Provider Resource Guide - The University of Arizona Health Plans

Transcription

Provider Resource Guide
2701 E. Elvira Road  Tucson, Arizona 85756
2502 E. University Drive, Suite 125  Phoenix, Arizona 85034
www.uahealthplans.com
Welcome to The University of Arizona Health Plans
The Health Plans have developed the Provider Resource Guide to be used as
a quick reference with your Provider Manual. You may access the most
current Provider Manual on our websites or request a hard copy by calling
your Provider Relations Representative. Our Provider Newsletter is updated
quarterly and posted on our websites as well. We appreciate your partnership
with us in providing quality care and service to our members!
Rev 01/2013
UPHP 1.0
The University of Arizona Health Plans Member ID Cards
Rev 01/2013
UPHP 2.0
Contact Us
Customer Care Center & General Information
Toll Free: 800‐582‐8686 or 520‐874‐5290
TTY/TDD users call: 800‐367‐8939 (or 777)
Email: ClaimsInquiry‐[email protected]
Claims Customer Service/Addresses
Claims Customer Service: University Family Care Claims
University Care Advantage Claims
University Healthcare Group Claims
Maricopa Health Plan Claims 800‐582‐8686 PO Box 35699, Phoenix, AZ 85069
PO Box 38549, Phoenix, AZ 85069
(managed by The University of Arizona Health Plans)
Provider Website (Claims and Enrollment Inquiry, Patient Rosters)
https://eservices.uph.org
Important Websites The University of Arizona Health Plans ‐ www.uahealthplans.com
University Family Care ‐ www.ufcaz.com
University Care Advantage ‐ www.universitycareadvantage.com
University Healthcare Group ‐ www.universityhealthcaregroup.com
Maricopa Health Plan ‐ www.mhpaz.com
(managed by The University of Arizona Health Plans)
Grievance and Appeals Submissions
Office: 520‐874‐5290
Toll Free: 800‐582‐8686
Fax: 866‐465‐8340
Email: [email protected]
Rev 01/2013
Address:
2701 E. Elvira Road
Tucson, Arizona 85756
UPHP 3.0
Network Development Contact List
Management/Administrative Staff Title/Department
Telephone
Lisa Gascoigne
[email protected]
Director of Network Development
520‐874‐5203
Network Development Assistant
520‐874‐5523
Rosie Rascon
[email protected]
Phoenix‐Based Provider Relations Staff
Telephone
Connie Leonardo
[email protected]
Provider Relations Rep
602‐344‐8387
Sean Seeger
[email protected]
602‐344‐8385
Gail Vanko
[email protected]
602‐344‐8392
Linda Reiter
[email protected]
602‐344‐8391
Alyssa Bellantoni
[email protected]
602‐344‐8362
Tucson‐Based Provider Relations Staff
Telephone
Staci Garcia
[email protected]
520‐874‐5524
Marta Rosengren
[email protected]
520‐874‐5532
Jamie Swanson
[email protected]
Sr. Provider Relations Rep
520‐874‐5079
Rev 01/2013
UPHP 3.1
Network Development Contact List (cont.)
Tucson‐Based Provider Relations Staff Continued…
Telephone
Pam Skelnik
[email protected]
520‐874‐5520
Sr. Claims Educator
Contracting Staff
Telephone
Ann Hudson
[email protected]
Contracting
602‐344‐8342
Monica Hamilton
[email protected]
Contracting
602‐344‐8378
Alphonso Villela
[email protected]
Contracting
602‐344‐8393
Patti Cooper
[email protected]
Contracting
602‐344‐8348
Database Staff
Telephone
Annette Salas
[email protected]
Operations Specialist
520‐874‐5542
Gabriella Bracamonte
[email protected]
Database Coordinator
520‐874‐5502
Database Specialist
520‐874‐5521
Carolina Juvera
[email protected]
Rev 01/2013
UPHP 3.2
Quick Reference Guide‐
Appointment Availability Standards
Primary Care
Emergency
Same Day of Request or Within 24 Hours of Call or Notification
Urgent
Within Two (2) Days of Request
Non‐Urgent Routine but in need of attention
(SNP ONLY)
(physicals or health maintenance visits)
Within Seven (7) Days of Request
Within 21 Days of Request
Specialty Care
Routine Emergency
Urgent
(physicals or health maintenance visits)
Within 24 Hours of Referral
Within Three (3) Days of Referral
Within 45 Days of Referral
Dental Care
Emergency
Urgent
Routine
Within 24 Hours of Request
Within Three (3) Days of Request
Within 45 Days of Request
Maternity Care
First Trimester
Second Trimester
Third Trimester
Within Fourteen (14) Days of Request
Within Seven (7) Days of Request
Within Three (3) Days of Request
Emergency
Immediately
Routine
(SNP ONLY)
Within 45 Days
Uncomplicated Pregnancy
• First 28 Weeks –Every 4 Weeks • 36 Weeks ‐ Every 2 Weeks
• Every Week Thereafter
High Risk Pregnancies
Within Three (3) Days of Identification of High Risk
Postpartum Visits
Approximately Six (6) Weeks After Delivery
Wait Time for scheduled appointments should not be more than 45 minutes (except if provider is unavailable due to an emergency)
Rev 01/2013
UPHP 4.0
Quick Reference Guide –
ICD ‐ 10
UAHP has started preparation for the conversion on the use of ICD‐10 codes effective October 1, 2014. ICD‐10 codes will be replacing ICD‐9 codes as mandated by CMS. It is important that you begin now to prepare your office for the change to ICD‐10.
The biggest change in ICD‐10 codes is the increased specificity of the codes. Professional coders are being urged to review/refresh their knowledge on Anatomy and Physiology. It is suggested that refresher courses be taken.
Some facts regarding ICD‐9 versus ICD‐10:
1. ICD‐9 diagnosis codes contain approximately 13,000 codes. ICD‐10 will contain approximately 120,000 codes.
2. ICD‐9 diagnosis codes contain 3‐5 alphanumeric digits. ICD‐10 will contain 5‐7 alphanumeric digits.
3. ICD‐9 procedure codes contain approximately 4000 codes. ICD‐10 will contain approximately 200,000 codes.
4. ICD‐9 procedure codes contain 3‐4 numeric digits. ICD‐10 will contain 7 alphanumeric digits.
5. Crosswalks will be available but difficult to manage due to the 1 to many relationships that will be present between ICD‐9 and ICD‐10.
UAHP has established the following email for our health plan providers to use for ICD‐10 questions. Please feel free to email any ICD‐10 questions and we will reply back with answers and resources at [email protected].
Rev 03/2013
UPHP 5.0
Electronic Claims Submission
The University of Arizona Health Plans accepts professional and institutional electronic claims from the following clearinghouses:
Emdeon ‐ Contact your software vendor or Emdeon directly at 800‐444‐4336. Medifax (www.medifax.com) or Envoy/NEIC – previously known as WebMED (www.emdeon.com).
Emdeon Payor Identification Numbers:
• 09908 Maricopa Health Plan, managed by The University of Arizona Health Plans
• 09830 University Family Care
• 09830 University Care Advantage
• 07503 University Healthcare Group
The SSI Group (www.thessigroup.com) ‐ Contact your software vendor or The SSI Group Sales and Marketing at 800‐881‐2739.
SSI Payor Identification Numbers:
• 99999 Payor Identification Number
• 0651 Sub‐identification Number
UAHP is ready to accept the EDI 5010 837 Claims Transactions and send the EDI
5010 835 Electronic Remittance Advices. If you are interested in submitting your
claims to UAHP electronically, please contact your trading partner. If you do not
already have a trading partner, UAHP is contracted with the following trading
partners: Emdeon, SSI and Office Ally and can provide contact information for
them. UAHP has adopted the AHCCCS 5010 837 Companion Guide. This guide
can be referenced on the AHCCCS website at:
http://www.azahcccs.gov/commercial/Downloads/EDIchanges/AZ837FFS_CG_v
01_201106_DRAFT.pdf
If you would like to sign up for electronic remittance advice and electronic
funds transfer, please contact your trading partner or your Provider Relations
Representative.
Contact DentaQuest Customer Service at 800‐417‐7140, for assistance in setting up your electronic claims submission system for dental claims.
Rev 01/2013
UPHP 6.0
Emdeon ERA Provider Setup Form
Rev 01/2013
UPHP 6.1
Rev 01/2013
UPHP 6.2
What’s New on eServices?
eServices is a secure website where you can check member eligibility, claims status
and now Primary Care Providers can view their current patient roster with
AHCCCS renewal dates.
Here’s how it works:
Eligibility Inquiry
1. Select Enrollment Inquiry
2. Enter your patient’s date of birth and ID # or first and last name
3. Select Find Member
If your patient is a UFC member, information will populate with the UFC effective
date and what PCP the member is assigned to. You can also scroll down to see if the
member has mandatory co‐pays.
Claims Status
1. Select Claims Lookup
2. Enter your Tax ID # (don’t use the dash) and the dates of service you would like to see
3. Select Find Claim
All claims we have received from your office during the selected date range will
populate. You can drill down to one claim, by selecting the claim #, or you can
export the results to Excel for sorting.
Patient Rosters
1. Select Patient Rosters
2. Enter your Tax ID # (don’t use the dash)
3. Select Load Roster
Patient rosters are updated daily so you have the most current information! The
member’s AHCCCS renewal date also appears on the electronic rosters, if available.
All members assigned to physicians under your Tax ID # will populate and can be
exported to Excel for sorting.
Register with eServices today at https://eservices.uph.org
Rev 01/2013
UPHP 7.0
Ask Me3
The Health Plan has joined forces with the Partnership for Clear Health
Communication to help members improve their health literacy skills through a
program called Ask Me 3.
There are many ways you can integrate the Ask Me 3 tools and resources into your
practice or organization to improve your communication with patients. Improved
communication can help increase your member’s ability to understand and act
upon the information you provide, ultimately improving their health outcomes.
There are numerous other ways to creatively integrate Ask Me 3 into your daily
work:
Review the Information Sheets written especially for you!
•
The printed information helps explain the scope and impact of low health
literacy, the importance of clear health communication, and the benefits of Ask
Me 3.
Share the Patient Information Sheets!
•
•
The highly informative Patient Information Sheet educates patients about the
Ask Me 3 program, and how using the three questions can help them better
communicate with doctors, nurses, physicians assistants, pharmacists and other
health care or information providers.
You can share it with patients by handing it out with any instructions or
insurance paperwork upon a patient’s departure from your office
Your Provider Relations Representative is available to assist you with the
implementation of the Ask Me 3 program, provide you with printed Information
Sheets and arrange for an in‐ service for you and your staff.
Rev 01/2013
UPHP 8.0
Ask Me 3 is a patient education program designed to promote communication between health care providers and patients in order to improve health outcomes. The programs encourages patients to understand the answers to three questions:
•What is my main problem?
•What do I need to do?
• Why is it important for me to do this?
Myth vs. Reality
Myth: My patients are generally well‐read and college‐educated. They understand the information I give them.
Reality: The average American reads at the 8th‐
9th grade level; however, health information is usually written at a higher reading level.
Most patients – regardless of their reading or language skills – prefer medical information that is simple and easy to understand.
Additional factors that may hinder understanding include:
What is Health Literacy?
Health literacy is the ability to read, understand, and effectively use basic medical instructions and information. Low health literacy can affect anyone of any age, ethnicity, background, or educational level.
People with low health literacy:
•Are often less likely to comply with prescribed treatment and self‐
care regimens.
•Fail to seek preventive care and are at higher (more than double) risk for hospitalization.
•Remain in the hospital neatly two days longer then adults with higher health literacy.
•Often require additional care that results in annual health care costs that are four times higher than for those with higher literacy skills.
Why is Health Literacy Important to Me?
•Intimidation, fear, vulnerability
Chances are high that some of your patients are among the 90 million people in the United State whose health may be at risk because of difficulty in understanding and acting on health information.
•Shock upon hearing a diagnosis
In fact, you may not even know that these patients are in your practice because:
•Extenuating stress
within the patient’s family
•They are often embarrassed or ashamed to admit they have difficulty understanding health information and instructions.
•Multiple health conditions to understand and treat
•They are using well‐practices coping mechanisms that effectively mask their problem.
Rev 01/2013
UPHP 8.1
Ask Me 3 is a patient education program designed to promote communication between health care providers and patients in order to improve health outcomes. The programs encourages patients to understand the answers to three questions:
•What is my main problem?
•What do I need to do?
• Why is it important for me to do this?
Facts
•According to the Institute of Medicine, nearly half of all American adults – 90 million people – have difficulty understanding and using health information.
•Everyone in the United States is susceptible regardless of age, race, education or income.
•Low health literacy costs
the health system as much as
$58 billion a year.
•Only 50 percent of all patients take medications as directed, leading to compliance issues and possible negative health outcomes.
•Adults with low health literacy average 6 percent more hospital visits – and remain in the hospital nearly two days longer – then adults with higher health literacy.
What can Providers do?
Health literacy is now known to be vital to good patient care and positive health outcomes.
1. Answer 3
Along with encouraging your patients to use the Ask Me 3 approach, simple techniques can increase your
patients’ comfort level with asking questions, as well as compliance with your instructions after they leave
appointments.
•Create a safe environment where patients feel comfortable talking openly with you
•Use plain language instead of technical language or medical jargon
•Sit down (instead of standing) to achieve eye level with your patient
•Use visual models to illustrate a procedure or condition
•Ask patients to “teach back” the care instructions you give to them
2. Learn more about low health literacy
http://www.npsf.org/askme3/ has fact sheets on the issue of low health literacy, a white paper detailing the scope and impact of the problem, and communication tools to help you in your practice.
3. Incorporate new knowledge into your practice
Broadening your knowledge of the low literacy issue and associated concerns will help your to better treat your patients
•Annual health care costs for those with low literacy skills are four times higher than those with higher literacy skills.
Rev 01/2013
UPHP 8.2
Pain Scale
Rev 01/2013
UPHP 9.0
Important Information
Arizona Early Intervention Program (AzEIP)
AzEIP is the collective effort of private and public programs and community
members. AzEIP provides services such as speech, occupational and physical
therapy and other supports to families and children, ages 1‐3, at risk of or
who have a developmental delay.
Vaccines For Children Program (VFC)
• All Primary Care Providers (PCPs) must coordinate with the Arizona
Department of Health Services Vaccines for Children (VFC) Program in
the delivery of immunization services. Immunizations must be provided
according to the Advisory Committee on Immunization Practices
Recommended Schedule.
• PCPs must be enrolled and re‐enroll annually with the VFC Program in
accordance with the AHCCCS contract requirements.
• The Early Periodic Screening, Diagnosis, and Treatment (EPSDT)
Program covers all child and adolescent immunizations as specified in
the AHCCCS Recommended Childhood Immunizations Schedules.
• All appropriate immunizations must be provided to establish and
maintain up to date immunization status for each EPSDT member.
Arizona State Immunization Information Systems (ASIIS)
Providers must document each member’s immunizations in ASIIS within 30
days. All immunizations must be documented with the Arizona State
Immunization Information System (ASIIS) at www.asiis.state.az.us. ASIIS
offers free training classes:
• ASIIS training classes are conducted each month
• Advanced classes are taught quarterly
Please call ASIIS at 1‐877‐491‐5741 or 602‐364‐3899 for more information.
Americans with Disabilities Act (ADA) Information Line
For questions about ADA requirements including ADA Standards for
Accessible Design, free ADA materials, or information about filing a
complaint, call:
• Telephone: 800‐514‐0301
• TTY: 800‐514‐0383
Rev 01/2013
UPHP 10.0
Missed or Canceled Appointments
Member “No Shows”
Please notify the Customer Care Center if a member consistently misses
appointments or cancels without rescheduling. Complete the “No Show
Log” or furnish a copy of your own “No Show” profile and fax to the
Customer Care Center at (520) 874‐3434 (see Quick Reference Guide).
The Customer Care Center will contact the member to provide education
on the importance of keeping appointments and provide assistance in
scheduling future appointments.
The Customer Care Center also
encourages providers to talk to his/her patient regarding the importance of
keeping their appointments.
Note: SNP members cannot be charged for “no show” appointments.
Penalty for Missed Appointments
Childless Adult and TANF members residing in rural counties, outside of Maricopa and Pima counties, that miss a scheduled appointment by more than 20 minutes will be charged $ 3.00. The parent or adult must give the provider 24 hour notice to avoid the fee. Physicians, nurse practitioners and physician assistants are permitted to charge the fee and prohibit members from rescheduling their appointments until the member has paid the missed appointment fee.
Prior to implementation of the missed appointment fee, providers must submit a plan to AHCCCS for approval that addresses how they intend to:
• Provide notice of appointments to members 48 hours prior to appointment,
• Provide written notice by mail, e‐mail, or text message,
• Track who they charged the fee and how they will report the fees to the State.
Providers may submit their plan for AHCCCS approval to [email protected]. Rev 01/2013
UPHP 11.0
No Show Log
Rev 01/2013
UPHP 11.1
Dental Services
DentaQuest has been delegated for the benefit administration of dental
services for our AHCCCS and SNP members. As a part of their duties,
DentaQuest will be responsible for contracting with all dental providers,
including clinics, and providing necessary authorizations and utilization
management. Additionally, DentaQuest will process all dental and
dental anesthesia claims, conduct some oversight of quality of care and
provide all dental network communications and provider education.
DentaQuest Contact Information
1‐800‐440‐3408 or www.dentaquest.com
Denta Quest Claims Address:
DentaQuest of AZ‐Claims
12121 North Corporate Pkwy
Mequon, WI 53092
Dedicated line: 800‐440‐3408
To submit claims electronically via eclaims the Payor ID is CX014 Effective July 1, 2012, DentaQuest will take over dental anesthesia for MHP, UFC and UCA. Dental anesthesia prior authorization requests should be sent directly to:
DentaQuest of Arizona, LLC‐OR Authorizations
P.O. Box 339
Mequon, WI 53092
Fax: 262‐834‐3575
Please note: Facility claims (OR, ASC, etc.) will continue to go to UAHP for processing and adjudication.
Rev 01/2013
UPHP 12.0
Rev 01/2013
UPHP 12.1
Parental Evaluation of Development Status
(PEDS Tool)
The Arizona Health Care Cost Containment System (AHCCCS) implemented the
Parental Evaluation of Development Status (PEDS Tool) in January of 2006. The
following is a quick reference guide to the PEDS Tool, its purpose and billing
requirements.
•
•
•
•
•
The PEDS Tool is designed for use in conjunction with the well‐child (EPSDT)
visit for further assessment of developmental milestones including social,
emotional and cognitive development for NICU graduates.
Providers must be trained prior to using the tool and will be reimbursed for
using the PEDS Tool. Contact the Arizona Academy of Pediatrics at 602‐532‐
0137 or go to www.azpedialearning.org and click on Web‐Based Non CME
Courses and choose PEDS Tool to become certified online. This training is
free.
ALL PCP Providers must complete PEDS Tool training in order to bill and
must be the rendering provider. A “Peds Tool Trained” provider cannot
delegate PEDS Tool evaluations to another non‐Peds Tool trained provider
including a provider they may be supervising.
CPT code 96110 is only to be used in association with the PEDS Tool. Because
this is a service that can only be provided by a PCP (Pediatrician, Family
Medicine, and Internal Medicine) the Health Plan will only accept code 96110
to be billed on a CMS 1500 form. All Peds tool code 96110 billed on a UB form
will be denied.
PEDS Tool trained providers will be reimbursed for use of the tool on
members who are graduates from the NICU. Providers should bill code CPT
96110 with modifier EP to be reimbursed at the Peds tool rate.
Claim payment requirements
• Provider must be PEDS Tool Trained
• Claims should be submitted with the EP modifier
• Completed PEDS Score Form must be submitted with the EPSDT Form
• Claims submitted must be for NICU graduates. Provider must submit medical
records when applicable
Please submit your PEDs Response Forms, Score Forms and Interpretation
Forms with the EPSDT Forms to:
The University of Arizona Health Plans
EPSDT / PEDS Tool
2701 E Elvira Road
Tucson, AZ 85706
Rev 01/2013
UPHP 13.0
Guidelines for Prior Authorization Requests
If you have reviewed the PA Grid and are not sure if services require PA, please call the
PA Department directly for assistance at 1‐800‐582‐8686 or email at [email protected].
Please note the following Specialty Consultation services require Prior Authorization from
our Health Plan prior to referring a member for services:
• Pain Management
• Adult Allergy ‐ Please reference PA Grid for limitations
• Plastic Reconstructive Surgery (including hand surgery)
Standard Authorization Request (up to 14 days for approval) – under 42 CFR 438.210,
means a request for which a Contractor must provide a decision as expeditiously as the
member’s health condition requires, but not later than 14 calendar days if the member or
provider requests an extension or if the Contractor justifies a need for additional
information and the delay is in the member’s best interest.
Expedited Authorization Request (up to 72 hours for approval) – under 42 CFR 438.210,
means a request for which a provider indicates or a Contractor determines that using the
standard timeframe could seriously jeopardize the member’s life or health or ability to
attain, maintain or regain maximum function. The Contractor must make an expedited
authorization decision and provide notice as expeditiously as the member’s health
condition requires, but no later than three working days following the receipt of the
authorization request, with a possible extension of up to 14 days if the member or provider
requests an extension or if the Contractor justifies a need for additional information and the
delay is in the member’s best interest.
If you have an urgent request, please fax it in and call us the same day to inform us that
an expedited request has been submitted.
• Do not submit the request as EXPEDITED unless it is truly an expedited request. Please follow guidelines for standard and expedited above.
• Accurately complete the authorization request. Use the most current form which can be found on our website.
• Add all contact information including phone numbers (with area code) and fax numbers.
• Make sure to document if the procedure requested is to be done outpatient, inpatient, hospital, etc.
• Fax all pertinent information including: physician orders, notes, any test results, previous treatment and therapy notes, if pertinent.
Rev 01/2013
UPHP 14.0
Rev 01/2013
UPHP 14.1
Rev 01/2013
UPHP 14.2
Rev 01/2013
UPHP 14.3
Pharmacy Prior Authorization and Non‐Formulary Request Date_______________________________________
Member Name___________________________________
Provider Name_______________________________
Insurance ID #___________________________________
Provider Phone #_____________________________
Date of Birth_____________ Phone #________________
Provider Fax #_______________________________
Type of Request
Insurance Plan
Standard
University Family Care
Maricopa Health Plan
University Care Advantage
University Healthcare Group Expedited
Medical Information
Requested Medication: ___________________________________________________________________________
Dosing Regimen: _______________________________________________________________________________
Quantity: ________________________________ Duration of Therapy: ____________________________________
Diagnosis Pertaining to Requested Medication: _______________________________________________________
_____________________________________________________________________________________________
Reason for Exception: ___________________________________________________________________________
______________________________________________________________________________________________
Alternative Medication(s) Tried and Reason(s) for Failure: _______________________________________________
The University of Arizona Health Plans Office Use Only
Please fax this completed form to 866‐349‐0338 UAHP 4/12
Rev 01/2013
UPHP 14.4
Case Management
The University of Arizona Health Plans offers Case Management services,
(also called condition management), to all of our members based upon their
unique needs. Our Case Management Department consists of a Medical
Director, Manager, Behavioral Health Professionals, Registered Nurses, and
Licensed Practical Nurses. Our approach to case management is based upon
the Wagner Care Model through which we leverage the member’s entire
support system as well as the support of the Health Plan to help the member
attain the best possible outcomes.
Member’s who can benefit from case management are identified in many
ways and by different individuals. We receive referrals from providers,
facility case managers, by member’s themselves and by individuals within the
Health Plan, as well as through claims data analysis. The Health Plans offer
complete educational programs to our members with diabetes, asthma, and
congestive heart failure, as well as case management support based upon
their individual needs.
Once a referral is received or a member is identified through claims data
analysis, the member is contacted and offered Case Management services.
Upon enrollment into Case Management, we begin to identify areas within
the members treatment plan and lifestyle that we can educate the member
about, advocate for services and develop a plan of care that focuses on the
areas the member is ready to change. A detailed, individualized plan of care
for each member in case management facilitates communication with the
member’s Primary Care Provider, who is our key partner in the member’s
care.
It is important that our providers take an active role in the Case Management
member support system. We encourage our providers to refer members that
will benefit from case management services.
We also welcome and
encourage our provider’s involvement in the plan of care for their patients.
Our Case Management staff can be reached Monday through Friday, 8:00 am to 5:00 pm, by calling 1‐800‐582‐8686.
Rev 01/2013
UPHP 15.0
Rev 01/2013
UPHP 15.1
Clinical Practice Guidelines
The University of Arizona Health Plans (UAHP), including University Family Care
(UFC), Maricopa Health Plan (MHP), University Care Advantage (UCA) and
University Healthcare Group (UHCG), endorses or develops clinical practice
guidelines in order to support physicians and other clinical providers in the
assessment, diagnosis, and treatment of UAHP members.
UAHP Clinical Guidelines are:
 based on valid and reliable clinical evidence or a consensus of health care
professionals in that field
 selected with consideration of the needs of UAHP members
 adopted in consultation with UAHP providers
 based on National Practice Standards
 developed by health care professionals and based on a review of
peer‐reviewed articles published in the United States when national practice
guidelines are not available
UAHP Clinical Practice Guidelines are recommendations to support clinical
decision‐making. Primary care physicians, specialists, and other health care
providers are expected to collaborate with their patient and / or the patient’s
surrogate to develop and implement treatment plans that are individualized to meet
the specific needs of each patient. This collaboration allows deviation from the
guideline in unique clinical situations and should be clearly substantiated in the
medical record.
UAHP Clinical Practice Guidelines are endorsed or developed with designated,
desired outcomes and associated, standardized measures of effectiveness.
UAHP Practice Guidelines are disseminated to all affected providers and are
available to all providers, members, potential members, and affiliated allied health
professionals upon request.
Clinical practice guidelines may include treatment that requires prior
authorization and or / is not covered by a member’s UAHP benefit structure.
Please refer to the UAHP Prior Authorization Grid and / or Referral Guidelines
for additional information. Links to both the Prior Authorization Grid and the
Formulary are listed below for your convenience.
Rev 01/2013
UPHP 16.0
Clinical Practice Guidelines – Endorsed by UAHP
• AIDS / HIV
www.aidsinfo.nih.gov
• Antibiotic Resistance Surveillance and Prevention Program.
http://www.azdhs.gov/phs/oids/hai/
• Asthma, Diagnosis and Management.
http://www.nhlbi.nih.gov/guidelines/asthma/asthgdln.pdf
• Attention Deficit/Hyperactivity Disorder
http://aappolicy.aappublications.org/cgi/content/abstract/pediatrics;128/5/1007
• Bronchitis, Antibiotic Use for Treatment of Uncomplicated Acute Bronchitis
http://www.annals.org/cgi/content/full/134/6/521
• Chronic / Congestive Heart Failure
http://circ.ahajournals.org/content/119/14/1977.full.pdf
• Mental Health Disorders in Adults
http://psychiatryonline.org/guidelines.aspx
• Diabetes Mellitus
http://care.diabetesjournals.org/content/34/Supplement_1/S11.full
• Immunizations / EPSDT
http://www.cdc.gov/vaccines/recs/schedules/child‐schedule.htm#printable
• Myocardial Infarction, Management of Patients with ST‐Elevation
http://circ.ahajournals.org/content/120/22/2271.full.pdf
• Pediatric Overweight and Obesity, Prevention and Reduction
http://pediatrics.aappublications.org/content/120/Supplement_4/S229.abstract
• Otitis Media, Acute
http://pediatrics.aappublications.org/cgi/content/full/113/5/1412
• Overweight and Obesity in Adults, Identification, Evaluation and Treatment
http://www.nhlbi.nih.gov/guidelines/obesity/ob_home.htm
• Tobacco Cessation
http://www.ahrq.gov/clinic/tobacco/tobaqrg.pdf
• Mycobacterium Tuberculosis
http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5417a1.htm
• Venous Thromboembolic Disease (DVT & PE); Antithrombotic Therapy
http://chestjournal.chestpubs.org/content/133/6_suppl
Rev 01/2013
UPHP 16.1
Clinical Practice Guidelines – Endorsed by UAHP (cont.)
Additional Information can be located using the following links:
Prior Authorization Grids:
• University Family Care
http://www.ufcaz.com/WebsiteMedia/Docs/PA_Grid.pdf
• University Healthcare Group
http://www.universityhealthcaregroup.com/ContentDocuments/PA_Grid.pdf
• Maricopa Health Plan
http://www.mhpaz.com/WebsiteMedia/Docs/PA_Grid.pdf
• University Care Advantage
http://www.universitycareadvantage.com/docs/PA_Grid.pdf
UAHP Formularies:
• University Family Care
http://www.ufcaz.com/docs/UFC_DrugFormulary.pdf
• University Healthcare Group
http://www.universityhealthcaregroup.com/ContentDocuments/HCG_PHARMACY.pdf
• Maricopa Health Plan
http://www.mhpaz.com/docs/MHP_DrugFormulary.pdf
• University Care Advantage
http://www.universitycareadvantage.com/docs/Formularies/2012_UCA_Comprehensive_Formulary.pdf
Additional guideline resources are available through the National Guideline Clearinghouse at www.guidelines.gov.
UAHP Practice Guidelines are reviewed by the UAHP Quality Management / Performance Improvement (QM/PI) Committee at least annually to determine if the Guidelines remain applicable, represent best practice standards, and reflect the current medical standards. The guidelines noted above were last reviewed and approved in January 2012.
The UAHP Chief Medical Officer, Medical Directors and other applicable clinical resources are available to providers that request and / or require additional information related to UAHP Clinical Practice Guidelines. Please contact your UAHP Provider Relations Representative for any questions, comments or if you require clarification.
Rev 01/2013
UPHP 16.2
Fraud, Waste and Abuse
Fraud is defined as an intentional deception or misrepresentation made by a person with the
knowledge that the deception could result in some unauthorized benefit to him/herself or
some other person. It includes any act that constitutes fraud under applicable federal or state
law.
Abuse is defined as provider practices that are inconsistent with sound fiscal, business, or
medical practices, and result in an unnecessary cost to health programs, or in reimbursement
for services that are not medically necessary or fail to meet professionally recognized
standards for health care. It also includes recipient practices that result in unnecessary costs
to the health program.
Provider Fraud
•
•
•
Individual participating or non‐participating providers who deliberately submit claims
for services not actually rendered, or bill for higher‐priced services than those actually
provided.
Providers of medical equipment and home health services who defraud the Medicare
program and private payers, often paying kickbacks to dishonest physicians who
prescribe unnecessary products and services.
Charges are submitted for payment for which there is no supporting documentation
available, such as x‐rays or lab results.
Our Goal: Eliminating Fraud and Abuse
To eliminate fraud and abuse successfully, everyone must work together to prevent, identify,
and report inappropriate and potentially fraudulent practices. This can be accomplished by:
•
Monitoring claims submitted for compliance with billing and coding guidelines
•
Adherence by providers and facilities to Treatment Record Standards
•
Education of all staff members who have any contact with PHI
•
Referring cases of suspected fraud and abuse
Examples of Potential Fraud, Abuse or Suspicious Activity
Falsifying Claims/Encounters
•Alteration of Claim
•Super imposed material
•White Outs
•Erasures
•Altered Changes
•Different colored inks used
Rev 01/2013
UPHP 17.0
Fraud, Waste and Abuse (cont.)






•
Incorrect Coding
•
Double Billing
•
Up coding
•
Billing for services not rendered
Misrepresentation of services/supplies
Substitution of services
Misspelled Medical Terminology
No provider information on claim
Diagnosis does not correspond to treatment rendered
Member Eligibility Fraud
•
Ineligible member using eligible member’s ID card to obtain services
•
Misrepresentation of medical condition
•
Failure to report third party billing
•
Eligibility determination issues
What Laws Regulate Fraud & Abuse?




False Claims Act (FCA)
Anti‐Kickback Statute
Deficit Reduction Act
The False Claims Whistleblower Employee Protection Act




Stark Law
HIPAA
Criminal Penalties for Acts involving Federal Health Care Programs
Administrative Remedies for False Claims and Statements
False Claims Act
Under the False Claims Act (FCA),31 U.S.C. §§3729‐3733, those who knowingly submit,
or cause another person or entity to submit, false claims for payment of government
funds are liable for three times the government’s damages plus civil penalties of $5,500 to
$11,000 per false claim.
Stark Law
Self‐Referral (Stark Law) Statutes, Social Security Act, §1877, pertains to physician
referrals under Medicare and Medicaid. Referrals for the provision of health care
services, if the referring physician or an immediate family member has a financial
relationship with the entity that receives the referral, is not permitted.
Rev 01/2013
UPHP 17.1
Anti‐Kickback Statute
Under the Anti‐Kickback Statute, 41 U.S.C, it is a criminal offense to knowingly and
willfully offer, pay, solicit or receive any remuneration for any item or service that is
reimbursable by any federal healthcare program. Penalties many include exclusion from
federal health care programs, criminal penalties, jail and civil penalties for each violation.
Examples of kick‐backs: money, discounts, gratuities, gifts, credits and commissions.
HIPAA
The Health Insurance Portability and Accountability Act (HIPAA), 45 CFR, Title II, §201‐250,
provides clear definition for Fraud & Abuse control programs, establishment of criminal
and civil penalties and sanctions for noncompliance. This act protects the privacy of the
patient.
Deficit Reduction Act
The Deficit Reduction Act (DRA), Public Law No. 109‐171, §6032, passed in 2005, is
designed to restrain Federal spending while maintaining the commitment to the federal
program beneficiaries. The Act requires compliance for continued participation in the
programs. The development of policies and education relating to false claims,
whistleblower protections and procedures for detecting and preventing fraud & abuse must
be implemented.
The False Claims Act Whistleblower Employee Protection Act
Under this legislation, 31 U.S.C. §3730(h),a company is prohibited from discharging,
demoting, suspending, threatening, harassing or discriminating against any employee
because of lawful acts done by the employee on behalf of the employer or because the
employee testifies or assists in an investigation of the employer.
A whistleblower is an employee, former employee, or member of an organization, especially
a business or government agency who reports misconduct to people or entities that have the
power and presumed willingness to take corrective action.
Rev 01/2013
UPHP 17.2
What is a Fraud & Abuse Violation?
•
•
Fraud & Abuse Violations occur when a person deliberately uses a misrepresentation or
other deceitful means to obtain something to which he/she is not otherwise entitled.
Any employee, member, vendor or provider has the right to make a Fraud & Abuse‐
related complaint to the Health Plan if he/she feels that there has been suspicious
activities.
How is suspicious activity reported?
Complaints from members, vendors, providers, employees, etc.
•
Send a written statement to the Inspector General, 701 E. Jefferson St., MD 4500, Phoenix, AZ 85034 or fax to 602‐417‐4102.
•
Include all information, claim, or tip that supports alleged misconduct
Sanctions and Penalties for Fraud and Abuse Violations
The Health Plan must have and apply appropriate sanctions against providers and vendors
who fail to comply with the policies and procedures of the Health Plan and/or the
requirements of the Federal Laws and Statutes. The Federal and State Government agencies
will prosecute these providers and vendors accordingly. Conviction of Fraud and Abuse can
carry civil and criminal penalties. Payments to a provider may be suspended if a credible
allegation of fraud is determined.
Civil Penalties:
•
$5,500 to $11,000 per claim plus up to 3 times the amount of damages
Criminal Penalties:
•
Felony conviction: 5‐20 years in jail
•
Misdemeanor conviction: 1 year in jail
Provider Responsibilities
The Health Plan providers are responsible for understanding:
 Coding Standards ‐ Select appropriate CPT code for service rendered
 The Health Plan Provider Standards‐ Understand roles and responsibilities as
participating providers and know licensure responsibilities and restrictions
 Documentation standards ‐ The Health Plan adheres to national standards for
documentation
Rev 01/2013
UPHP 17.3
How does AHCCCS Deal with Fraud, Waste and Abuse?
The AHCCCS Program has established a multifaceted approach towards Program Integrity.
Program Integrity is defined as the “planning, prevention, detection, and
investigation/recovery activities undertaken to minimize or prevent overpayments due to
Medicaid fraud, waste, or abuse.”
The AHCCCS Program Integrity efforts are spearheaded by the Office of the Inspector
General (OIG) in coordination with resources deployed by contracted health plans.
What authority does the AHCCCS Office of the Inspector General have? •
Employs a staff of 55 individuals responsible for investigating member and provider fraud. •
The OIG has full subpoena power and the authority to administer oaths. •
Once a case has been confirmed, the OIG is empowered to impose civil and monetary penalties. •
The OIG also has the authority to exclude a provider from participation in the AHCCCS system.
How is Fraud, Waste and Abuse Reported to AHCCCS?
Once suspicious activities have been identified and investigated, there are several ways
Fraud is reported to AHCCCS.
Internet:
Fraud is reported directly to the state via the web by going to
www.azahcccs.gov and clicking on the “Fraud and Abuse” link under the
Common Resources section.
Fax:
Information is faxed to 602‐417‐4102
Telephone:
Suspected fraud by an AHCCCS member can be reported by calling 602‐
417‐4193 in Maricopa County and 888‐487‐6686 outside Maricopa
County. If you want to report suspected fraud by a medical provider,
please call 888‐487‐6686 or 602‐417‐4045 in Maricopa County.
Mail:
Inspector General
701 E. Jefferson St., MD 4500
Phoenix, AZ 85034
Rev 01/2013
UPHP 17.4
How do The Centers for Medicare& Medicaid Services (CMS) Deal with Fraud, Waste and Abuse?
Through the Fraud Prevention Initiative, the Centers for Medicare & Medicaid
Services (CMS) is working to ensure that correct payments are made to legitimate
providers for covered appropriate and reasonable health care services.
In 2010, CMS formed the Center for Program Integrity (CPI). This involved pulling
together existing anti‐fraud components from other areas of the agency, as well as
forming new ones.
CMS Fraud Reporting Tools
Email:
[email protected]
Fax: Information is faxed to 800‐223‐8164
(No more than 10 pages)
Telephone:
Fraud can be reported by calling 800‐447‐8477
Mail:
Office of Inspector General
Department of Health & Human Services
ATTN: HOTLINE
PO Box 23489
Washington, DC 20026 Rev 01/2013
UPHP 17.5
Electronic Health Records
Rev 01/2013
UPHP 18.0
Electronic Health Records (cont.)
Rev 01/2013
UPHP 18.1
Quality Care Desk Aid
Rev 01/2013
UPHP 19.0
Quality Care Desk Aid (cont.)
Rev 01/2013
UPHP 19.1
www.ufcaz.com
Transportation
How does an AHCCCS member get to a doctor’s appointment if they don’t have a way of getting there?
University Family Care (UFC) is contracted with Medical Transportation Brokerage of Arizona (MTBA) to provide transportation for UFC members. What services does MTBA provide? Services include transportation to and from doctor’s appointments, pharmacy pickup, urgent care, and outpatient surgery. UFC members that utilize transportation frequently may qualify for an unlimited bus pass, which will entitle them to general transportation for the approved period. Those members will be required to use their bus pass for all of their medical transportation needs unless approved otherwise by the Health Plan. MTBA also provides blanket transportation for UFC members with reoccurring routine dialysis or cancer treatments. The only transports that MTBA is not delegated to handle are trips to and from the emergency room. In a true emergency situation, UFC members will need to dial 911 and utilize emergency transportation. How does it all work? When a UFC member or a provider office calls The University of Arizona Health Plans Customer Care Center, they are first prompted to select their language of choice. Once that is established the UFC member or provider office is given a second set of options including “Transportation.” When selecting the transportation option, they are transferred directly to MTBA’s call center. MTBA has two call centers, one in Phoenix and one in Tucson. Both call centers are staffed by specially trained representatives who are familiar with medical transportation, Health Plan policy, and HIPAA. MTBA currently employs over 70 Customer Service Representatives (CSR’s) and they are still growing their staff to meet our member’s needs. Rev 01/2013
www.ufcaz.com
UFC 1.0
Transportation (cont.)
What if a member lives in Douglas, but needs to come to Tucson to see a specialist? Will a cab pick them up?
Out of county transportation is provided when a specialist or service is not available in the county of the member’s residence. The member will be transported to the next closest provider who can render appropriate services. This requires at least three (3) business days notice.
Greyhound Bus or shuttles must be utilized for ALL out of county transports except in the following situations:
• If a member is in a wheelchair
• If a member is being discharged from the hospital
• If a member is on the Health Plan’s transplant list
• If a member has a medical condition prohibiting them from riding the bus (this requires approval from the Health Plan)
If a member states they are unable to ride the bus and is not wheelchair bound, the attending physician needs to forward the Physician Justification for Direct Transportation form to the Health Plan, who will review and either approve or deny direct transportation. A Social Worker and/or non‐medical personnel cannot compete the medical necessity letter – only the PCP/PA/CNP/Health Plan’s Case Manager. Recertification of medical necessity is required every six (6) months.
Greyhound bus tickets are ordered by MTBA’s Customer Service Representatives Monday through Friday. Members can pick up tickets on the date of travel or the day before depending on the Greyhound Bus locations and time of departure. A ticket request can be sent to Greyhound Bus no more than 10 days before departure.
MTBA will provide Greyhound transportation for the member and one (1) escort. There must be a necessity for the escort – legal guardian, interpreter, medical decisions, etc.
MTBA provides blanket transportation. This is direct transportation for members with critical medical conditions that require multiple medical appointments. Example: John Doe has End Stage Renal Disease (ESRD) and must receive dialysis treatments three times per week.
Rev 01/2013
www.ufcaz.com
UFC 1.1
Physician Justification for Direct Transportation
Date:
AHCCCS ID#:
Patient Name:
Date(s) of Service:
Location of appointment (out of County):
Practice Name:
City, Zip:
Practice Address:
Medical Justification for Direct
Transportation:
PCP information:
Practice Name:
Physician Name:
Physician’s Signature:
I hereby attest that I am this patient’s Primary Care Physician (MD, DO, PA, NP).
Fax Request to (520) 874-3434
Health Plan Internal Use Only
Approved
Rev 01/2013
Denied
Approval Expiration Date
(add to Seibel- expiration is 6
months from health plan
approval)
www.ufcaz.com
________________________________
UFC 1.2
How does a member get on the blanket transportation list? The member, provider, or facility (in this case dialysis facility) notifies the Customer Care Center and faxes medical documentation including the member’s treatment schedule. This can be faxed to Customer Care at 520.874.3434. The designated Customer Care Representative will add the member to the blanket transport list and notify MTBA. In the case of John Doe, he will be on the blanket transport list indefinitely unless he terms with the Health Plan or receives a transplant. Other blanket transportation examples:
Member has physical therapy Tuesday and Thursday at 2:00 pm from 10/14/11 through 11/9/11. Member has radiation M, Tues, W, Thur, F at 9:45 am from 10/25/11 through 11/30/11. These members will be on the blanket transport list only during the specified date range.
Transportation requirements and information for members that require extra care including wheelchair or stretcher services:
• Members may not arrange this type of travel for themselves. Wheelchair or stretcher services require approval either by UFC or a qualified medical professional from the originating facility.
• Transport will be provided by a qualifying subcontractor with the necessary equipment.
• Full‐sized, rear‐loading van with special straps and locks to secure a wheelchair or stretcher.
• Two‐person staff, driver and attendant.
• If the member has oxygen if must be self regulating.
• The member can not have MRSA or any other contagious infection transmittable by contact.
• If the member requires IV medication, a qualified medical professional must accompany the member in the back of the can. MTBA will return the medical professional to their point of origin free of charge at the end of the trip.
Rev 01/2013
www.ufcaz.com
UFC 1.3
Family & Friends Transportation Program
At The University of Arizona Health Plans we understand the important role that family and friends play in the health and wellness of our members. Nobody understands our member’s needs as well as their loved ones. The Family & Friends Program was designed to reward those who are there for our members when they need them most.
What is the Family & Friends Transportation Program?
MTBA will reimburse a member’s family member or friend at a rate of 25‐Cents per mile for providing the member’s transportation to or from any approved appointments. Anything that qualifies for routine transportation can be substituted for the Family & Friends Program.
What information is needed?
•
•
•
•
•
•
•
•
•
Member’s AHCCCS ID#
Member’s Full Name
Member’s Date of Birth
Member’s Address Member’s Phone Number Claimants Name, Address & Phone Number (If different than member)
Attending Physicians Name
Date of Service
Exact travel locations along with traveled miles (for mileage verification purposes)
How to enroll? The University of Arizona Health Plans’ Customer Care Center can provide further information on this and other programs in your area.
Customer Care Center: 1‐800‐582‐8686
Rev 01/2013
www.ufcaz.com
UFC 1.4
Rev 01/2013
www.ufcaz.com
UFC 2.0
EPSDT
(Early Periodic Screening Diagnosis and Treatment)
What is EPSDT?
E arly: Identifying the problem early – starting at birth
P eriodic: Regular visits at the age‐appropriate intervals
S creening: Performing physical, mental, developmental, dental, hearing, vision, and other screening tests to detect potential problems
D iagnosis: Diagnostic testing to follow‐up when a risk is identified
T reatment: Treating the problems found to correct or improve health conditions
Did you know you can perform an EPSDT screening during a regular office visit? You can
also bill for the office visit and the EPSDT screening. A modifier 25 code can be used if an
EPSDT visit is done in conjunction with a preventive visit.
If a child comes in because they are not feeling well and that particular child is due for an
EPSDT screening, you can perform the EPSDT screening and administer necessary
immunizations (only if the child is not running a temperature).
Who is eligible? Children from newborn to 20 years of age, who are enrolled in a Medicaid (AHCCCS) program.
Who can perform an EPSDT screening? PCP, NP, and PA
It is important that each child receives an EPSDT screening. These screenings can help identify problems early and allow you to test and treat accordingly. Every child deserves a happy, healthy life ‐ We need your help in making that happen!
If you have any questions, please call our Customer Care Center at 1‐800‐582‐8686 and ask for the EPSDT Coordinator.
Rev 01/2013
www.ufcaz.com
UFC 3.0
Quick Reference Guide‐EPSDT
How Often Should Screenings Occur?
EPSDT is the child health component of Medicaid, which is AHCCCS in Arizona.
The purpose of EPSDT is to improve the health of children by covering a
medically necessary evaluation and other medical services for members under
the age of 21. Newborns to children 20 years of age, who are enrolled in a
Medicaid (AHCCCS) program, are eligible for EPSDT.
Please note all
immunizations MUST be documented with the Arizona State Immunization
Information System (ASIIS) at www.asiis.state.az.us. Providers must also be
enrolled with Vaccines for Children (VFC) if they are caring for children.
First 15 Months of Life – 6 Visits
1st Screening: 2‐4 Days Old
4th Screening: 4 Months Old
2nd Screening: 1 Month Old
3rd Screening: 2 Months Old
After the First 9 Months of Life:
12 Months Old
24 Months Old
11‐12 Years Old
15 Months Old
3‐6 Years Old
13‐18 Years Old
18 Months Old
7‐10 Years Old
19‐20 Years Old
AHCCCS approved EPSDT Tracking Forms can be found on the AHCCCS website: http://azahcccs.gov/shared/Downloads/MedicalPolicyManual/AppendixB.pdf
Completed EPSDT forms can be faxed to 520‐874‐7184 or mailed to:
EPSDT Department
2701 East Elvira Road
Tucson, AZ 85756
Rev 01/2013
www.ufcaz.com
UFC 3.1
Quick Reference Guide‐EPSDT
Birth to 21 Years Old
WELL‐CHILD VISIT – SERVICES:
Lead Screening and Testing
• Verbal Lead Assessment: 6 MOS THRU 6 YRS
• Blood Lead Testing: 1 AND 2 YRS OF AGE
Immunization
• Up‐to‐Date per Periodicity Schedule
• MUST be documented in ASIIS
EPSDT DOCUMENTATION:
Electronic Health Records: the EPSDT portion MUST adhere to and contain all of the components found within the standardized AHCCCS approved EPSDT tracking form. A copy of the electronic medical records MUST be sent to the health plan as replacement for the current “yellow copy” that is submitted.
Ensure that ALL required data is filled in. Health plans are required to follow‐up with providers to address missing information. Common omissions: verbal lead screen, blood lead test, BMI.
Member information on submitted forms
• Date of Birth
• AHCCCS ID #
Submit copy of AHCCCS approved EPSDT form to health plan by fax 520‐874‐7184 or mail to:
EPSDT Department
2701 E. Elvira Rd.
Tucson, AZ 85756
NICU GRAD/PEDS TOOL
• NICU graduates‐birth to 8 years of age at every visit
• PEDS Tool free in‐office or online training at www.azaap.net
DENTAL
Referrals starting as early as 12 months based on results of oral health assessment, mandatory by age 3 years.
Rev 01/2013
www.ufcaz.com
UFC 3.2
EPSDT Resources
EPSDT AND THE PREGNANT WOMAN SCREENING FORM REQUIREMENTS
• Members under the age of 21 qualify for EPSDT services.
• It is important that pregnant EPSDT age members are encouraged to use their EPSDT benefits.
• Hormone levels cause teeth and gums to swell, trapping food that can lead to infections which cause preterm labor. • It is very important to refer young pregnant members to a contracted dentist.
• Your office should utilize the EPSDT Screening form for members ages, 13‐17 and 18‐
21.
• Fill out all referrals made and submit these forms to UAHP by mail or fax to 520‐874‐
7184, following the first visit with a pregnant member of EPSDT age. BEHAVIORAL HEALTH
• Behavioral health toolkits with clinical guidelines (assessment tools and algorithms) for the diagnosis of ADD/ADHD, depression, and/or anxiety disorders available at www.ufcaz.com under provider educational resources. • Identify need for evaluation on AHCCCS approved EPSDT form so we can assist in the collaboration and follow‐up with BH providers.
CRS
• The Children’s Rehabilitative Services program provides medical care and support services to AHCCCS‐enrolled children and youth who have certain chronic or disabling conditions. Children may be referred for potential enrollment in CRS by a parent, the child’s PCP or specialist provider, or the health plan. • Once a child is accepted into the CRS program for an eligible condition, treatment for the eligible condition is coordinated through the CRS network of providers.
• The child continues to receive all preventative and primary care services from their PCP.
• UFC reviews all requests for EPSDT services and is required to refer to CRS as appropriate, if not already done so by the requesting provider.
OBESITY GUIDELINES
• Information related to referrals and treatment codes available at www.ufcaz.com under provider educational resources/maternal‐child health.
• Other clinical practice guidelines and resources available at www.aap.org/healthtopics/overweight.cfm.
Rev 01/2013
www.ufcaz.com
UFC 3.3
EPSDT Community Resources
The March of Dimes Product Catalog
Products reflect more than 70 years of experience in promoting healthy behaviors that lead to
healthy pregnancies and healthy babies and providing support to parents when a baby is born
too soon or when there's a loss. Our goal is to provide businesses and health care professionals
with the consumer and continuing education products they need to improve the health of
mothers and babies. http://www.marchofdimes.com/catalog/
WIC
Arizona Women, Infants, & Children (WIC) is a federally funded program providing nutritious
foods, nutrition and breastfeeding education, and referrals. WIC serves pregnant, breastfeeding,
and postpartum women, and infants and children under age five who meet WIC eligibility
guidelines. www.AZWIC.GOV - 1-800-252-5942
Arizona Pregnancy and Postpartum Depression Warmline:
When you call the warmline you will leave a message and a trained volunteer who will return
your call as soon as possible.
The warmline volunteers offer support, encouragement,
resources, and referrals within your community in the state of Arizona.
http://postpartumcouples.com ‐ (888) 434‐MOMS
Arizona Smokers' Helpline
The Arizona Smokers' Helpline (ASHLine) provides free services in both English and Spanish.
Telephone quit coaches are highly-trained professionals, many of whom are former tobacco
users, who act as a "personal trainer" for quitting tobacco. A coach will help set goals, work
toward a quit date, and develop a personal plan for success. http://www.ashline.org/ 1-800-556-6222
Nurse Family Partnership
Nurse-Family Partnership is a free, voluntary program that partners first-time moms with nurse
home visitors. A specially trained nurse will visit the first time mom throughout their pregnancy
and until the baby turns two years old.
http://www.nursefamilypartnership.org/locations/Arizona
South Phoenix NFP
4041 N. Central Ave
Phoenix, AZ 85012 602‐224‐1740
Rev 01/2013
Tucson Nurse‐Family Partnership
1101 N 4th Ave
Tucson, AZ 85705 520‐624‐5600 x 506
www.ufcaz.com
UFC 3.4
EPSDT Community Resources (cont.)
Birth to Five Helpline
Monday – Friday 8am ‐8pm
Free parenting advice and resources for families.
The Birth to Five Helpline is available toll‐free at 1‐877‐705‐KIDS.
Arizona Coalition Against Domestic Violence
If you are scared and you need to talk, call the National Domestic Violence Hotline at: 1‐800‐799‐SAFE (7233) or 1‐800‐787‐3224 (TTY) Contact the Arizona Coalition Against Domestic Violence at: 602‐279‐2900 or 1‐800‐782‐6400.
http://azcadv.org/
Health Start
The Health Start Program utilizes community health workers to provide education, support,
and advocacy services to pregnant/postpartum women and their families in targeted
communities across the state. What are the goals of the program?
•To prevent low birth weight in infants
•Increase care for high‐risk pregnant women
•To ensure that every program child is appropriately immunized and has a medical home.
•To provide health education to pregnant/postpartum women and their families on topics
ranging from prenatal care, parenting, preconception/interconception education, breast
feeding and well childcare to safety, and other issues
•To screen for early identification of developmental delays and make appropriate referrals
for treatment.
Maricopa County ‐ Phone: (602) 364‐1421
Nogales ‐ Phone: (520) 375‐6050
www.azdhs.gov/phs/owch/healthstart.htm
Teen Outreach Pregnancy Services (TOPS)
To provide teen specific pregnancy, childbirth, and parenting educational support so teens
and their families can experience a positive outcome. The pregnant teen receives 20 hours of
health education and mentoring from a Registered Nurse and a Case Manager. Each teen
receives a visit by their case manager to assess individual risks and needs. Also, goals are
discussed, as are program expectations and commitments. If needed, the teen receives
assistance in obtaining obstetric health care, as well as referrals to other agencies when
needed. http://www.teenoutreachaz.org/contact.html In the Tucson Area ‐ Toll Free: 1‐877‐
882‐2881. Contact us in Maricopa County ‐ TOPS East Valley: Phone: 480‐668‐8800 ‐ TOPS
West Valley: Phone: 623‐334‐1501
Rev 01/2013
www.ufcaz.com
UFC 3.5
EPSDT Prior Authorization
Most EPSDT screening, diagnostic, and rehabilitation therapies services by Contracted
Providers Do Not Require Prior Authorization (PA). This includes office visits to specialists,
evaluations, and physical, occupational, and speech therapies.
Exceptions:
•Chiropractic
•Genetics
•Neuropsychological
•Pain Management
•Podiatry
•ALL Out‐of‐Network Providers
EPSDT Diagnostic and Treatment Services by all providers that Require Prior Authorization (PA):
•Allergy Testing and Immunotherapy
•Chiropractic
•Durable Medical Equipment (over $300)
•Elective Surgeries and Hospital Admissions (with the exception of tonsillectomy and myringotomy with tubes‐no PA required)
•Genetic testing
•Home Health
•Incontinence briefs (ages 3‐20)
•MRI/MRA
•Neuropsychological Services
•Nutritional Supplements/Therapies (Certif. of Medical Necessity)
•Pain Management
•Periodontic services, oral surgery, orthodontics, and/or any dental treatment services totaling over $750
•Personal Care Services
•Podiatry
•Transplants
Prior Authorization grid and list of contracted Providers can be found at www.ufcaz.com
Rev 01/2013
www.ufcaz.com
UFC 3.6
Translation Services
Translation Services for The University of Arizona Health Plans
1
Call The University of Arizona Health Plans – Maricopa Health Plan Customer Care Center
at: (520) 874‐5290 or 1 (800) 582‐8686
2
Provide the representative with the member’s AHCCCS ID number and the nature of the
translating services required
3
You will be placed on hold while the representative connects you with the translation services
Important Translation Tips
Working with an Interpreter – Give the Interpreter specific questions to relay. Group your thoughts
or questions to help conversation flow quickly.
Length of call – Expect interpreted comments to run a bit longer than English phrases. Interpreters
convey meaning‐for‐meaning, not word‐for‐word. Concepts familiar to English speakers often require
explanation or elaboration in other languages and cultures.
Interpreter identification – Translation Services Interpreters identify themselves by first name only.
For reasons of confidentiality, they do not divulge either their full names or phone numbers.
Document translation – Maricopa Health Plan is responsible for translating written documents for our
members. If you have a written document that needs to be translated for an MHP member, call the
Customer Care Center at (520) 874‐5290 or 1(800) 582‐8686.
Rev 01/2013
www.ufcaz.com
UFC 4.0
Important Numbers
(University Family Care)
Department
Telephone
Fax Behavioral Health
520‐874‐5290 or 800‐582‐8686
520‐874‐3411
Case Management
877‐874‐3933
520‐874‐5290 or 800‐582‐8686 or email: ClaimsInquiry‐
520‐874‐5750
Claims Customer Service
520‐874‐7046
[email protected]
Contracting
602‐344‐8348
602‐344‐8358
Provider Relations
520‐874‐5523
520‐874‐7144
Credentialing
520‐874‐2483 or email:
[email protected]
520‐874‐7027
Customer Care
520‐874‐5290 or 800‐582‐8686
EPSDT Coordinator
520‐874‐5236
Grievance & Appeals
520‐874‐5290 or 800‐582‐8686
520‐874‐3462 or 866‐465‐8340
520‐874‐5230
520‐874‐3420
Hospital Admission Notification
Maternal Child Health Maternity
Maternal Child Health Pediatric
520‐874‐3434
877‐874‐3933
877‐874‐3933
520‐874‐7056
Member Eligibility
520‐874‐5290 or 800‐582‐8686
520‐874‐3434
Pharmacy
520‐874‐5290 or 800‐582‐8686
866‐349‐0338
Prior Authorization
520‐874‐5290 or 800‐582‐8686
520‐874‐3418
Quality Management
520‐874‐2760
Translation Services
520‐874‐5290 or 800‐582‐8686
Transportation
Dialysis: 520‐874‐5225
All other transport: 800‐582‐8686
Utilization Management
866‐466‐8777
Rev 01/2013
www.ufcaz.com
UFC 5.0
Important Resources
Arizona Regional Extension Center
Electronic Health Records
Telephone: 602‐688‐7200
Fax: 602‐343‐5191
Email: [email protected]
www.azhec.org
Arizona Smokers’ Helpline
Telephone: 800‐55‐66‐222
Fax: 866‐897‐1263
www.ashline.org
Arizona Early Intervention Program (AzEIP)
Telephone: 602‐532‐9960 or 888‐439‐5609
Fax: 602‐200‐9820
www.azdes.gov/azeip
Cultural Competency (Ask Me 3 Program)
http://www.npsf.org/askme3/
Arizona Women, Infants & Children (WIC)
http://www.azwic.gov/
Rev 01/2013
www.ufcaz.com
UFC 6.0

Provider Resource Guide - The University of Arizona Health Plans

Transcription

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