NEBRASKA Spring AAHAM
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What’s New in
Nebraska
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UHC0048_061009
TODAY’S AGENDA INCLUDES:
ICD-10
Optum Cloud
Advance Notification Contact Info
Enhanced HIPAA Edits
PATH Member Rewards
Advocate Hotline
United Healthcare Military &
Veterans/TRICARE
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UHC0048_061009
ICD-10 On Hold
To support our providers during this transition, UnitedHealthcare
offers the following tools at UnitedHealthcareOnline.com to
assist you in becoming ICD-10 compliant for 2015:
•
ICD-10 Education - on-demand educational resources
designed to provide general information regarding ICD-10
and the implementation process.
•
ICD-10 Tools - in collaboration with the American Academy
of Professional Coders (AAPC), the largest coding organization in
the country, we have created a suite of tools including ICD10 code selection decision trees and detailed clinical
documentation improvement webinars.
•
Submit questions to [email protected]. Please
allow
up to15 business days for a response.
Additional resources can be found on cms.gov/ICD10.
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OPTUM CLOUD DASHBOARD
Optum Cloud Dashboard - Is a cloud-based website that
has new features and functionality which allows providers
to submit claim reconsideration requests electronically with
attachments.
New Enhancements:
• The Eligibility & Benefits center- check eligibility, get in and out
of network benefit info, review coordination of benefits info and
review copay and coinsurance
• Claims Management- flag claims for automatic review and view
line level and claim level remark codes
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ADVANCE NOTIFICATION LIST
• Advance Notification List - The Advance
Notification list of procedure codes has moved
online for your convenience at UnitedHealthcare
Online.com Clinician Resources > Advance &
Admission Notification Requirements.
Confidential property of UnitedHealth Group. Do not distribute or reproduce without the express permission of UnitedHealth Group.
Enhanced HIPAA Edits to be Applied to
Claim Submissions
•Effective April 23, 2014, UnitedHealthcare will apply an enhanced level of
HIPAA edits to professional (837p) and institutional (837i) claims
submitted electronically to most UnitedHealthcare and affiliate payer IDs.*
•Because the new edits will be applied on a pre-adjudication basis, an
increase in the number of claim rejections may occur. This will enable you to
identify and correct rejected information prior to the claim’s acceptance into
our adjudication system for processing.
•The benefit will be fewer denied claims and less interruption to revenue
streams.
•The primary impact to you will come from edits that will validate code sets
(such as diagnosis, procedure modifier and national drug codes) at a preadjudication level.
The complete list of enhanced edits has been distributed to clearinghouses
and software vendors.
Confidential property of UnitedHealth Group. Do not distribute or reproduce without the express permission of UnitedHealth Group.
Confidential property of UnitedHealth Group. Do not distribute or reproduce without the express permission of UnitedHealth Group.
Confidential property of UnitedHealth Group. Do not distribute or reproduce without the express permission of UnitedHealth Group.
Confidential property of UnitedHealth Group. Do not distribute or reproduce without the express permission of UnitedHealth Group.
Confidential property of UnitedHealth Group. Do not distribute or reproduce without the express permission of UnitedHealth Group.
Contact Us
[email protected]
UnitedHealthcareonline.com
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UHC0048_061009
TRICARE Updates
UnitedHealthcare Military & Veterans
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UHC0048_061009
Updated Provider Handbook
The UnitedHealthcare Military & Veterans TRICARE Provider Handbook
has been updated and the new edition is available online at
www.uhcmilitarywest.com.
The changes in the Handbook will be effective on July 1, 2014 for currently
contracted providers and immediately for providers newly contracted
on or after April 1, 2014.
A summary list of changes to the Handbook has also been posted for your
convenience.
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UHC0048_061009
Submit Referrals/Authorization Online
•To Submit a Referral or
Authorization Request:
•Log in to your UHCMilitaryWest.com
account.**
•From the authenticated Provider Home
Page, click on the Submit Referral or
Authorization Request link.
•Updates include selecting Episodes of Care
and adding attachments
•** Only UnitedHealthcare Military & Veterans in-
network, and TRICARE-contracted providers with
a UHCMilitaryWest.com account, can submit
referrals or authorizations online.
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Prior Authorization Changes
•Changes to the PAL:
• Durable Medical Equipment over $150
• Orthotics
• Prosthetics
• Questionable Services List
•List of Codes Removed:
• The list of codes requiring Prior Authorization has been removed as it was not a
comprehensive list
• Please utilize the narrative Prior Authorization List and also reference the of
Questionable Services List to determine what requires Prior Authorization
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UHC0048_061009
DME Authorization Requirements
Pricing Criteria
Authorization needed for all Durable Medical Equipment (DME) greater than
$150.00
DME Tip Sheet:
•A detailed DME tip sheet can be found on www.uhcmilitarywest.com – Providers >
Claims > Durable Medical Equipment Claims Filing Tip Sheet
REQUIRED ITEMS which must be on all DME authorization requests:
•patient’s name
•procedure code(s)
•diagnosis code(s)
•beginning and ending dates equipment is needed
•physician’s statement of prognosis
•valid physician signature – not certified NP or PA
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DME Authorization Requirements
Authorizations satisfy Certification of Medical Necessity (CMN) requirements
if DME item costs $150 - $2000
•Exceptions: five (5) items require additional clinical information through submission of the
appropriate CMS form http://www.cms.gov/Medicare/CMS-Forms/CMS-Forms/CMS-FormsList.html
Proof of Medical Necessity is required for authorization if DME item costs
over $2000
•Be sure to include:
•
“required item list” (patient name, diagnosis codes, procedure codes, etc.) and
•
supporting clinical information justifying the need
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DME Upgrades
DME upgrade is covered when medically necessary:
•Item otherwise meets the DME benefit requirement
•Medically necessary
•Prescription specifically states the medical reason why upgrade is necessary
(ex: the beneficiary does not have the physical strength or balance required to lift a standard
walker and, therefore, one with wheels is required)
DME upgrade for deluxe, luxury, or immaterial feature device when
beneficiary preference (not medically necessary):
•TRICARE-allowed amount for base model may be applied to the upgraded equipment if item
otherwise meets the DME benefit requirement
•The beneficiary will be solely responsible for the difference between the base model (standard
equipment) allowed amount and provider’s billed charges.
•Upgrade must be within the range of services that are appropriate for the medical condition
When a beneficiary prefers to upgrade:
•Provider may collect charges that exceed the cost the government would pay for the standard
equipment only when:
• Beneficiary given written notice the upgrade has been (or may be) denied and
• Beneficiary agrees in writing to be financially liable for the difference between
charges for the upgraded item and the charges for the standard item.
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PGBA’s Website: myTRICARE.com
myTRICARE.com Functionality
•Verify Eligibility (including PCM, program, deductible, and OHI information)
•Check Referral/Authorization Status
•Check claim status
•View and print remits
•Claim Data Reports
•AskUs confidential questions online
•Validate provider file demographics
•Validate/submit NPI numbers
•Submit your claims via XPressClaim
•Unlimited number of users allowed to register per account
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myTRICARE.com AskUs Feature
No need to telephone PGBA; ask questions online
Receive a prompt reply in your personal, secure myTRICARE
mailbox
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Thank You For Your Participation!
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Questions
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UHC0048_061009