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Pennsylvania | Spring 2014

Community Plan

Practice Matters: PA - Winter 2013 Provider Services Center: 877-842-3210

Important information for health care professionals and facilities

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In This Issue...

• Promoting Oral Health at Every Age

• Effective Treatment of ADHD

• Medicaid & CHIP Facility Outpatient Fee Schedule Updates

• Preparing for ICD-10 Compliance and Implementation

• Meeting the Needs of Children With Sickle Cell Disease

• Right Place. Right Time. Right Care.

• Improving Pregnancy Outcomes

• Utilization Review

• Member Rights and Responsibilities

• Care Management and Disease Management

Practice Matters: TX - Summer 2013 Customer Service Center: 888-362-33681

Community Plan

Practice Matters: PA - Spring 2014 Provider Services Center: 877-842-32101

Important information for health care professionals and facilities

Diagnosis of ADHD requires a comprehensive medical evaluation to rule out potential physical conditions. The reliability of diagnosing ADHD has been shown to improve when appropriate guidelines are used, and when additional history is collected from both parents and teachers.

Treatment has been shown to work best with a team approach when behavioral health clinicians, doctors, parents, teachers, and other health care professionals, along with the family and child, work together. The treatment plan may include behavioral therapy, medication, parent training and education. This combination helps the child focus their attention and control behavior issues. It is important to monitor the child’s progress. Visits with a behavioral health clinician are recommended at least monthly until optimal results are achieved.

The National Committee for Quality Assurance (NCQA) rates performance on the following HEDIS® measures for children with ADHD between ages 6-12:• The percentage with a new prescription dispensed

for ADHD medication that had one follow-up visit with a practitioner with prescriptive authority within 30 days of the initiation of treatment (Initiation Phase).

• The percentage with a prescription dispensed for ADHD medication that remained on the medication for at least 210 days and had at least two additional follow-up visits with a practitioner within nine months after the Initiation Phase ends.

Visit UHCCommunityPlan.com to view the ADHD clinical practice guideline and you can findadditionalinformationandtoolsrelated to ADHD and other behavioral health topics at https://www.liveandworkwell.com/ member/prevention.

Source: Optum (2013). Network Notes. Retrieved from https://www.ubhonline.com/html/regionalInformation/newsletters/NN_Fall2013_BHquality.pdf

Promoting Oral Health at Every AgeUnitedHealthcare Community Plan is focused on and committed to educating our membership on the need for and value of Preventive Dental Care as it relates to overall health. In this newsletter, and in several upcoming newsletters, we will continue to highlight this important initiative and provide examples of information that we will be sharing with our members.

Click here to see an example of communications for our pediatric members on this topic.

Together with you, we hope to help our members live healthier lives.

Effective Treatment of ADHDAttention-Deficit/HyperactivityDisorder(ADHD)isoneof the most commonly diagnosed childhood behavioral health disorders with prevalence estimates ranging from three to nine percent of school-age children. These children exhibit inattentiveness and may appear hyperactive and impulsive. Many children exhibit these common behaviors periodically, but a child with ADHD exhibits these behaviors persistently, intensely, and in a variety of settings.

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

Community Plan

Practice Matters: PA - Spring 2014 Provider Services Center: 877-842-32102

Important information for health care professionals and facilities

Medicaid & CHIP Facility Outpatient Fee Schedule UpdatesEffective March 1, 2014, UnitedHealthcare Community Plan implemented changes to the Facility Outpatient Fee Schedule for our Medicaid and CHIP members. For covered services, facilities are required to identify procedures by valid revenue codes, and common procedural terminology (CPT)/ healthcare common procedural coding system (HCPCS) codes and/or modifierstoreceivepayment.

UnitedHealthcare Community Plan of Pennsylvania’s fee schedule will continue to be based on the Department of Public Welfare (DPW) Medical Assistance (MA) Outpatient Program fee schedule. The DPW will update and publish the MA fee schedule periodically, and we will use this as the primary source for our fee schedule. Where no fee exists on this primary source, we will use alternativesourcestogapfillforCPTandHCPCScodesnotreflectedontheDPWfeescheduleincludingCMSand the Vaccines for Children Program.

Preparing for ICD-10 Compliance and ImplementationAlthough many industry experts speculate ICD-10 will be become effective Oct. 1, 2015, Health and Human ServiceshasnotconfirmedtheactualICD-10compliancedate. Regardless of the effective date, we recommend you continue working toward ICD-10 compliance to give you enough time to prepare staff, implement new processesandmakeanytechnologymodificationsnecessary to successfully launch your ICD-10 program.

The vice president of ICD-10 Training and Education at AAPC, the country’s largest medical coding organization, cautions in AAPC’s recent white paper on ICD-10*, “Practices that take a strategic approach to ICD-10 implementation will not have the productivity struggles as those who do not take ICD-10 seriously”.

We offer an array of ICD-10 education, tools, resources and partnerships on UnitedHealthcareOnline.com > Quick Links > ICD-10 and Regulatory Outreach to help you gain ICD-10 compliance.

If you have any questions about ICD-10, send them to icd10questions@uhc.com.

* ICD-10: The History, the Impact, the Keys to Success

Meeting the Needs of Children With Sickle Cell DiseaseIn November, we will launch a new care management model to support pediatric members living with Sickle Cell disease in the Philadelphia area.

If you would like to connect one of your patients with our program, please contact us at megan_hollingworth@uhc.com for more information.

We appreciate your partnership and assistance in getting these young members the care they need to help them live healthier lives.

Right Place. Right Time. Right Care.Like us, you may have noticed an increase in some of our members using emergency rooms for primary care treatments. We are working to help connect these members with an appropriate Medical Home to shift the focus from episodic, illness-based care to integrated, member-centered care that includes preventive care services. The Medical Home model expands and increases access to medical treatment, including preventive care services, while reducing inappropriate

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

Community Plan

Practice Matters: PA - Spring 2014 Provider Services Center: 877-842-32103

Important information for health care professionals and facilities

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ER utilization. If you have developed an innovation that reduced the need for ER usage among your patients, we would like to hear about it. We want to spotlight your “best practice”.

Please email megan_hollingworth@uhc.com to participate. Thank you.

Improving Pregnancy OutcomesWe are engaged in a group of initiatives to target the health care of pregnant women and newborns. This includes educating women about the risks of early-term births and supporting women who struggle with opioid use and addiction in pregnancy.

We follow guidelines published by the American College of Obstetrics and Gynecology (ACOG) and are partnering with the March of Dimes to reduce the frequency of non-medically indicated deliveries prior to 39 weeks of gestation.

How You Can HelpPlease help us by educating expectant mothers that healthy babies are worth the wait, and adhere to evidence-based protocols and guidelines. Early-term births at 37 to 38 weeks can lead to newborn health complications, including respiratory distress syndrome, increased Transient Tachypnea of the Newborn (TTN), sepsis and feeding problems, resulting in increased Neonatal Intensive Care Unit (NICU) admissions and extended hospital stays.

The use of progesterone in pregnancy can reduce the incidence of preterm birth in some women. UnitedHealthcare Community Plan wants to make sure your patients who are at risk receive it.• A woman with a singleton gestation and a prior

spontaneous preterm singleton birth should be offered progesterone supplementation (17P) starting at 16-26 weeks and 6 days of gestation, regardless of trans-vaginal ultrasound cervical length, to reduce the risk of recurrent spontaneous preterm birth.

• Vaginal progesterone is recommended as a management option to reduce the risk of preterm birth in asymptomatic women with a singleton gestation, without a prior preterm birth, who have undergone a trans-vaginal sonographic cervical length examination between 19 weeks and 23 weeks and 6 days; who have a cervical length of less than or equal to 25MM (short cervix); and begin treatment before 24 weeks of gestation.

The American College of Obstetricians and Gynecologists 409 12th Street, SW, P.O. Box 96920, Washington, DC 20090-6920Prediction and prevention of preterm birth. Practice Bulletin No. 130. American College of Obstetricians and Gynecologists. Obstet Gynecol 2012; 120:964–7

Long Acting Reversible Contraception: Implants and Intrauterine Devices Short inter-pregnancy intervals are associated with an increased risk of prematurity. Long-acting, reversible contraceptives may be the answer for your patients. Promoting the use of long-acting, reversible contraceptive devices may help lower unintended pregnancy rates.

The American College of Obstetricians and Gynecologists 409 12th Street, SW, P.O. Box 96920, Washington, DC 20090-6920Long-acting reversible contraception: implants and intrauterine devices. Practice Bulletin No. 121. American College of Obstetricians and Gynecologists. Obstet Gynecol 2011; 118:184–96.

Opioid Use - Neonatal Abstinence SyndromeOpioid abuse has taken the lives of many people and is a nationwide issue, even effecting newborn children. Neonatal Abstinence Syndrome (NAS) is caused by maternal opiate use when infants, who are born addicted to the drugs the expectant mother takes, undergo withdrawal upon delivery.

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

Community Plan

Practice Matters: PA - Spring 2014 Provider Services Center: 877-842-32104

Important information for health care professionals and facilities

Signs of withdrawal usually present from within 24 hours to several days after delivery and may include serious neurologic, gastrointestinal and respiratory symptoms such as abnormal sleep patterns, tremors, vomiting, high-pitch crying, irritability, hyperactivity, seizures, weight loss and failure to gain weight.

Overthepastdecade,wehaveseenasignificantrisein the incidence of babies born with NAS and this rise is paralleled by an increase in the prescribing and use of narcotic pain medications in women of childbearing age. Due to the seriousness of the condition, the primary place of care for a baby with NAS is the Neonatal Intensive Care Unit (NICU). The human costs of NAS aregreat.Thesebabiesareoftenbornintodifficultsocialcircumstances and can present challenges for new parents trying to care for a distressed baby while often simultaneously working through their own distress. In total, the circumstances place tremendous strains on the health care, child welfare and human services systems.

Please educate your patients who are pregnant or are planning to get pregnant about NAS and the risks associated with opioid use and abuse and other methods for pain management.

Please don’t hesitate to reach out to our team at Healthy First Steps by calling 800-599-5985 and we will provide you and our members with access to resources and support.

References:• Topics in Brief: Prenatal Exposure to Drugs of Abuse,

Drug Abuse Among• Pregnant Women in the U.S.• National Institute on Drug Abuse - Revised May 2011• Prescription Drugs: Abuse and Addiction -

Preventing and Recognizing

• Prescription Drug Abuse• National Institute on Drug Abuse -

Updated October 2011• Combating Misuse and Abuse of

Prescription Drugs: Q&A With Michael Klein, Ph.D.• US Food and Drug Administration -

Posted July 28, 2010• Tobacco, Alcohol, Drugs, and Pregnancy,

Frequently Asked Questions• The American College of Obstetricians

and Gynecologists

Utilization ReviewUnitedHealthcare Community Plan staff performs concurrent review on inpatient stays in acute, rehabilitation and skilled nursing facilities, as well as prior authorization reviews of selected services. A listing of services requiring prior authorization is available in the Provider Manual. A physician reviews all cases in which the care does not appear to meet guidelines. Decisions regarding coverage are based on the appropriateness of care and service and existence of coverage. The decisionsareinnowayinfluencedbyfinancialorincentives of any kind. The treating physician has the right to request a peer-to-peer review with the reviewing physician and to request a copy of the criteria used in the review. The denial letter contains information on how to request materials and how to contact the reviewer. Members and practitioners also have the right to appeal denial decisions.

Appeals are reviewed by a physician who was not involved in the initial denial decision and who is of the same or similar specialty as the requesting physician.

If you have questions about UM, you can talk to our staff. Just call 800-600-9007. Information on requesting an appeal is included in the denial letter.

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

Community Plan

Practice Matters: PA - Spring 2014 Provider Services Center: 877-842-32105

Important information for health care professionals and facilities

Member Rights and ResponsibilitiesJust a reminder, the UnitedHealthcare Community Plan Member Rights and Responsibilities can be found in the Provider Manual. The Provider Manual is located at UHCCommunityPlan.com. Member Rights and Responsibilities are distributed to new members upon enrollment and annually thereafter.

Care Management and Disease ManagementThe UnitedHealthcare Community Plan Personal Care Model® is a holistic approach to care for members with complex needs, especially for those with chronic conditions. The goal is to keep our members in the community with the resources necessary to maintain the highest functional status possible.

What can the UnitedHealthcare Community Plan Case Manager provide for your patients?• Telephonic contact with members and home

visits as needed• Disease management programs• Health education and educational materials• Ahealthassessmentwithstratificationofdiagnosis

and severity of condition and psychosocial needs• Referral to community resources as needed• Assistance with medical transportation• Arrangements for DME and ancillary services as

needed or ordered by the physician• Outreach to members to promote assistance with

keeping doctor’s appointments• Work with members to identify and address barriers

to seeking health care and to following their medical treatment plan of care.

Areas of Expertise

• Disease Management programs– Diabetes– CHF– Asthma– HIV– COPD– Sickle Cell

• Special Needs Case Management (adults and children)

• Complex Needs Case Management• Pediatrics/NICU Case Management• Emergency Room Utilization Case Management• Healthy First Steps Program for pregnant women

(do not have to be high risk to receive this service).

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practicematters

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Practice Matters is a quarterly publication for physicians and other health care professionals and facilities in the UnitedHealthcare network.

Community Plan

Pennsylvania