Presentation Title

Document Sample
Presentation Title Powered By Docstoc
					                                                                               The Local Service Model
                                                                               Formula




                                                        Provider Satisfaction = Administrative Simplification
                                                             Administrative Simplification = Affordable,
                                                                     Accessible Healthcare




Confidential property of UnitedHealth Group. Do not distribute or reproduce without the express permission of UnitedHealth Group.
How Do We Communicate?                                                                                                              2




             UnitedHealthcare Online
               Primary source of communication

           Administrative Guide
               Updated annually – effective 12/01/2008
               Available online


              Network Bulletin (newsletter)
               Published every other month beginning in Jan.
               Alerts you to any change in policies or procedures and updates to the
                Administrative Guide
               Enroll at www.unitedhealthcareonline-emailnews.com and enter your e-mail
                address

           Direct Mailings
               As needed for any significant changes or updates


Confidential property of UnitedHealth Group. Do not distribute or reproduce without the express permission of UnitedHealth Group.
Tools for Administrative Simplification
                                                                                                                                    3



 Our tools:
 • Simplify the administrative process before the patient even steps into the
   office, through point of service and beyond
 • Reduce the amount of paper coming in and out of your office
 • Help the environment stay green
 Use UnitedHealthcare Online to:
  Check Eligibility, Benefits & Claims Status
  Submit & Adjudicate Professional Claims with real time adjudication
  Submit and verify Status of Notifications
  Submit a Pre-Determination of Benefits
 Electronic Claim Submission products:
 • Real Time Adjudication through UnitedHeatlhcareOnline.com
 • Submit claims through Ingenix EDI Solutions or the clearinghouse of your
   choice
 With Electronic Payments & Statements you:
 • Eliminate Paper - Receive your payments and EOBs electronically
 UnitedHealthcare ID cards: Swipe Card Technology
 • Verify member eligibility and co-payment information
 • Speed patient Check-In
 • Reduce the risk of claim denials




Confidential property of UnitedHealth Group. Do not distribute or reproduce without the express permission of UnitedHealth Group.
Service Solutions
                                                                                                                                                                         4




       • When you should visit Unitedhealthcareonline.com
  Patient Eligibility & Benefits                                                                     Notifications:
  •Check Patient Eligibility & Benefits                                                              •Submit new, update existing, and check status of notifications
  •Access Patient Personal Health Records
  •Find patients Home Health Care, rehabilitation, and/or durable medical
  equipment benefits                                                                                 Tools & Resources
                                                                                                     •Review the prescription drug list
                                                                                                     •Update Facility or Practice information
                                                                                                     •Review notice of Privacy Policy and Practices
   Claims & Payments                                                                                 •Learn about United Healthcare Products and Services
   •Claim pre-determination and bundling logic using Claim Estimator                                 •Access reimbursement and medical policies
   •Submit Claims using real time adjudication
   •Check Claim status
   •Request a claim adjustment or reconsideration when attachments are                              Clinician Resources
   not needed                                                                                       •Access and review clinical program information and patient safety
   •Look up your fee schedule                                                                       resources




                                                              Registration in No Time

                •Simply visit Unitedhealthcareonline.com and click the “New User” link in the upper
                right hand corner and follow the prompts

                •Your organizations administrator can also obtain a User ID and password for
                Unitedhealthcareonline.com. If you have any questions about registration, call 1-
                866-UHC-FAST (1-866-842-3278)



Confidential property of UnitedHealth Group. Do not distribute or reproduce without the express permission of UnitedHealth Group.
Service Solutions Continued
                                                                                                                                                                            5



                        When you should call or write
                   There are a few situations when you should call or write to us rather than visiting the website

                                                                                                                            Write to United Healthcare
                Call the United Voice Portal @ (877)842-3210                                                   When filing an appeal. When submitting a request for
                                                                                                               reconsideration requiring paper documentation such as
  Automated responses to many of your questions can be
  obtained through the United Voice Portal.                                                                    proof of timely filing or when filing a formal appeal, use
                                                                                                               the ClaimReconsideration Request Form found on
  • After calling the United Voice Portal, you will be prompted
                                                                                                               UnitedHealthcareOnline.com and send to the
  to make a selection by simply saying Claims, Benefits & Eligibility, Care
  Notifications, Privacy Practices or Other Professional Services A Health Care                                appropriate address as outlined on the form. For
                                                                                                               further details see back page of this document and/or
  Professional Services Associate is available from 7 a.m. to 7 p.m. Central
                                                                                                               visit UnitedHealthcareOnline.com > Claims &
  Standard Time and can be reached by saying „representative‟ after entering the
  Member‟s ID number.                                                                                          Payments > Claim Reconsideration > Claim
                                                                                                               Reconsideration Request Form or Related Links.
  Claim Status
  • Find electronic 835s or get answers to your questions regarding 835s
  Care Notifications
  • Determine if a procedure or medication requires notification
  Other professional services
  • Check claim reconsideration request status if not viewable on
  UnitedHealthcareOnline.com                                                                                   Call your Local Network Account Manager
  • Notify UnitedHealthcare of a new physician in your practice or check                                      If you have a question regarding your contract with
  credentialing status                                                                                        UnitedHealthcare. Visit UnitedHealthcareOnline.com >
  • Request UnitedHealthcare participation To obtain a Quick Reference of the                                 Contact Us > Network Contacts
  United Voice Portal Visit UnitedHealthcareOnline.com>Tools & Resources>
  Products & Services>UnitedHealthcareOnline> Navigating the United Voice
  Portal Quick Reference
                                                                                                                    Additional Help & Training Materials
                                                                                                             Check out UnitedHealthcareOnline.com for additional
                                                                                                             resources including Frequently Asked Questions, Quick
                                                                                                             Reference materials, Step-by-Step help and tutorials. We
                                                                                                             encourage you to become familiar with these resources
                                                                                                             as you start to use UnitedHealthcareonline.com




Confidential property of UnitedHealth Group. Do not distribute or reproduce without the express permission of UnitedHealth Group.
Changes to Botox and Myobloc Policy
                                                                                                                                    6




                • Effective May 1, 2009, Prescription Solutions, a UnitedHealth Group company providing
                  specialty pharmacy services and consumer health products, will become a participating
                  specialty pharmacy vendor for Myobloc and Botox.
                • As of May 1, 2009, UnitedHealthcare will require that all network physicians currently
                  billing UnitedHealthcarefor the administration of Botox/Myobloc to UnitedHealthcare
                  members use Prescription Solutions as the specialty pharmacy vendor to obtain these
                  medications. Physicians will no longer purchase these medications through a
                  manufacturer or wholesaler and bill UnitedHealthcare (also referred to as “buy and bill”)
                  for Botox or Myobloc.
                • This is outlined in the Botox and Myobloc protocol in the 2009 UnitedHealthcare
                  Physician, Health Care Professional, Facility and Ancillary Provider Administrative Guide
                  (pg 62).
                • Prescription Solutions will dispense Botox and Myobloc in compliance with the
                  UnitedHealthcare Botox/Myobloc Drug Policy, and the member‟s benefit and eligibility.
                  Prescription Solutions will advise the member of any cost share responsibility for the
                  medication.




Confidential property of UnitedHealth Group. Do not distribute or reproduce without the express permission of UnitedHealth Group.
Benefits of Policy Changes
                                                                                                                                    7




                • Cost-effective procurement of Myobloc and Botox from a contracted national
                  specialty pharmacy vendor.
                • Support line for questions/procurement of Myobloc and Botox.
                • A clear understanding and application of UnitedHealthcare‟s drug policy on
                  benefit coverage of Myobloc and Botox; dispensing by Prescription Solutions
                  guided by the drug policy and clinical review support of the UnitedHealthcare
                  clinical coverage review (CCR) team.
                • Prospective communication of coverage through a collaborative prospective
                  review process by Prescription Solutions and the UnitedHealthcare CCR
                  team.




Confidential property of UnitedHealth Group. Do not distribute or reproduce without the express permission of UnitedHealth Group.
Process for requesting Botox/Myobloc
                                                                                                                                    8




                • Obtain the “Botox” or “Myobloc” Enrollment form for UnitedHealthcare
                  members which captures the clinical criteria and demographic/eligibility
                  information needed. This can be through the UHC website or by calling
                  Prescription Solutions toll-free at (888) 293-9309.
                • Complete the form and provide necessary documentation describing the
                  patient's clinical condition and need for Botox or Myobloc.
                • Fax the form to Prescription Solutions at (800) 853-3844. Prescription
                  Solutions will fax back confirmation that the request was received. Contact
                  Prescription Solutions to check the status of your order.
                • Determination and Dispensing: If the case criteria meets the UnitedHealthcare
                  Botox/Myobloc Drug Policy, Prescription Solutions will call to coordinate the
                  Botox/Myobloc delivery to the physician's/healthcare professional's office for
                  administration
                • After the initial dispense for a Botox/Myobloc request that meets the clinical
                  criteria, the prescription will be active for one year from the date it was written.
                  Prescription Solutions will contact you in advance of future supply
                  requirements to determine a delivery schedule. Or, you can call or fax
                  Prescription Solutions to request a subsequent dispense of the medication
                  and setup delivery.


Confidential property of UnitedHealth Group. Do not distribute or reproduce without the express permission of UnitedHealth Group.
Botox/Myobloc Process Cont’d
                                                                                                                                    9




                • If the UnitedHealthcare Botox/Mybloc Drug Policy criteria are NOT met:
                • The case will be reviewed by the UnitedHealthcare CCR team and a determination will be
                  made.
                • Prescription Solutions will notify the provider or clinic of the UnitedHealthcare clinical
                  coverage review approval or adverse determination by phone.
                • In the case of adverse determination UnitedHealthcare will also send a letter
                  communicating the decision. Instructions regarding the appeal process will be included in
                  the notification.
                • To check the status of an appeal or denied initial request, please call the phone number
                  listed on the back of the member's health care ID card. We recommend that you submit
                  your request well in advance of the anticipated injection date to allow time for additional
                  review.




Confidential property of UnitedHealth Group. Do not distribute or reproduce without the express permission of UnitedHealth Group.
Provider Relations Service Model                                                                                                           10




  To check status of a claim
  Providers use the tools found on                                                 If an adjustment is needed
  unitedhealthcareonline.com                                                       Use the tools found on unitedhealthcareonline.com, or
                                                                                   Submit a paper reconsideration, or,
                                                                                   Call Healthcare Professional Services at 877-842-3210
                                                                                         Obtain a tracking number for future reference




                                                                                If the Issue remains unresolved after 30 days
                                                                                • Contact your local Provider Advocate or Network
                                                                                    Account Manager – provide the tracking number
                                                                                    and a brief description of why you feel the issue is
                                                                                    still unresolved.




                   Network Account Managers and other business partners will work together
                             until the issue is resolved on behalf of the Provider.

Confidential property of UnitedHealth Group. Do not distribute or reproduce without the express permission of UnitedHealth Group.
Medical ID Card Swipe Technology
                                                                                                                                    11




                • UnitedHealthcare members carry advanced magnetic stripe ID Cards which
                  can greatly reduce transaction errors by minimizing the hand-keying of
                  member information on most “enrollee number” searches – including Eligibility
                  & Benefits and Personal Health Record. Just select “Card Swipe” as your
                  search method and swipe the member‟s ID card.
                • To begin using this new feature, you will need a keyboard emulator magnetic
                  stripe card reader that plugs into your computer (little to no set-up and no
                  software required).
                • UnitedHealthcare has arranged a discounted purchase price for our
                  network physicians and health care professionals through a preferred
                  distributor - Bayscan Technologies. Current price for a reader is $55,
                  including shipping (taxes may be applicable). To order your discount card
                  reader(s) through BayScan Technologies, call the number or visit the Web site
                  below.
                • Important: To receive the special discounted price, be sure to indicate
                  that you are part of the UnitedHealthcare Network and supply your TIN
                  when ordering.
                • Telephone
                  1-877-229-7226
                • Web site: BayScan Technologies


Confidential property of UnitedHealth Group. Do not distribute or reproduce without the express permission of UnitedHealth Group.
Electronic Payments and Statements
                                                                                                                                    12




                EPS
                • Standard way of doing business for the future
                • Electronic version of your remittance from
                  www.unitedhealthcareonline.com
                • Viewing and printing hard copies from our website
                • Receive your money faster
                • Deposit account only
                • Enrollment by Tax identification number
                • Enrollment forms in your pakcets




Confidential property of UnitedHealth Group. Do not distribute or reproduce without the express permission of UnitedHealth Group.
Imaging Accreditation Program
                                                                                                                                                  13




            •    1. What is the UnitedHealthcare Imaging Accreditation Program?
                  Imaging accreditation specifically addresses the quality and safety of medical imaging through the
                  application of nationally recognized standards for providers of outpatient imaging services.

            •    2. What are the imaging procedures subject to accreditation?
                  The following imaging procedures are subject to accreditation: CT, MRI, PET, nuclear medicine, nuclear
                  cardiology and echocardiography. The most current and complete list of corresponding CPT codes is
                  available on UnitedHealthcareOnline.com via Clinician Resources > Radiology > Imaging Accreditation.

            •    4. What facilities and/or physicians are required to obtain accreditation?
                  Facilities and physicians that perform outpatient imaging studies and bill on a CMS/Health Insurance
                  Claim Form (HICF) 1500 or the electronic equivalent must obtain accreditation. Accreditation will apply to
                  global and technical service claims.

            •    5. How is the professional component affected by the accreditation requirements?
                 The professional component is exempt from the imaging accreditation requirement.

            •    6. Who are the accreditation agencies UnitedHealthcare will recognize to obtain accreditation
                  for this program?
                 American College of Radiology (ACR) Intersocietal Accreditation Commission (IAC)
                 www.acr.org www.intersocietal.org or by phone at1-800-770-0145 1-800-838-2110

            •    7. Is there a preferred agency?
                  UnitedHealthcare has no preference. Both the ACR and IAC accreditations are accepted. It is not
                  necessary to obtain accreditation from both agencies for the same modality.

            •    8. What is the first step to begin the imaging accreditation process?
                  The first step toward obtaining accreditation is to review the accreditation guidelines and application
                  processes located on the American College of Radiology (ACR) or Intersocietal Accreditation Commission (IAC) Web sites.

                  OR
            •    Call the agencies using the phone numbers above to obtain a packet of information. Compliance with the Imaging Accreditation
                 policy will become a condition of eligibility for reimbursement from UnitedHealthcare beginning in the fourth quarter of 2009.



Confidential property of UnitedHealth Group. Do not distribute or reproduce without the express permission of UnitedHealth Group.
Website Tutorials and Web Seminars
                                                                                                                                    14




                • Claims and Payments - Covers how to submit reconsiderations, how to look up
                  your fee schedule, claim status, and how to use the claim estimator tool.
                • Patient Eligibility and Benefits
                • Notifications – Covers how to look up status and how to submit.
                • Practice/Facility Profile – Covers to update group/practice profile

                • UnitedHealthcareOnline.com and Electronic Payments & Statements Webcasts:

                • Instructions for Accessing Webcasts
                • Audio information: Dial in #: (888) 844-7278
                • Access Code: 5447883
                • Webcast information: https://uhc-enterprise.webex.com
                • Time: Every other Thursday at 2 p.m. (Eastern)
                (Sessions generally run between 1 and 1 ½ hours long. See handout in packets for specific
                   dates)




Confidential property of UnitedHealth Group. Do not distribute or reproduce without the express permission of UnitedHealth Group.
Northeast Contact Information
                                                                                                                                                      15




                •    All claims related issues will be handled by the Provider                      Massachusetts – Senior Network Account Managers
                     Service lines of United HealthCare, Oxford Health Plans
                     and AmeriChoice (Rhode Island).                                                     • Gary Petersen – (781) 419-8673
                        United HealthCare: 1-877-842-3210                                               • Mike Grady – (781) 419-8676
                        Oxford Health Plans: 1-800-666-1353 choose                                      • Christine Dragon – (413)-533-0145
                            prompt #2 and provider type; for claims issues
                            choose #4 and then 2                                                         • Lisa Garrigan - (781) 419-8658
                        Americhoice: 1-866-362-3368
                                                                                                    New Hampshire – Senior Network Account Managers
                                                                                                         • Lisa Garrigan – (781) 419-8658
                •    Massachusetts – Network Account Managers
                       Richard O‟Brien – (781) 419-8662                                                 • Amy Johnson – (207) 253-1012
                       Eric Zimmerman – (781) 419-8696
                       Donna Muse – (781) 419-8672
                       Gidget Knowles – (781) 419- 8666                                            Vermont/Maine – Senior Network Account Managers
                       Virginia Rodriguez – (781) 419 - 8654                                            • Amy Johnson – (207) 253-1012
                •    New Hampshire – Network Account Managers
                       Suzanna Hawk – (781) 419-8670
                       Gidget Knowles – (781) 419-8654

                •    Vermont/Maine – Network Account Managers
                       Minnie – (207) 253-1014


                •    Massachusetts Network Account Team:
                •    (800)444-7855




Confidential property of UnitedHealth Group. Do not distribute or reproduce without the express permission of UnitedHealth Group.

				
DOCUMENT INFO