rhode island | summer 2015 practicematters · 2019-06-20 · icd-10 coding to replace icd-9 - the...

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Rhode Island | Summer 2015

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Practice Matters: RI - Summer 2015 Provider Services Center: 877-842-3210

Important information for health care professionals and facilities

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In This Issue...• Person-Centered Care Model Comes to Rhode Island

• The Provider Satisfaction Survey Results Are In

• Changes to the Communities of Care Program

• Elimination of the Adult Day Notification Requirement

• Introducing the ICD-10 Coding Practice Tool

• New Information Needed for Institutional Claims Submissions

• Tips on Claim Resubmission and Correction Process

• Early Childhood Carries

• Reviews Help Ensure Patients Receive Proper Care

• Coordination of Care among Primary Care Physicians and Specialists

• Appointment Availability Standards

• Interpreter Services for Medicaid Members

• Balance Billing

• Member Panel Reports

• National Drug Code (NDC) Billing Update

• UnitedHealthcare Community Plan Group Numbers

• Important Contact Information

• Working with Us

• Paper Claims Submission

• Appeals and Grievances

We hope you enjoy the summer edition of Practice Matters. In this issue, you can read about a new patient-centered care model, ICD-10 coding practice tool, early childhood caries, and much more. Happy summer!

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

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The Provider Satisfaction Survey Results Are InThank you to everyone who took the time to complete the 2014 Physician and Practice Manager Satisfaction Survey. The survey showed that there are three primary areas where UnitedHealthcare Community Plan needs to focus our attention for improvements. Those are: provider service, case management, and pharmacy prior authorization. Throughout the year, we will seek ways to make improvements in those areas and report back how we will do that.

The annual survey, conducted and analyzed by an independent third party, is an important tool for measuring our performance and identifying areas for improvement. Your answers help us gain a better understanding of what we do well and where we can work to make changes.

Thank you to everyone who completed the survey. This year we had a 10 percent response rate, which was similar to last year’s.

The next survey will be fielded between August and October to a random sample of primary care providers and specialists. Please complete the survey if you receive a request. Your feedback is important to us.

Patient-Centered Care Model Comes to Rhode IslandWe are excited to announce the launch of an innovative, community-based care management program in Rhode Island for UnitedHealthcare Community Plan members.

The Patient-Centered Care Model is our new clinical model to find and engage members with significant health and other issues, then work with them to resolve these challenges. Our team of community health workers travels to members’ homes to build trust and address their health issues collaboratively.

The model reduces preventable admissions, readmissions and non-emergent visits to the emergency department, enhances behavioral and physical health coordination of services, and increases access to Primary Care Physicians (PCPs) and specialists. This holistic approach supports members and addresses their medical, behavioral, social and environmental needs.

The primary goal is to help members receive the right care from the right care providers. The model empowers members, care providers and our community partners to improve care coordination and improve outcomes for individuals through:

• Care management provided in homes• Community-based interventions to locate and engage

members • Connecting members to an appropriate medical

home• Providing behavioral health referrals• Linking members with needed community resources• Removing barriers to care


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Changes to the Communities of Care ProgramAs of June 1, 2015 we removed the Primary Care Provider Lock In and Dedicated Provider Model from the Communities of Care program to make the program more effective.

Communities of Care is for members who have high rates of emergency room utilization. It helps them address their health care needs by connecting them with primary care physicians to reduce unnecessary emergency room use. The program rewards members for their participation and supports them with the help of Peer Navigators and Care Managers.

Elimination of Adult Day Notification RequirementWe recently removed the Adult Day Notification requirement for providers seeing UnitedHealthcare Community Plan members. Providers need to continue to check eligibility and submit claims electronically.

Introducing the ICD-10 Coding Practice ToolOct.1, 2015 signals the effective date for transition to ICD-10 coding to replace ICD-9 - the coding system used by physicians and health care professionals to record and identify diagnoses and procedures for claims payments.

ICD-10 affects diagnosis coding and inpatient procedure coding only. It does not affect current procedural terminology (CPT) coding for outpatient procedures.

To assist physicians with the transition to ICD-10, we developed the Physician ICD-10 Coding Practice Tool, an online self-service tool available as of July 29 at UnitedHealthcareOnline.com under Quick Links. Click ICD-10 and Regulatory Outreach. The tool is specific to physicians and their office staff to practice the new coding. It is not intended for facilities.

FeaturesThe Physician ICD-10 Coding Practice Tool allows providers to practice selecting ICD-10 codes for various clinical scenarios across 35 medical specialties. Each clinical scenario for commonly used diagnosis codes includes a medical example, medical history and office notes, and users can compare codes used by peer physicians within each specialty.

Clinical ScenariosThe clinical scenarios included in the tool were chosen based on the number of claims submitted by the most common clinical specialties, including:

Allergy/Immunology OphthalmologyAudiology OptometryCardiology Orthopedic SurgeryChiropractic Care OtolaryngologyDermatology Pediatric Medicine

Emergency Medicine Physical Medicine and Rehabilitation

Endocrinology Physical Therapy

Family Medicine Plastic and Reconstructive Surgery

Gastroenterology PodiatryGeneral Practice PsychiatryGeneral Surgery Psychology, ClinicalHematology PsychologyHematology-Oncology Pulmonary MedicineInfectious Disease Radiation OncologyInternal Medicine RheumatologyNephrology Thoracic SurgeryNeurology UrologyObstetrics & Gynecology Vascular SurgeryOccupational Therapy

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https://www.unitedhealthcareonline.com/b2c/CmaAction.do?viewKey=PreLoginMain&forwardToken=PreLoginMain


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Example scenarioScenario (aligned with Medical History and Office Visits Notes)Patient in for weekly B12 injection Medical History Member is currently under treatment for severe B12 deficiency; no other medical history. Office Visit Notes Member was given 1000 mcg. Vitamin B 12 Intramuscular in her left deltoid for severe B12 deficiency. Patient tolerated injection without complications; Patient to return to office in one week.

Access and RegistrationTo access the tool, please register at UnitedHealthcareOnline.com > Tools & Resources > Health Information Technology > ICD-10. When you register, you’ll get a username and password for secure access to the tool. You can then access the tool as often as you would like. If needed, you also can pick-up where you left off from a previous session the next time you access the tool.

ResourcesFor assistance using the Physician ICD-10 Coding Practice Tool, a link to the How to Guide will be available and accessible via the Services & Support page of the tool. If you need technical assistance, call 855-819-5909 during the following hours:

Monday-Friday, 6 a.m. to 10 p.m. CTSaturday, 6 a.m. to 6 p.m. CTSunday, 9 a.m. to 6 p.m. CT

New Information Needed for Institutional Claims SubmissionsAll institutional claims (uniform billing) submitted by paper or electronic transactions must now include the individual attending physician’s first and last name with a valid National Provider Identifier (NPI). This edit helps ensure that we maintain compliance with State Medicaid guidelines. Please continue to include the appropriate taxonomy code for billing and attending providers.

Tips on Claim Resubmission and Correction ProcessHealth care professionals can resubmit or correct professional (CMS 1500) and institutional claims (UB-04) by making the necessary changes in their practice management system for the corrected claim to be printed or submitted electronically or by making the necessary corrections to the original submitted paper claim. Please check your UnitedHealthcare Community Plan Provider Manual and reimbursement policies to reconfirm billing types allowed for reconsideration.

Please resubmit the entire claim as originally submitted – even line items that were previously paid correctly. Under National Uniform Billing Committee (NUBC) claim frequency guidelines, when sending a replacement or voided claim, the entire original or previous submission must be replaced or voided.


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How to make a resubmission or corrected claim request:

• Online: Visit UnitedHealthcareOnline.com oraccess OptumCloud Dashboard. (Resubmissionswith attachments can only be done via OptumCloudDashboard).

• Mail: Print the UnitedHealthcare ClaimReconsideration form available atUnitedHealthcareOnline.com > Tools & Resources >Forms > Claim Reconsideration Request Guide.

– Complete the Claim Reconsideration Requestform as instructed and mark the box on Line 4 for Corrected Claims. Continue to the comments section and list the specific changes made and rationale or other supporting information.

– Enter the words “Corrected Claim” in the comments field on the claim form.

– Filling in CMS 1500:• Original claim number in Box 22• Enter the appropriate claim frequency code left-

justified in the field.7 – Replacement of prior claim8 – Void/cancel of prior claim

– Filling in UB 04:• Bill type in Box 4• Enter the appropriate claim frequency code in

the third position of the Type of Bill7 – Replacement of prior claim8 – Void/cancel of prior claim

Please double check claims for errors prior to submitting the first time and make sure to send your claims directly to the UnitedHealthcare Community Plan address on the back of the member’s identification card or as outlined in your state’s Provider Manual.

For more information on completing your claim, go to:• nucc.org or nubc.org• CMS Claims Processing Manual at

cms.hhs.gov/Manuals/IOM/list.asp and refer tothe CMS-1450 and CMS-1500 data sets

• For electronic claim submissions, refer to theHealth Insurance Portability and Accountability ActImplementation Guides at wpc-edi.com.



https://www.unitedhealthcareonline.com/ccmcontent/ProviderII/UHC/en-US/Assets/ProviderStaticFiles/ProviderStaticFilesPdf/Claims%20&%20Payments/Claim_Reconsideration_Reference_Guide.pdf

http://www.nucc.org/

http://www.nubc.org/

http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/index.html?redirect=/Manuals/IOM/list.asp

http://www.wpc-edi.com/


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Early Childhood Caries By Michael D. Weitzner, DMD, MSVice President of National Clinical Operations - Dental

The American Academy of Pediatric Dentistry defines Early Childhood Caries as, “the presence of one or more decayed (non-cavitated or cavitated lesions), missing (due to caries), or filled tooth surfaces in any primary tooth in a child 71 months of age or younger.” At UnitedHealthcare Community Plan, we are concerned about the presence of early childhood caries, particularly among disadvantaged children, and creating clinical programs to meet their needs while increasing overall levels of preventive health.

The dental profession historically has focused on treating the downstream effects of disease rather than managing the disease itself. This is not necessarily working for disadvantaged children and there is an opportunity to improve how we treat caries and not just cavities.

Since caries, or tooth decay, is a bacterial disease caused by bacteria residing in the biofilm that can be transmitted from mother or other caregiver to children, educating would-be and pregnant mothers as well as very young children about preventive dental care, we may help prevent bacterial colonies from inoculating the child in any meaningful way. For those already at risk, there are approaches that can help control those bacteria without having to resort to removing tooth structure.

Bacteria do their greatest damage in an acidic environment, typically caused by the ingestion of sugar or sugar producing carbohydrates, which leads to destruction of dental hard tissue. This can be buffered by saliva but for those with low or no salivary flow, the destruction is that much greater.

Socioeconomics can also play a role – the disadvantaged may have more disease, poorer diets, less access to care or to information that can help keep them healthy and are less educated on dental disease or how to prevent and treat it. It is this population we can help the most.

Managing caries begins by understanding the level of risk a child has of getting future decay. One model we have been closely evaluating, Caries Management by Risk Assessment — or CAMBRA — suggests that defining that risk is a matter of assessing the balance between a member’s caries risk factors and caries protective factors.

Examples of caries risk factors include: previous history of caries, parent/caregiver history of caries, heavy plaque, frequent snacking, deep pits or fissures, low salivary flow, exposed roots, and presence of orthodontic appliances.

Examples of caries protective factors include: availability of fluoride — including fluoride in drinking water, use of fluoride rinses, fluoride toothpaste, and in-office fluoride treatments — particularly varnishes. Antimicrobials, such as chlorohexidine and xylitol, also can stop bacterial growth. As also noted, salivary flow is another inhibitor. When there is little or no saliva, saliva stimulators



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can be used, or other buffers, such as baking soda, to raise the pH in the mouth and make the environment less acidic.

Understanding how these risk and protective factors relate, allows a clinician to assess the child’s risk level and then tailor their treatment accordingly.

Assessing risk is a key first step in understanding the child’s risk of disease. We do that by:1. Screening the member – including a risk assessment2. Providing anticipatory guidance to the caregiver and child to help guide and change their

behavior3. Reaching out to members through physicians’ offices, Headstart programs, schools and

health fairs to get them a dental home when the first tooth erupts and no later than age 14. Working with dentists, physicians, academia and other partners to help shift the paradigm

from treating cavities to treating caries

Preventive care along with ongoing re-examination of risk and treatment adjustments will lead to measurable improvements in oral health for disadvantaged children in the long-term.

Physicians are in a unique position to identify children at risk and advise parents of the importance of their child seeing a dentist at a very young age, preferably by no later than age 1.

The American Academy of Pediatric Dentistry (AAPD) and the American Academy of Pediatrics encourage families to establish a dental home when the first tooth erupts and no later than age 1. The AAPD defines a dental home as “… the ongoing relationship between the dentist and thepatient, inclusive of all aspects of oral health care delivered in a comprehensive, continuously accessible, coordinated, and family-centered way. Establishment of a dental home begins no later than 12 months of age and includes referral to dental specialists when appropriate.” A dental home can be a private dentist office, but also could be a federally qualified health center (FQHC), school-based setting, or academic institution.

Once the child is identified and referred to a dental home, the focus shifts to treating that child.

The primary goal is preventing disease, which can start with the mother, and doing what is needed to prevent disease from starting. If caught early enough, non-surgical approaches to treatment can be used, leading to remineralizing tooth structure. And antimicrobials such as fluoride, chlorohexidine and xylitol can be used to varying degrees, depending on the risk level of the child. If restorative work is necessary, the goal is to be as conservative as possible. The child’s dental health needs to be maintained through frequent recalls and re-examination of risk, adjusting treatment needs accordingly.

Dr. Michael D. Weitzner is Vice President, National Clinical Operations at UnitedHealthcare. He oversees dental clinical program development, focusing on disease management and wellness programs. He also is Chair of the Clinical Policy & Technology Committee, which makes guideline and technology recommendations based on principles of evidence-based dentistry.



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Reviews Help Ensure Patients Receive Proper CareUnitedHealthcare Community Plan performs concurrent reviews on inpatient stays in acute, rehabilitation and skilled nursing facilities, as well as prior authorization reviews of select services. A list 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 benefit coverage. We do not provide financial or other rewards to our physicians for issuing denials of coverage or for underutilizing services.

The treating physician has the right to request a peer-to-peer review with the reviewing physician and copy of the criteria used in the review. The denial letter contains information on how to request materials and contact the reviewer. Members and practitioners also have the right to appeal denial decisions. Information on requesting an appeal is included in the denial letter.

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

If you have questions, please call 401-732-7373 during normal business hours.

Coordination of Care among Primary Care Physicians and SpecialistsPrimary care physicians (PCPs) and specialists share responsibility for communicating essential patient information with each other regarding consultations and referrals. Non-communication affects quality of care and can negatively affect health outcomes.

Relevant information that the PCP should provide to the specialist includes the patient’s history, diagnostic tests and results, and the reason for the consultation. The specialist is responsible for timely communication to the PCP of the results of the consultation, and ongoing recommendations and treatment plans.

Information exchange among health care providers should be timely, relevant and accurate to facilitate ongoing patient care management. The partnership between the PCP and specialist is based on the consistent exchange of clinical information, and this communication is a key factor in providing quality patient care.

Appointment Availability StandardsUnitedHealthcare Community Plan providers must follow these appointment availability standards for our members:

Type of Service StandardEPSDT Within 6 weeks

Routine Adult Physical Within 180 days

Routine Appointment Within 30 days

Urgent Care Within 24 hours

Emergency Care Immediate

After-Hours Care 24/7 for PCPs

Interpreter Services Available for Office VisitsProfessional interpreter services are available for onsite outpatient medical and mental health appointments. This service can be coordinated by calling Member Services at 800-587-5187 at least 72 hours before the appointment. If a member needs to cancel an appointment after an interpreter is scheduled, call the same number to cancel or reschedule.



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American Sign Language interpreter requests require additional time to coordinate. Please request those services at least 14 days before the appointment by completing the Interpreter Services Fax Request Form at the back of the Provider Manual.

Balance BillingParticipating providers cannot balance bill members or bill them for a missed appointment. Our care providers must accept as payment in full the amounts established under your provider agreement and applicable reimbursement regulations of the Rhode Island Executive Office of Health and Human Services.

If you are providing a service not covered by the plan, please inform your patient before the procedure and let them know you will directly bill them. If you don’t explain to a member in advance that they are responsible for the service costs, you may not be reimbursed. You must receive this consent to pay for a non-covered service in writing.

Member Panel ReportsUnitedHealthcare Community Plan of Rhode Island members are encouraged to select a participating physician, health center or a hospital-based primary care clinic as their PCP. If a member does not select a PCP, we will assign one.

Each month, we send member panel reports to all PCPs, listing new and existing members. We encourage new members to contact their PCP to schedule a visit. If a member newly assigned to your practice does not call to schedule an initial visit, please contact them to schedule one.

National Drug Code Billing UpdateProviders must include National Drug Code (NDC) information when billing Healthcare Common Procedure Coding System (HCPCS) codes for a physician-administered drug in an office or outpatient setting. The following codes are required to be submitted with NDC information: A9542 Q0169 Q9953 A9543 Q0173 Q9954 A9581 Q0175 Q9957 J7302 Q0177 Q9958 Q0138 Q0180 Q9960 Q0144 Q0515 Q9961 Q0163 Q2009 Q9962 Q0164 Q2017 Q9963 Q0166 Q4074 Q9964 Q0167 Q4079

UnitedHealthcare Community Plan Group NumbersDo you know how to identify a UnitedHealthcare Community Plan member by their group number? The following list shows the current UnitedHealthcare Medicaid Group numbers:

RIte Care

Full Benefit Open Light91000 Full benefits 9170091003 Extended family planning N/A91004 Adult SPMI 9170491010 SOBRA women 9171091011 Extended family planning N/A




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Rhody Health Partners

Group Open Light12100 Other disabled 21-44 1220012102 Other disabled 21-44 1220212104 Other disabled 21-44 1220413100 Other disabled 45+ 1320013102 Other disabled 45+ 1320213104 Other disabled 45+ 1320414100 SPMI 1420014102 SPMI 1420214104 SPMI 1420415103 MDD 15203

Children with Special Health Care Needs

Group Open Light95100 SSI child < 15 9511095200 SSI child > 15 9521095300 Katie Beckett 9531095400 Adoption subsidy 95410

Rhody Health Partners ACA Adult Expansion

Group Light87600 Male 19-24 8761087601 Female 19-24 8761187602 Male 25-29 8761287603 Female 25-29 8761387604 Male 30-39 8761487605 Female 30-39 8761587606 Male 40-49 8761687607 Female 40-49 8761787608 Male 50-64 8761887609 Female 50-64 87619

Important Contact Information• Member Services: 800-587-5187• Provider Services: 877-842-3210• Care Management: 401-732-7373 or 800-672-2156• Optum Behavioral Solutions: 800-435-7486• Prior Notification (medical and obstetrics):

866-604-3267 or 866-950-7757 (fax)• Healthy First Steps: 800-599-5985 or

877-353-6913 (fax)• Pharmacy Prior Authorization (for medications that

require prior authorization, injectables and specialty pharmacy): 800-310-6826 or 866-940-7328 (fax)

• Transportation through LogistiCare: 855-330-9131• Visit UHCCommunityPlan.com > For Health Care

Professionals > Rhode Island to view the provider manual, announcements, newsletters, clinical practice guidelines, authorization request forms and more.

Working with UsFor claims-related issues, try one of the following methods first:

• Use the claim reconsideration tools on UnitedHealthcareOnline.com.

• Call Provider Services at 877-842-3210. Remember to get a tracking number for future reference.

If your issue is not resolved or 30 days pass with no follow-up, contact your local Provider Advocate.

If you need help with contracting, such as obtaining copies of fee samples for your contract, please call your Provider Advocate. The Advocate can help you or send your question to the appropriate Network Management representative.



http://www.uhccommunityplan.com/health-professionals/ri.html



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If you don’t know who your Provider Advocate is or are having trouble reaching that person, call Network Management at 860-702-6133. Be prepared to provide the applicable tax ID number, a brief description of the issue and a phone number or email address where we can contact you.

Paper Claims SubmissionPaper claims can be mailed to:

UnitedHealthcare Community PlanP.O. Box 31361Salt Lake City, UT 84131

Appeals and GrievancesTo submit an appeal or grievance, please call 800-587-5187 or mail to:

UnitedHealthcare Medicaid AppealsP.O. Box 31364Salt Lake City, UT 84131


475 Kilvert Street Warwick, RI 02886Doc#: PCA17167_20150708 © 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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rhode island | summer 2015 practicematters · 2019-06-20 · icd-10 coding to replace icd-9 - the...

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