New Jersey Fall/Winter practicematters. For More Information. Call our Provider Services Center at Visit UHCCommunityPlan.

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1 New Jersey Fall/Winter 2017 practicematters For More Information Call our Provider Services Center at Visit UHCCommunityPlan.com

2 In This Issue... Expansion of Dual-Eligible Special Needs Program 2017 CAHPS Member Satisfaction Scores Use of Imaging Studies with Low Back Pain HEDIS Measure for Medication Reconciliation Post-Discharge Primary Care Provider and Primary Care Dental Coordination Changes to Member Appeal Process A Reminder about Comprehensive Diabetes Care p.1 Helping Members Control Their Blood Pressure HEDIS Measures for Respiratory Conditions Guidance for Managing Antidepressant Medications Treating Members with Substance Abuse Managing Medication for People with Asthma Annual Monitoring for Patients on Persistent Medications UHCprovider.com Our New Care Provider Website Overcoming Barriers with 270/271 Eligibility and Benefits Transactions We hope you enjoy this edition of Practice Matters. In this issue, you can read about the expansion of the Dual Special Needs program, CAHPS survey results, treatment of members with substance abuse, and much more. Practice Matters: Fall/Winter 2017 Provider Services Center:

3 Expansion of Dual-Eligible Special Needs Program Beginning Jan. 1, 2018, UnitedHealthcare Dual Complete ONE, also known as Dual Special Needs Plan (D-SNP) or HMO SNP, will expand to serve members who live in Cumberland, Salem and Sussex counties. The plan had served members in Atlantic, Bergen, Burlington, Camden, Essex, Gloucester, Hudson, Hunterdon, Mercer, Middlesex, Monmouth, Morris, Ocean, Passaic, Somerset and Union counties. This fully integrated D-SNP plan better integrates coordination of care for members enrolled in Medicaid and Medicare in New Jersey. Here are a few of the plan features: Integrates all available Medicaid and Medicare managed care benefits across acute, primary, behavioral health and long-term care Submit the claim once using the Medicare ID and we ll coordinate collections from different payer sources, such as Medicare and Medicaid Preventive services at no cost to our members Reimbursement is based on your existing network agreement. Members receive a single ID card with both Medicare and Medicaid ID numbers For more information about UnitedHealthcare Dual Complete ONE, visit UHCCommunityPlan.com > For Healthcare Professionals > New Jersey > Dual Complete ONE. You ll find frequently asked questions, Quick Reference Guide and other resources related to UnitedHealthcare Dual Complete ONE CAHPS Member Satisfaction Scores UnitedHealthcare conducts an annual Consumer Assessment of Health Providers and Systems (CAHPS) Health Plan Survey to measure satisfaction with health care and the health plan quality of service. UnitedHealthcare Community Plan of New Jersey monitors member satisfaction with care and services to help make sure member interactions are working effectively and identify ways that we can improve on member satisfaction scores. The 2017 CAHPS survey results showed high overall satisfaction with customer service 88.8 percent for adults and 86.3 percent for children. Survey respondents were asked to rate their personal doctor for their children on a scale from 1-10, with 10 being a perfect score. The survey found that 86.3 percent of respondents rated their personal doctor for children an 8, 9 or 10. Adults rated their personal doctor 78.8% on a score of 8, 9 or 10. The survey also found: Overall health care scores are at 82.7 percent for adults and 73.4 percent for children. Ease of receiving care, tests or treatment increased from 78.2 percent in 2016 to 84.1 percent in Ability to receive an appointment for a checkup or routine care at a doctor s office or clinic as soon as needed also improved from 73.9 percent in 2016 to 82.1percent in 2017 for adults. A continued area of focus for 2018 is coordination of care. We re taking steps to educate specialists to share information about member test results and observation feedback with Primary Care Providers (PCPs) and encouraging PCPs to provide a comprehensive assessment to specialists when making a referral. 1

4 Use of Imaging Studies with Low Back Pain Back pain can be excruciating, and low back pain is the fifth most common reason for a physician or outpatient visit. Unless red flags are present (e.g. neurologic deficits, fever, trauma, malignancy), current recommendations are to not order imaging tests in the first four to six weeks. Studies have shown there s no clinically significant difference in patient outcomes between those who had immediate imaging versus those who had usual care, such as applying heat and taking an over-the-counter pain reliever. In addition, studies have shown that patients with occupation-related back pain who had early magnetic resonance imaging (MRI) had an eightfold increase risk of surgery. The National Committee for Quality Assurance (NCQA) has included Use of Imaging Studies for Low Back Pain as a reportable measure for the HEDIS 2018 audit. The measure will count the percentage of members with a primary diagnosis of low back pain who did not have an imaging study (x-ray, MRI, CT scan) within 28 days of diagnosis. The measure is reported as an inverted rate; a higher score indicates appropriate treatment of low back pain. For more information on imaging for back pain, go to aafp.org/patient-care/clinicalrecommendations/all/cw-back-pain.html. HEDIS Measure for Medication Reconciliation Post-Discharge As a reminder, this measure requires care providers and/ or pharmacists to review the medications prescribed to our members at an inpatient facility and compare them against the medication they were taking prior to admission. After reviewing the medication list, please include any new or discontinued medication and/or changes in dosage or frequency. The review must take place within 30 days after discharge. Medication reconciliation can help: Improve adherence to the treatment plan given Address medication errors or duplications Educate your patients on their new medications and side effects Lower the risk for adverse interactions Primary Care Provider and Primary Care Dental Coordination Continuous quality improvement is part of the UnitedHealthcare Community Plan culture. We re working to help ensure that our care providers have the information they need to help members get dental care and coordinate treatment related to dental needs. Our provider network is an essential part of our team. If a member needs dental care, the member s Primary Care Provider (PCP) should refer them to a dental provider. The referral process should include two-way communication between the referring provider and the provider receiving the referral. The Primary Care Dentist (PCD) should communicate a diagnosis and proposed treatment to the PCP and work together to achieve optimal dental health for our members. (continued on next page) 2

5 (continued from previous page) Changes to Member Appeal Process As a participating UnitedHealthcare Community Plan care provider, you may occasionally submit appeals on behalf of our members. On July 1, 2017, we altered the New Jersey Managed Care Organization member appeal process for denials of health care services to mirror changes to the federal rules. The PCP to PCD Referral Process A referral to a dentist by age 1 or soon after the eruption of the first primary tooth is mandatory and, at a minimum, a dental visit twice a year with follow up during well child visits to ensure that all needed dental preventive and treatment services are provided through age 20. PCPs can refer to any in-network pediatric or general dental provider for routine and emergency dental care for all members, regardless of age. No referral form is needed. Members are free to see any in-network dental provider. For a list of dental specialists, contact Provider Services at General dentists, as well as pediatric dentists who treat patients through age 6, may be found in the provider listing at myuhc.com: 1. Click Find a Dentist 2. Choose New Jersey from the Location drop down menu 3. Choose NJ Community Plan Medicaid/Fam Care/Medicare from the Select a Network drop down menu 4. Populate the search criteria to locate a provider The PCD should communicate a diagnosis and proposed treatment to the PCP. The PCP and PCD should work together to achieve optimal dental health for our members. Here are highlights of changes to the member appeal process: We shortened the timeframe to request an Internal (Stage 1 or Level 1) Appeal from 90 days to 60 days We eliminated the Stage 2 or Level 2 Appeal We shortened the timeframe to request an Independent Utilization Review Organization (IURO) Appeal (previously known as a Stage 3 or Level 3 Appeal) from four months to 60 days We extended the timeframe to request a Medicaid Fair Hearing from 20 days to 120 days If members need to request an appeal for a denial of a health care service, they will receive the appropriate letter from us at each stage or level of their appeal. The letters will guide them through the process, and members can call us if they have any questions. We re Here to Help If you have questions or need more information, please call Member Services at , TTY 711, 8 a.m. to 6 p.m. Easter Time, Monday through Friday. The phone number also is listed on the back of a member s ID card. For more information, go to UHCCommunityPlan.com> For Healthcare Professionals > New Jersey > Bulletins > Changes to Member Appeal Process - Effective July 1,

6 A Reminder about Comprehensive Diabetes Care Diabetes is the seventh leading cause of death in the United States. According to the Centers for Disease Control and Prevention 2014 National Diabetes Fact Sheet, 29.1 million adults in the United States have diabetes and 79 million of American adults have prediabetes, the precursor to diabetes. The rate of new cases of diagnosed diabetes in the United States has begun to fall, but the numbers are still high. Recent studies show that early detection of diabetes symptoms and treatment can decrease the chance of developing debilitating complications, including heart disease, blindness, kidney failure and lower-extremity amputations. Diabetes control and care consists of many complex components. A healthy lifestyle that includes weight management, physical activity, healthy eating should be the cornerstone of therapy for a patient with diabetes. Education for the patient should include an explanation of the disease and emphasizing how the body uses glucose and forms insulin. Patients should be informed how diabetes can cause serious health complications. When drug therapy is initiated, lifestyle initiatives should continue to help lower glucose levels and increase insulin sensitivity. HbA1c should continue to be monitored, and HbA1c testing should be done at least twice a year to determine what the average blood glucose level was for the last two to three months. Positive compliance with National Committee for Quality Assurance (NCQA) and HEDIS is < 8 and < 7 for select population. The NCQA has included Comprehensive Diabetes Care as a report measure for the Healthcare Effectiveness Data and Information Set (HEDIS ). The measure will count the percentage of members who are ages with diabetes (type 1 or Type 2) who had the following: Hemoglobin A1c control (<7 percent) Eye Exam ( retinal ) performed. Medical attention for nephropathy BP control (<140/90mm Hg) For more information, visit diabetes.org/. Helping Members Control Their Blood Pressure According to the CDC, about 75 million American adults have high blood pressure about one in three adults. It s important to educate your patients of the risk factors and physical lifestyle factors that can make them more likely to develop high blood pressure. A recommendation to control high blood pressure includes both lifestyle changes and medication therapy. NCQA has included controlling high blood pressure as a reportable measure for the HEDIS 2017 Audit. The measure focuses on the percentage of members ages who had a diagnosis of hypertension and whose blood pressure was adequately controlled during the measurement year based on the following criteria. The measure is reported as single rate and is the sum of all three groups: Members ages whose BP was <140/90 Members ages with a diagnoses of diabetes whose BP was <140/90 Members ages without a diagnoses of diabetes whose BP was < 150/90 For more information, go to cdc.gov/heartdisease/index.htm and cdc.gov/stroke/index.htm. Hemoglobin A1c testing Hemoglobin A1c poor control (>9 percent) Hemoglobin A1c control (<8 percent) 4

7 HEDIS Measures for Respiratory Conditions The CDC Antibiotic Resistance Solutions Initiative seeks to cut inappropriate prescribing of antibiotics in doctors offices by 50 percent. But many patients believe antibiotics are relatively benign and can be used to fight symptoms of an upper respiratory infection. When a member requests an antibiotic for treatment of an upper respiratory infection (URI), there s a great opportunity for education. Most care providers understand the problem of overprescribing antibiotics and do their best not to contribute to it. Yet, it s easy to underestimate how a patient or caregiver can influence the outcome of a sick visit. Being prepared with alternative strategies to manage symptoms can greatly impact the use of antibiotics by patients with adults and children with URI. Patient education on the danger of antibiotic resistance should be discussed in every sick visit. There are two measures that are counted in the yearly Healthcare Effectiveness Data and Information Set (HEDIS) audit that relate to this treatment concern: HEDIS measure URI, Appropriate Treatment for Children with Upper Respiratory Infection, includes the percentage of children, ages 3 months to 18 years old, who were given a diagnosis of URI and were not prescribed an antibiotic. This measure is reported as an inverted rate; a higher rate indicates appropriate treatment of children with URI (i.e., the proportion for whom antibiotics were not prescribed). HEDIS measure AAB, Avoidance of Antibiotic Treatment in Adults with Acute Bronchitis, measures the percentage of adults ages with a diagnosis of acute bronchitis who were not prescribed an antibiotic. This measure is also reported as an inverted rate. A higher rate indicates appropriate treatment of adults with acute bronchitis (i.e., the proportion for whom antibiotics were not prescribed). Guidance for Managing Antidepressant Medications In the United States, approximately 20 million adults suffer from some form of a depressive disorder. Without appropriate treatment, the symptoms can last for years and lead to death by suicide or other causes. Fortunately, many people with depressive disorders can improve with the right medications. HEDIS uses a measure that assesses the percentage of adults age 18 and older with a diagnosis of major depression who were newly treated with antidepressant medication and remained on an antidepressant medication treatment. Two rates are reported for this measure: Effective Acute Phase Treatment: The percentage of members who remained on an antidepressant medication for at least 84 days (12 weeks). Effective Continuation Phase Treatment: The percentage of members who remained on an antidepressant medication for at least 180 days (6 months). (continued on next page) 5

8 (continued from previous page) adequate care. The Healthcare Effectiveness Data and Information Set (HEDIS) has developed a measure that assesses the percentage of adolescent and adult members with a new episode of AOD dependence who initiate treatment through an inpatient admission, outpatient visit, intensive outpatient encounter or partial hospitalization within 14 days of the diagnosis. The measure also assesses an engagement phase, in which those members have two or more additional services within 30 days of the initial encounter. To help you improve outcomes for this measure, please consider the following: Here s some guidance to help achieve higher quality of care for our members diagnosed with major depression: 1. Discuss all aspects of the member s medication regime and encourage questions. 2. Stress the need to continue medication even if the member is feeling better. 3. Schedule a follow-up visit to evaluate the member s status and adjust medication regime if necessary. 4. If the medication is proving effective, consider providing a 90-day supply. 5. Refer the member to a behavioral health professional when appropriate. Treating Members with Substance Abuse Research shows that substance abuse causes more deaths, illnesses and disabilities in the United States each year than any other preventable health condition. According to the National Institute of Drug Abuse, the cost of care for substance abuse has risen to over $166 billion annually. An immediate referral to a behavioral health provider (BHP) for any member with a diagnosis of AOD dependence. The treatment should be started within 14 days. If you or the member doesn t want to begin treatment with a BHP, make a follow-up appointment within 14 days of diagnosis to initiate treatment. Schedule two additional visits within 30 days of initiating treatment. Managing Medication for Members with Asthma Finding the right asthma medication for your patients will improve their condition and allow them to live a more active and normal life. To help accomplish this, we track the percentage of patients, ages 5 to 85, who were identified as having persistent asthma and were prescribed appropriate medications that they stayed on 50 percent to 75 percent of the year. You can help by monitoring these patients annually for use and compliance of their bronchodilator and corticosteroid medication. Identifying people with alcohol and other drug (AOD) disorders is an important first step to treatment, but appropriate identification does not always lead to 6

9 Annual Monitoring for Patients on Persistent Medications Glycemic control, management of hypertension and reducing dietary salt intake are essential during the care of patients with diabetic nephropathy. Careful management and control is needed to prevent the progression of kidney disease and other complications. By performing therapeutic monitoring tests, you can meet quality improvement requirements while helping these patients receive hypertensive care. Health care standards say care providers should monitor levels in the percentage of members age 18 and older who received at least 180 days of ambulatory medication therapy for a select therapeutic agent during the measurement year, as well as at least one therapeutic monitoring test for the therapeutic agent in the measurement year. Any of the following therapeutic monitoring tests meets these criteria: Members on angiotensin converting enzyme (ACE) inhibitors or angiotensin receptor blockers (ARB) should have a complete metabolic lab panel or a serum potassium test and a serum creatinine test. Members on digoxin should have a complete metabolic lab panel or a serum digoxin test (HEDIS specifications no longer allow a blood urea nitrogen test). Members on diuretics should have a complete metabolic lab panel or a serum potassium test and a serum creatinine test. These tests do not have to take place on the same service date, only within the measurement year. UHCprovider.com Our New Care Provider Website UHCprovider.com is your new home for the latest news, policy information and access to Link selfservice tools. You told us you wanted provider content in one place, and we heard you. The new site is the first step in bringing provider content together for your convenience, and will begin by replacing UHCWest. com, UnitedHealthcareOnline.com and the healthcare professional content on UHCCommunityPlan.com over the coming months. UHCprovider.com is available now and includes several new features: 24/7 access to the Link self-service tool dashboard A predictive search function with filtering and sorting capabilities to help you find what you need faster and easier An easy-to-read design whether you re on a desktop computer, tablet or smart phone UHCprovider.com was designed with your feedback in mind, but our job is just beginning. Tell us how we re doing by clicking the Feedback button on the right side of any page. Your suggestions will help us continue to improve so we can better meet your needs. You ll be able to access your state-specific content on UHCCommunityPlan.com until late spring Watch for additional information in the Spring 2018 edition of Practice Matters. 7

10 Overcoming Barriers with 270/271 Eligibility and Benefits Transactions UnitedHealthcare wants to help you overcome barriers to obtain member eligibility and benefits from your 270/271 Health Care Eligibility and Benefit Inquiry and Response transactions. For more information on 270/271 EDI transactions, go to UHCprovider.com > Menu > Resource Library > Electronic Data Interchange (EDI) > Electronic Transactions > EDI 270/271: Eligibility and Benefit Inquiry and Response. If you have any questions, please contact EDI Support: Our current search logic allows you to enter different criteria related to the member or patient for the eligibility and benefits inquiry transaction (270). If the information given in the request doesn t match the data in our system, you will receive an AAA code telling you what information did not match in the eligibility and benefits transaction response (271). We ve outlined suggestions to resolve errors for the most common reasons we re unable to find a match. We recommend researching the information and resubmitting a 270 transaction to help ensure your records are accurate. Verify information is accurate from the member ID card, patient records or contacting the member when receiving the following 271 responses: If you receive: AAA*Y**73*C~AAA*Y**71*C~ (Invalid or missing name and DOB) Then verify name and date of birth in your records and include member ID If you receive: AAA*Y**75: (Subscriber/insured not found) Then member has no active coverage or may not be a UnitedHealthcare member If you receive: AAA*Y**71 (Subscriber/insured birth date does not match patient database) Then check formatting of date of birth should be YYMMDD UnitedHealthcare Community Plan EDI issue reporting form or ac_edi_ops@uhc.com or

11 New Jersey practicematters Practice Matters is a quarterly publication for physicians and other health care professionals and facilities in the UnitedHealthcare network. Doc#: PCA _ UnitedHealth Group, Inc. All Rights Reserved. P.O. Box 2040 Edison, NJ 08837