Convenience Care Clinics Expands Member Utilization ... · Plan ... septoplasty and ... UnitedHealthcare Community Plan offers physicians and other health care professionals the

For more information

Call our Provider Service Centerat 800-557-9933

Visit UHCCommunityPlan.com

In This Issue:

• Convenience Care Clinics ExpandsMember Services . . . . . . . . . . . . . . . . . 1

• Physician Satisfaction SurveyUnderway . . . . . . . . . . . . . . . . . . . . . . . 2

• Prompt Responses to MedicarePart D Prescription Appeals InquiriesEnsure Continuity of Care . . . . . . . . . 2

• New Clinical Guidelinesfor UnitedHealthcare CommunityPlan . . . . . . . . . . . . . . . . . . . . . . . . . . . 2

• National Institute for MentalHealth Resources: Focus onMedications . . . . . . . . . . . . . . . . . . . . . 3

• When Forces Collide: TraumaticBrain Injury Masquerading asADHD in Adolescents . . . . . . . . . . . . 3

• UnitedHealthcare CommunityPlan Provider Portal Online-Authorizations and NotificationProcess . . . . . . . . . . . . . . . . . . . . . . . . . 6

• Getting Started with EDI is simple . . 7

Important information from UnitedHealthcare for physicians and other health careprofessionals and facilities serving UnitedHealthcare Medicaid members

Convenience Care Clinics Expands MemberServicesUnitedHealthcare Community Plan has recently expanded ourprovider network to include walk-in clinics at various TakeCareHealth Clinics (Walgreens) and Minute Clinics (CVS) stores inOhio, Texas, New York,Wisconsin, Mississippi and Delaware.When provided with primary care physician information, theconvenience care clinic will make every attempt to submitnotification to that primary care physician to ensure continuityand quality of care. Convenience care clinic staff do not assistpatients with referrals for specialty care services. Convenience careclinics treat patients over the age of 19 months and will not beoffering immunizations for the vaccine for children (VFC)program in this setting. Convenience Care Clinics offer extendedhours, and in most cases are open until 8:00 pm.

Some common conditions that can be treated in the conveniencecare clinics:

Vaccines• Flu (seasonal)• Hepatitis A (adult)• Hepatitis (adult)• Meningitis• Pneumonia• Td (Tetanus, Diphtheria)

Fall 2012

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New Mexico | Winter 2012


Utilization Management Access to Utilization Management Staff The Utilization Management department is available to physician, other health care professionals and members during regular business hours from 8 a.m. to 5 p.m., Monday through Friday and may be reached by calling the customer service line 877-236-0826 and selecting Prior Authorizations from the voice activated menu. If you are a physician or other health care professional, please have your Tax I.D. number and the member’s information available. Answers to questions about the utilization management process, including prior authorization, inpatient notification questions, and criteria used for decision making are available by calling the customer service line and selecting Prior Authorizations to speak with a representative. Providers can submit request for prior authorization via fax to 866-968-7582.

Prior authorization requirements are outlined in the “The Prior Notification Guide for In-Network Providers.” To receive a copy of this guide, contact your Provider Advocate or obtain a copy at UHCCommunityPlan.com/health-professionals/NM/provider-information. The New Prior Notification Guide for in-Network Providers became effective September, 2012.

New Additions for Prior Authorization Include the Following:Ambulatory/Outpatient Procedures

• Ablation procedures for venous insufficiency and varicose veins• Gynecomastia/for medical necessity

In This Issue:• Utilization Management Access to

Utilization Management Staff .........1

• Provider Disputes - Reconsiderations and Appeals .........2

• Member Rights and Responsibilities .........................3

• Clinical Practice and Preventive Health Guidelines .........3

• Quality Improvement Program Overview ..........................4

• Annual HEDIS Measures ...............4

• Member Satisfaction - Adult CAHPS Survey .....................6

• Value Added Benefits – Increased Podiatry Services .............7

• Coronary Artery Disease and Lipid Management ...................8

• Inside the Star Rating Initiative With James Carney, MD, MBA ......8

• Cultural Needs ................................9

• Pharmacy Updates ..........................9

• Global Days Policy Reminder .......10

• Updated Information About 17 Alpha-Hydroxyprogesterone Caproate (17P) Injection ...............11

• Recovery and Adherence ...............13

For more information

Call our Provider Service Center at 877-236-0826

Visit UHCCommunityPlan.com

http://UHCCommunityPlan.com/health-professionals/NM/provider-information

http://UHCCommunityPlan.com/health-professionals/NM/provider-information

http://UHCCommunityPlan.com

(continued from previous page)


• Rhinoplasty, septoplasty and turbinate resection authorization required if medical necessary

• Panniculectomy and body contouring procedures

• Video EEG• Pulmonary rehabilitation services • Plagiocephaly• Reconstructive Surgery• Botox for medical necessary

Equipment

• Cochlear implants• Bone Growth Stimulators

Processes Continue:

• DME > $1000.00 continue to need Prior Authorizations

• There are several Not a Covered Benefit (NCB) services and procedures per the state regulations outline on the Prior Authorization Guide, such as Gastric Bypass Surgery

• If you need PA for UHCS Medicare Health Plan members, call 800-537-2977. Non-emergent, medically necessary transportation and lodging can be requested by calling Logisticare at 866-400-8233.

• Native American member’s who access services via Indian Health Services providers do not require prior-authorization for services.

• Out-of-network providers require prior-authorization on all services and DME.

• For questions and evaluation of organ transplants, please contact our Optum Transplant Team: Phone 800-418-4994 option 5, Fax to 877-814-0488.

• Requests for Early and Periodic Screening, Diagnosis and Treatment

(EPSDT) under the age of 21 can call 877-236-0826 prompt Service Coordination and ask for the EPSDT Coordinator.

• Request for Home Community Base Services ( HCBS), call 877-235-0826 option for Service Coordination to initiate HCBS services for C Waiver members:

• Attendant Care Services (Available to PCO/CCW members)

• Assisted Living Services• Environmental Modifications

(limited to $5,000 every five years)• Private Duty Nursing/Waiver• Respite Services (limited to 100 hours

per ISP Year)• Emergency Response System• Transition Good and Services• Adult Day Care

Provider Disputes - Reconsiderations and AppealsProviders have the right to file a grievance or appeal with UnitedHealthcare Community Plan, including the right to file an appeal Plan regarding provider payment issues. Any appeal filed regarding utilization management decisions shall be filed within 90 days from notice of action and requires the member’s written consent. UnitedHealthcare Community Plan can assist providers in resolving claims issues. Physicians and other health care professionals should call the Customer Call Center at 877-236-0826 for questions regarding claims status on previously submitted claims.

Time Limits for Filing a Dispute A physician or health care provider must submit any dispute challenging an adverse determination within

NM - Winter 2012 Provider Service Center: 877-236-0826

Important information for health care professionals and facilities

I Fall 2012 2 Provider Service Center: 800-557-9933

Illnesses• Bladder infection treatment (females 12-65)• Bronchitis (ages 10-65)• Laryngitis• Ear infections• Pinkeye and styes• Sinus infections (ages five and up)• Strep throat• Swimmer’s ear

Skin Conditions• Athlete’s foot• Acne• Cold sores (ages 12 and up)• Deer tick bites (ages 12 and up)• Impetigo• Minor burns and rashes• Minor sunburn• Poison ivy (ages three and up)• Scabies• Shingles• Ringworm• Swimmer’s itch (ages three and up)

Other servicesFlu diagnosis (ages 10-64)• Mononucleosis• Pregnancy testing

Physician Satisfaction SurveyUnderway

The annual PhysicianSatisfaction Survey processhas begun, and you shouldhave received your first faxnotification. There willbe two more invitations toparticipate before thesurvey closes in October.

Your response letsUnitedHealthcareCommunity Plan know

how we can improve our working relationshipand better meet the needs of your practice. Welook forward to your participation in the surveyprocess.

Prompt Responses to Medicare Part DPrescription Appeals Inquiries EnsureContinuity of Care

When you or your patient, files an appeal withUnitedHealthcare, we will contact your office viafax or phone to request certain key informationneeded as part of the appeal process.

By federal law, UnitedHealthcare must render anappeal decision within 72 hours for an expeditedrequest and seven calendar days for a standardrequest.

Your assistance in responding to these requestspromptly helps ensure continuity of themember’s treatment plan.

New Clinical GuidelinesUnitedHealthcare Community Plan

UnitedHealthcare Community Plan Pharmacyand Therapeutic Committee has approved a newclinical guideline for Antiemetic ContinuousPump Therapy for the Treatment of Nausea andVomiting in Pregnancy.

Notification - Effective Oct. 1, 2012, the use ofAntiemetic Medication through a continuoussubcutaneous pump in the treatment of nauseaand vomiting in pregnancy will no longer becovered under UnitedHealthcare CommunityPlan.

Providers may request clinical review criteria bycontacting the Pharmacy Prior Notificationdepartment at 800-310-6826.



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12 months from the end date of service or date of discharge. For a hospital claim or prior period coverage, the provider must submit any dispute challenging the claim within 12 months from the date of discharge or 12 months from the date of eligibility posting, whichever is later.

Provider DisputesShould the provider receive an adverse determination or reimbursement that does not meet expectations, the provider should exhaust all processing procedures before initiating the Provider Dispute process. Providers are encouraged to contact the Customer Call Center or their Provider Relations Specialist if they need assistance with understanding the payment amount or denial reason. If the physicians and other health care professionals has exhausted all processing procedures and still has a dispute, the provider has the right to submit a written request for reconsideration. If the reconsideration request response does not meet the provider’s expectation, the provider has the right to submit a written request for an appeal.

Provider Reconsideration and Appeals forms may be found online at UHCCommunityPlan.com by selecting Physicians and Other Health Care Professional > Claims, Forms, and Manuals. Once on the Claims site, select the State (New Mexico) in Box 1 and what you are looking for (Provider Forms) in Box 2. From here, you may access all local guideline information for members, physicians and other health care professionals.

Physicians and other health care professionals should mail the completed reconsideration or appeal form and supporting documentation to:

UnitedHealthcare CoLTS Appeals & Grievances PO Box 31364 Salt Lake City, UT 84131-0364

Our contracted providers can review the entire content for Provider Disputes (Reconsiderations and Appeals) information, in the Provider Administrative Manual located on UHCCommunityPlan.com.

Member Rights and ResponsibilitiesWe inform our members that they have certain rights and responsibilities, all of which are intended to help uphold the quality of care and services they receive from you. We encourage our contracted physicians and other health care professionals to review these rights and responsibilities in the Provider Administrative Manual located on UHCCommunityPlan.com.

Clinical Practice and Preventive Health GuidelinesUnitedHealthcare Community Plan adopts Clinical Practice and Preventive Health guidelines from recognized sources as defined by the National Committee on Quality Assurance (NCQA) and Utilization Review Accreditation Commission (URAQ). Clinical and preventive health guidelines are systematically developed evidence-based statements that help providers make decisions about appropriate health care for specific clinical circumstances.

UnitedHealthcare Community Plan offers physicians and other health care professionals the ability to regularly view the most current Clinical Practice and Preventive Health guidelines via the UnitedHealthcare Community plan website. You are encouraged to check the site often for the most up-to-date information. To access these guidelines please visit: UHCCommunityPlan.com. Copies of Clinical Practice and Preventive Health Guidelines are also available upon request to the Provider Services phone line or via Provider Service Representatives.





















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Quality Improvement Program OverviewTo continuously improve the care and services provided to members, UnitedHealthcare Community Plan uses Healthcare Effectiveness Data and Information Set (HEDIS) reporting to measure our health care performance. HEDIS is a set of standardized performance measures that are related to many significant public health issues. Nationwide, our HEDIS 2012 scores demonstrated improvements in the number of our adult members who had their body mass index (BMI) screened, an increase in follow-up visits following hospitalizations for mental illness, and an increase in diabetic HbA1c and LDL testing.

UnitedHealthcare Community Plan will continue to target multiple areas for improvement in 2012 through national initiatives including, the number of yearly well visits received by children ages three to six, the number of timely prenatal and postpartum visits, and proper patient use of asthma medications.

We also conduct annual member surveys to see how well we are meeting our member’s needs. Our 2011 Consumer Assessment of Healthcare Providers and Systems (CAHPS) surveys showed improvement in how our members rate their personal doctor, the specialists they see most often, and their overall health care. Members told us that they want it to be easy to get approvals for the tests and treatments they need through their Health Plan. We listened and in 2012 are working to improve processes in our prior authorization center.

Annual HEDIS MeasuresUnitedHealthcare Community Plan Reports Audited HEDIS results each year. We would like to thank those who participated in the HEDIS project this year by submitting requested medical record information and/or collaborating with the on-site review nurses.

This is the third submission of HEDIS® data for UnitedHealthcare Community Plan of New Mexico. A total of 39 measures were reported for the Effectiveness of Care and Access/Availability of Care domains out of a total of 104 measures. A total of 19 measures improved from 2011 to 2012, one measure remained the same and 14 measures declined. UnitedHealthcare Community Plan saw statistically significant improvements for:

• Adult BMI Assessment• Comprehensive Diabetes Measures: • HbA1c Testing• HbA1c Control <8• LDL-C Control • BP Control 140/80• BP Control 140/90

UnitedHealthcare Community Plan’s measure of performance compared to Quality Compass National HMO benchmarks are summarized on the following page.






















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Percentile Met/Exceeded Measures

<10th BREAST CANCER SCREENING, CERVICAL CANCER SCREENING, CHOLESTEROL MANAGEMENT

10th COMPREHENSIVE DIABETES CARE - Eye Exam and LDL-C Screen

25th WELL CHILD CHECK - BMI, Nutrition Counsel AND Physical Activity Counseling PHARMACOTHERAPY OF COPD - Bronchodilator, CONTROLLING HIGH BLOOD PRESSURE, COMPREHENSIVE DIABETES CARE - HbA1c >9.0% - Poor Control AND HbA1c < 8.0% Control, ANNUAL DENTAL VISITS

50th SPIROMETRY IN COPD, PHARMACOTHERAPY OF COPD - Corticosteroid, COMPREHENSIVE DIABETES CARE - HbA1c Screen, LDL-C Control, BP 140/90, MONITORING OF PERSISTANT MEDICATIONS - Anticonvulsants

75th COMPREHENSIVE DIABETES CARE - Nephropathy, MONITORING OF PERSISTANT MEDICATIONS - Total, ADOLESCENT WELL CHILD VISITS

90th MONITORING OF PERSISTANT MEDICATIONS - ACE/ARB, Diuretics, ADULT ACCESS TO PREVENTIVE/AMBULATORY SERVICES - AGES 20-44, 45-64, 65+, Total


We will be reaching out to physicians and other health care professionals as part of our performance improvement process to collaborate efforts to improve preventive health screening rates and HEDIS® metrics.





















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Member Satisfaction - Adult CAHPS SurveyThe UnitedHealthcare Community Plan Quality Improvement Program strives to continuously improve the care and services provided to members. Each year we measure performance based on via the annual Consumer Assessment of Healthcare Providers and Systems (CAHPS®) survey and

annual Provider Satisfaction Survey. Quality improvement initiatives are developed annually based upon the results of these surveys. In 2011 ratings improved in five of the eight measures. Opportunities to improve all ratings with focused interventions are ongoing.

2010 Plan Average

2011 Plan Average

2012 Plan Average

2012 Mean Score for Plan

Percentile for Accreditation 2012

2012 UnitedHealthcare National Average

Rating of Personal Doctor 75.77% 79.75% 79.31% 2.5237 90th 77.46%

Rating of Specialist 81.29% 76.73% 79.00% 2.5479 90th 77.60%

Rating of All Health Care 64.04% 60.50% 68.01% 2.2511 50th 68.79%

Rating of Health Plan 66.93% 71.57% 71.37% 2.3558 50th 71.78%

Getting Needed Care 80.11% 83.40% 80.83% 2.4057 90th 74.07%

Getting Care Quickly 83.20% 81.86% 83.51% 2.4486 90th 80.72%

How Well Doctors Communicate 87.12% 88.53% 88.44% 2.5495 50th 88.46%

Customer Service *NA *NA 82.50% 2.4177 50th 77.15%

Shared Decision Making 57.91% 60.47% 59.73% 2.5106 None Available 58.30%

If you would like further information on our Quality Improvement Program, our annual goals, or our progress towards meeting our goals, please call 877-236-0826.





















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Value Added Benefits – Increased Podiatry ServicesIn our efforts to provide benefits that are not currently covered, but would be of value to our members, UnitedHealthcare has added extra podiatry care for all our members regardless of diagnosis. CoLTS member will be allowed four podiatry visits yearly even if they do not have a qualifying diagnosis such as diabetes or peripheral vascular disease.

Specifically, the following CPT codes will be covered up to four visits yearly:

• G0127• G0245-G0247• 11055-11057• 11719-11721

If you have any questions or comments, contact William Orr, MD, Medical Director at 505-449-4116 or at [email protected].

VAB Title Eligibility Benefit Description Limitation

Disease Management Tools Enrollment in Disease Management

Scales for members with CHF.

BP cuffs for members with Diabetes and HTN.

Ordered by Service Coordinator

Routine Podiatry Care All members 4 visits yearly for routine podiatry care; specific diagnostic codes not required.

4 visits yearly

Annual Physical Examinations Medicaid only An annual physical examination is covered.

Dual members not included as Medicare usually covers an annual Physical examination.

Grab Bar Installation PCO members Installation of Grab Bars will be a covered benefit.

Grab Bars are a DME benefit but not their installation; Colts C cover service thru environmental modifications.

Pharmacy Transportation All members Transportation to and from the pharmacy to pick up prescription medication.

In addition to the podiatry benefit, other value-added services follow:

mailto:william_f_orr%40uhc.com?subject=


Coronary Artery Disease and Lipid ManagementReducing a patient’s LDL-C can improve cardiovascular health and reduce the incidence of cardiovascular events. Using statin therapy to reduce LDL-C to less than 100 is a proven method of treatment. However, treatment should not stop with reducing LDL-C. Statin therapies decrease LDL-C, but are ineffective with HDL and triglyceride counts. Current literature recommends physicians consider adding a fibrate to statin therapy when the triglyceride level is greater than 150, and extended release niacin when the HDL is less than 40 for men and 50 for women. According to a 2008 article by Cziraky, Watson, and Talbert, despite controlled LDL-C levels, evidence indicates that high triglycerides and low HDL-C levels are independent cardiovascular risk factors that should be managed along with these current practice guidelines:

• Smoking cessation • Antiplatelet agents and anticoagulants• Blood pressure control• Lipid management• Beta Blockers• Renin-angiotensin-aldosterone

system blockers• Diabetes management• Pain Control• Depression Screening• Physical activity• Weight management • Nutrition• Immunizations

For further information regarding Coronary Artery Disease clinical practice guidelines, refer to the website: http://guideline.gov/content.aspx?id=16259&search=coronary+artery+disease

Inside the Star Rating Initiative With James Carney, MD, MBAAs UnitedHealthcare’s National Medical Director for Physician Engagement for Medicare Solutions, Dr. Carney plays a lead role with others in developing and communicating strategies to aid physicians in supporting their patients to live healthier lives and manage chronic conditions by obtaining recommended preventive care screenings.

Why Star Ratings Matter for Quality of Care “UnitedHealthcare’s mission is to help people live healthier lives. The Centers for Disease Control and Prevention (CDC) report that screenings and preventive care services continue to be under-utilized. Star ratings emphasize patient care and satisfaction, using national clinical quality measures – including screenings and preventive care and service quality measures – as well as patient feedback, so that health plans, physicians and members can work together to improve individual and total population quality of care and experiences,” said Dr. Carney.

UnitedHealthcare Approach According to Dr. Carney: “UnitedHealthcare has dedicated enterprise-wide resources and personnel to work together to create a proactive member





















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http://guideline.gov/content.aspx?id=16259&search=coronary+artery+disease

http://guideline.gov/content.aspx?id=16259&search=coronary+artery+disease


engagement, physician engagement and operational excellence approach to support Star Ratings improvement.

This initiative promotes transparency about Star Ratings and is intended to provide physicians with information, tools such as View 360, and incentives that support the additional time and resources they need to strengthen the physician-patient relationship and to help them deliver high quality, comprehensive, affordable health care services.

Our approach is patient-centered and focuses on coordinated care for members to help them understand their benefits and receive the care they need to live healthier lives.”

About Dr. CarneyDr. Carney began his career in the National Health Service Corps as an Internist working in under-served communities in Kentucky and Maryland. Later, he practiced in a staff model HMO, and then a small group practice in Delaware and Pennsylvania. He lives in Richmond, Virginia with his wife and is the father of two adult daughters.

To live a healthier life, Dr. Carney plays golf and tennis. His personal health goals include: maintaining a healthy body weight and an acceptable cholesterol profile to lower the risk for coronary artery disease; eating a well-balanced diet; and promoting overall physical mobility in order to stay active.

Cultural NeedsAt UnitedHealthcare Community Plan we believe our members have the right to receive care that is culturally competent and respects their cultural and ethnic background and origins. Primary language information is obtained from members when they enroll and they are assisted in choosing a Primary Care Physician (PCP) who will meet their cultural needs. United HealthCare provides access to a language line for translation of communication between UnitedHealthcare staff and non-English speaking members. The language line use is tracked by the Customer Service Center and reported regularly to the health plan. Each health plan then assesses its practitioner availability to insure that the cultural, ethnic, racial, and linguistic needs of its members are being met.

The Provider Directory is available at UHCCommunityPlan.com and lists the languages spoken in provider offices.

Pharmacy UpdatesPharmacy Updates are available at UHCCommunityPlan.com. The pharmacy hotline is 800-922-1557.





















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Global Days Policy Reminder If you have received a denial for ‘Payment Being Included in Allowance for Another Service’ before filing an appeal, please reference the Global Days Policy. The full plan is available on-line at UHCCommunityPlan.com/assets/Global-Days-Policy-(R0005)-1-1-11.pdf.

A few reminders follow:

• Pre-operative visits are not separately reimbursable services when performed within the assigned global period.

• Major Procedures: 90-day global value begins with the day before surgery.

• Minor Procedures (global value other than 90 days): Global period begins the day of surgery.

• Complications following a procedure, including all additional medical and/or surgical services required of the physician (not resulting in a return trip to the operating room) that occur within the designated global period are included in the Global Package.

• Procedures having a zero-, 10- or 90-day global value that are performed during the post-operative period of a procedure having a 10- or 90-day global value are considered to be included in the Global Package of the initial procedure unless an appropriate modifier is appended.

• 58 – Staged or related procedure or service by the same physician during the post-operative period.

• 78 – Unplanned return to the operating/procedure room by the same physician or other qualified health care professional following initial procedure for a related procedure during the post-operative period.

• 79 – Unrelated procedure or service by the same physician during the post-operative period.

• Services of physicians and other health care professionals of the same specialty within and using the same federal tax identification number are deemed as performed by the same physician providing global period services.

UnitedHealthcare Community Plan Evaluation & Management Services included in the global period are listed within policy as well as the global day values. If you have any questions, please contact Provider Services at 800-445-1638 or your local Provider Advocate.





















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http://UHCCommunityPlan.com/assets/Global-Days-Policy-(R0005)-1-1-11.pdf

http://UHCCommunityPlan.com/assets/Global-Days-Policy-(R0005)-1-1-11.pdf


Updated Information About 17 Alpha Hydroxyprogesterone Caproate (17P) Injection

UnitedHealthcare Community Plan has updated its drug policy for use of 17 alpha-hydroxyprogesterone caproate (17P) injection, encompassing both the compounded drug and Makena, effective Oct. 1, 2012.

UnitedHealthcare’s Policy Regarding Compounded 17P and Makena

UnitedHealthcare understands the importance of access to 17P and we continue to support the physician’s discretion to use either compounded preservative-free 17P if the prescribing practitioner has determined that a compounded product is necessary for the particular patient and would provide a significant difference for the patient as compared to the FDA-approved commercially available drug product, or Makena.

Relying on evidenced-based medicine and outcomes-based research, UnitedHealthcare has updated its drug policy for use of 17 alpha-hydroxyprogesterone caproate (17P) injection, both the compounded drug and Makena, effective Oct. 1, 2012. This policy applies to Commercial, Medicare and Community Plan business.

Options for Providing 17P to Your Patients Who Are UnitedHealthcare Community Plan Members

• State Fee-for-Service Pharmacy Program Some members of UnitedHealthcare Community Plan have pharmacy benefits that are not processed through

UnitedHealthcare Community Plan, but through the state’s fee-for-service program.

• Home Health Services UnitedHealthcare has a preferred relationship with the Women’s and Children’s Health division of Alere Health. This home health service offers a compounded, preservative-free 17P administration program, which includes in-home obstetric nurse administration, education about the risk factors and signs and symptoms of preterm labor, weekly assessments and 24/7 nurse-line support. For more information please contact Alere at 800-950-3963 or alere.com.

• Buy-and-Bill for Compounded 17P Compounded, preservative-free 17P can be located in your area by calling or visiting the International Academy of Compounding Pharmacist Locator Service at 800-927-4227 or iacprx.org. Compounding pharmacies will continue to compound 17P as long as the prescribing practitioner has determined and documented that a compounded product is necessary for the particular patient and would provide a significant difference for the patient as compared to Makena.

• Reimbursement for Buy and Bill for Compounded 17PFor providers who administer compounded, preservative-free 17P in their office through the buy-and-bill process, reimbursement is achieved by submitting a medical claim for the medication HCPCS code-J2675 progesterone injection, per 50 mg (bill 5 units per injection-250 mg/injection) with the CPT code-96372 for therapeutic, prophylactic, or diagnostic injection (specify substance or drug); subcutaneous or intramuscular, and the diagnostic code V23.41- supervision of pregnancy with





















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http://www.uhccommunityplan.com/assets/Makena-17p.pdf



http://www.alere.com/us/en.html

http://iacprx.org





















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history of preterm labor. Please contact your local provider relations representative or call provider customer service if you have questions about reimbursement.

• Pharmacy Direct Bill UnitedHealthcare Community Plan for MakenaMakena can be obtained from either Prescription Solutions by OptumRx, or CVS Caremark Specialty Pharmacy, depending upon the state. Please refer to the table.

Makena Vendors – UnitedHealthcare Community PlanPlease consult the table below to determine which pharmacy is the designated UnitedHealthcare Community Plan vendor for Makena in your state.

Contact informationCVS Caremark Specialty Pharmacy phone: 800-237-2767 fax: 800-323-2445Prescription Solutions by OptumRx phone: 888-293-9309 fax: 800-853-3844

State VendorArizona OptumRx

Delaware CVS Caremark Specialty Pharmacy

District of Columbia CVS Caremark Specialty Pharmacy

Florida CVS Caremark Specialty Pharmacy

Hawaii CVS Caremark Specialty Pharmacy

Iowa OptumRx

Kansas OptumRx Effective Jan. 1, 2013

Louisiana Contact State Medicaid Agency

Maryland OptumRx

Michigan OptumRx

Mississippi CVS Caremark Specialty Pharmacy

Nebraska CVS Caremark Specialty Pharmacy

New Jersey OptumRx

New Mexico OptumRx

New York CVS Caremark Specialty Pharmacy

Ohio CVS Caremark Specialty Pharmacy

Pennsylvania CVS Caremark Specialty Pharmacy

Rhode Island OptumRx

South Carolina CVS Caremark Specialty Pharmacy

Tennessee Contact State Medicaid Agency

Texas CVS Caremark Specialty Pharmacy

Washington OptumRx

Wisconsin Contact State Medicaid Agency



Prior AuthorizationUnitedHealthcare Community Plan requires prior authorization for compounded 17P or Makena whether administered in the office or by a home health service.

• Prior Authorization for Compounded 17P Please submit the UnitedHealthcare Community Plan’s standard medical prior authorization form with supporting documentation (documents regarding prior premature deliveries [e.g., delivery notes, discharge summaries that state gestational age at time of delivery, the reason for the premature birth], current gestational age) to the fax number listed on the form. If authorized, you will be issued an authorization number that you will need to provide to the pharmacy.

• Prior Authorization for MakenaPlease submit the UnitedHealthcare Community Plan’s standard medical prior authorization form with supporting documentation (documents regarding prior premature deliveries [e.g., delivery notes, discharge summaries that state gestational age at time of delivery, the reason for the premature birth], current gestational age) to the fax number listed on the form. If authorized, you will be issued an authorization number that you will need to provide to the pharmacy.

Upon completion of the manufacturer’s standard Makena Referral/Prescription form, place the authorization number on the top and submit via fax to the specialty pharmacy provider identified for your state (see table on page 12). These specialty pharmacy providers will bill UnitedHealthcare Community Plan directly.

Direct Billing For a complete list of pharmacies that will ship to you and bill UnitedHealthcare Community Plan directly and for more information on this policy go to UnitedHealthcare Community Plan 17P and Makena Drug Policy.

Recovery and AdherenceClinicians want individuals in their care to get better and believe that if the treatment plans they offer are followed their patient’s condition will improve. Yet treatment plans don’t work when patients don’t adhere to them. The connection between a lack of adherence and negative outcomes seems obvious, yet the World Health Organization (2003) states that for chronic illness, only 50 percent of patients adhere to their long-term therapy in developed countries.

Do the principles of recovery and resiliency offer any insights and support to approaching this problematic disconnect? There are several insights that can be adapted in most practices to help bridge this gap.

Focus on Strengths, GoalsSpend time on where patients are going and not where they are stuck.

A recovery-directed conversation with a patient focuses on individual strengths and personal goals rather than symptom severity or being sick. A conversation that focuses primarily on symptoms may further the negative self-image and sense hopelessness contributed to chronic illnesses. When a conversation includes a clear focus on the patient and their personal goals, and frames medication as one strategy toward meeting those goals, the individual is often more motivated and hopeful.





















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http://www.makena.com/media/PDFs/referral-prescription-form.pdf



Educate More, Direct LessA recovery oriented interaction in each appointment provides education on treatment — including addressing widely held, but inaccurate beliefs about medication. Of critical importance is putting written educational materials in patient’s hands. Written material supports different learning styles and affords an opportunity to easily share information with support networks.

Acknowledge Challenges and Invite ParticipationIt helps for patient’s to hear that many people find it very hard to take medicine regularly. Let them know that you want to hear the particular challenges they face in using medicine as a tool in their recovery plan. Inquiring about challenges lets patients know that you are committed to working with them toward solutions.

Support Engagement Through Tools and Community Resources Engagement is not synonymous with compliance. Compliance means an individual obeys a directive from a health care provider. Engagement signifies that a person is involved in a process through which he harmonizes robust information and professional advice with his own needs, preferences and abilities in order to prevent, manage and cure disease1.

Connecting members to local community resources can reduce isolation and increase treatment adherence. Links to reputable support groups can be found on our member portal. Tools like the Wellness Recovery Action Plan® (WRAP) have been shown to significantly enhance skills for coping with prodromal symptoms, use of wellness tools in


their daily routines, and hope for recovery2. A free version of WRAP can be downloaded from the Substance Abuse and Mental Health Services Administration (SAMHSA) web site.

SAMHSA recently issued this definition of recovery:

A process of change through which individuals improve their health and wellness, live a self-directed life and strive to reach their full potential.

SAMHSA further states:

Recovery involves individual, family, and community strengths and responsibility: Individuals, families, and communities have strengths and resources that serve as a foundation for recovery. In addition, individuals have a personal responsibility for their own self-care and journeys of recovery. The full article is available on the SAMHSA blog posting March 23, 2012.

These four simple tips reflect a recovery oriented way to support increased adherence while building a treatment plan that incorporates the patient’s own strengths and goals while providing them with the information and support they need to achieve those goals.

By Sue Bergeson, Vice President of Consumer Affairs

1 A New Definition of Patient Engagement: What is Engagement and Why is it Important?, Center for Advancing Health © 2010 http://www.cfah.org/pdfs/CFAH_Engagement_Behavior_Framework_current.pdf.

2 Cook, J. A., Copeland, M. E., Hamilton, M. M., Jonikas, J. A., Razzano, L. A., Floyd, C. B., et al. (2009). Initial outcomes of a mental illness self-management program based on Wellness Recovery Action Planning. Psychiatric Services, 60(2), 246-249.





















14

http://www.cfah.org/pdfs/CFAH_Engagement_Behavior_Framework_current.pdf

http://www.cfah.org/pdfs/CFAH_Engagement_Behavior_Framework_current.pdf

New Mexico

Provider Service Center: 800-557-9933

Practice Matters is a quarterly publication for physicians and other health care professionals and facilitiesin the UnitedHealthcare network.

M47507MS 8/12 © 2012 UnitedHealth Group, Inc. All Rights Reserved.

795 Woodlands ParkwaySuite 301Ridgeland, MS 39157


UnitedHealthcare Community Plan now offers Real-time 270/271 Electronic Health Care EligibilityInquiry and ResponseTransactions and Real-time276/277 Electronic Health Care Claim Status Inquiryand ResponseTransactions as a quick and easy way tostreamline administrative tasks..

This information is also available through the SecureProvider Portal and by phone, however real timetransactions save your office that added step.

Please see the Companion Guides located within theEDI Section on your State’s home page onUHCCommunityPlan.com for setup guidelines.

Electronic Claim SubmissionTips• Include your tax identification number (TIN) alongwith your NPI number.

• Member ID numbers are required.

• The Payer ID number indicates where clearinghousesshould direct their claims.

8220 San Pedro NESuite 300Albuquerque, NM 87113M47507NM 11/12 © 2013 UnitedHealth Group, Inc. All Rights Reserved.

Practice Matters is a quarterly publication for physicians and other health care professionals and facilities in the UnitedHealthcare network.

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