’smanaged care plan for services covered by the contract.

The provider is prohibited from requesting any monetary compensation from the recipient, orhis/her responsible relative, except for any applicable Medicaid copayments.

A provider may charge a Medicaid recipient, including a Medicaid or FHPlus recipient enrolled in amanaged care plan, only when both parties have agreed prior to the rendering of the servicethat the recipient is being seen as a private pay patient.

This agreement must be mutual and voluntary.

It is suggested that the provider maintain the patient’s signed consent to be treated as private pay inthe patient record.A provider who participates in Medicaid fee-for-service may not bill Medicaid fee-for-service for anyservices included in a recipient’s managed care plan, with the exception of family planning services,when the provider does not provide such services under a contract with the recipient’s health plan.A provider who does not participate in Medicaid fee-for-service, but who has a contract with one ormore managed care plans to serve Medicaid managed care or FHPlus members, may not billMedicaid fee-for-service for any services. Nor may any provider bill a recipient for services that arecovered by the recipient’s Medicaid managed care or FHPlus contract, unless there is prior agreementwith the recipient that he/she is being seen as a private patient as described above. The provider mustinform the recipient that the services may be obtained at no cost to the recipient from a provider thatparticipates in the recipient’s managed care plan.


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Claim SubmissionThe prohibition on charging a Medicaid or FHPlus recipient applies: when a participating Medicaid provider or a Medicaid managed care or FHPlus participating

provider fails to submit a claim to Computer Sciences Corporation (CSC) or the recipient’smanaged care plan within the required time frame; or

when a claim is submitted to CSC or the recipient’s managed care plan, and the claim is deniedfor reasons other than that the patient was not eligible for Medicaid or FHPlus on the date ofservice.

CollectionsA Medicaid recipient, including a Medicaid managed care or FHPlus enrollee, must not be referred toa collection agency for collection of unpaid medical bills or otherwise billed, except for applicableMedicaid copayments, when the provider has accepted the recipient as a Medicaid or FHPluspatient.Providers may, however, use any legal means to collect applicable unpaid Medicaid copayments.

Emergency Medical CareA hospital that accepts a Medicaid recipient as a patient, including a Medicaid or FHPlus recipientenrolled in a managed care plan, accepts the responsibility of making sure that the patient receives allmedically necessary care and services.Other than for legally established copayments, a Medicaid or FHPlus recipient should never berequired to bear any out-of-pocket expenses for: medically necessary inpatient services; or, medically necessary services provided in a hospital-based emergency room (ER).

This policy applies regardless of whether the individual practitioner treating the recipient in the facilityis enrolled in the Medicaid program.When reimbursing for ER services provided to Medicaid managed care or FHPlus enrollees, healthplans must apply: the Prudent Layperson Standard; provisions of the Medicaid Managed Care/FHPlus Model Contract; and, Health Department directives.

Editor’s note: Effective September 1, 2005, Family Health Plus members have a copay for non-urgentand non-emergency ER visits.


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Claim ProblemsIf a problem arises with a claim submission, the provider must first contact CSC. If the claim is for aservice included in the Medicaid managed care or FHPlus benefit package, the enrollee’s managedcare plan must be contacted. If CSC or the managed care plan is unable to resolve an issue becausesome action must be taken by the recipient’s local department of social services (e.g., investigation ofrecipient eligibility issues), the provider must contact the local department of social services forresolution.For questions regarding Medicaid managed care or FHPlus, please call the Office of Managed Care at(518) 473-0122. For questions regarding Medicaid fee-for-service, please call the Office of MedicaidManagement at (518) 473-2160.

2.7 Medical RecordsUCH requires that participating provider medical records be kept in a manner that is current, detailed,organized, that complies with all state and federal laws and regulations, and that is accessible by thetreating provider and UCH. To support this requirement, UCH has established Medical RecordDocumentation Standards. Information regarding these standards is included in Section 9 (QualityManagement) of this manual.

2.7.1 Access to Medical Records

By Univera Community HealthA participating physician or other provider must maintain medical records and provide such medical,financial and administrative information to UCH as it may reasonably require to ensure compliancewith applicable laws, rules, and regulations; and for program management purposes. Participatingphysician offices must: Maintain medical records in a manner that is individualized, current, organized, detailed, legible

and confidential. Make records available to UCH staff for review when requested. Provide copies of patient charts to UCH without cost, per the individual Participating Provider

Agreement.Note: Medical record documentation auditing and reporting are part of “health careoperations” as defined by HIPAA and thus do not require patient authorization forrelease of protected health information. For information about HIPAA, see theparagraph headed HIPAA Compliance that appears earlier in this Section 2.

By MembersMembers have the right to see their medical records. UCH member handbooks state that any requestsfor medical records should be directed, in writing, to a member’s physician. Each member age 18 orover, or an emancipated minor, must sign his or her own written request.


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2.7.2 Charges for Photocopying Medical RecordsSubject to the terms of a provider’s participation agreement, a participating provider may not chargeUCH for photocopying a patient’s medical record. New York State Public Health Law Article 1, Title 2,Section 18 (2.e) states that providers may impose reasonable charges when a patient (subject)requests copies of his/her medical records, not to exceed 75 cents per page. However, members maynot be denied access to their records due to inability to pay.

2.7.3 Advance Care DirectivesUCH encourages providers to discuss with members end-of-life care and the appointment of an agentto assume the responsibility of making health care decisions when the member is unable to do so.Information for members about advance care planning is available on UCH’s Web site.UCH’s Medical Records Documentation Standards state that medical charts must includedocumentation indicating that adults age 18 years and older, emancipated minors, and minors withchildren have been given information regarding advance directives. See Section 9 (QualityManagement) for additional information about this requirement and about advance care directives.For convenience, UCH has created a form (Advance Care Directive Medical Record Notation) thatproviders may use to record discussions about advance directives and then include the form in thepatient’s medical record. This form is included at the end of this Section 2.

Note: Treatment decisions cannot be conditional on the execution of advancedirectives.

2.8 Prenatal, Postpartum and Newborn Care

2.8.1 New York State RequirementsUCH is obligated by the NYS Department of Health to have participating providers follow thestandards defined by Public Health Law 2522 Subdivision 1 with appropriate detail as defined inaccordance with 10 NYCRR § 85.40. The DOH requires decreasing wait times for initial prenatal careappointment depending on the trimester of pregnancy: first trimester – appointment within 3 weeks,second trimester – appointment within 2 seeks, third trimester – appointment within 1 week.The DOH standards address requirements and benefits of the state’s Prenatal Care AssistanceProgram (PCAP) including: prenatal diagnostic and treatment services, risk assessment, developmentof care plan and coordination of care, nutrition services, health education, psychosocial assessment,HIV services, internal quality assurance, postpartum services and records and reports.The standards address: Medical records that document the provision of care and services required and that are

maintained in a manner consistent with medical record confidentiality requirements. Comprehensive risk assessment, including but not limited to: genetic, nutritional, psychosocial,

and historical and emerging obstetrical/fetal and medical-surgical risk factors.


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Nutrition services including: assessment, enrollment in the Women, Infants and Children (WIC)program, and referral of at-risk members to a nutritionist or registered dietician.

Health education that is culturally, linguistically and developmentally appropriate for the member. Diagnostic and treatment services. Access and availability standards, including after-hours emergency consultations.

UCH has policies and standards addressing many of the areas listed above, as well as a clinicalguideline that addresses some of the standards specific to obstetrics.

2.8.2 Clinical Guideline for Prenatal and Postpartum CareUCH’s guideline for prenatal and postpartum care is meant to serve as a reference for physicians andhealth professionals who provide services to pregnant members of UCH’s programs. (Instructions foraccessing guidelines are in Section 9 of this manual.)UCH’s prenatal and postpartum guideline addresses the following as well as other care specific toobstetrics:

Comprehensive risk assessment, including but not limited to genetic, nutritional, psychosocial andhistorical and emerging obstetrical/fetal and medical/surgical risk factors.

Nutrition assessment and referral. Prenatal diagnostic treatment services and postpartum services, including recommendations for

HIV testing and counseling and post-HIV-test counseling. Coordination of care between providers of prenatal care and the primary care physician,

pediatrician, and other related providers. Management and coordination of care for high risk pregnancies. After-hours emergency consultations. Postpartum services that include referral to and coordination with a neonatal care provider for

pediatric care services.In addition to the guideline mentioned above, UCH has established Criteria for Consultation orTransfer of Care to OBGYN for Prenatal Patients at Risk. Both documents are available on the UCHWeb site or from Provider Service.

2.8.3 Medicaid Prenatal Care Medical Record ReviewUCH has a medical record review process designed to assess practitioners’ compliance with the NewYork State requirements, including those of the Prenatal Care Assistance Program (PCAP). SeeSection 9 of this manual for additional details.


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2.8.4 Birth & BeyondSM Case Management ProgramParticipating providers must refer all pregnant members of PlusMed, Child Health Plus and FamilyHealth Plus to the Birth & Beyond Case Management Program. To refer a member to Birth & Beyond,a participating provider must complete an application. (See the paragraphs under Case Managementin Section 4 of this manual for a description of this program and the enrollment process.)

2.8.5 Newborn CoverageThe newborn child of a Child Health Plus member does not automatically receive health coverage. Toenroll the newborn of a Child Health Plus member, the parent or guardian must complete anapplication. For information about insurance options for the newborn, the mother or guardian may callCustomer Service. (Refer to the Contact List at the end of this Section 2.)The newborn child of a PlusMed or Family Health Plus member is automatically enrolled in the sameplan as his/her mother from the date of birth. Pregnant members should contact their Medicaidcaseworker at the local Department of Social Services to enroll the unborn child prior to birth. Thedelivery hospital will notify the county, but initiating the enrollment process earlier may help preventany delays or problems with the newborn’s coverage. Automatic enrollment does not apply when thechild is younger than six months and weighs less than 1200 grams (2 lbs., 10 oz.) or is determined tobe eligible for an SSI category; or when the mother is enrolled in certain special needs or partialcapitation plans. In such situations, the child will be enrolled in an appropriate special program.

2.9 Early and Periodic Screening, Diagnostic, and Treatment

2.9.1 OverviewThe federal Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) benefit is Medicaid'scomprehensive and preventive child health program for individuals under the age of 21. EPSDT wasdefined by law as part of the Omnibus Budget Reconciliation Act of 1989 (OBRA 89). It requires thatany medically necessary health care service listed at Section 1905(a) of the Social Security Act beprovided to an EPSDT recipient even if the service is not available under the State's Medicaid plan tothe rest of the Medicaid population.UCH is obligated by the NYS Department of Health to have participating providers follow the servicestandards defined by the federal EPSTD mandate. In New York State, the EPSDT mandate isimplemented through the Child Teen Health Program (CTHP).The EPSTD/CTHP manual is available at the NYS DOH Medicaid Web site for reference.http://www.emedny.org

2.9.2 New York’s Child Teen Health ProgramNew York State follows EPSTD guidelines through its Child Teen Health Program (CTHP). Care andservices are provided in accordance with the periodicity schedule and guidelines developed by theNew York State Department of Health. They generally follow the recommendations of the Committee


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on Standards of Child Health, American Academy of Pediatrics. The guidelines also emphasizerecommendations such as those described in Bright Futures in order to guide health care providersand improve health outcomes for members.CTHP promotes the provision of early and periodic screening services and well care examinations,with diagnosis and treatment of any health or mental health problems identified during these exams.

2.9.3 Clinical GuidelinesUCH has established clinical guidelines for preventive care as a reference for physicians and otherhealth professionals who provide services to pediatric and adolescent members of UCH programs.(Instructions for accessing guidelines are in Section 9, Quality Management, of this manual.)The clinical guideline recommends care for infants, children and adolescents in accordance withEPSDT guidelines.

2.9.4 UCH and Provider RequirementsUCH and its providers must comply with the CTHP program standards and do at least the following foreligible members: Educate pregnant women and families with under age 21 enrollees about the program and its

importance to a child’s or adolescent’s health. Educate network providers about the program and their responsibilities. Conduct outreach, including by mail, telephone, and through home visits (where appropriate), to

ensure children are kept current with respect to their periodicity schedules. Schedule appointments for children and adolescents pursuant to the periodicity schedule, assist

with referrals, and conduct follow-up with children and adolescents who miss or cancelappointments.

Ensure that all appropriate diagnostic and treatment services, including specialist referrals, arefurnished pursuant to findings from a CTHP screen.

Achieve and maintain an acceptable compliance rate for screening schedules.The package of services includes administrative services designed to assist families in obtainingservices for children that include outreach, education, appointment scheduling, administrative casemanagement and transportation assistance.

2.9.5 Periodicity RequirementsProviders must follow the most current version of the American Academy of Pediatrics (AAP)Recommendations of Preventive Pediatric Health Care (AAP Periodicity Schedule), available from theAAP. See the AAP Web site at www.aap.org.


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2.9.6 Screening, Diagnosis and Treatment RequirementsThe following services are required during a CTHP exam: Comprehensive health and developmental history. Immunizations in accordance with the most current recommended immunization schedule as

appropriate. (See the UCH Preventive Health Services guideline or the DOH Web site.) Comprehensive, unclothed physical exam. Laboratory tests as specified, including at least:

The most current lab testing recommendations of the AAP Recommendations for PreventivePediatric Health Care, and

Lead poison screening, with blood levels drawn at ages one and two years. Children betweenages three and six years who have not been previously tested should be tested.

Health education. Vision services. Hearing services. Dental services. In other words, the first oral exam by a dentist should occur within six months of

the first primary tooth’s eruption. Routine preventive dental care should occur every six months,with additional visits made based on a dentist’s assessment. Health professionals should reinforceoral health supervision within regular health supervision visits.

When a screening exam indicates the need for further evaluation of an individual’s health, diagnosticservices or referrals must be provided as appropriate, and such services or referrals made withoutdelay.Treatment or other measures must be provided to correct or ameliorate defects and physical andmental illness or conditions discovered by the screening services.

2.9.7 Transportation AssistanceSome individuals receiving EPSDT services have a transportation assistance benefit. For PlusMedmembers, this benefit is obtained through Medicaid. For Family Plus Members aged 19 or 20, thetransportation benefit is available through Univera Community Health. Child Health Plus membersdo not have a non-emergency transportation assistance benefit.

2.10 Vaccines for ChildrenAll providers administering vaccines to children covered by PlusMed (Medicaid managed care) orChild Health Plus members must participate in the New York Vaccines for Children (VFC) program.VFC provides the vaccines free of charge. For more information about VFC and how to get vaccines,providers should call VFC directly. (The telephone number is listed in the Contact List in Section 2 ofthis manual.)


2—18 August 2006

While Univera Community Health will not reimburse for the vaccine for PlusMed or Child Health Plusmembers, claim history is needed for quality measures and compliance reporting to the DOH.Therefore, in addition to billing for vaccine administration, providers should also submit claims for thevaccine for charges of $0.VFC applies only to children with PlusMed or Child Health Plus coverage. It does not apply to FamilyHealth Plus. Bill Univera Community Health directly for the vaccines for Family Health Plus members.

2.11 Sterilization and Hysterectomy Consent FormsSterilization procedures, whether incidental to maternity or not, require completion of a patient consentform in accordance with Medicaid guidelines covering informed consent procedures for Hysterectomyand Sterilization specified in 42 CFR, Part 441, sub-part (F), and 18 NYCRR Section 505.13 and 18NYCRR, Part 508.

2.11.1 Informed Consent for SterilizationPatients must be at least 21 years of age at the time of informed consent and mentally competent, andthey must complete and sign DSS-3134, Sterilization Consent Form, at least 30 days but not morethan 180 days prior to a bilateral tubal ligation or vasectomy procedure or any other medicalprocedure, treatment or operation for the purpose of rendering an individual permanently incapable ofhaving a child. “Informed consent” means that the patient gave consent voluntarily after the provider planning toperform the procedure: Offered to answer any questions, Told the patient that he or she is free to withhold or withdraw consent to the procedure at any time

before the sterilization without affecting his or her right to future care or treatment and withoutloss or withdrawal of any of his or her federally funded benefits,

Told the patient that there are alternative methods of family planning and birth control, Told the patient that the sterilization procedure is considered to be irreversible, Explained the exact procedure to be performed on the patient, Described the risks and discomforts the patient may experience including effects of any

anesthesia, Described the benefits and advantages of sterilization, and Advised the patient that the sterilization will not be performed for at least 30 days following the

informed consent.In addition, the provider planning to perform the procedure: Has made arrangements so that the above information was effectively communicated to a blind,

deaf or otherwise disabled person;


August 2006 2—19

Provided an interpreter if the patient did not understand the language on the consent form or theperson who obtained informed consent; and

Permitted the patient to have a witness present when consent was given.

2.11.2 HysterectomyHysterectomy is covered only in cases of medical necessity and not solely for the purpose ofsterilization. Patients must be informed that the procedure will render them permanently incapable ofreproducing. A patient must complete DSS-3113, Acknowledgment of Receipt of HysterectomyInformation, at least 30 days prior to the procedure. Prior acknowledgment may be waived when awoman is sterile prior to the hysterectomy or in life-threatening emergencies where prior consent isimpossible.

2.11.3 Submission of Forms Required for PaymentThe performing provider must send a copy of the completed Sterilization Consent Form orAcknowledgment of Receipt of Hysterectomy Information form to UCH either prior to submitting aclaim for the procedure or with the claim for the procedure. UCH will deny payment for sterilizationprocedures or hysterectomy if the physician fails to submit evidence of informed consentgiven within the required time frames noted in the preceding paragraphs.

2.11.4 Where to Get FormsProviders must request blank forms, Sterilization Consent Form or Acknowledgment of Receipt ofHysterectomy Information, from the NYS Department of Health by completing a Request for Forms orPublications form and faxing or mailing it to the DOH. For contact information, see Sterilization andHysterectomy Consent Forms on the Contact List at the end of this Section 2.

2.12 Forms and ChartsThese forms and charts are reproduced on the following pages: Chart: Contact List, Univera Community Health (3 pages) Sample ID Cards: PlusMed, Child Health Plus, Family Health Plus Form: PCP Change Form Chart: Credentialing Site Review Checklist Form: Provider Information Update Form (3 pages) Form: Advance Directive Medical Record Notation


2—20 August 2006

CONTACT LISTUnivera Community Health

Name Comments Telephone Fax

Provider Service (716) 857-4444(800) 617-1114

(716) 857-4610(800) 742-6153

Behavioral HealthDepartment

For BH providers to arrange for aninpatient concurrent treatmentreview or inquire about casemanagement.

(716) 656-1344(800) 330-9314

(716) 568-2381(800) 430-9905

Behavioral Health Referralsand Preauthorizations See Referrals or Preauthorizations

CAQH (Council for AffordableQuality Healthcare)

For physician credentialinghttps://caqh.geoaccess.com/oas/ (888) 599-1771

Care CallsSupport for members with asthma,coronary artery disease,depression, and/or diabetes.Provider may call to refer.

(800) 860-2619(716) 504-5580

(716) 847-0047(800) 404-1442

Case Management,Behavioral Health See Behavioral Health Department, above

Case Management, Medical (716) 843-7879(877) 281-2273

(716) 847-0047(800) 404-1442

Case Management, Perinatal(Birth and BeyondSM)

To submit forms or to askquestions about the program

Call CustomerService (716) 857-6224

Claim Status Submit Claim Status Request form to Provider Service, aboveClaim Status, Web-based Registration required for use http://www.wnyhealthenet.org/indexIE.jspClaims Submission,Electronic See Trading Partner Support, below

Claims Submission, PaperUnivera HealthcarePO Box 23000Rochester, NY 14692

CompassionNet Case management for children withlife-threatening illnesses

(716) 857-6211(877) 741-3915

Computer SciencesCorporation (CSC) - ePaces

Institutional (Clinics, hospitals, etc.)Practitioner (MDs, Dentists)Professional (DME, non-MDs)

(800) 522-1892(800) 522-5518(800) 522-5535


August 2006 2—21


Credentialing Credentialing questions ONLY (716) 857-6208(716) 504-5650 (716) 504-5529

CuraScript Pharmacy Specialty pharmacy for specificself-administered medications (866) 413-4137

Customer Service 205 Park Club LaneBuffalo, NY 13221

(800) 683-3781(716) 847-1433

Disease Management See Care Calls.

ePaces Software for Medicaid eligibilityinquiries Call Computer Sciences Corp.

Fair Hearing https://www.otda.state.ny.us/oah/oahforms/erequestform.aspFair Hearing SectionNYS Office of Temporary and Disability AssistanceP.O. Box 1930Albany, NY 12201-1930

(800) 342-3334 (518) 473-6735

Inpatient Admissions(Hospital or Skilled NursingFacility)

Facility must notify UCH (716) 857-4500(800) 610-1113

(800) 245-5370(716) 857-4694

Medical BenefitsManagement (To discussalternatives to hospitalization)

M to F, 8:00 a.m. to 5:00 p.m.All other times (Pager)

(716) 504-5574(716) 443-9929

Medical Director Call Provider Service.

Membership To join Child Health Plus, PlusMedor Family Health Plus

(716) 504-0560(800) 494-2215

Member Eligibility PhoneLine

Requires assigned PIN. To obtainPIN, call Provider Service.

(716) 504-5600(866) 782-9661

Member Eligibility, Web-based Registration required Http://www.wnyhealthenet.org/indexIE.jsp

Member GrievancesMail to:UCH Customer Service Dept205 Park Club LaneBuffalo, NY 13221

During regular business hours, callCustomer Service.After hours, call(800) 205-9082.

National Provider Identifier(NPI)

National Plan & ProviderEnumeration System (NPPES).Apply on line athttps://nppes.cms.hhs.gov/NPPES/Welcome.do

Fox Systems, Inc.Apply by phone at(800) 465-3203


2—22 August 2006


NYS DOH Office ofManaged Care

Questions regarding Medicaidmanaged care or Family HealthPlus

(518) 473-0122

NYS DOH Office ofMedicaid Management

Questions regarding Medicaid fee-for-service

(518) 473-2160

New York Vaccines forChildren (NYVFC) program

Medicaid managed care (PlusMed)and Child Health Plus only

(800) 543-7468

Pharmacy, Help DeskFLRx Help Desk, 6th Floor165 Court StreetRochester, NY 14647

(800) 724-5033

Pharmacy, Drug PriorAuthorization (800) 956-2397

Preauthorization See separate entry for imagingservices

(800) 610-1113(716) 857-4500

(800) 245-3370(716) 857-4694

Preauthorization, ImagingStudies CT, MRA, MRI, PET (888) 576-7783

(716) 857-6303(888) 465-1373(716) 857-6361

Privacy Officer For complaints regarding memberprivacy (866) 584-2313

Provider File Maintenance To update Provider Information (716) 857-4589 (800) 915-4574

Quality ManagementFor copies of clinical guidelines,patient education tools, orinformation about access to thePatient Management Reminder.

(800) 574-2390 (716) 857-6355

Referrals M to Th, 8:30 a.m. to 5:00 p.m.F, 9:00 a.m. to 5:00 p.m.

(716) 857-4500(800) 610-1113

(716) 857-4694(800) 245-3370

Referrals, Web-based Registration required http://www.wnyhealthenet.org/indexIE.jspSpecialty Pharmacy See Curascript

Sterilization andHysterectomy ConsentForms (Medicaid & FHP)

New York State Dept of HealthRoom 2029 Corning TowerEmpire State PlazaAlbany, NY 12237

(518) 473-4852 (518) 486-1432

Trading Partner Support Electronic transactions includingclaim submittal

(877) 843-8520(585) 238-4618

WNY HealtheNet SystemAdministrator (PCI) M to F, 7:00 a.m. to 7:00 p.m. (877) 895-4724

(end)


August 2006 2—23

Sample PlusMed Member Identification Card

PlusMedAll medical care (except emergency care) must be provided orauthorized in advance by your Primary Care Physician.

EMERGENCY CARE: In the event of an emergency medical condition,go to the nearest hospital or emergency care facility.

John A. Patient Univera Community HealthID#: 123456789 00 CIN#: AB12345C Customer Service:DOB: 01/28/1956 Eff. Date: 01/01/2001 716-847-1433Primary Care Doctor: orMary Doctor 1-800-683-3781Doctor Phone #: (123) 123-1234

Office Visit: $0

Phone Numbers and Emergency Information on Back A PROGRAM OF: Univera Community Health 205 Park Club Lane, Buffalo, New York 14221-5239

Sample Child Health Plus Member Identification Card

Group Code CAll medical care (except emergency care) must be provided orauthorized in advance by your Primary Care Physician.


Mary A. Patient Univera Community HealthID#: 123456789 00 Rx ID#: AB12345C Customer Service:DOB: 01/28/1996 Eff. Date: 01/01/2001 716-847-1433Primary Care Doctor: orJohn Doctor 1-800-683-3781Doctor Phone #: (123) 123-1234

Office Visit: $0Rx:

FLRx Pharmacy Help Desk: 1-800-724-5033


Sample Family Health Plus Member Identification Card

Group Code FAll medical care (except emergency care) must be provided orauthorized in advance by your Primary Care Physician.


Mary A. Patient Univera Community HealthID#: 123456789 00 Rx ID# and CIN#: AB12345C Customer Service:DOB: 01/28/1996 Eff. Date: 01/01/2001 716-847-1433Primary Care Doctor: orJohn Doctor 1-800-683-3781Doctor Phone #: (123) 123-1234

Office Visit: $0Rx:

FLRx Pharmacy Help Desk: 1-800-724-5033



2—24 August 2006

PCP Change FormThis form will not be processed if the signature of the member or his/her parent or guardian is notsupplied below.

Today’s Date:

To Be Completed by the Member

Medicaid ID# or Client Identification Number (CIN):

Member Name: (Please print.)

Parent/Guardian Name: (if applicable) (Please print.)

Reason for Changing PCP:

Signature of Member orParent/Guardian:

(Signature required)

Name of New Medical PCP:

Name of New OB/GYN:

Effective Date of Change: Today First day of the upcoming month (check one box)

Fax the completed form to Univera Community Health Customer Service(716) 857-4610 or 1(800) 742-6153

Rev. 7/06205 PARK CLUB LANE, BUFFALO, NEW YORK 14221-5239


August 2006 2—25

Credentialing Site Visit ChecklistUnivera Community Health performs an office site review as part of the provider credentialing/recredentialingprocess. Provider sites must meet the following standards for the credentialing process to proceed.

Facility and EnvironmentClean, private restroom for patients

Waiting and treatment rooms clean, sanitary,and of adequate sizePatient care areas ensure privacyHandicap accessibleWell maintained

Office Operations Confidentiality policy for staff Process to identify and contact patients who

miss appointments

Access to Care Emergency coverage, 24 hours a day, seven

days a weekUrgent medical care available within 24 hours

Adult base-line medical exam available within12 weeks

Routine health maintenance care within fourweeks

Non-urgent sick visits within 48 to 72 hours Well-child visits within four weeks Routine behavioral health care within 10

business days Urgent behavioral health care within 48 hours

Rev. 7_05

Pharmaceuticals Access to medications limited Prescription pads stored in secure location Needles, syringes, and controlled substances

secured

Office Record Maintenance System in place to ensure a neat and legible

record for each patient Patient name, ID number on each page, all

entries dated, sequential and signed orinitialed by author

Problem list included Stored securely to maintain confidentiality and

privacy Maintained for period required by law

System in place to ensure that providerreviews all clinical informationAllergies displayed prominently

System in place to capture biographic andpersonal data and appropriate medical history

Provider Information Update Form

Instructions: Please complete this form and return by mail or fax to the addresses shown on the last page. This form must bepersonally signed by the provider (no signature stamps can be accepted).

1) Provider Name: __________________________________________________

2) Provider's Tax ID Number: _________________________________________ individual number group number

If this is a group number, what is the name of the group? ________________________________________________________________________

3) Provider's License Number: __________________________________________ State Issued ______________________

4) NPI Number(s) for: Provider #: ______________________________________(National Provider Identifier)

Group #: ___________________ Group Name: _________________________________________

Group #: ___________________ Group Name: _________________________________________

***For the remaining questions, fill out only the ones that require a change or update to your information ***

5) Address Change: (please check appropriate box) Street Address _____________________________________________________________

Suite/Bldg # _______________________________________________________________

Address/telephone change City _____________________________________________________________________

Additional location/telephone State ____________ Zip Code _________________ County ________________________

Terminating location/telephone Phone ( )____________________________ Fax ( )_____________________________

Termination date of location/telephone __________________________

Billing Address/Telephone change Effective date of new address_________________________________________________

Email: Office _____________________ Physician _____________________________

Handicap accessible? Yes No

Accessible to public transportation? Yes No

Old Address: (if address change checked) Street Address _____________________________________________________________

Suite/Bldg # _______________________________________________________________

City _____________________________________________________________________

State ____________ Zip Code _________________ County ________________________

Phone ( )____________________________ Fax ( )_____________________________

Email: Office _____________________ Physician _____________________________

6) Is the tax ID listed above a change? Yes No (If yes, attach a copy of W-9 Form – Paper only)

Effective date of new tax ID # _____________________

What is the Old tax ID # __________________________

7) What hours are you available to see patients? (For more than 2 locations, please attach an additional sheet – Paper only)

Location 1: _____________________________ Location 2: _____________________________

Office Start Office End Office Start Office EndMonday Monday

Tuesday Tuesday

Wednesday Wednesday

Thursday Thursday

Friday Friday

Saturday Saturday

Sunday Sunday

8) For Primary Care Physicians Only – Are you accepting new patients? Yes No

9) For Primary Care Physicians Only – List names of on-call physicians below (attach additional sheet if necessary – Paper only)

Name Effective Date Cross Cover? Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

10) What languages are spoken in this office? _________________________________________________________________

11) Hospital affiliations:

Hospital Name Hospital Address

12) Do you have a nurse practitioner or physician's assistant who works with you? Yes No If yes, please list below.

Name NP or PA Effective Date NP PA

NP PA

NP PA

NP PA

13) Additional comments.

______________________________________________________________________________________________________

______________________________________________________________________________________________________

______________________________________________________________________________________________________

______________________________________________________________________________________________________

Practitioner's signature required _________________________________________________________________ Date __________________ (stamps not acceptable)

Please fax, e-mail or mail this signed form to:Fax: (800) 915-4574 Mail:Univera HealthcareE-mail: [email protected] Provider File Maintenance

205 Park Club LaneBuffalo, New York 14221

For NPI (National Provider Identifier) only, please mail or fax thiscompleted form to the address below:National Provider Identifier TeamAttn: Techniplex165 Court StreetRochester, NY 14647Fax Number: (800) 561-6504


August 2006 2—29

Advance Care Directive Medical Record Notation

Patient Name: Patient DOB:

Date Initials

Has the patient received information regarding Advance Care Directives? Yes No

Has the patient issued an Advance Care Directive? Yes No DNR Date: ___/___/___

Health Care Proxy Date: ___/___/___If yes, pleasespecify:

Living Will Date: ___/___/___

If yes, is copy in the medical record? Yes No

If no, have you readdressed Advance Care Directives with this patient? Yes No

Comments:

Rev. 06/04

univera community health participating provider … · univera community health participating...

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