docProvider Resource Guide - The University of Arizona Health Plans
download 
Report Transcription
Provider Resource Guide - The University of Arizona Health Plans
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 Provider Resource Guide 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 www.uahealthplans.com UPHP 1.0 The University of Arizona Health Plans Member ID Cards Rev 01/2013 www.uahealthplans.com 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‐CustomerService@uahealth.com 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 PO Box 37279, Phoenix, AZ 85069 PO Box 37169, 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: grievance@uahealth.com Rev 01/2013 Address: 2701 E. Elvira Road Tucson, Arizona 85756 www.uahealthplans.com UPHP 3.0 Network Development Contact List Management/Administrative Staff Title/Department Telephone Lisa Gascoigne Lisa.Gascoigne@uahealth.com Director of Network Development 520‐874‐5203 Network Development Assistant 520‐874‐5523 Rosie Rascon Rosie.Rascon@uahealth.com Phoenix‐Based Provider Relations Staff Telephone Connie Leonardo Connie.Leonardo@uahealth.com Provider Relations Rep 602‐344‐8387 Sean Seeger Sean.Seeger@uahealth.com Provider Relations Rep 602‐344‐8385 Gail Vanko Gail.Vanko@uahealth.com Provider Relations Rep 602‐344‐8392 Linda Reiter Linda.Reiter@uahealth.com Provider Relations Rep 602‐344‐8391 Alyssa Bellantoni Alyssa.Bellantoni@uahealth.com Provider Relations Rep 602‐344‐8362 Tucson‐Based Provider Relations Staff Telephone Staci Garcia Staci.Garcia@uahealth.com Provider Relations Rep 520‐874‐5524 Marta Rosengren Marta.Rosengren@uahealth.com Provider Relations Rep 520‐874‐5532 Jamie Swanson Jamie.Swanson@uahealth.com Sr. Provider Relations Rep 520‐874‐5079 Rev 01/2013 www.uahealthplans.com UPHP 3.1 Network Development Contact List (cont.) Tucson‐Based Provider Relations Staff Continued… Telephone Pam Skelnik Pamela.Skelnik@uahealth.com 520‐874‐5520 Sr. Claims Educator Contracting Staff Telephone Ann Hudson Ann.Hudson@uahealth.com Contracting 602‐344‐8342 Monica Hamilton Monica.Hamilton@uahealth.com Contracting 602‐344‐8378 Alphonso Villela Alphonso.Villela@uahealth.com Contracting 602‐344‐8393 Patti Cooper Patricia.Cooper@uahealth.com Contracting 602‐344‐8348 Database Staff Telephone Annette Salas Annette.Salas@uahealth.com Operations Specialist 520‐874‐5542 Gabriella Bracamonte Gabriella.Bracamonte@uahealth.com Database Coordinator 520‐874‐5502 Database Specialist 520‐874‐5521 Carolina Juvera Carolina.Juvera@uahealth.com Rev 01/2013 www.uahealthplans.com 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 www.uahealthplans.com 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 ICD10.HPQuestions@uahealth.com. Rev 03/2013 www.uahealthplans.com UPHP 5.0 Quick Reference Guide‐ 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 www.uahealthplans.com UPHP 6.0 Emdeon ERA Provider Setup Form Rev 01/2013 www.uahealthplans.com UPHP 6.1 Rev 01/2013 www.uahealthplans.com 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 www.uahealthplans.com 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 www.uahealthplans.com 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 www.uahealthplans.com 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 www.uahealthplans.com UPHP 8.2 Pain Scale Rev 01/2013 www.uahealthplans.com 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 www.uahealthplans.com 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 missedappts@azahcccs.gov. Rev 01/2013 www.uahealthplans.com UPHP 11.0 No Show Log Rev 01/2013 www.uahealthplans.com UPHP 11.1 Quick Reference Guide – 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 www.uahealthplans.com UPHP 12.0 Rev 01/2013 www.uahealthplans.com UPHP 12.1 Quick Reference Guide‐ 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 www.uahealthplans.com UPHP 13.0 Quick Reference Guide‐ 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 priorauth@uph.org. 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 www.uahealthplans.com UPHP 14.0 Rev 01/2013 www.uahealthplans.com UPHP 14.1 Rev 01/2013 www.uahealthplans.com UPHP 14.2 Rev 01/2013 www.uahealthplans.com 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 www.uahealthplans.com UPHP 14.4 Quick Reference Guide‐ 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 www.uahealthplans.com UPHP 15.0 Rev 01/2013 www.uahealthplans.com 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 www.uahealthplans.com 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 www.uahealthplans.com 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 www.uahealthplans.com 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 www.uahealthplans.com 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 www.uahealthplans.com UPHP 17.1 Fraud, Waste and Abuse (cont.) 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 www.uahealthplans.com UPHP 17.2 Fraud, Waste and Abuse (cont.) 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 www.uahealthplans.com 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 www.uahealthplans.com 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: HHSTips@oig.hhs.gov 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 www.uahealthplans.com UPHP 17.5 Electronic Health Records Rev 01/2013 www.uahealthplans.com UPHP 18.0 Electronic Health Records (cont.) Rev 01/2013 www.uahealthplans.com UPHP 18.1 Quality Care Desk Aid Rev 01/2013 www.uahealthplans.com UPHP 19.0 Quality Care Desk Aid (cont.) Rev 01/2013 www.uahealthplans.com UPHP 19.1 Provider Resource Guide www.ufcaz.com Quick Reference Guide‐ 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 Quick Reference Guide‐ 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 Quick Reference Guide‐ Transportation (cont.) 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 Quick Reference Guide‐ Transportation (cont.) 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 Quick Reference Guide‐ 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 5th Screening: 6 Months Old 3rd Screening: 2 Months Old 6th Screening: 9 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 Quick Reference Guide‐ 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 Quick Reference Guide‐ 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 Quick Reference Guide‐ 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 Quick Reference Guide‐ 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 Quick Reference Guide – 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 CustomerService@uahealth.com Contracting 602‐344‐8348 602‐344‐8358 Provider Relations 520‐874‐5523 520‐874‐7144 Credentialing 520‐874‐2483 or email: hpcredentials@uahealth.com 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: info@azhec.org 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
