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practicemattersOhio | Winter 2015

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Call our Provider Services Center at 800-600-9007 Visit UHCCommunityPlan.com

Practice Matters: OH - Winter 2015 Provider Services Center: 800-600-9007

Important information for health care professionals and facilities

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In This Issue...• Taking Steps toward Quality Improvement

• Symposium Puts Focus on Diabetes Prevention

• Health Fair Addresses Community Needs and Concerns

• HealthSpot Gives Members Convenient Way to Seek Care

• Home Clinical Visits Now Available for Qualifying Members

• New Coverage Guidelines for Elective Obstetric Deliveries before 39 Weeks

• What a Case Manager Provides to Members

• A Member’s Right to Culturally Competent Care

• Where to Get Pharmacy Updates

• Enroll in Electronic Payments & Statements

• Special Needs Plan Model of Care Training

• Reducing Radiation Exposure in Pediatric Populations

We hope you enjoy the winter edition of Practice Matters. In this issue, you can read about quality improvement efforts, diabetes prevention, managing electronic payments and much more.

Practice Matters: TX - Summer 2013 Customer Service Center: 888-362-33681 Practice Matters: OH - Winter 2015 Provider Services Center: 800-600-90071

Important information for health care professionals and facilities

Taking Steps toward Quality ImprovementUnitedHealthcare Community Plan continuously looks for ways to help improve access to quality care and services for members. Each year, we use Healthcare Effectiveness Data and Information Set (HEDIS) reporting to measure our health care performance.

In 2014, one of our HEDIS performance goals was to increase the number of diabetic members who had annual HbA1C testing. In 2015, our scores showed an increase nationwide in the number of these members who had this test performed.

For 2015-16, some of the areas we are targeting for improvement include: increasing the number of members who have an annual dental visit; raising the number of women who have a postpartum visit three to eight weeks after delivery; and increasing the appropriate use of corticosteroid therapy for members who have asthma.

We also conduct annual member surveys to see how well we meet member needs. This year we conducted the Consumer Assessment of Healthcare Providers and Systems (CAHPS) survey and saw improvements in how members rate their personal physician, how well they feel physicians communicate and how informed they perceive their personal physician is about care the member received from other physicians.

We will incorporate feedback from the survey results into our efforts to improve the member experience with great customer service by training staff to handle member calls more effectively the first time. We are also improving provider directory search tools.

For more information, please call Provider Services at 800-900-6007.

Symposium Puts Focus on Diabetes PreventionUnitedHealthcare Community Plan of Ohio hosted the Central Ohio Health Symposium in October to provide the community with information on diabetes prevention. Novo Nordisk pharmaceutical company partnered with us on the event, which was held at New Birth Christian Ministries in Columbus.

Guest speaker was NBA Hall of Famer Dominique Wilkins, who shared his personal journey with Type II Diabetes and how he manages his blood sugar levels. He also talked about the importance of knowing your family medical history and A1C numbers.

UnitedHealthcare Relationship Specialists Hawa Farah and Tamara Drayton led a roundtable discussion. Participants included Columbus City Council members, Novo Nordisk representatives and others.

Local Matters, a nonprofit specializing in transforming the food system through education and increased access to healthful and affordable food, provided grocery shopping tips and offered free groceries to each participant. Kroger Pharmacy and The Little Clinic were among the local vendors who were available for health screenings, including blood pressure, cholesterol, and A1C checks for those at risk for diabetes.

Practice Matters: TX - Summer 2013 Customer Service Center: 888-362-33682 Practice Matters: OH - Winter 2015 Provider Services Center: 800-600-90072

Important information for health care professionals and facilities

Health Fair Addresses Community Needs and ConcernsEstablishing a level of trust and comfort between doctors and their patients is an important first step in getting patients to take a more active role in their preventive health and wellness. That was the goal of our Meet Your Providers Citywide Health Fair in October.

Attendees received free health screenings from care providers from Black Doctors Columbus, Ohio and Edify Community Health. They spoke with our physicians and asked questions about their health concerns and needs. They learned about our online service that helps members access the type of physicians they are seeking, based on requested criteria, including race and gender preference. Attendees were connected with the appropriate resources they needed to better access the care and providers that they desired.

The event is held annually by Black Doctors Columbus. The goal is to link members with providers and other resources. Our community relationship specialists do follow up with members who attended.

HealthSpot Gives Members Convenient Way to Seek CareThere’s a convenient new way for members to get a health care visit without an appointment – it’s the HealthSpot station, a virtual health care kiosk now open at select area Rite Aid pharmacies. Members can find a care provider from top health systems such as Cleveland Clinic, University Hospitals and Kettering Health Network for basic conditions such as colds and coughs, allergies, pinkeye and more.

Our members don’t require a co-payment for visits; all other plans have the same co-pay as a regular office visit.

To learn more or find locations near you, visit healthspot.net.

Home Clinical Visits Now Available for Qualifying MembersHouseCalls, annual in-home visits by our licensed clinicians, are now available free to members. HouseCalls is for everyone — even people who are healthy and regularly see their Primary Care Provider (PCP). The program is intended to enhance members’ health care experiences and help them stay ahead on health issues.

Here’s how HouseCalls works:• We contact the member to schedule a HouseCalls visit.• We provide the member an appointment reminder

call and/or send a reminder postcard before the appointment.

• The 45 to 60-minute visit includes a review of medical history, medications and diagnoses, a physical exam and education specific to the member’s conditions. It also might include lab work and flu vaccines (where available and accepted).

• After the visit, the clinician will give the member a list of suggested topics to discuss with their PCP.

• We mail their PCP a follow-up letter with a summary of the results of the visit and any lab results.

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Practice Matters: TX - Summer 2013 Customer Service Center: 888-362-33683 Practice Matters: OH - Winter 2015 Provider Services Center: 800-600-90073

Important information for health care professionals and facilities

HouseCalls visits are not meant to replace the annual wellness visit or care you provide to members. The program supports your role in the member’s health care, and we encourage members to discuss health concerns with you. If you have any questions, please contact HouseCalls at 866-686-2488.

New Coverage Guidelines for Elective Obstetric Deliveries before 39 WeeksEffective Jan. 1, 2016, to comply with Ohio Department of Medicaid requirements, UnitedHealthcare Community Plan will only cover cesarean sections, labor inductions and deliveries following labor inductions when the gestational age of the fetus is less than 39 weeks if the maternal and/or fetal condition(s) indicate medical necessity as defined in the Ohio Administrative Code available at codes.ohio.gov/oac > 5160 Medicaid > Chapter 5160-1 General Provisions.

To help ensure payment for medically necessary cesarean sections, labor inductions and deliveries following labor inductions before 39 weeks, please use one of the following modifiers when billing delivery services:

• U1 Modifier: Medically necessary delivery before 39 weeks of gestation

• U2 Modifier: Delivery at 39 weeks of gestation or later

• U3Modifier: Non-medically necessary delivery before 39 weeks of gestation

Obstetrical services billed with a U3 modifier will be denied.

If you have questions, please call Provider Services at 800-600-9007.

What a Case Manager Provides to MembersThe UnitedHealthcare Community Plan Case Management program 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.

Here’s what a case manager can provide to your members:• Telephone contact with members and home visits as

needed• Disease management programs• Health education and educational materials• A health assessment with stratification of diagnosis

and severity of condition and psychosocial needs• Referral to community resources as needed• Assistance with medical transportation• Arrangements for Durable Medical Equipment (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 following their medical treatment plan of care

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Practice Matters: TX - Summer 2013 Customer Service Center: 888-362-33684 Practice Matters: OH - Winter 2015 Provider Services Center: 800-600-90074

Important information for health care professionals and facilities

Areas of Case Manager Expertise

• Disease Management programs – Diabetes – Congestive Heart Failure – Asthma – HIV – Chronic Obstructive Pulmonary Disease – Sickle cell

• Special Needs Case Management for adults and children

• Complex Needs Case Management• Pediatrics/neonatal intensive care unit (NICU) Case

Management• Emergency Room Utilization Case Management• Healthy First Steps Program for pregnant women;

members do not have to be high risk to receive this service.

For more information or to make a referral, call our referral line at 800-366-7304.

A Member’s Right to Culturally Competent CareUnitedHealthcare Community Plan’s members have a right to receive care that is culturally competent and respects their cultural and ethnic background and origins. Upon enrollment, information regarding primary language is obtained and members are assisted in choosing a Primary Care Physician who will meet their cultural needs.

UnitedHealthcare Community Plan provides access to a language line for translation of communications between UnitedHealthcare Community Plan staff and non-English speaking members. The language line use is tracked by the Customer Service Center and reported regularly to the health plan so we can be sure we are offering adequate access to practitioners who can help ensure that the cultural, ethnic, racial, and linguistic needs of our members are being met.

Where to Get Pharmacy UpdatesPharmacy updates are available at UHCCommunityPlan.com. Go there to find:

• A list of covered pharmaceuticals, including restrictions and preferences

• Pharmaceutical management procedures• Explanations on limits or quotas• How to submit and support an exception request• Generic substitution, therapeutic interchange and

step-therapy protocols

For more information, call 800-310-6826.

Enroll in Electronic Payments & StatementsNow you can use a single tool to access and manage payment information for most UnitedHealthcare health plans. Enrollment in Electronic Payments & Statements (EPS) applies to payments from UnitedHealthcare Commercial, UnitedHealthcare Medicare Solutions, UnitedHealthcare Oxford and 17 additional UnitedHealthcare Community Plan states that were recently added.

EPS is UnitedHealthcare’s solution for electronic remittance advice (ERA) and electronic funds transfer

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Practice Matters: TX - Summer 2013 Customer Service Center: 888-362-33685 Practice Matters: OH - Winter 2015 Provider Services Center: 800-600-90075

Important information for health care professionals and facilities

(EFT). It allows you to receive direct deposit of claim payments into your designated bank account(s) and access explanation of benefits (EOBs)/remittance advice online or via 835 ERA files.

Enrollment in EPS applies to payments from UnitedHealthcare Community Plan in Arizona, Delaware, Florida, Hawaii, Iowa, Kansas, Louisiana, Maryland, Massachusetts, Michigan, Mississippi, Nebraska, New Jersey, New Mexico, New York, Ohio, Pennsylvania, Rhode Island, Tennessee, Texas, Washington and Wisconsin.

There’s never been a better time to enroll in EPS. You can learn more by:

• Visiting WelcometoEPS.com• Watching a short video demo • Attending a live 30-minute webinar for an overview

and answers to questions

You can enroll in EPS online or send us a completed enrollment form. If you have questions, please call 866-842-3278, option 5.

Special Needs Plan Model of Care TrainingEach year UnitedHealthcare provides Special Needs Plan Model of Care training to all UnitedHealthcare Special Needs Plan providers, which is a Centers for Medicare & Medicaid Services requirement. This training, which will be available online via WebEx, will assist you in understanding the tools available to support members’ care.

Models of Care are considered integral to helping ensure that the unique needs of each Special Needs Plan member are identified and addressed. A Model of Care is comprised of the following clinical and non-clinical elements:

• Description of the Special Needs Plan population• Care coordination• Special Needs Plan provider network• Model of Care quality measurement and

performance improvement

To access the training, go to UnitedHealthcareOnline.com > Tools & Resources > Training & Education. Scroll down to Medicare & Medicaid Topics. For more information, please call UnitedHealthcare Clinical Services at 855-896-5593.

Reducing Radiation Exposure in Pediatric PopulationsThe effect of radiation on the pediatric population is a growing concern. UnitedHealthcare Military & Veterans recently reviewed the methods used to diagnose acute appendicitis over one year in a pediatric population of 80 TRICARE West Region beneficiaries.

Our review found that 51.3 percent of these beneficiaries had computed tomography (CT) scans as the first diagnostic imaging study, 36.2 percent had ultrasounds and 12.5 percent had no imaging study. These numbers show there is an opportunity to find and implement safe strategies to reduce potential radiation exposure in children by reducing CT scans.

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Practice Matters: TX - Summer 2013 Customer Service Center: 888-362-33686 Practice Matters: OH - Winter 2015 Provider Services Center: 800-600-90076

Important information for health care professionals and facilities

When diagnosing acute appendicitis in the pediatric population, we encourage emergency department and radiology care providers to use ultrasounds instead of CT scans, when aligned with medical necessity and appropriate levels of care. Recent literature supports our findings:

• According to the American College of Radiology, ultrasound diagnostic examination of the abdomen is preferred over CT for diagnosing acute appendicitis in children due increased radio-sensitivity to ionizing radiation, smaller body size and less body fat.

• A retrospective study published by the Journal of the American Medical Association (JAMA) evaluated the use of CT for children younger than age 15 from 1996 to 2010. Nationally, four million pediatric CT scans of the head, abdomen/pelvis, chest, or spine performed each year are projected to cause 4,870 future cancers. Implementing readily available dose-reduction strategies, combined with the elimination of unnecessary imaging, could dramatically reduce future radiation-induced cancers from CT use in pediatrics.

• The American College of Emergency Physicians (ACEP) agrees that pediatric populations presenting to the emergency department with abdominal pain and suspected appendicitis should have an ultrasound as the first radiologic study in the diagnostic work-up.

By reducing CT scans for children, UnitedHealthcare Military & Veterans believes the potential radiation exposure — and potential future cancers — also will be reduced. In many cases, increasing the use of ultrasound when diagnosing acute appendicitis may be a viable alternative.

Sources:

Smith M.P., Katz D.S., Rosen M.P., Lalani T., Carucci L.R., Cash B.D., Yee J. Expert panel on gastrointestinal imaging. ACR Appropriateness Criteria right lower quadrant pain--suspected appendicitis. [online publication]. Reston (VA): American College of Radiology (ACR); 2013. 10 p. [74 references]; Retrieved from acsearch.acr.org/docs/69357/Narrative.

Migliorett, D., Johnson, E., Williams, A., Greenlee, R., Weinmann, S., Solberg, L., Smith-Bindman, R. The use of computed tomography in pediatrics and the associated radiation exposure and estimated cancer risk. JAMA Pediatrics. 2013; 167 (8): 700-707 doi: 10.1001/jamapediatrics.2013.311; Retrieved from archpedi.jamanetwork.com/article.aspx?articleid=1696279.

Valesky, W., Aponte, E., Secko, M., & Mehta, N. Ultrasound for appendicitis; American College of Emergency Physicians (ACEP) June 1, 201; Retrieved from acepnow.com/article/ultrasound-appendicitis.

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9200 Worthington Road 3rd FloorWesterville, OH 43082Doc#: PCA19050_21051123 © 2015 UnitedHealth Group, Inc. All Rights Reserved.

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

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