A newsletter for Providers associated
with Maricopa Health Plan,
University Physicians Healthcare Group &
Maricopa Care Advantage
intouch
Winter 2010/2011
inside
this issue:
page 3
Behavioral Health
Updates and Assistance
page 5
Helping to Avoid
the Spread of Flu
page 6-7
How to Read UPHP’s
Explanation of Benefits
page 8
Ensuring
Reimbursement for
Laboratory Services
2 011
Medicare SNP
B E N E F I T S
Our Medicare SNP members will be receiving
their 2011 Benefit Information shortly. Many
important features of our benefits remain the
same for 2011:
• Medicare A and B services continue to be
covered, including coordination of AHCCCS
benefits under the current guidelines
• $0 copayment for preventive services
• Annual well exam
• UPCA and MCA continue to provide
personalized support to our members via
our Ultimate Care Model, going above and
beyond to support our member’s needs and
help you in managing their health. Some of
these features are:
– A Case Management call to new members
within the first 30 days
– A Model of Care and Individual Care Plans
that address each member’s unique needs
– A Referral program that allows you to
notify us of case management and other
needs
Some changes will occur in 2011, including
Dental, Hearing and Vision.
See page 2 for benefits changes
2011
Continued from page 1
Medicare SNP Benefits
Allowable Codes Description
2010
Benefit Limits
2011 Benefit Limits
Every six months
Maricopa/Pima – One per year
Oral Exams
D0120
or
D0150
Periodic oral evaluation,
established patient
Cochise/Pinal/Santa Cruz –
Every six months
Comprehensive oral evaluation –
new or established patient
Prophylaxis (cleanings)
D1110
Prophylaxis – adult
Every six months
Cochise/Pinal/Santa Cruz –
Every six months
or
D1120
Maricopa/Pima – One per year
Prophylaxis – child
Dental X-rays
D0210
or
D0330
Once a year
All Counties – One per year
Topical application of fluoride
Once a year
(prophylaxis not included) – child
All Counties – One per year
Intraoral – complete series
(including bitewings)
Panoramic Film
Fluoride Treatment
D1203
or
D1204
Topical application of fluoride
(prophylaxis not included) – adult
Hearing Tests
Once a year
All Counties – No Benefit
One per year,
every three years –
$800 per ear,
$1600 limit
All Counties – No Benefit
Determination of refractive state
Once a year
All Counties – One per year
V2020-V2499
Various glasses frames and/or lens
$150 every two years
Maricopa – $75 every two years
or
or
Pima – $100 every two years
V2500-V2599
Various contact lens
Cochise/Pinal/Santa Cruz –
$100 every two years
92551, 92559-92560,
92590-92595, 92597,
V5008-V5011
Comprehensive audiometry
threshold evaluation and speech
recognition
Routine Hearing Aids
V5014-V5298, V5336 Hearing aids
Routine Eye Exam
92002-92014, 92015,
99172-99173
Glasses or Contact Lens
Page 2
Behavioral
Health UPDATES AND ASSISTANCE
Behavioral Health Benefit Changes October 1, 2010
Effective October 1, 2010 AHCCCS will automatically assign all
AHCCCS Health Plan members into a Regional Behavioral Health
Authority (RBHA) or Tribal RBHA (TRBHA). Members will be
assigned based on the zip code in which they reside; the T/RBHA
will be identified on the member’s AHCCCS ID card. Although
everyone will be assigned to a T/RBHA, some members will be
actively receiving behavioral health services and others will not.
MHP will continue to provide assistance with coordination of care
between the RBHA and PCP, and to assist members with receiving
the behavioral health care they need. Do you have a member in
need of behavioral health assistance? Members can contact our
Customer Care Center and speak with a representative, or your
office can contact our case management department to make a
referral through the Customer Care Center at 800-582-8686.
Need a Brief, One-Time Psychiatric Consultation
for One of Your Patients?
Contact our Behavioral Health Coordinator at (520) 874-5214 for
assistance with arranging a one-time psychiatric consultation for
your member being treated for depression, anxiety, or ADD /
ADHD. A RBHA psychiatrist can assist you in choosing a
medication or identifying other options for the member.
Behavioral Health Toolkits Located on our Website
Do you ever wish you had a screening tool for treating MHP
members with behavioral health diagnoses? We can help!
Check out the toolkits posted on our website under the Provider
Educational Resources button, Behavioral Health Toolkits
link. Each Toolkit contains screening tools, an algorithm for
when to treat the member, when to refer to RBHA, and a list
of psychotropic medication universally available through all
AHCCCS health plans.
MHP requires the use of a screening tool of your choice when
diagnosing and treating members for anxiety, depression, or
ADD / ADHD.
Transitioning of Members To
or From the RBHA
When you learn that a member you are
treating for a behavioral health diagnosis
has psychiatric co-morbidities, the member
makes a suicide attempt, or has an inpatient
psychiatric hospitalization, their behavioral
health care should be transitioned to RBHA
for specialty care. On the other hand,
members treated at RBHA for depression,
anxiety or ADD / ADHD can be transitioned
back to your care (if you agree) when they
have been stable for at least six months.
The Health Plan will cover the same
medication at the same dosage for members
transitioning back to the PCP with anxiety,
depression or ADD / ADHD. Contact our
Behavioral Health Coordinator for questions
about transitioning members either way:
(520) 874-5214.
Page 3
H E D I S
Care for
®
C o r n e r
Older
Adults
HEDIS® Specifications
for Medical Record
Document
University Physicians Health Plan (UPHP) is
committed to providing quality care to our
older adult members enrolled in the Medicare
Advantage and Special Needs Plans. Aspects of
care provided to our members are measured
through the Healthcare Effectiveness
Data and Information Set (HEDIS®), a set
of standardized performance measures
developed by the National Committee for
Quality Assurance (NCQA). Annual HEDIS®
rates for Medicare Advantage plans are
publicly reported on NCQA and Centers
for Medicare and Medicaid (CMS) websites
and provide comparative information to the
public regarding health plan performance.
®
The “HEDIS Corner” will provide
information about performance measures,
documentation tips and health plan
interventions directed at improving the
annual HEDIS® rates for UPHP.
This Issue: Documentation Tips for the
“Care for Older Adults” Measure
The measure “Care for Older Adults” includes
four indicators for services provided to adults
age 66 years and older. The measure-specific
criteria found in the NCQA Publication
“HEDIS® 2010 Technical Specifications,
Volume 2” provide the basis for the medical
record documentation that is reviewed by
health plan clinical staff when conducting
HEDIS® audits.1
1
Resource: HEDIS 2010 Technical Specifications
(Volume 2); NCQA Publications
Page 4
1
Advance Care Planning
2
Medication Review
3
Functional Status Assessment
Copies of advance directives, living wills, powers of attorney,
actionable medical orders, or documents designating a
surrogate decision maker that are present in the medical record
serve as evidence of advance care planning. Progress notes detailing
advance care planning discussions between a provider and a patient
also fulfill documentation requirements for this measure.
Medical record documentation must include a current
medication list and evidence of at least one comprehensive
medication review by a prescribing practitioner or clinical
pharmacist during the year. If the patient is not taking medications,
a dated progress note reflecting that the patient is not taking any
medications is sufficient for compliance with this measure.
Medical record documentation for this indicator may
include:
• Assessment of the patient’s cognitive status, ambulatory status,
sensory ability, functional independence and social activities, or
• Notes detailing any loss of independent performance, such
as bathing, dressing, eating, transferring, urinary control and
walking, or results of a standardized functional status assessment
tool.
4
Pain Screening
Medical record documentation for this indicator includes
at least one comprehensive pain screening or a pain
management plan. Application of standardized pain screening
tools, such as the Multidimensional Pain Inventory or Faces Pain
Scale, is acceptable. Pain management plans may include notations
of no pain intervention with rationale, plans for pain treatment
and pain reassessment. Pain screening that is limited to a single
condition; event or body system does not meet criteria for a
comprehensive evaluation.
Proper documentation allows UPHP to show compliance with
care provided to our older adult members and paves the way for
successful public reporting for our Medicare Advantage Plan.
Health Care Providers Play an Important Role
in Helping to Avoid the Spread of Flu
Whitney Anderson, CIGNA
An average of 114,000 people are hospitalized for flu-related
complications and 36,000 Americans die each year from complications
of the flu, according to the Centers for Disease Control and Prevention
(CDC). Each year, about one in every 1,000 children younger than fiveyears old will be hospitalized because of the flu, and last year over 150
children in the United States died from complications of the flu.
But despite these statistics and the fact that health care workers are
recommended to get a flu shot, only 38 percent of all health care
workers get the vaccine each year, according to Infection Control Today.
Physicians and nurses are among those health care workers not being
vaccinated, which increases the likelihood of transmitting the disease to
others around them.
A press release issued by the American Medical Association on September
23, 2004, said a recent survey had been conducted and determined
almost 100 percent of the patients who received the flu shot got one
because their doctor had advised them to get a flu shot.
Some of the complications caused by the flu include bacterial
pneumonia, dehydration and worsening of a chronic medical condition
such as heart failure, asthma or diabetes. Therefore, a flu shot is
recommended for the following people who have an increased risk for
serious complications from the flu:
• adults 65-years old and older, pregnant women
• individuals with chronic illness
• health care workers
• residents of long-term health care facilities
• infants six to 23 months old
Some tips to avoid the flu this season, which is typically December
through March:
• Avoid close contact with people who are sick with the flu;
• Wash hands often with soap and hot water;
• Eat a balanced diet including fruits and vegetables;
• Get plenty of sleep – a minimum of between seven and eight hours a
night;
• Avoid touching your eyes, nose or mouth if you did not wash your
hands first;
• Avoid smoking as it can prevent airways from clearing bacteria and
viruses; and
• Get immunized.
Page 5
ATTENTION
Hospitals
Skilled Nursing
Facilities
&
Please be aware
that inpatient notifications must be faxed to
Maricopa Health Plan (MHP) within 24 hours
of admission. If MHP is not notified within
24 hours your claim may be denied.
Important reminder
As a registered provider with the AHCCCS Administration,
(Arizona’s Medicaid Program), you are obligated under
42 C.F.R. §1001.1901(b), to screen all employees,
contractors, and/or subcontractors to determine whether
any of them have been excluded from participation in
Federal health care programs. You can search the HHS-OIG
website, at no cost, by the names of any individuals or
entities. The database is called LEIE, and can be accessed at
http://www.oig.hhs.gov/fraud/exclusions.asp
Podiatry
Due to the recent AHCCCS benefit changes
with Podiatry; our adult members (over the
age of 21) are in need of physicians who
can provide Podiatry services. If you are a
physician that performs Podiatry services,
please notify your provider representative. If
there are other services that you provide that
you believe we may not be aware of please let
us know. We look forward to the opportunity
to join efforts in serving our members.
Page 6
How to Read UPHP’s
Explanation
of Benefits
At University Physicians Health Plans we are
committed to providing the highest level of
service to our providers and members. Some
providers have requested more information
on how to read our Explanation of Benefits
(EOB) form. To fulfill this request, University
Physicians Health Plans has created an EOB
rubric that explains all facets of our EOB
and what they mean to you; the provider.
Knowing how to read the EOB can be critical
to proper billing practices and posting of
payments to your accounts receivable.
Below you will find a detailed explanation
of our EOB and all of the information that it
offers:
REMITTANCE ADVICE
Section 1
1. Date of remittance advice
2. Name of Plan/Program member is
enrolled with
3. Internal number assigned to provider
4. Name/address of service provider
Section 2
5.
6.
7.
8.
9.
10.
11.
Member name
Member identification number
Referral/Authorization number
Referral/Authorization type
From - To service dates
Claim number
Date payment posted to Health Plans
accounts payable
12. Service provider account number
13. Identified statistical (capitated or global)
from non-statistical (fee-for-service) claim
Section 3 Line item detail
14. Procedure code
15. Disposition reason (denial, contract
adjustment, prompt pay discounts, etc.)
16. Description of procedure code
17. From - To service dates
18. Total billed amount per service line
19. Amount rejected per service line
20. Member deductible amount per service
line
21. Member co-pay amount per service line
22. Amount approved for payment per
service line
23. Amount withheld (for contracts
with a withhold provision)
24. Net amount of payment per
service line
25. Breakdown of adjudication
(total lines for entire claim appear
* claims totals *)
26. Total claim for member
27. Total amount billed for all service
lines
28. Total amount rejected for all
service lines
29. Total amount applied to member
deductibles for all service lines
30. Total amount applied to member
co-pays for all service lines
31. Total amount approved for
payment to all service lines
32. Total amount withheld for all
service lines
33. Net amount for claims for all
service lines
Section 4 RA & Claims Totals
Section 5 Vendor Summary
34. Totals for EOB
35. Total amount billed for entire
EOB
36. Total amount rejected for entire
EOB
37. Total amount applied to member
deductibles for entire EOB
38. Total amount applied to member
co-pays for entire EOB
39. Total amount approved for
payment for entire EOB
40. Total amount withheld for entire
EOB
41. Net amount for claims for entire
EOB
42. Totals for EOB
43. Total amount billed for entire
EOB
44. Total amount rejected for entire
EOB
45. Total amount applied to member
deductibles for entire EOB
46. Total amount applied to member
co-pays for entire EOB
47. Total amount approved for
payment for entire EOB
48. Total amount withheld for entire
EOB
49. Net amount for claims for entire
EOB
If you have any questions, please call 800-582-8686.
Page 7
Ensuring Reimbursement for
Laboratory Services
All insurance carriers, from
government sponsored payors to
commercial payors, only pay for
those medical services that are
covered, reasonable, and necessary
for each patient based on his/her
signs, symptoms and conditions as
evaluated and managed by his/her
treating physician. The physician
is responsible for determining the
medical necessity of any laboratory
services that may be needed to
diagnose or treat a patient. Missing
or incorrect ICD-9 diagnosis
codes, which establish the medical
necessity of the laboratory tests
ordered, are a common reason for
the denial of reimbursement for
many laboratory tests.
For example, a patient may visit
his/her physician for a routine well
visit and during the visit present
symptoms that require diagnostic
laboratory testing to determine the
cause of the symptoms. Frequently,
the physician only includes ICD9 diagnosis codes on the test
requisition reflecting the routine
well visit and fails to include the
correct ICD-9 diagnosis codes
that indicate the signs, symptoms
and conditions that the patient
is presenting and which requires
laboratory tests to diagnose the
medical problem. This results in a
denial of the claim because medical
necessity for the laboratory tests
is not properly established and
the patient is then responsible
for paying for the non-covered
laboratory tests.
Therefore, it is important for
each physician to choose the
ICD-9 diagnosis codes that most
accurately reflect the patient’s
symptoms to support the medical
necessity of any laboratory tests
ordered. ICD-9 diagnosis codes
must be included on the laboratory
test requisition or order submitted
by the physician to the laboratory
and must be documented in the
physician’s medical record to
confirm that the physician has
determined the medical necessity of
each ordered laboratory test.
It has come to our attention
there are
laboratories in the community promoting their services to our providers.
Maricopa Health Plan (MHP) is only contracted with Laboratory
Corporation of America, Medical Diagnostic Laboratory, and Sonora Quest
Laboratories. If you receive information from any other labs, you should
not use them as a part of MHP. If any changes are made to the MHP
Laboratory network we will notify our providers.
Page 8
Guidelines for
University Physicians Health Plans, as
directed by AHCCCS, uses the following
HEDIS® specifications to measure
performance on cervical cancer screening:
Cervical Cancer
Screening
• The percentage of women, who:
– were ages 21 through 64 years at the
end of the measurement year,
– were continuously enrolled with one
Contractor during the measurement
year,
– had no more than one break in
enrollment, not exceeding 31 days,
and
– had one or more Pap tests during the
measurement year or the two years
prior to the measurement year.
The U.S. Preventive Services Task Force
(USPSTF) has also published guidelines
for cervical cancer screening, along with
USPSTF, the American Cancer Society
and the American College of Obstetrics
and Gynecology. These screening
recommendations are based on the
conclusion by expert panels that most
women with an established history of
cervical health have no better outcomes
from being screened annually than having
a test every three years.
USPSTF recommends:
• Raise the age to begin screening to
within 3 years of the start of sexual
activity or age 21, whichever comes first.
• Screening should be done at least every
3 years in women with a cervix.
• Routine Pap screening for women
who have had a total hysterectomy for
benign disease is not recommended.
• Discontinue routine screening at age
65 in women who have had adequate
recent screening with normal Pap smears
and without risk factors
• Evidence is insufficient to recommend
for or against use of new technologies
like liquid based cytology tests and HPV
testing as primary screening.
American Cancer Society adds:
• Screen yearly until age 30 before lengthening the interval to
every three years.
• Liquid-based cytology tests are endorsed.
• Discontinue screening at age 70 if have had at least three normal
tests and no abnormal results in the last 10 years.
American College of Obstetrics and Gynecology differences:
• Start screening a few years after the start of sexual activity.
• Screen yearly until three normal Pap tests, then the interval can
be lengthened to every three years and discontinued at age 65 in
women with a negative history.
• Yearly pelvic exams with visual inspection of the vulva and
vagina are still indicated, as is screening for sexually transmitted
illness for women at risk.
Page 9
HCC, Documentation TIPS
Clinical documentation for
coding purposes has reached
a new level of importance
as providers work to obtain
data for quality measures
& to produce one complete
and accurate chart for RADV
audits.
To achieve positive
results, here are a few
documentation tips to
follow:
• Remember the coding
golden rule, if it isn’t
documented, it can’t be
coded.
• Document ALL conditions
established upon
admission & throughout
the stay.
• Be sure to document those
CHRONIC conditions
so the SEVERITY of the
illness can be captured.
Condition specific
tips include:
Acute Myocardial
Infarction
• Document if the MI is
NSTEMI or STEMI.
• Document any
arrhythmias &
associated treatment.
• Document old MI’S that
happened in the past.
Chest pain/angina
• If it’s angina, specify
whether it’s stable,
unstable or an acute MI,
acute pericarditis etc.
• Document any
contributing conditions
such as GERD, gall
bladder etc.
• Document the primary
source of angina eg:
CAD, pulmonary artery
hypertension etc.
Page 10
New Provider
Additions
Malignancies
• Document the primary
source of the malignancy &
whether that primary source
is STILL being treated or
has been treated and is no
longer present. Do not use
the term “history of” if the
malignancy is still present.
Only use this term if the
primary source is totally
gone.
• Document a malignancy as
a malignancy if a scan or
x-ray confirms it. “Mass” is
not “cancer,” “Tumor” is not
“cancer.”
* Document if there is any
metastasis and to which body
part is affected.
Alcohol/substance use/abuse
• Specify whether the patient
has a history of alcohol
problems, whether this is a
case of periodic or episodic
abuse or whether the patient
is alcohol dependent.
• Document if the patient is
an occasional abuser or is
dependant on alcohol or
illegal or controlled drugs.
• Document whether the
patient suffers from
substance abuse & name the
substance. Writing (+) coc or
(+) barb or (-) ETOH means
nothing. Coding staff may
not apply codes from these
notes.
Remember, specific
documentation is vital to
painting the true clinical
picture of each member. If
you have any questions, please
see the clinical coders in your
organization. Working together
we all can improve clinical
documentation, capture severity
of each condition and identify
our member’s needs.
Maricopa Health Plan’s Network
Development Department has made
many additions to our provider network
this quarter. Notable additions are:
• Home Health Services
– All N One Home Health Agency
– Assisteo Home Health
– BrightStar of Greater Scottsdale
– Crdentia Corporation
– Focus Care of Arizona
– Head to Toe Therapy
• Arizona Medical Infusion –
This new vendor provides BiPAP,
CPAP, Enteral Nutrition, Nebulizers,
Ostomy Supplies, Oxygen, Urological
Supplies, Wheelchairs and Wound
Care Supplies.
• McCleve Orthotics & Prosthetics –
Prosthetics & Orthotics
• MedAssure – This new vendor
provides Wheelchairs, Hospital beds,
Lifts & Slings, Mobility Products,
Bathroom Safety Products, Respiratory
Products, and Bariatric Products.
• Sizewise Rentals – This new vendor
provides Bariatric Ancillary items,
Bariatric Beds and Hospital Beds.
• Valley Respiratory Services –
This new vendor provides Respiratory
Supplies.
• Stand Up MRI of Arizona –
Radiology
• Arizona Surgical Specialists
Center – Ambulatory Surgery Center
• Outpatient Rehabilitation
– Integrated Physical Therapy
– Oakeson Physical Therapy
– STI Physical Therapy
For a complete listing of new and
existing providers, please access our web
page at www.mhpaz.com and click on
Find a Doctor/Pharmacy. Or you
can contact our Customer Care Center
at 1-800-582-8686.
FRAUD
&
FRAUD is defined by Federal law (42 CFR 455.2) as
“an intentional deception or misrepresentation made by a
person with the knowledge that the deception could result
in some unauthorized benefit to himself or some other
person. It includes any act that constitutes fraud under
applicable Federal or State law.”
ABUSE is defined by Federal law (42 CFR 455.2) as
“provider practices that are inconsistent with sound fiscal,
business, or medical practices, and result in an unnecessary
cost to the Medicaid program, 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 cost
to the Medicaid program.”
Examples of Provider Fraud & Abuse:
• Falsifying Claims/Encounters that include the following
items:
– Alteration of a claim
– Incorrect coding
– Double billing
– False data submitted
• Administrative/Financial actions that include the
following items:
– Kickbacks
– Falsifying credentials
– Fraudulent enrollment practices
– Fraudulent Third Party Liability (TPL) Reporting
ABUSE
• Falsifying Services that include the following
items:
– Billing for Services / Supplies Not Provided
– Misrepresentation of Services / Supplies
– Substitution of Services
Office of Inspector General at AHCCCS has
now uploaded their 2010 Fraud and Abuse
Presentation.
You can find this presentation at:
http://www.azahcccs.gov/commercial/default.aspx
So what can you do if you suspect an individual
has committed fraud? Report it! It’s the law!
AHCCCS policy is to report fraud within 10 days
of when you first discover it.
If you suspect that a person, doctor or company
has committed fraud, report it. You may not
have all of the information or be able to get
the information, but report what you have.
Include documents, statements, pictures, etc.
It is always better to report partial information
than to not report it at all. If you are concerned
about reporting fraud, don’t worry. Arizona
Revised Statute 36-2918.01.B states in part that if
a person makes a complaint in good faith, then
they are immune from any civil liability.
Being vigilant about preventing and reporting
fraud is very important. Preventing fraud at
every level, from the doctor or hospital to the
customer that comes into your office, will help
improve the quality and level of service existing
members receive.
– Fraudulent Recoupment Practices
Page 11
2502 E. University Dr., Ste 125
Phoenix, AZ 85034
PRSRT STD
US POSTAGE
PAID
PHOENIX, AZ
PERMIT NO. 498
aby
B Arizona
Baby Arizona is an AHCCCS
program designed to help women
receive the early prenatal care
that is so important for a healthy
pregnancy and a healthy baby. This
program assists those mothers-to-be
who need it most by helping them
receive professional medical care in a
timely manner at no cost while their
AHCCCS eligibility is being assessed.
Maricopa Health Plan believes this
program contains many features
that are beneficial for our members
and we encourage you to participate
by becoming a Baby Arizona
provider. The AMA (Arizona Medical
Association) supports Baby Arizona
and has developed a Participating
Provider Agreement form
which can be downloaded from
www.babyarizona.gov.
After completing the Participating
Provider Agreement, Baby Arizona
will initiate training for your staff.
This training must be completed
prior to implementing the Baby
Arizona program in your office.
Additional staff may be trained at
any time by completing the request
form provided on the above website
or by fax at (602) 417-4162.
Health Services phone referral (ADHS
Pregnancy and Breast Feeding hotline)
to set up an office appointment for
the patient. Your office will provide
clinical services for the patient in this
initial visit and assist in the S.O.B.R.A.
eligibility process. For all information
pertaining to becoming a Baby Arizona
provider, please refer to the above
website.
Once you are enrolled in Baby
Arizona, you will be contacted
by referred patients or through
the Arizona Department of
MHP encourages you to join this very
worthwhile program which brings
critical prenatal services to those who
need them most.