UPDATE JULY 31, 2007
Provider Portal Update
In our ongoing effort to provide you with the information and tools you need, we have
reorganized the provider portal on our website. Below are some details related to the redesign.
For Providers Section
In the For Providers section (the public side of our website), we identified major topic headings
and placed all related information under those headings. This will allow you to access valuable
information — faster!
Section headings include:
• News and Information
• PFFS Terms & Conditions
• Pharmacy
• For Your Patients (a valuable section full of information that you can share with your patients)
• Medical Management
Provider OnLine
As exclusive members of Provider OnLine, we offer you a broad range of information “behind the
portal” in the more secure section of our website.
In Provider OnLine, you can:
• View real-time patient and claims data
• View PCP information and covered benefits
• Get an immediate response to questions about submitting claims
• See members’ historical coverage information
• Determine a member’s primary insurance coverage
• Search back issues of our Accountable Provider newsletters and updates
Questions regarding Provider OnLine or any Health Plan programs can be addressed through
your network manager or by calling Provider Services at 1-888-876-2756.
The Health Plan apologizes for any inconvenience you may have experienced logging in to the
Provider OnLine portal while we were updating our website.
Provider Services 1-888-876-2756
JULY 31, 2007 ACCOUNTABLE PROVIDER UPDATE
Notification of Hospital Discharge Appeal Rights
On November 27, 2006, the Centers for Medicare & Medicaid Services (CMS) published a
final rule, CMS-4105-F: Notification of Hospital Discharge Appeal Rights. Beginning
July 1, 2007, hospitals must deliver a revised version of the “Important Message” from
Medicare to inform Medicare beneficiaries who are hospital inpatients about their hospital
discharge appeal rights. Notice is required both for Original Medicare beneficiaries and for
those enrolled in Medicare health plans. Beneficiaries who choose to appeal a discharge
decision will receive a more detailed notice.
For more information on the final rule, forms, and notices, visit the CMS website at
www.cms.hhs.gov/BNI/12_HospitalDischargeAppealNotices.asp.
CMS Delays Dissemination of National Plan and Provider
Enumeration System (NPPES) Data
Approximately 98% of the estimated 2.3 million covered health care providers now have
National Provider Identifiers (NPIs). Health plans, health care clearinghouses, and health care
providers are now transitioning to the implementation phase for NPI compliance.
The NPPES Data Dissemination Notice (CMS-6060-N) was published on May 30, 2007. NPPES
health care provider data requiring disclosure under the Freedom of Information Act (FOIA) will
be made publicly available. The FOIA-disclosable data will be available in an initial file that you
can download from the Internet. Monthly update files will also be downloadable. And there is a
query-only database (the NPI Registry) where users can query by NPI or provider name.
The Notice stated that data will be available 30 days after the Notice publication date. However,
CMS now believes that health care providers need additional time to view their FOIA-
disclosable NPPES data and make updates and deletions (where permitted). Therefore, CMS
has decided to delay the dissemination of FOIA-disclosable NPPES health care provider
data until August 1, 2007, which is 60 days after the Notice publication date.
CMS will provide additional information regarding the date that changes will have to be
submitted so they will be included in the initial downloadable file. While they are aware that the
health care industry is in urgent need of the FOIA-disclosable NPPES health care provider data,
CMS believes it is in the best interests of the industry, and the health care providers in particular,
that the NPPES data be as accurate as possible.
For the latest information on Data Dissemination, as well as a list of the FOIA-disclosable data
elements, visit www.cms.hhs.gov/NationalProvIdentStand/06a_DataDissemination.asp on the
NPI website.
Provider Services 1-888-876-2756 2
JULY 31, 2007 ACCOUNTABLE PROVIDER UPDATE
Respiratory Health Management Program - Asthma Program now
Includes Members with COPD
Did you know?
UPMC Health Plan has recently expanded its Asthma Health Management Program to include
care for members with chronic obstructive pulmonary disease (COPD). COPD is one of a group
COPD is the 4th
of lung diseases, which includes emphysema and chronic bronchitis, and is characterized by
leading cause of
death in the airway obstruction that interferes with normal breathing. COPD is not totally reversible. Our
United States.This expanded program is called the Respiratory Health Management Program.
disease kills more The Respiratory Health Management Program uses a team approach. Case managers,
pharmacists, behavioral health specialists, and clinical account managers collaborate with
physicians to help members achieve and maintain control of their COPD. They will focus on
than 120,000
self-care, identifying triggers, and preventing acute asthma exacerbations.
Americans each
We will emphasize pharmacologic treatment and member education in the program and will treat
year—that’s 1
members with asthma or COPD holistically. The program will take into account not only physical
death every 4
minutes—and conditions but also the economic, social, cultural, and psychological factors that affect
can cause serious, management of the disease.
long-term In 2004 it was estimated that 11.4 million U.S. adults aged 18 and over had COPD. However,
close to 24 million U.S. adults have evidence of impaired lung function, indicating a possible
underdiagnosis. COPD is the fourth cause of death in the United States, and the number of
disability.
women dying from the disease has surpassed the number of men. An estimated 638,000 hospital
discharges for COPD were reported in 2004.
Smoking is the primary risk factor for COPD, and approximately 80 to 90 percent of COPD
deaths are caused by smoking. Smokers are 12 to 13 times more likely to die from COPD than
nonsmokers. Other risk factors for COPD include air pollution, secondhand smoke, history of
childhood respiratory infections, occupational exposure to industrial pollutants, and heredity.
For more information about the Health Plan’s Respiratory Health Management Program or to
enroll one of your patients, call 1-866-778-6073 and select option “1.” You can also enroll
a patient in the program by completing a Health Management Referral form found on the “For
Providers” section of our website under the “For Your Patients” tab. Simply fill out the form,
select the “Other” box, and write in “COPD.” Fax the form to the Health Plan at 412-454-2070.
Patients who are already enrolled in the Asthma Health Management Program can also be
referred for COPD.
Provider Services 1-888-876-2756 3
JULY 31, 2007 ACCOUNTABLE PROVIDER UPDATE
Technology Assessment Committee
The Technology Assessment Committee meets regularly to review medical technology.
The following chart details recent committee decisions.
Please refer to the designated policy for complete indications and limitations.
Subject Reason for Review UPMC Health Plan Summary
General Issues
Computed New Policy • Effective 9-1-07
Tomography • No Prior Authorization required
Angiography of • Not covered for screening asymptomatic
the Chest patients
Prophylactic New Policy • Effective 9-1-07
Mastectomy • Approved with Prior Authorization
• Approved for Commercial, Medicare, and
CHIP only
Prophylactic New Policy • Effective 10-1-07
Oopherectomy • Approved with Prior Authorization
X-Stop-Spinal New Policy • Effective 9-1-07
Implant • Approved with Prior Authorization
• Covered for Medicare only, including
UPMC for Life Specialty Plan
APU JULY2007 C20070705-01 (RT) 7/25/07 3.8M SS
4
Provider Services 1-888-876-2756