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Mae Douglas
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1 Summer 2011 Important information from UnitedHealthcare for physicians and other health care professionals and facilities serving UnitedHealthcare Medicaid members EXPANSION: Evercare Select to Cover Five of Seven of Geographical Service Areas in Arizona by Oct. 1, 2011 The Arizona Health Care Cost Containment System (AHCCCS) has awarded five of nine contracts to Evercare Select to provide services to Arizonans enrolled in the Arizona Long Term Care System (ALTCS) program. The contracts were awarded for up to five years, beginning on October 1, Contracts were awarded by regions of the state. Evercare Select has a contract in Pima County the exclusive contract in Santa Cruz county, Yuma/La Paz counties, Mohave/Coconino/Apache/Navajo counties and Yavapai County. The plan will continue to serve members in Maricopa County. Currently, more than twenty-five thousand Arizona residents are enrolled in the ALTCS program, which serves individuals who are low income, at risk of institutionalization and either elderly (age 65 and over), blind, or disabled. ALTCS members also receive medical care under the long term care program, including doctor's office visits, hospitalization, prescriptions, lab work, and behavioral health services. ALTCS has been viewed as a national model for its success in supporting over 70 percent of its members in the home or in community-based residential facilities rather than placing members in more costly nursing home settings. Articles of Importance to Read: Page 1 EXPANSION: Evercare Select to Cover Five of Seven of Geographical Service Areas in Arizona by Oct. 1, 2011 Page 2 Important Information: Getting Ready for 5010/ICD-10 Page 3 UnitedHealth Group is First to Achieve CAQH Core Certification Using 5010 Testing Platform Page 4 High Costs Associated with Asthma and Asthma Therapy Page 6 Immunization Code Information Medical Record Criteria Member Missed Appointments Cultural Competency Updates For more information Call our Provider Service Center at Visit

2 Important Information: Getting Ready for 5010/ICD-10 The federal government has mandated that all covered entities (including health care providers, clearinghouses and health plans) must transition to the latest version of the Health Insurance Portability and Accountability Act (HIPAA) electronic transaction standards and code sets. Two key dates are: Jan. 1, 2012 The 5010 version of the electronic transactions standards will replace the current 4010 version. Oct. 1, 2013 The International Classification of Diseases 9th Revision, Clinical Modification (ICD-9-CM), the current code set for reporting diagnosis, will be replaced by ICD- 10-CM. Evercare encourages physician practices and facilities to begin the preparation for these two important changes as soon as possible to streamline the process and reduce administrative burdens and potential rework.. If you are not familiar with 5010 and/or ICD-10 and what it may mean to your practice, a number of resources are available from industry groups like the American Medical Association (AMA), The American Academy of Professional Coders (AAPC), and the Medical Group Management Association (MGMA) that can help in educating you and your staff on the electronic transaction standards and code sets. It is an industry accepted standard that the first steps to a 5010 implementation plan is to speak with your practice management software vendor to ensure your system will be compliant with the upcoming changes. The Medical Group Management Association (MGMA) has developed a list of vendor-specific questions to assist you in this discussion. To view the questions, please visit the MGMA website. Once you determine that your systems are compliant, the next step is to ensure that testing is conducted of your practice management and electronic medical record system with your vendor and/or clearinghouse. At Evercare, our 5010/ICD-10 implementation plan is underway, and we are actively engaged in 5010 Trading Partner Testing. For ICD-10, we plan to be code ready six to nine months in advance of the 2013 mandate. (Please note that we will not ask our network participants to comply with any mandates early; rather, these timelines ensure that UnitedHealthcare has the ability to support your needs and conduct a thorough Trading Partner Testing program.) We want to assure you that we will be ready and we are eager to consult with our provider and facility network as they begin their implementation planning. Have you started external testing of version 5010? All HIPAA-covered entities that submit transactions electronically are required to upgrade from Version 4010/4010A to Version 5010 transaction standards by Jan. 1, We strongly suggest you develop a plan for testing (both internally and with external business partners) in preparation for the Jan. 1, 2012, deadline. Testing transactions using Version 5010 standards will ensure that you are able to send and receive compliant transactions effectively. Testing early will allow you to identify any potential issues and address them in advance. Here are key dates to know to ensure you are ready for the Version 5010 and ICD-10 transitions: Jan. 1, 2011 Begin external testing of Version 5010 for electronic claims. I Summer Provider Service Center:

3 Dec. 31, 2011 External testing of Version 5010 for electronic claims must be complete to achieve Version 5010 compliance. Jan. 1, 2012 All electronic claims must use Version 5010; Version 4010 claims are no longer accepted. Oct. 1, 2013 Claims for services provided on or after this date must use ICD-10 codes for medical diagnoses and inpatient procedures; CPT codes will continue to be used for outpatient services. Additional HIPAA 5010 and ICD-10 resources are posted on the UnitedHealthcare Online website. UnitedHealth Group is First to Achieve CAQH Core Certification Using 5010 Testing Platform 5010 data transactions include patient eligibility/verification and claim status Faster and more predictable administrative transactions enable doctors and hospitals to spend more time caring for patients CAQH and UnitedHealth Group (NYSE: UNH) announced on April 12, 2011 that UnitedHealth Group had completed the Committee on Operating Rules for Information Exchange (CORE ) Phase I and II testing process. This process certifies that UnitedHealth Group can deliver more efficient and predictable patient-eligibility and claims-verification information to doctors, hospitals, physician offices and other care providers, according to operating rules developed by CORE. UnitedHealth Group is the first health care organization to complete certification using the updated platform, which builds on nonmandated aspects of the Health Insurance Portability and Accountability Act (HIPAA) version 5010 requirements. This is an important milestone in the company s efforts to streamline patient-eligibility and claims status transactions, so that care providers can spend less time on administrative functions and more time treating patients. The CORE operating rules streamline administrative information exchanges and improve provider access to patient benefits coverage and financial information at the pointof-care. CORE is a multi-phase, collaborative health care industry initiative aimed at improving access to electronic patient administrative and payer information for care providers before or at the time of service, using any technology. Each phase expands the available data criteria and augments the functional requirements for electronic data exchange. CORE certification reflects UnitedHealth Group s commitment to streamlining administrative processes with doctors, hospitals and other care providers so they can spend more time providing quality care for their patients, said Timothy Kaja, senior vice president, UnitedHealth Group Provider and Network Service Operations. By becoming CORE certified, UnitedHealth Group is demonstrating that the concept of operating rules as mandated by the Patient Protection and Affordable Care Act (ACA) is an important part of making health care work better. We are pleased that UnitedHealth Group is CORE certified. The operating rules will ensure an effective flow of administrative data between us, said Murray E. Fox, M.D., FACOG, a Plano, Texas-based practicing physician and founder, president and CEO of Patient Physician Network, a 650-physician member network whose primary goal is to respond to the changing health care environment in the Dallas- Fort Worth area. Being able to rely on UnitedHealth Group for consistent and accurate electronic information about benefits coverage I Summer Provider Service Center:

4 and financial obligations enables us to streamline our internal processes and offer complete and timely information to our patients. Robin Thomashauer, executive director of CAQH, said: We are pleased to see UnitedHealth Group join the growing number of companies that have become CORE certified and the first to become CORE certified in a 5010 format. Advances such as this are essential to establishing the foundation for true administrative simplification, leading to improved transparency and reduced cost in health care. Continued advances in CORE operating rules and adoption by companies such as UnitedHealth Group and its physician partners will accelerate our nation s progress to that end. High Costs Associated with Asthma and Asthma Therapy Nearly 4,000 Americans die yearly from asthma. Asthma s impact on health, quality of life and the economy is substantial. 1 Although the onset of asthma can not be prevented, and asthma cannot be cured, it is a disease that can be successfully controlled. 1 The National Heart, Lung and Blood Institute (NHLBI) defines asthma as a chronic lung disease that inflames and narrows the airways. 2 Symptoms of asthma cause chest tightness, shortness of breath and coughing. The American College of Allergy, Asthma and Immunology (ACAAI) reported that the total annual cost for asthma management in 2007 was $19.7 billion dollars.3 Over 30 percent ($6.2 billion) of the total costs were directly linked to pharmaceutical spend. 3 It is believed that much of the costs associated with asthma therapy can be avoided or at least reduced. In 2007, the National Asthma Education and Prevention Program (NAEPP) issued the Expert Panel Report 3 (EPR-3): Guidelines for the Diagnosis and Management o Asthma Full Report The guidelines indicate that short acting beta agonists (SABA) are the preferred treatment for intermittent asthma. Inhaled corticosteroids (ICS) have remained the mainstay of therapy for persistent asthma. For patients that can not utilize ICS, alternative therapies such as cromolyn, theophylline and leukotriene receptor antagonists are considered appropriate treatment options. Adherence to these guidelines will help drastically reduce the total yearly costs associated with asthma. Table 1 illustrates a stepwise approach for managing intermittent to severe persistent asthma as outlined by the EPR-3. Evercare and UnitedHealthcare Community Plans offer a broad portfolio of preferred medications that cover each step of the treatment guidelines. Table 2 indicates the average price of each preferred medication covered by UnitedHealthcare Community Plans. Please take a moment to look at these tables. Please contact your Provider Advocate if you have any questions regarding this information. I Summer Provider Service Center:

5 Table: 1 Guideline Steps Intermittent Asthma Persistent Asthma SABA Low-dose ICS Alternative: Cromolyn, LTRA, Nedocromil, or Theophylline Low-dose ICS + LABA OR Medium-dose ICS Alternative: Low-dose ICS + either LTRA, Theophylline Medium-dose ICS + LABA Alternative: Medium-dose ICS + either LTRA, Theophylline High-dose ICS + LABA AND Consider Omalizumab for patients who have allergies High-dose ICS + LABA + oral corticosteroid AND Consider Omalizumab for patients who have allergies Table: 2 Cost of Preferred Products: UHC C&S Drug Class Drug Estimated Monthly Cost ($) SABA Ventolin HFA ICS Qvar Flovent Asmanex LABA Foradil Serevent ICS/LABA Combo Advair Dulera LTRA Singulair (ST) Oral Steroids Prednisone Methylprednisolone Other Cromolyn Inhalation Theophylline Biologic Xolair References 1. accessed 3/21/ accessed 3/21/11 3. American College of Allergy, Asthma & Immunology. Asthma Management and the Allergist: Better Outcomes at Lower Cost. accessed 3/21/11 4. National Heart, Lung, and Blood Institute. Expert Panel Report 3: Guidelines for the Diagnosis and Management of Asthma. Accessed September 9, I Summer Provider Service Center:

6 Immunization Code Information The UnitedHealthcare Employer & Individual Frequently Asked Questions (FAQ) document has recently been discussed in regards to the 2011 immunization codes changes. The staff of the Evercare and UnitedHealthcare Community Plan Payment Policy team has been hard at work researching the differing State specific regulations, the Vaccines for Children (VFC) requirements related to these new codes, and gathering information from health plan representatives in order to determine how each market should be billing for immunizations with respect to these new codes. After much research, state specific FAQ documents have been drafted, based on the differing methods of reimbursement being utilized by the different markets. For those markets utilizing immunization administration cost on VFC serum codes, nothing has changed, and thus no new document was drafted. For the remaining markets, these documents will be forwarded to the health plan representatives to be dispersed to providers for educational purposes. If you would like more information on the 2011 immunization code changes, please contact your Provider Advocate. Medical Record Criteria Evercare is contractually obligated to submit accurate, detailed and complete encounter data to the states. Consequently, Evercare participating providers are required to submit accurate, detailed and complete claims data and to maintain and provide, when requested, medical record documentation to support the claims. Here is a short checklist for your office to maintain medical records: Medical records must include: history & physical; allergies and adverse reactions; problem list; medications; preventive services/screening; and documentation of clinical findings for each visit All medical records are to be stored securely Only authorized personnel should have access to medical records Staff receive periodic training in patient confidentiality Medical records are organized and stored in a manner that allows easy retrieval Please call your Provider Relations Advocate if you have any questions regarding medical records criteria. Resources are available to you at UnitedHealthcareOnline.com > Clinician Resources > Patient Safety Resources > Medical Record Tools & Templates. Member Missed Appointments Evercare Select encourages providers to notify us of members who miss a scheduled appointment without giving 24 hour advance notice. If you have a member who is missing appointments, please contact your Provider Relations Representative for assistance. Cultural Competency Updates Cultural Competency is Important to Evercare. We Strive to: Provide ongoing information and education including resources to all stakeholders to ensure that services are provided effectively to members of all cultures. Obtain feedback on the cultural competency of member care, and the success of Evercare s performance and communication with regard to cultural competencies. Analyze utilization of our language line and utilization of the translation service including sign language interpretation to obtain feedback. I Summer Provider Service Center:

7 Analyze trends of member Appeals and Grievance reporting and develop plans to address trends identified. Create a Cultural Competent Library accessible to providers, Case Managers, and participants involved in the Self Directed Attendant Care (SDAC) program. Bridge the health literacy gap by educating others on the different approaches to health care management. To provide feedback, please contact Scott Jewart, Member Services Manager, at (602) Useful Websites Under Quick Links, choose Providers Guide to Quality and Culture Oral, Linguistic, and Culturally Competent Services Guides for Managed Care Plans Has information in both Spanish and English Diversity Rx Office of Minority Health html National Center for Cultural Competence Agency for Healthcare Research and Quality Federal Governmental Web Address Choose LEP Page Centers for Medicare and Medicaid Services Translation Service Translation Service Cross Cultural Health Care Program (CCHCP) Center for Linguistics and Cultural Competence in Health Care (CLCCHC) /default.asp Substance Abuse and Mental Health Services Administration (Children s Issues) assn.org/ama/pub/category/4849.html Links to Cultural Competency Issues Centers for Disease Control Center for Effective Collaboration and Practice c.org/cfusion/culture.cfm Emergency Medical Services for Children (good resource page) I Summer Provider Service Center:

8 Practice Matters is a periodic publication for physicians and other health care professionals and facilities in the UnitedHealthcare network North Third Avenue Phoenix, AZ M47507AZ EC 5/11 Provider Service Center:

FirstCare Health Plans (FirstCare) is on track to be ICD-10 ready by the October 1, 2015 deadline.

FirstCare Health Plans (FirstCare) is on track to be ICD-10 ready by the October 1, 2015 deadline. Overview In July 2014, the U.S. Department of Health & Human Services (HHS) issued a rule finalizing October 1, 2015 as the new compliance date for health care providers, health plans, and health care