Chapter 4: Medical Management · • Description for admitting diagnosis or ICD-9-CM, or its successor, diagnosis code; and ... Nursing facilities LTAC, SNF and Auth Required Extended

Physician, Health Care Professional,Facility and Ancillary Provider

Administrative GuideUHCCommunityPlan.com

2013 KanCare ProgramChapter 4: Medical Management

Community Plan

KanCare Program Administrative Guide 9/13Copyrighted by UnitedHealthcare 2013

Welcome to UnitedHealthcareThis administrative guide is designed as a comprehensive reference source for the information you and your staff need to conduct your interactions and transactions with us in the quickest and most efficient manner possible. Much of this material, as well as operational policy changes and additional electronic tools, are available on our website at UHCCommunityPlan.com.

Our goal is to ensure our members have convenient access to high quality care provided according to the most current and efficacious treatment protocols available. We are committed to working with and supporting you and your staff to achieve the best possible health outcomes for our members.

If you have any questions about the information or material in this administrative guide or about any of our policies or procedures, please do not hesitate to contact Provider Services at 877-542-9235.

We greatly appreciate your participation in our program and the care you provide to our members.

Important Information Regarding the Use of This Guide

In the event of a conflict or inconsistency between your applicable Provider Agreement and this Guide, the terms of the Provider Agreement shall control.

In the event of a conflict or inconsistency between your participation agreement, this Guide and applicable federal and state statutes and regulations will control. UnitedHealthcare reserves the right to supplement this Guide to ensure that its terms and conditions remain in compliance with relevant federal and state statutes and regulations.

This Guide will be amended as operational policies change.


Chapter 4: Medical Management1

Chapter 4: Medical Management .......................................................................................................................... 2 4.1 Referral Guidelines .............................................................................................................................. 2 4.2 Emergency Care Resulting in Admissions........................................................................................... 2 4.3 Admission Authorization and Prior Authorization Guidelines ........................................................... 3 4.4 The Patient-Centered Medical Home ............................................................................................... 10 4.5 Determination of Medical Necessity ................................................................................................. 12 4.6 Utilization Management .................................................................................................................... 13 4.7 Care Coordination/Management ..................................................................................................... 13 4.8 Coordination of Care with Providers ................................................................................................. 18 4.9 Disease/Condition Management Programs ...................................................................................... 19 4.10 Clinical Practice Guidelines .............................................................................................................. 20 4.11 Lock-in Program ............................................................................................................................... 21 4.12 Family Planning ................................................................................................................................ 24 4.13 Maternity Care .................................................................................................................................. 24 4.14 Healthy First Steps ............................................................................................................................ 25 4.15 Neonatal Resource Services (NICU Case Management) .................................................................. 26 4.16 Delivery Admissions .......................................................................................................................... 27 4.17 Newborn Admissions ........................................................................................................................ 27 4.18 Abortion ............................................................................................................................................ 27 4.19 Hysterectomy Claims ........................................................................................................................ 29 4.20 Sterilization ....................................................................................................................................... 31 4.21 Sterilization Consent Form ............................................................................................................... 32 4.22 Concurrent Review ............................................................................................................................ 34 4.23 Discharge Planning and Continuing Care ........................................................................................ 34 4.24 Preventive Health Care Standards ..................................................................................................... 34 4.25 Recommended Childhood Immunization Schedules ........................................................................ 38 4.26 Kan Be Healthy Periodicity Schedule ................................................................................................ 38

Table of Contents



4.1 Referral GuidelinesProviders caring for our members are generally responsible for initiating and coordinating referrals of members for medically necessary services beyond the scope of their practice. Providers are expected to monitor the progress of referred members’ care and ensure that members are returned to their care as soon as medically appropriate. We require prior authorization of all out-of-network referrals. The request is generally processed like any other authorization request. The nurse reviews the request for medical necessity and/or service. If the case does not meet criteria, the nurse routes the case to the Medical Director for review and determination. Out-of-network referrals are generally approved for, but not limited, to the following circumstances:

•Continuityofcareissues

•Necessaryservicesarenotavailablewithinnetwork

Out-of-network referrals are monitored on an individual basis and trends related to individual physicians or geographical locations are reported to Network Management to assess root causes for action planning.

4.2 Emergency Care Resulting in AdmissionsPrior authorization is not required for emergency services. Emergency care should be rendered at once, with notification of any admission to the Prior Authorization Department at 866-604-3267 or fax your Prior Authorization Form (see the Appendix) by 5 p.m. the next business day. Nurses in the Health Services Department review emergency admissions within one working day of notification. UnitedHealthcare uses evidence based, nationally accredited, clinical criteria for determinations of appropriateness of care. UnitedHealthcare Community Plan does not reward for denials or provide financial incentives that encourage under-utilization. The criteria is available in writing upon request or by calling 866-604-3267.

Admission to inpatient starts at the time the order is written by a physician that a member’s condition has been determined to meet an acute inpatient level of stay.

Care in the Emergency Room

UnitedHealthcare members who visit an emergency room should be screened to determine whether a medical emergency exists. Prior authorization is not required for the medical screening. UnitedHealthcare provides coverage for these services without regard to the emergency care provider’s contractual relationship with UnitedHealthcare. Emergency services, i.e. physician and outpatient services furnished by a qualified provider necessary to treat an emergency condition, are covered both within and outside UnitedHealthcare’s service area.

An emergency is defined as a medical or behavioral condition, which manifests itself by acute symptoms of sufficient severity, including severe pain, that a prudent layperson possessing an average knowledge of medicine and health, could reasonably expect in the absence of immediate medical attention to result in:

•Placingthehealthofthepersonafflictedwithsuchconditioninseriousjeopardy(or,withrespecttoapregnantwoman, the health of the woman or her unborn child), or in the case of a behavioral condition, perceived as placing the health of thepersonorothersinseriousjeopardy

•Seriousimpairmenttosuchperson’sbodilyfunctions

•Seriousdysfunctionofanybodilyorganorpartofsuchperson

•Seriousdisfigurementofsuchperson

Chapter 4: Medical Management



4.3 Admission Authorization and Prior Authorization GuidelinesAll UnitedHealthcare Community Plan admission authorizations must contain the following information:

•PatientnameandIDnumber;

•FacilitynameandTaxIdentificationNumber(TIN)orNationalProviderIdentification(NPI);

•Admitting/attendingphysiciannameandTIN/NPI;

•DescriptionforadmittingdiagnosisorICD-9-CM,oritssuccessor,diagnosiscode;and

•Admissiondate.

All UnitedHealthcare Community Plan prior authorizations must contain the following information:

•CustomernameandIDnumber;

•OrderingphysicianorhealthcareprofessionalnameandTIN/NPI;

•RenderingphysicianorhealthcareprofessionalandTIN/NPI;

•ICD-9-CM,oritssuccessor,diagnosiscodeforwhichtheserviceisrequested;

•Anticipateddate(s)ofservice;

•Typeofservice(primaryandsecondary)procedurecode(s)andvolumeofservice,whenapplicable;

•Servicesetting;and

•FacilitynameandTIN/NPI,whenapplicable.

For Behavioral Health and Substance Use Disorders authorizations, please see the current Network Manual and the KanCare Manual Addendum available on www.ubhonline.com.

The Prior Authorization Fax Request Form is at UHCcommunityPlan.com >Health Professionals > Select State > Provider Forms. A copy of the form is also available in the Appendix.

If you have questions, please contact Prior Authorization Intake at 866-604-3267.



Service KS Medicaid1/1/2013

Chip (KBH) 1/1/2013

KS LTC 1/1/2013

Abortions Auth Not Required - Requires consent form at time of claims payment (unless state mandate)

Auth Not Required - Requires consent form at time of claims payment (unless state mandate)

Auth Not Required - Requires consent form at time of claims payment

Ambulance Services - Emergency (Par) Not Required Not Required Not Required

Ambulance Services - Non emergency, Facility to Facility transports (Par)

Auth Required Auth Required Auth Required

Ambulance Services - Non emergency, Facility to Facility transports (Par)


Ambulance Services - Non emergency, other than Facility to Facility (Par)


Dental - Comprehensive Services Auth Required. Anesthesia and facility charges covered if criteria met.

Auth Required. Anesthesia and facility charges covered if criteria met.

Auth Required. Anesthesia and facility charges covered if criteria met.

Drugs - Botox Auth Required Auth Required Auth Required

Drugs - Synagis Auth Required - Determine if managed by Pharmacy or Medical

Auth Required - Determine if managed by Pharmacy or Medical

Auth Required - Determine if managed by Pharmacy or Medical

Elective Inpatient Admissions Auth Required Auth Required Auth Required

Home Health Care All services in the home


• Aide Auth Required Auth Required Auth Required

• Private duty nursing Auth Required Auth Required Auth Required

• PT/OT/ST Auth Required Auth Required Auth Required

• Skilled nursing Auth Required Auth Required Auth Required

• Social worker Auth Required Auth Required Auth Required

• Home Infusion Auth Required Auth Required Auth Required

This prior authorization list is subject to modifications.

Services Requiring Prior Authorization




Chip (KBH) 1/1/2013

KS LTC 1/1/2013

Hospice services Auth Required Auth Required Auth Required

Intensive Outpatient (IOP) Please see Optum Behavioral Health Manual

Please see Optum Behavioral Health Manual


Nursing facilities LTAC, SNF and Extended Care

Auth Required

No Auth for Nursing Facility Custodial (Residential) Stays

Auth Required


Auth Required


Outpatient Drug and Alcohol Please see Optum Behavioral Health Manual



Outpatient Mental Health Please see Optum Behavioral Health Manual



Outpatient Surgery - Gastric Bypass Surgery Auth Required Auth Required Auth Required

Pain Management Services Not Required Not Required Not Required

Partial/Day Hospitals for MH or Drug/Alcohol




Cosmetic Surgery Auth Required Auth Required Auth Required

Ablative Procedures for Venous Insufficiency and Varicose Veins


Blepharoplasty and Brow Ptosis Repair Auth Required Auth Required Auth Required

Breast Reduction Auth Required Auth Required Auth Required

Panniculectomy and Body Contouring Procedures


Rhinoplasty, Septoplasty and Turbinate Resection


Gyncomastia Auth Required Auth Required Auth Required

Radiology (Imaging studies) Auth Required Auth Required Auth Required

MRI (magnetic resonance imaging) Auth Required Auth Required Auth Required

MRA (magnetic resonance angiogram) Auth Required Auth Required Auth Required

PET (positron emission tomography) Auth Required Auth Required Auth Required

SPECT MPI Auth Required Auth Required Auth Required

Sleep study Auth Required Auth Required Auth Required

Sterilization (includes hysterectomy) Auth Not Required - Requires consent form at time of claims payment (unless state mandate)







Chip (KBH) 1/1/2013

KS LTC 1/1/2013

• Tubal ligation Auth Not Required - Requires consent form at time of claims payment (unless state mandate)



• Vasectomy Auth Not Required - Requires consent form at time of claims payment (unless state mandate)



Therapy/Rehab (OP/office setting) Auth Required after 12th Visit

Auth Required after 12th Visit


• Occupational Therapy Auth Required after 12th Visit



• Physical Therapy Auth Required after 12th Visit



• Speech Therapy Auth Required after 12th Visit



Transplant Services Auth Required Auth Required Auth Required


* Inpatient Acute, Sub-Acute, Rehab, and SNF admissions require prior authorization.* All non-par service require prior authorization.* Prior notification not required for emergency services however hospitals must provide notification within two business days

of inpatient admission.



Prior Authorization is required on all DME equipment valued over $500.

KS Medicaid1/1/2013

Chip (KBH) 1/1/2013

KS LTC 1/1/2013

Apnea monitors Auth Required Auth Required Auth Required

Bone Growth Stimulators Auth Required Auth Required Auth Required

Cochlear Implants Auth Required Auth Required Auth Required

CPAP /Bi-Pap Auth Required Auth Required Auth Required

Electrical Stimulation for Treatment of Pain and Muscle Rehab


Hearing Aids Auth Required Auth Required Auth Required

High Frequency Chest Wall Compression Device


Hospital beds Auth Required Auth Required Auth Required

Insulin Pump Auth Required Auth Required Auth Required

Mechanical Stretching and Continuous Motion Passive Device


Orthotics Auth Required Auth Required Auth Required

Oxygen Auth Required Auth Required Auth Required

Oxygen Reauthorizations Auth Required Auth Required Auth Required

Plagiocephaly Auth Required Auth Required Auth Required

Prosthetics Auth Required Auth Required Auth Required

Stair Glides Auth Required Auth Required Auth Required

Wheel Chair Manual all wheelchair parts regardless of $ amount


Wheel Chairs Power & Scooters Auth Required Auth Required Auth Required

Wound Vacuum Devices (Wound Vac) Auth Required Auth Required Auth Required

State Specific Requirements

Incontinent Supplies Enteral Feedings Nutritional Supplements- food thickener Ostomy Supplies Intermittent Catheter Indwelling Catheter Chux/Pads Diapers Pull Ups Wipes Gloves Skin Protectant Cream Diabetic Supplies Oxygen and CPAP Supplies

Auth required regardless of $ amount in place of service home




Home and Community Based Services 1/1/2013

Assistive Services (aka Home Mods) Self-Directed Personal Svc Prov-Directed Personal Svc FMS Behavior Therapy Cognitive Rehab Home Delivered Meals Medication Reminder Medication Reminder Install Medication Reminder Dispenser Occup Therapy PERS - Install PERS - Rental Phy Therapy Sleep Cycle Support Speech/Lang Therapy Transitional Living Skills Health Maintenance Monitoring Independent Case Mgmt Int Intensive Med Care Specialized Med Care Agency Directed Service Tech Self Direct Service Attendant Medical Respite Wrap Around/Comm Support Independ Living/Skill Build Parent Support & Training Respite Care Consult Clinical & Therapy Svc Family Adjust Counseling Intensive Individual Supports Interpersonal Communication Therapy Parent Support & Training Respite Care Assistive Technology

All Services Require Authorization.

Please see the Long-Term Care Manual.




Home and Community Based Services 1/1/2013

Self-Directed Comp Support Auth Required

Prov-Directed Comp Support Auth Required

Prov-Directed Attend Care Level I Level II

Auth Required

Self-Direct Attendant Care Auth Required

Home Telehealth Auth Required

Home Tele Install Auth Required

Med Reminder Auth Required

Wellness Monitoring Auth Required

Adult Day Care Auth Required

Nurse Eval Visit Auth Required

Self-Directed Personal Svc Auth Required

Sleep Cycle Support Auth Required

Assistive Services Auth Required

Oral Health Auth Required Proc code?



4.4 The Patient-Centered Medical Home1. Billing for Nursing Facility Room and Board Services

The Patient-Centered Medical Home (PCMH) is an approach to providing comprehensive primary care to patients. The PCMH is a health care setting that facilitates relationships between individual patients, their physicians, and when appropriate, the patient’s family. A medical home is defined as primary care that is accessible, continuous, comprehensive, family-centered, coordinated, compassionate, and culturally effective.

This new clinical model is at the heart of Health Care Reform and delivery system transformation. Engaging patients in Communities of Care will improve the efficiency and effectiveness of the health care system. This model expands our relationship with providers from justpaymentmodeltoclinicalvalue-addedservicesindeliveringmoreefficientandeffectivecaretoourmembers.Italsoimprovestrustand satisfaction with our network community. UnitedHealthcare Community & State is uniquely positioned with many existing tools and capabilities to support Primary Care Physicians in this new process. UnitedHealthcare supports activities such as risk stratification, evidence-based interventions and advanced analytics. The core principal characteristics of a PCMH are based on the following:

•PersonalPhysician

•PhysicianDirectedPractice

•WholePersonCareOrientation

•CoordinatedCare

•QualityandSafety

•EnhancedCareAccess

•Optimizationthroughhealthinformationtechnologyintegration(e.g.,Rx,patientregistry)

•Eachpatienthasapersonalphysician

•Practiceoperatesasateam

•Scopeofservicesiscomprehensive

Key Aspects of the PCMH

Primary Care Practice Transformation: A practice team commits to:

•Expanding patient access and engagement – the practice has a process for same day appointments for routine and urgent care based on practice’s triage of members.

i. The practice can provide timely clinical advice by phone or email during office hours and documents the phone or emailintotheMember’sclinicalrecord;

ii. Members must have access after hours.

iii. Electronicaccesstoinformation(e.g.,clinicalsummaries,secureelectronicmedicalrecords);

iv. ContinuityofCare–Musthaveaprocesstoassignmemberstopersonalclinicianorteam;maintainrecordof members;monitoringtheproportionofmembervisitsthatoccurwithanassignedphysician/team

v. Developingamember/PrimaryCarePhysicianpartnershipinthecareofthememberscondition(s);documentsand explainswhatamedicalhomeisandhowiffunctions;howtouseitthePCMH(e.g.,patientself-managementand support and how this is holistic approach)



vi. Explain how to use the medical home (referrals hours of operation, how to seek help after hours)

vii. Explain the role of the member (e.g.,members sharing information about their medications, change in condition, symptoms, self-care needs, etc.)

viii. The practice must engage in activities that demonstrate an understanding of and meets cultural and linguistic needs ofthemembersintheirpractice;

ix. The practice’s care team manages the members in defining their roles internally, meets on members who are in their care and has a clear communication process, trainings

•Improvingchronicconditionpopulationmanagement– UnitedHealthcare will help participating practices to not only identify atriskmembers,butalsodevelopstrategiestoachievesuccessfuloutcomes;

•Providingteam-basedcarethatfocusesoncaretransitions&coordination;

•Monitoringperformanceonkeyquality/utilizationmeasuresandeffectively;

•Utilizingavailabletechnologies including patient registries and e-prescribing where available.

Primary Care Practice Support:

UnitedHealthcare will commit to assisting participating PCMH practices in their transformation and acquisition of their NCQAPPC©-PCMH™certificationby;

•Providingenablingtechnologies

•Providingtimely/actionablepatientclinicaldata

•Providing/supportingcarecoordinationthroughCareManagementservices

We also support the Medical Home in the tracking and monitoring of specific aspects of the members’ care and status of their condition in our clinical systems. This data provides the basis for alerting health care professionals if early intervention is warranted, reinforces members’ disease-specific education, and further promotes behavior change, compliance, and improved quality of care. The UnitedHealthcare Community Plan Care Management Program defines quality care as treatment that:

•Improvesthemember’sphysicalandemotionalstatus;

•Promoteshealthandhealthylifestylesandbehaviors;

•Encouragesearlydetectionandtreatment;

•Involvesmembersininformeddecision-making;

•Isprovidedbyahealthcareteamsensitivetoillness-relatedissues;

•Isbasedonevidence-basedmedicalprinciples;

•Usestechnologyandotherresourceseffectively;

•Isaccessibletomembersinatimelyfashion;and,

•Issufficientlydocumentedinmedicalrecords.



In support of the PCMH we also provide consultative support by assigning a Medical Home Consultant who works directly with the leadership of their assigned physician practices. This committed roll is designed to support the practice transformation from a reactive model of patient care to a proactive Medical Home, using data to effectively measure, monitor and manage care of priority, high-risk members and present results and outcomes to the Practice’s executive leadership.

We have also integrated workflows across the entire continuum of care with special emphasis on Transition of Care, and integrate and leverage resources from UnitedHealthcare Community Plan to communicate on members who may be hospitalized.

Upon launch of the Medical Home, UnitedHealthcare Community Plan will establish:

•aclearsetofgoalsaroundthegapstobeaddressed

•goalsettingthatneedstobedonewiththeCEO,CMOandCOOofthepractices.

Onamonthlybasis,UnitedHealthcareCommunityPlanassignedstaffwilljointlyassessinterventionstodrivegoalstoresults.

Practices engaging in the PCMH model will be creating a comprehensive approach to managing care and a positive approach to better patient outcomes.

4.5 Determination of Medical NecessityUnitedHealthcare evaluates medical necessity according to the following standard.

Medically necessary services or supplies are those necessary to:

•Prevent,diagnose,correct,preventtheworseningof,alleviate,ameliorate,orcureaphysicalormentalillnessorcondition;

•Maintainhealth;

•Preventtheonsetofanillness,conditionordisability;

•Preventortreataconditionthatendangerslifeorcausessufferingorpainorresultsinillnessorinfirmity;

•Preventthedeteriorationofacondition;

•Promotethedevelopmentormaintenanceofmaximalfunctioningcapacityinperformingdailyactivities,takingintoaccountboth thefunctionalcapacityoftheindividualandthosefunctionalcapabilitiesthatareappropriateforindividualsofthesameage;

•Preventortreataconditionthatthreatenstocauseoraggravateahandicaporcausephysicaldeformityormalfunctionandthere is no other equally effective, more conservative or substantially less costly course of treatment available or suitable for the member.



The services provided, as well as the type of provider and setting, must reflect the level of services that can be safely provided, must be consistent with the diagnosis of the condition and appropriate to the specific medical needs of the member and not solely for the convenience of the member or provider of service. In addition, the services must be in accordance with standards of good medical practice and generally recognized by the medical scientific community as effective.

Experimental services or services generally regarded by the medical profession as unacceptable treatment are considered not medically necessary. These specific cases are determined on a case-by-case basis.

The determination of medical necessity must be based on peer-reviewed publications, expert pediatric, psychiatric and medical opinion, and medical/pediatric community acceptance. In the case of pediatric members, the standard of medical necessity shall include the additional criteria that the services, including those found to be needed by a child as a result of a comprehensive screening visit or an inter-periodic encounter, whether or not they are ordinarily covered services for other members, are (a) appropriate for the age and health status of the individual, and (b) will aid the overall physical and mental growth and development of the individual and the service will assist in achieving or maintaining functional capacity.

4.6 Utilization ManagementUtilization Management (UM) decision making is based only on appropriateness of care and service and existence of coverage. The organization does not specifically reward practitioners or other individuals for issuing denials of coverage or care. Financial incentives for Utilization Management decision makers do not encourage decisions that result in underutilization. A provider may call UnitedHealthcare Community Plan Utilization Management at 866-604-3267 to answer any questions about Utilization Management or denials. Someone is available to take your calls 24 hours a day, seven days a week.

4.7 Care Coordination/ManagementOur Care Management program is guided by the principles of the UnitedHealthcare Personal Care Model. We developed the Personal Care Model to address the needs of medically underserved and low-income populations. The Personal Care Model places emphasis on the individual as a whole, to include the environment, background and culture. If you need to directly refer a member who is not currently in the Care Management program, you may call 877-542-8997.

Our model of Care Coordination/Care Management provides a platform for systematic, comprehensive care that closes the gap in the treatment of acute, chronic, co-morbid and other conditions that impact health and self-care. This model is founded upon best practices and principles for the care of children with special needs, the disabled, elderly, chronically ill, and frail individuals. We apply an individualized, holistic approach to help members navigate complex delivery systems, stabilize or delay progression of their illnesses or conditions, and promote independence and quality of life. We utilize advanced technology to improve communications and streamline day-to-day operations.



Specialty Programs for Care Management include but are not limited to: High Risk Care Management, Care Coordination for members receiving LTSS benefits, Disease Management, Maternity Care Management (Healthy First Steps), Neonatal Intensive Care Unit (NICU) Care Management,Transplant Programs, Obesity Management/Bariatric Surgery Programs.

Our Care Coordination model:

•IntegratesPrimary,Acute,Behavioral,andLong-TermServicesandSupports(LTSS)careservicesintooneconsumer-driven, seamless system of care

•Incorporateshealthriskscreening,medical/socialassessment,careplanning,andongoingcareplanmonitoringtoidentifyand address member needs.

•Assignshighestriskmembers,membersexperiencingtransitions,andmembersreceivingLTSStoadedicatedCareCoordinator who assists the member and their families to plan & coordinate care, provide education for enhanced self management, and refer to appropriate community resources for additional support

•Providesmemberswithtimely,medicallynecessaryhealthcareservicesintheleastrestrictiveandmostappropriatesetting

•Focusesonpreventive,primary,andsecondarycarethatslowsillnessprogressionanddisability

•Involvesmembers,caregivers,physicians,andotherprovidersinthecareplanningprocess

•Worksincollaborationwithproviders,caregivers,communityresources,andotherswhoareinvolvedinthecareofthemember.

If you need to directly refer a member who is not currently in the Care Management program, you may call 877-542-9235.

Identification and Stratification

AllmemberswhoareenrolledinLTSSWaiverPrograms-FrailElderly(FE),PhysicalDisability(PD),TraumaticBrainInjury(TBI),Technology Assisted (TA), Serious Emotional Disturbance (SED), and Autism - are immediately assigned to a Care Coordinator for comprehensive assessment and coordination of physical/behavioral health needs and LTSS.

The Health Risk Assessment and our predictive modeling and stratification system are the primary tools for identifying High Risk (Non LTSS/Waiver) members and those with other specialty needs for Care Management programs and/or assignment to a dedicated Care Coordinator.

Health Risk Assessment

The Health Risk Assessment is an initial assessment tool used for new and existing members, to identify a member’s health risks. Based upon the member’s response to a series of question, the tool will assign a score that corresponds to a level. These levels are as follows:

•Level1:Low-riskmemberswhoaretypicallyhealthy,stableoronlyhaveonemedicalconditionthatiswellmanaged.

•Level2:Moderate-riskmemberswhomayhaveaseveresinglecondition,ormultipleconditionsacrossmultipledomains of Care Management.

•Level3:High-riskmemberswhoaremedicallyfragile,havemultipleco-morbiditiesandneedcomplexCareManagement.



Stratification

Our multi-dimensional, episode-based predictive modeling tool, compiles information from multiple sources including claims, laboratory and pharmacy data and uses it to predict future risk for intensive care services. On a monthly basis, the system uses algorithms to identify members for High Risk or Specialty Care Management Programs. The algorithm takes into consideration inpatient and emergency room (ER) use. An “Overall Future Risk Score” is assigned to each member and represents the degree to which the High Risk Care Management or Specialty Program has the opportunity to impact members’ health status and clinical outcomes. This assists Care Managers in identifying members who are most likely to benefit from interventions.

Outreach and other Identification Processes

While LongTerm Care/Waiver Program enrollment, Health Risk Assessments and retrospective data are the first line of identification of new members in the UnitedHealthcare Care Management Program, we have developed an extensive outreach program that supports real-time identification and referral for our Care Management services.

Through community partnerships and relationships, our staff encourages and educates providers, ER staff, and hospital discharge planners, and other community-based providers to refer program members for a greater intensity and frequency of Care Management interventions when the situation requires it. Our Care Management staff is responsible for collaborating with other community partners such as program care managers, clinic staff, other health care team community partners, and fiduciary entities in order to identify members.

Finally, in addition to claims and pharmacy data, we integrate authorization and pre-certification information into the Care Management software system. This data provides real-time identification of members experiencing health care barriers and self-care deficits.

Care Management Interventions

After a member has been identified, the Care Coordinator contacts the member, member’s parent or caregiver by telephone to engage them in the Care Management Program. Program and health education materials targeted to the member’s specific care opportunities and Care Management interventions are shared with the member.

Members have the right to opt out of Care Management programs if they do not wish to participate, however to be eligible to receive LTSS, the member must consent to in-home assessment and ongoing reassessment by the Care Coordinator.

Because our High Risk Care Management and Specialty Programs provide benefits and quality-of-life improvements that ultimately impact the overall costs in care, our enrollment staff makes every attempt to enroll members in the available programs. We employ anumberofstrategiestolocateandcontactthemember’sparentsorcaregivers,includingafter-hourcalls;searchingforupdatedmemberinformationbycontactingthePCP/specialistofficeandreviewingpriorauthorizationinformation;andsendingwrittencorrespondence. We document and track contacts to ensure that all options have been exhausted prior to reporting failure to contact.



As part of full engagement in the Care Management Programs, the Care Coordinator performs a comprehensive health risk and needs assessment that identifies additional risk factors, current and past medical history, personal behaviors, family history, social history, functional capabilities, and environmental risk factors. This information is used to augment and validate the risk stratification of members. We also institute disease specific assessments to augment the Health Risk Assessment.

We deploy evidence-based interventions for our Care Management Programs. The following general interventions have been structured to improve members’ health status:

•HealthRiskAssessment;

•HealthandCarePlanreviewsviainhomeassessmentorphonecalls;

•ProvideassignedCareCoordinator’scontactinformationtothemember/family;

•Ongoingmonitoringofclaimsandothertoolstore-assessriskandneeds;

•Accesstoprogramwebsitesformembers;

•Post-hospitalizationandemergencyroomassessment;

•Educationalmaterialssenttothememberforpreventivecare&otherconditionspecificself-carereference;

•CommunicationwiththePCPidentifyingthemember’sinvolvement,interventionandpointofcontactforCareManagement Programs;and

•Additionaland/orspecificinterventionsconductedtoindividualizetheplanofcare.

Plan of Care

The Care Coordinator develops and implements an individualized plan of care for members requiring services, reviews the member’s progressandadjuststheplanofcare,asnecessary,toensurethatthemembercontinuestoreceivetheappropriatecareintheleastrestrictive setting. The Care Coordinator will involve the member, member’s family and providers caring for our member in the plan of care development process. Care Coordinators assist providers when necessary to direct the course of treatment in accordance with the evidence-based clinical guidelines that support our Care Management Program. The plan of care addresses the following areas of care as relevant to the member’s needs:

•LongTermServicesandSupports(formembersenrolledinWaiverprograms)basedonfunctionalabilityandavailable community supports,

•Behavioralhealth,

•Nutrition,

•Medication,

•PreventiveCare,

•Self-monitoringofsymptoms,vitalsignsandearlyidentificationofpotentialcomplications,

•Emergencymanagement/co-morbidconditionactionplan,

•Caregiverbackupand/ordisasterplans,

•Routinefollow-upwithPCPorspecialtyproviders,and

•Otherauthorizedservicesortreatments.



When the plan of care is implemented, our goals are:

•Toensurethememberisleveragingpersonal,family,andcommunitystrengthswhenableandavailable;

•Toensureweareusingevidence-basedguidelinesandbestpracticesforeducationandself-managementinformationwhile integratinginterventionstoaddressco-morbidities;

•Tomodifyourapproachorservicesbasedonthefeedbackfromthemember,family,andotherhealthcareteammembers;

•Todocumentservicesandoutcomesinawaythatcanbecapturedandmodifiedinordertocontinuallyimprove;

•Tocommunicateeffectivelywiththeprimarycareprovider/specialistandotherprovidersinvolvedinthemember’scare;

•Tosupportmemberadherencetotreatmentplansandself-carebestpractices;and

•Tomonitormembersatisfactionwithservices,adjustingasneeded.

Pharmacy

UnitedHealthcare’s pharmacy management is integrated into our Care Management Program and, like the Care Management Program, is based on our Personal Care Model which emphasizes the whole individual, including environment, background and culture.

UnitedHealthcare integrates pharmacy management for asthma into our regular Care Management Program.

With the exceptions of the asthma component, pharmacy management services, UnitedHealthcare provides pharmacy management through OptumRx, our pharmacy benefit manager, and a United Health Group company. OptumRx administers Disease Therapy Management (DTM) programs that are clinical, patient-focused programs offered as part of Specialty Pharmacy Care Management services.TheobjectiveofourDTMprogramsistoimprovepatientqualityofcarethrougheducationandcommunication.

OptumRx Specialty Pharmacy offers DTM programs for the following disease states/conditions required by the Board for the Kansas Medicaid plan programs:

•Rheumatoidarthritis,

•Growthdisorders,

•Hemophilia,

•Riskofrespiratorysyncytialvirusduetoprematurity.

Additional programs to be provided to Kansas Medicaid plan program members include:

•HepatitisC,

•Multiplesclerosis,

•Anemiarelatedtochemotherapy.



The Plan of Care (POC) will address the following areas of care:

•Psychosocialadjustment,

•Nutrition,Complications,Pulmonary/cardiacrehab,

•Medication,

•Prevention,

•Self-monitoringofsymptomsandvitalsigns,

•Emergencymanagement/co-morbidconditionactionplan,

•Appropriatehealthcareutilization.

Our Care Management Program is supported by UnitedHealthcare’s integrated clinical system, which includes basic and comprehensive supplemental assessments, facilitates the development of integrated care plans, and includes ongoing monitoring and evaluation tools.

4.8 Coordination of Care With ProvidersEach member is encouraged to select a medical home for community-based health and preventive services. Providers caring for our members receive reports regarding the health status of members participating in our Care Management Program. As this link is established, we involve the provider in the plan of care development process and assist them in directing the course of treatment in accordance with evidence-based clinical guidelines.

The Care Manager collaborates with the member’s provider on an ongoing basis to ensure integration of physical and behavioral health issues. In addition, the care manager will ensure the plan of care supports the member’s/caregiver’s preferences for psychosocial, educational, therapeutic and other non-medical services. The Care Manager ensures the plan of care supports providers’ clinical treatment goals and builds the plan of care to reflect personal, family and community strengths.

The Care Manager and member will review the member’s compliance with the treatment during each assessment cycle. Treatment, including medication compliance, is established as a health care goal with interventions and progress towards that goal documented in each assessment session. At any point that the care manager recognizes that the member is non-compliant with part or all of the treatment plan, the care manager will:

•Worktoidentifyandunderstandthemember’sbarrierstosuccess;

•Problemsolveforalternativesolutionswiththemember;

•Reportnon-compliancetothetreatingprovider/specialist,offerpotentialsolutionsandintegrateproviderfeedback;

•Facilitateagreementforchangebetweenallpartiesandmonitorprogressofthechange.



As the member’s medical home, the provider caring for our member is continuously updated on the member’s participation in the Care Management Program, the member’s compliance with the plan of care and any unscheduled hospital admissions and emergency room visits. The provider receives notifications of when members are enrolled and disenrolled from the Care Management Program the assigned Care Manager for the Care Management Program, and how to contact the Care Manager. In addition, the provider receives notification of members who have generated care opportunities related to the Care Management Program. These evidence-based medical guidelines are generated from our multi-dimensional, episode-based predictive modeling tool.

We also distribute clinical practice guidelines upon the provider’s request and provide training for providers and their staff on how best to integrate practice guidelines into everyday physician practice. When a provider demonstrates a pattern of non-compliance with clinical practice guidelines, the Medical Director may contact the provider by phone or in person to review the guideline and identify any barriers that can be resolved.

4.9 Disease/Condition Management ProgramsDisease/Condition Management is a specialized component of our Care Coordination program. UnitedHealthcare Community Plan Disease Management focus is on conditions prevalent in our KanCare population and in which members’ self-care efforts have been shown to significantly impact health outcomes to the positive.

1. Coronary Artery Disease

2. Chronic Obstructive Pulmonary Disease

3. Prenatal Care especially for High Risk Pregnancies (Healthy First Steps program)

4. Diabetes mellitus

5. Asthma

6 Smoking Cessation programs

7. Obesity (Pediatric & Adult)

8.MajorDepression

TheprimaryobjectivesofDisease/ConditionManagementaretosupportmembersinestablishingandmaintainingastabilized,improved state of health. This is achieved by reducing risk factors and improving the overall health of members through encouragement of appropriate self-care, reinforcement of physician – member relationship, member and provider education, improved monitoring, and targeted interventions.

Care Coordinators assist members to understand what they can do to be good partners in their health care, help members find resources their healthcare providers feel will be of benefit to them, and reinforce the health care provider’s treatment plan.



Upon the identification of members meeting the disease management program criteria, PCPs will receive a letter informing them of the member’s inclusion in the Disease/Condition Management program, invites the Primary Care Provider’s partnership, informs how to use Disease Management services to augment the treatment plan, and provides disease-specific resources, e.g., clinical guidelines, patient education materials, etc. Care Coordinators communicate with providers regarding changes in a member’s condition and/or needs for assistance (e.g., durable medical equipment needed, care issues, etc.).

Members are assessed for the targeted health conditions and monitored against goals for:

•Diseasespecificeducationandinterventions

•Medicationandtreatmentadherence

•Symptommonitoringandself-care

•Nutritionandweightmanagement

•Lifestylechangessuchasphysicalactivityorsmokingcessation

•Educationandassistancewithadvancedirectivesandcaregiversupport

•Referralstointernalandcommunityprograms

The Disease Management Program utilizes various sources and databases to track members’ satisfaction and effectiveness of interventions. Assessment of Disease/Condition management incorporates audited HEDIS or HEDIS-like results specifically relevant to the condition upon which there is focus. Assessment of members’ satisfaction with Programs follows the UnitedHealthcare Community Plan standards and processes but with specific focus for issues relevant to Condition Management.

4.10 Clinical Practice GuidelinesUnitedHealthcare adopts clinical practice guidelines as the clinical basis for our Care Management program. Clinical guidelines are systematically developed, evidence-based statements that help providers make decisions about appropriate health care for specific clinicalcircumstances.WeadoptclinicalguidelinesfromrecognizedsourcesasdefinedbytheNationalCommitteeonQualityAssurance(NCQA)andUtilizationReviewAccreditationCommission(URAC).

UnitedHealthcare uses nationally recognized, evidence-based clinical criteria to guide our medical necessity decisions, including Milliman Healthcare Management Guidelines, Behavioral Health Level of Care Guidelines, and CMS policy guidelines. Milliman is widely regarded for its scientific approach, using comprehensive medical research to develop recommendations on optimal length of stay goals, best-practice care templates, and key milestones for the best possible treatment and recovery. Our Behavioral Health Level ofCareGuidelinesprovideobjectiveandevidence-basedadmissionandcontinuingstaycriteriaformentalhealthandsubstanceabuseservices. These guidelines are integrated into our clinical system.



For specific state benefits or services not covered under national guidelines, we develop criteria through the review of current medical literature and peer reviewed publications, Medical Technology Assessment Reviews and consultation with specialists.

The clinical practice guidelines are reviewed and revised annually. The UnitedHealthcare Executive Medical Policy Committee (EMPC) reviews and approves nationally recognized clinical practice guidelines. The guidelines are then distributed to the National QualityManagementOversightCommittee(NQMOC)andtheHealthPlanQualityManagementCommittee.

Medical guidelines are available and shared with providers upon request and are available on the provider website, UHCCommunityPlan.com. Policies and guideline updates are communicated through provider notices prior to implementation.

4.11 Lock-in ProgramThe Lock-in Program coordinates care and ensures that Members selected for enrollment in the Lock-in Program use services appropriately and in accordance with department rules and policies. The Lock-in Program ensures that the Member is locked into a pharmacy, a hospital, and a Primary Care Physician, when the Member meets the identified criteria.

A Member can be selected for the Lock-in Program review when any one or more of the following occur:

1.AutilizationreviewreportindicatestheMemberhasnotutilizedhealthcareservicesappropriately;or

2. Medical providers, social service agencies, or other concerned parties have provided direct referrals to the State or to UnitedHealthcare Community Plan.

3. Member identified as committing fraud (reported and/or data analytics).

When a Member is selected for Lock-in Program review, our staff (with clinical oversight) reviews their medical and/or billing history to determine if the Member has utilized health care services at a frequency or amount that is not medically necessary. A Member may be placed in the Lock-in Program when medical and/or billing histories document any of the following:

a.Concurrentlyobtainingservicesfromtwoormoreprovidersofthesamespecialty,notinthesamegrouppractice,withnoreferrals;

b.Usingtwoormoreemergencyfacilitiesfornon-emergentdiagnosis;

c.Concurrentlyusingtwoormoreprescribingphysicianstoobtaindrugsfromthesametherapeuticclassofmedication;

d. Two or more occurrences of having prescriptions for the same therapeutic class of medication filled two or more times on the same or subsequent day by the same or different providers

e. Concurrently using two or more pharmacies to obtain quantity of drugs from the same therapeutic class of medication which exceedthemanufacturer’smaximumrecommendeddosageasapprovedbytheFoodandDrugAdministration(FDA);

f.ReportofMemberusingthemedicalcardtopurchasedrugsonaforgedprescription;

g.ReportofMemberloaningacardtoanotherindividualtoobtainMedicaidreimbursedservices;

h.OnrequestorrecommendationofStateLegalorKDHE-DHCFforcause;or

i. Consistently seeking/obtaining medical services which are not supported by diagnosis or medical records/documentation.

Member lock-in period is 12 months. After the lock in has ended, the member will be re-reviewed at an interval of 6 months and 12 months. If the member is found to be over utilizing again they will be placed on an extended lock-in.



As a result of the Lock-in Program review, our staff may take any of the following steps:

1.Determinethatnoactionisneededandclosethemember’sfile;

2. Send the Member and, if applicable, the Member’s authorized representative, a letter of concern with information on specific findingsandnoticeofpotentialplacementintheLock-inProgram;

or

3. Staff will present the case to the Medical Director or his clinical designee, who will determine that the utilization guidelines for Lock-in Program placement establish that the Member has utilized healthcare services at an amount or frequency that is not medically necessary, in which case the department or MCO will take one or more of the following actions:

a.RefertheMemberforCaseManagement/CareCoordinationandeducationonappropriateuseofhealthcareservices;

b.RefertheMembertoothersupportservicesoragencies;or

c. Place the Member into the Lock-in Program for an initial placement period of twelve (12)months and assign the Member to a Care Coordinator and/or a Behavioral Health Advocate (co-managed).

When a Member is initially placed in the Lock-in Program:

1. UnitedHealthcare Community Plan places the Member for twelve (12) months, with all of the following types of healthcare providers:

a. Primary Care Physician

b. Pharmacy

c. Hospital

2. The Managed Care Member will remain with UnitedHealthcare Community Plan for no less than twelve (12) months unless:

a.TheMembermovestoaresidenceoutsideourservicearea;or

b. The Member’s assigned provider no longer participates with us and is available in another MCO, and the Member wishes to remain with the current provider.

3. A Managed Care Member placed in the Lock-in Program must remain in the Lock-in Program for the initial twelve (12) month period regardless of whether the member changes MCOs or becomes a Fee-for-Service Member.

When the Member is initially placed in the Lock-in Program, we send the Member and, if applicable, the Member’s authorized representative, a written notice containing at least the following components:

1. Action MCO intends to take relate to Lock-In

2. Reasons for this action

3. Instructions for the Member to choose a primary pharmacy or physician as their only source for obtaining prescribed drugs

4. Member’s right to file an appeal

5. Effective date of the lock-in, which is at least thirty (30) days after the date of the letter

6. And any other requirements under federal, state laws and regulations

7. The duration of the enrollment and re-evaluation period



Provider Participation

Providers participating in UnitedHealthcare Community Plan will see any Lock-in Program Members assigned to them.

When a Provider is selected for a Lock-in Program Member, the PCP’s office is contacted to confirm that the PCP is taking new patients, verify the Provider’s practice location and inquire about appointment availability.

1. Provider(s) must be located in the Member’s local geographic area, and/or be reasonably accessible to the Member.

2. Primary Care Provider supervises and coordinates health care services for the Member, including continuity of care and referrals to specialists when necessary.

3. Pharmacy fills all prescriptions for the Member.

4. Hospital provides all non-emergent hospital services.

A Member placed in the Lock-in Program cannot change assigned providers for twelve (12) months after the assignments are made, unless:

1.TheMembermovestoaresidenceoutsidetheprovider’sgeographicarea;

2.TheProvidermovesoutoftheMember’slocalgeographicareaandisnolongerreasonablyaccessibletotheMember;

3.TheProviderrefusestocontinuetoservetheMember;

4. The Member did not select the Provider. The Member may request to change an assigned Provider once within thirty (30) calendardaysoftheinitialassignment;

5. The Member’s assigned Provider no longer participates with us. In this case, the Member may select a new Provider from the list of available Providers in our network or follow the assigned Provider to the new MCO

UnitedHealthcare Community Plan may remove a Member from the Lock-in Program if the Member:

1.SuccessfullycompletesatreatmentLock-inProgramthatisprovidedbyaChemicalDependencyServiceProvider;

2.SubmitsdocumentationofcompletionoftheapprovedtreatmentLock-inProgramtothedepartment;and

3. Maintains appropriate use of health care services within the utilization guidelines for six (6) months after the date the treatment ends.

4. The decision to remove a Member from the Lock-in Program will be documented in the case notes so that it contains complete informationincluding,ifapplicable,medicaljustificationforwhytheMemberwasremovedfromtheLock-inProgram.



4.12 Family PlanningFamily planning services are covered when provided by physicians or practitioners to members who voluntarily choose to delay or prevent pregnancy. Covered services also include the provision of accurate information and counseling to allow members to make informed decisions about specific family planning methods available. Members have a choice to receive services from their UnitedHealthcare PCP/PCCM clinic or go directly to a local health department or family planning clinic. Members do not need a referral (permission) from the Health Plan for the services below:

•FamilyPlanningservicesandbirthcontrol

•Immunizations

•HIVandAIDStesting

•TBscreeningandfollow-upcare

•Sexuallytransmitteddiseasetreatmentandfollow-upcare

4.13 Maternity CarePregnant UnitedHealthcare members should receive care from UnitedHealthcare participating providers only. UnitedHealthcare will consider exceptions to this policy if 1) the woman was in her second trimester of pregnancy when she became an UnitedHealthcare member, and 2) if she has an established relationship with a non-participating obstetrician.

Providers should notify UnitedHealthcare promptly of a member’s confirmed pregnancy to ensure appropriate follow-up and coordination by the UnitedHealthcare Healthy First Steps coordinator.

Providers need to contact Healthy First Steps by submitting an American College of Gynecology or any initial prenatal visit form to Healthy First Steps via fax 877-353-6913. Providers with questions regarding Healthy First Steps should call 800-599-5985. (See more information about Healthy First Steps below.)



The following information must be provided to UnitedHealthcare within one business day of the visit when the pregnancy is confirmed:

•Patient’snameandmemberIDnumber

•Obstetrician’sname,phonenumber,andmemberIDnumber

•Facilityname

•Expecteddateofconfinement(EDC)

•PlannedvaginalorCesareandelivery

•Anyconcomitantdiagnosesthatcouldaffectpregnancyordelivery

•Obstetricalriskfactors

•Gravida

•Parity

•Numberoflivingchildren

•Previouscareforthispregnancy

An obstetrician does not need approval from the member’s provider for prenatal care, testing or obstetrical procedures. Obstetricians may give the pregnant member a written prescription to present at any of the UnitedHealthcare participating radiology and imaging facilities listed in the provider directory.

4.14 Healthy First Steps (Maternity Case Management)Designed to improve birth outcomes and reduce Neonatal Intensive Care Unit (NICU) admissions, the Healthy First Steps program uses early identification to:

•Helpovercomecommonsocialandpsychologicalbarrierstoprenatalcare;

•Increasememberunderstandingoftheimportanceofearlyprenatalcare;

•Increasethemother’sself-efficacybyidentifyingandbuildingthemother’ssupportsystem;

•Ensureappropriatepostpartumandnewborncare;

•Developthephysician/memberpartnershipandrelationshipbeforeandafterdelivery.



4.15 Neonatal Resource Services (NICU Case Management)Our Neonatal Resource Services program manages NICU cases inpatient and post-discharge to reduce costs and improve outcomes. Our dedicated team of NICU nurse case managers, social workers and medical directors collaborate to provide both clinical care and psychological services.

Neonatal Resource Services (NRS)

Neonatal Resource Services (NRS) Program helps to ensure quality of care and efficiency in treatment of NICU babies. The NRS Program Eligible Member is defined as a newborn who has been admitted to the NICU upon birth (including babies that get transferred from PICU to NICU) and/or any infants readmitted within the first 30 days of life. All babies admitted to the NICU will be followed by NRS. (Detained babies will also be eligible for the program for the initial inpatient hospitalization only).

NRS Neonatologists and NICU nurses proactively manage NICU patients through evidence based medicine and the use of care plans. The NRS nurse case manager will:

•Collaboratewiththefamily,physician,andDischargePlanneronacoordinateddischargetoensuretimelyprovisionofcareand delivery of services

•Developalternatestrategiesforcaremanagementinterventions(asneeded)

•Facilitatethedischarge

•Coordinateservicespost-dischargeasrequiredifmemberisunderNRScasemanagement (The NRS Program also provides onsite nurses in many markets.)

The NRS program includes a multidisciplinary approach to case management in the 30 day post discharge period. The NRS nurse case manager’s role is comprehensive and includes:

•Dischargeplanningandfacilitationoftimelyrelease

•Coordinationofalternativecareoptions,includinghomecare,equipmentandskillednursing

•Post-dischargeSupportfor30days,exceptdetainedbabies

•Educatingparentsandfamiliesonlocalcommunityresourcesandsupportservicesavailable

•Casemanagersprovidebenefitsolutionstofamiliesinordertoensureappropriateservicesfortheneonate

Home Care and All Prior Authorization Services

Home Care should be pre-certified by the agency or the hospital Discharge Planner ordering the home care by calling the Prior Authorization Department at 800-366-7304 or sending a fax to 866-841-9336.



4.16 Delivery AdmissionsAuthorization for delivery is not required, but delivery notification is requested. Please call 866-604-3267 or fax the following information for the newborn to UnitedHealthcare Intake at 866-943-6474:

•Dateofbirth

•Birthweight

•Gender

•Deliverytype

•Gestationalage

4.17NewbornAdmissionsThe hospital must notify UnitedHealthcare prior to or upon the mother’s discharge, if the baby stays in the hospital after the mother is discharged. HFS will conduct concurrent review of the newborn’s extended stay. The hospital should make available the following information:

•Dateofbirth

•Birthweight

•Gender

•Anycongenitaldefect

•Nameofattendingneonatalogist

4.18AbortionBenefit Category - Physicians’ Services Indications and Limitations of Coverage Abortions are covered only under the following conditions:

1.Ifthepregnancyistheresultofanactofrapeorincest(usetheG7modifier);or

2.Inthecasewhereawomansuffersfromaphysicaldisorder,physicalinjury,orphysicalillness,includingalife-endangering physical condition caused by or arising from the pregnancy itself.

The Abortion Necessity form (next page) must be completed in order for the claim to be processed. The Abortion Necessity Consent Form can also be found at the following web address: https://www.kmap-state-ks.us/Documents/Content/Forms/Consent/Abortion.pdf

Prior Authorization is not required for Abortions. The Abortion Necessity Consent Form must be completed in its entirety and submitted with the claim.



Revied 07/2011

Revised 07/2011

Kansas Medical Assistance ProgramP.O. Box 3571 Provider Line: 1-800-933-6593 From the office of the fiscal agentTopeka, KS 66601-3571 Beneficiary Line: 1-800-766-9012

Abortion NecessityI, _____________________________________ (name of physician), certify on the basis of my

professional judgment, the pregnancy of _____________________________________ (name of patient)

of __________________________________________________________________________ (address),

____is suffering from a physical disorder, physical injury or physical illness, including a life-endangering

physical condition, caused by or arising from the pregnancy itself.

___ is a result of rape.

___ is a result of incest.

______________________________________________ _______________________(Signature of Patient) (Date 00/00/0000)

______________________________________________ _______________________(Signature of Physician) (Date 00/00/0000)

_______________________________________________________________________(Physician’s Address)

______________________________________________(Physician’s NPI)

This form must be completed in its entirety. Incomplete information may result in the claim being denied.



4.19 Hysterectomy ClaimsHysterectomies are covered only for medically indicated reasons. One of the following conditions must also be met and documented. If one of these three options does not apply to the situation for which you have provided service, you may not be reimbursed.

•TheindividualorherrepresentativesignstheHysterectomyNecessityFormacknowledgingreceiptofinformationthatthesurgery will make her permanently incapable of reproducing. The Sterilization Consent Form is not an acceptable substitute.

•Thephysicianmustcertifyinwritingthattheindividualwasalreadysterileandstatethecauseorreasonforthesterilityonanattachment to the claim. The signature in field 31 of the claim form will not suffice.

•Thephysicianmustcertifyinwritingthatthesurgerywasperformedunderalife-threateningsituationandindividualcertificationwas not possible. Include a description of the nature of the emergency. The signature in field 31 of the claim form will not suffice. Refer to Section 4300 of the General Special Requirements Manual.

A copy of the hysterectomy statement must be attached to the surgeon’s claim at the time of submission. The Hysterectomy Consent Form, located on the next page, can be photocopied for your use. A copy of the hysterectomy statement is not required to be attached to related claims (anesthesia, assistant surgeon, hospital, or rural health clinic) at the time of submission. However, no related claim will be paid until the hysterectomy statement with the surgeon’s claim has been reviewed and determined to be correct, unless the related claim has the correct hysterectomy statement attached.

A total hysterectomy and the removal of tubes/ovaries cannot be billed as separate procedures when performed by the same provider. This applies to the following procedure codes:

•Totalhysterectomy:58150,58152,58180,and58200

•Removaloftubes/ovaries:58700,58720,58920,58925,58940,and58943



Revied 07/2011

Revised 07/2011

Kansas Medical Assistance ProgramP.O. Box 3571 Provider Line: 1-800-933-6593 From the office of the fiscal agentTopeka, KS 66601-3571 Beneficiary Line: 1-800-766-9012

Hysterectomy Necessity

To be completed by the individual receiving the hysterectomy or her representative, if any:

_____________________________________. (Please print name and relation to patient.)

Please select one of the following choices and place your initials on the line next to the statement that best

describes your situation.

____Prior to surgery, I received, orally and in writing, information stating that the hysterectomy would

render me permanently incapable of reproducing. I understand that I will not be able to become pregnant or

bear children.

___ I am already sterile and incapable of bearing children. My physician and I have orally discussed my

illness, and he or she has given me written information on my illness that has led to the decision for this

surgery. The illness/disease/symptoms that I have is called:

_____________________________________________________________________.

______________________________________________ _______________________(Signature of Patient or Representative) (Date 00/00/0000)______________________________________________ _______________________(Signature of Physician ) (Date 00/00/0000)



4.20 SterilizationProviders must comply with the procedures outlined below prior to performing the sterilization service. A completed Federal Consent Form must be submitted with claims for all voluntary sterilization procedures. Additionally, Federal consent requirements for voluntary sterilization require:

•Therecipienttobeatleast21yearsofageatthetimeconsentissigned.

•Therecipienttobementallycompetent.

•Consentistobevoluntaryandobtainedwithoutduress.

•Thirtydays,butnotmorethan180days,mustpassbetweenthedateofinformedconsentandthedateofsterilization,exceptin the case of a premature delivery or emergency abdominal surgery.

•Atleast72hoursmusthavepassedsincetherecipientgaveinformedconsentforthesterilizationiftherecipientistobe sterilized at the time of a premature delivery or emergency abdominal surgery.

•Theinformedconsentmustbegivenatleast30daysbeforetheexpecteddateofdeliveryinthecaseofprematuredelivery.

•Thepersonsecuringtheinformedconsentandthephysicianperformingthesterilizationprocedurearerequiredtosignanddate the consent form.

•CopyofthesignedFederalConsentFormmustbesubmittedbyeachproviderinvolvedwiththehospitalizationand/orthe sterilization procedure.

•Thatsterilizationconsentsmaynotbeobtainedwhenaneligiblerecipient:

– is in labor or childbirth.

– is seeking to obtain or obtaining an abortion.

– is under the influence of alcohol or other substances that affect that recipient’s state of awareness.



Benefit Category - Physicians’ Services Note: This may not be an exhaustive list of all applicable benefit categories for this item or service.

Indications and Limitations of Coverage

A - Covered Conditions

•Paymentmaybemadeonlywheresterilizationisanecessarypartofthetreatmentofanillnessorinjury,e.g.,removalofauterus because of a tumor, removal of diseased ovaries (bilateral oophorectomy), or bilateral orchidectomy in a case of cancer of the prostate.Denyclaimswhenthepathologicalevidenceofthenecessitytoperformanysuchprocedurestotreatanillnessorinjury isabsent;and

•Sterilizationofamentallyretardedbeneficiaryiscoveredifitisanecessarypartofthetreatmentofanillnessorinjury.

Monitor such surgeries closely and obtain the information needed to determine whether in fact the surgery was performed as a means oftreatinganillnessorinjuryoronlytoachievesterilization.

B - Noncovered Conditions

•Electivetuballigationandvasectomiesarecovered,hysterectomiesarenot,ifthestatedreasonfortheseproceduresissterilization;

•Asterilizationthatisperformedbecauseaphysicianbelievesanotherpregnancywouldendangertheoverallgeneralhealthof thewomanisnotconsideredtobereasonableandnecessaryforthediagnosisortreatmentofillnessorinjurywithinthemeaning of §1862(a)(1) of the Act. The same conclusion would apply where the sterilization is performed only as a measure to prevent the possibledevelopmentof,oreffecton,amentalconditionshouldtheindividualbecomepregnant;and

•Sterilizationofamentallyretardedpersonwherethepurposeistopreventconception,ratherthanthetreatmentofanillnessorinjury.

CMS guidelines The previous guidelines noted on this page can be found at the following web address:

http://www.cms.gov/medicare-coverage-database/details/ncd-details.aspx?NCDId=13&ncdver=1&bc=AAAAQAAAAAAA&

4.21 Sterilization Consent FormIf the provider is performing a sterilization procedure, which may only be performed on patients 21 years of age and older and who are mentally competent, the Federal Sterilization Consent Form must be completed and must accompany the claim form.

Federal government auditors closely monitor the proper and timely completion of the consent form and UnitedHealthcare is required to insist on proper adherence to the requirements. Providers must wait 30 days between the patient signing the consent form and performance of the procedure, except in the case of premature delivery or emergency abdominal surgery. The consent expires 180 days from the member’s date of signature. A new consent form is required if the procedure is to be performed after the 180 day period.

Sterilizations require submission of completed federally mandated consent form. Elective hysterectomy, tubal ligation, and vasectomy, if the stated reason for these procedures is sterlization is non-covered



Form Approved: OMB No. 0937-0166 Expiration date: 12/31/2012

NOTICE: YOUR DECISION AT ANY TIME NOT TO BE STERILIZED WILL NOT RESULT IN THE WITHDRAWAL OR WITHHOLDING OF ANY BENEFITS PROVIDED BY PROGRAMS OR PROJECTS RECEIVING FEDERAL FUNDS.

CONSENT FOR STERILIZATION

CONSENT TO STERILIZATION

I have asked for and received information about sterilization from

Doctor or Clinic. When I first asked

for the information, I was told that the decision to be sterilized is com- pletely up to me. I was told that I could decide not to be sterilized. If I decide not to be sterilized, my decision will not affect my right to future care or treatment. I will not lose any help or benefits from programs receiving Federal funds, such as Temporary Assistance for Needy Families (TANF) or Medicaid that I am now getting or for which I may become eligible.

I UNDERSTAND THAT THE STERILIZATION MUST BE CONSIDERED PERMANENT AND NOT REVERSIBLE. I HAVE DECIDED THAT I DO NOT WANT TO BECOME PREGNANT, BEAR CHILDREN OR FATHER CHILDREN.

I was told about those temporary methods of birth control that are available and could be provided to me which will allow me to bear or father a child in the future. I have rejected these alternatives and chosen to be sterilized.

I understand that I will be sterilized by an operation known as a. The discomforts, risks

and benefits associated with the operation have been explained to me. All my questions have been answered to my satisfaction.

I understand that the operation will not be done until at least thirty days after I sign this form. I understand that I can change my mind at any time and that my decision at any time not to be sterilized will not result in the withholding of any benefits or medical services provided by federally funded programs.

I am at least 21 years of age and was born on: Date

I, , hereby consent of my own

free will to be sterilized by Doctor or Clinic

Ethnicity:Hispanic or LatinoNot Hispanic or Latino

Race (mark one or more): American Indian or Alaska NativeAsianBlack or African AmericanNative Hawaiian or Other Pacific IslanderWhite

INTERPRETER'S STATEMENT If an interpreter is provided to assist the individual to be sterilized:

I have translated the information and advice presented orally to the individual to be sterilized by the person obtaining this consent. I have also read him/her the consent form in language and explained its contents to him/her. To the best of my knowledge and belief he/she understood this explanation.

Interpreter's Signature DateHHS-687 (05/10)

STATEMENT OF PERSON OBTAINING CONSENT

BeforeName of Individual

signed the

consent form, I explained to him/her the nature of sterilization operation, the fact that it is

intended to be a final and irreversible procedure and the discomforts, risks and benefits associated with it.

I counseled the individual to be sterilized that alternative methods of birth control are available which are temporary. I explained that sterilization is different because it is permanent. I informed the individual to be sterilized that his/her consent can be withdrawn at any time and that he/she will not lose any health services or any benefits provided by Federal funds.

To the best of my knowledge and belief the individual to be sterilized is at least 21 years old and appears mentally competent. He/She knowingly and voluntarily requested to be sterilized and appears to understand the nature and consequences of the procedure.

Signature of Person Obtaining Consent Date

Facility

AddressPHYSICIAN'S STATEMENT

Shortly before I performed a sterilization operation upon

Name of Individualon

Date of SterilizationI explained to him/her the nature of the sterilization operation

Specify Type of Operation, the fact that it is

intended to be a final and irreversible procedure and the discomforts, risks and benefits associated with it.

I counseled the individual to be sterilized that alternative methods of birth control are available which are temporary. I explained that sterilization is different because it is permanent.

I informed the individual to be sterilized that his/her consent can be withdrawn at any time and that he/she will not lose any health services or benefits provided by Federal funds.

To the best of my knowledge and belief the individual to be sterilized is at least 21 years old and appears mentally competent. He/She knowingly and voluntarily requested to be sterilized and appeared to understand the nature and consequences of the procedure.

(Instructions for use of alternative final paragraph: Use the first paragraph below except in the case of premature delivery or emergency abdominal surgery where the sterilization is performed less than 30 days after the date of the individual's signature on the consent form. In those cases, the second paragraph below must be used. Cross out the paragraph which is not used.)

(1) At least thirty days have passed between the date of the individual's signature on this consent form and the date the sterilization was performed.

(2) This sterilization was performed less than 30 days but more than 72 hours after the date of the individual's signature on this consent form because of the following circumstances (check applicable box and fill in information requested):

Premature delivery Individual's expected date of delivery:Emergency abdominal surgery (describe circumstances):

Physician's Signature Date

by a method called . My

consent expires 180 days from the date of my signature below. I also consent to the release of this form and other medical records

about the operation to: Representatives of the Department of Health and Human Services, or Employees of programs or projects funded by the Department but only for determining if Federal laws were observed.

I have received a copy of this form.

Signature DateYou are requested to supply the following information, but it is not re-

quired: (Ethnicity and Race Designation) (please check)

Specify Type of Operation





4.22 Concurrent ReviewUnitedHealthcare performs concurrent review on all hospitalizations for the duration of the stay based on contractual arrangements with the hospital. UnitedHealthcare performs fax, telephonic or onsite utilization reviews at the facility.

UnitedHealthcare uses evidence based, nationally accepted, clinical criteria guidelines for determinations of appropriateness of care.

The Inpatient Care Manager may certify extension of the length of stay, but may not deny any portion of the stay. Only a medical director or physician advisor can deny an extension of the length of stay.

UnitedHealthcare notifies the facility when the Inpatient Care Manager refers a hospital stay for review by a medical director or physicianadvisor.Ifamedicaldirectororphysicianadvisordeterminesthattheextendedstayisnotjustified,UnitedHealthcarenotifies the facility by phone and fax within one working day.

The attending physician, facility, or provider caring for the member may appeal any adverse decision, according to the procedures in the Complaints and Grievances section.

4.23 Discharge Planning and Continuing CareThe Inpatient Care Manager contacts the provider caring for the member, the attending physician, the member, and member’s family to assess needs and develop a plan for continuing care beyond discharge, if medically necessary.

UnitedHealthcare Inpatient Care Managers facilitate of care across multiple sites of care. The Inpatient Care Managers work with the member, family members, physicians, hospital discharge planners, rehabilitation facilities, and home care agencies. They evaluate the appropriate use of benefits, oversee the transition of patients between various settings, and refer to community-based services as needed.

Care Coordinators supporting members with LongTerm Services & Supports (LTSS) are actively engaged in discharge planning to assist with needed in-home assessments where post-discharge functional changes may require revision to Care Plans.

4.24 Preventive Health Care StandardsUnitedHealthcare’s goal is to partner with providers to ensure that members receive preventive care. UnitedHealthcare endorses and monitors the practice of preventive health standards recommended by recognized medical and professional organizations. Preventive health care standards and guidelines are available at UHCCommunityPlan.com. Standards such as well child, adolescent and adult visits, childhood and adolescent immunizations, lead screening, and cervical and breast cancer screening are included in the website. Education is provided to both members and providers related to preventive health services and members are offered assistance with gaining access to these services if needed. Members may self-refer to all public health agency facilities for medical conditions treated by those agencies.

Following are charts that outline preventative care recommendations for both children and adults.



2012 HE

DIS

Measures at a G

lance – Adults ages 18 and older – P

reventive careG

enderA

ges18 to 20

21 to 39

40 to 6

465 and older

¨M

/FA

dolescent Well-C

are Visits • O

ne or more w

ell-care visits each year

¨M

/FC

hildren and Adolescent’s A

ccess to P

rimary C

are Practitioners ages 1

8

and 19

• Patients seen at least once annually

¨M

/FA

nnual Dental Visit

• Refer for dental care annually

¨F

Chlam

ydia Screening in W

omen up

to age 24

• Chlam

ydia test annually if patient is sexually active• C

hlamydia test annually if patient is sexually active

¨M

/FA

ccess to Preventive/A

mbulatory

Health S

ervices Ages 20 and O

lder• P

atients seen at least once annually (C

omm

ercial - at least every three years)• P


omm



omm



omm

ercial - at least every three years)

¨M

/FB

ody Mass Index (B

MI) A

ssessment

up to age 74• D

ocument date and value of B

MI and w

eight• For age 1

8 m

embers - docum

ent BM

I percentile also• D


MI and w

eight• D


MI and w

eight• D


MI and w

eight

¨M

/FC

ontrolling High B

lood Pressure (B

P)

• BP

reading at each visit • Monitor/treat to m

aintain control • D

ocument date hypertension (H

TN) diagnosed

• BP



ocument date H

TN diagnosed

• BP



ocument date H

TN diagnosed

• BP



ocument date H

TN diagnosed

¨M

/FM

edical Assistance w

ith Sm

oking and Tobacco U

se Cessation

• Advise sm

okers and tobacco users to quit • D

iscuss cessation products and strategies• A

dvise smokers and tobacco users to quit

• Discuss cessation products and strategies

• Advise sm

okers and tobacco users to quit • D

iscuss cessation products and strategies• A

dvise smokers and tobacco users to quit

• Discuss cessation products and strategies

¨M

/FA

nnual Monitoring for P

atients on P

ersistent Medications

• Annual serum

potassium and serum

creatinine/blood urea nitrogen test for patients on persistent A

CE

/AR

Bs,

digoxin, or diuretics • Annual serum

concentration level test for patients on persistent anticonvulsants

• Annual serum

potassium and serum


CE

/AR

Bs,



• Annual serum

potassium and serum


CE

/AR

Bs,



• Annual serum

potassium and serum


CE

/AR

Bs,



¨F

Timeliness of P

renatal Care

• Initial prenatal visit in the first trimester

(or within 4

2 days of enrollm

ent in plan) • Initial prenatal visit in the first trim

ester (or w

ithin 42

days of enrollment in plan)


(or within 4

2 days of enrollm

ent in plan)

¨F

Postpartum

Care

• Postpartum

care visit between 21 an

d 56 days after

delivery (not during the C-section suture rem

oval apppointm

ent)

• Postpartum


d 56 days after


oval apppointm

ent)

• Postpartum


d 56 days after


oval apppointm

ent)

¨F

Frequency of Ongoing P

renatal Care

• Greater than or equal to 81percent of expected prenatal visits*



¨F

Cervical C

ancer Screening

• P

ap test at least every three years

• Pap test at least every th

ree years

¨F

Breast C

ancer Screening up to age 6

9

• M

amm

ogram at least every o

ther year

• Mam

mogram

at least every three years

¨M

/FC

olorectal Cancer S

creening A

ges 50

-75

• Fecal occult blood test (FO

BT) every year (or) • Flexible

sigmoidoscopy every five years (or) • C

olonoscopy every 10 years

• Fecal occult blood test (FOB

T) every year (or) • Flexible sigm

oidoscopy every five years (or) • Colonoscopy every

10 years

¨M

/FInfluenza Vaccination C

omm

ercial A

ges 50

-64

; Medicare A

ges 65

and O

lder

• A

nnual imm

unization for influenza• A

nnual imm

unization for influenza

¨M

/FA

spirin Use and D

iscussion

• D

iscuss risks and benefits of using aspirin• D

iscuss risks and benefits of using aspirin

¨M

/FP

neumonia Vaccination

• P

neumonia vaccination

¨F

Osteoporosis Testing

• Bone density test for w

omen

¨M

/FG

laucoma S

creening • R

efer for eye exams for glaucom

a by an eye care professional

¨M

/FFall R

isk Managem

ent• D

iscuss fall risk • Manage fall risk

¨M

/FP

hysical Activity in O

lder Adults

• Discuss and advise physical activity

¨M

/FP

otentially Harm

ful Drug-D

isease Interactions

Avoid prescription dispensing for:

• Tricyclic antidepressants, antipsychotics or sleep agents for patients w

ith a history of falls • Tricyclic antidepressants or anticholinergic agents for patients w

ith dementia • N

onaspirin NS

AID

s (non-steroidal anti-inflam

matory drug) or C

ox-2 S

elective NS

AID

s for patients w

ith chronic renal failure (CR

F)

¨M

/FU

se of High-R

isk Medications

• Avoid prescribing high-risk m

edications

¨M

/FC

are for Older A

dults Ages 66 and O

lder • A

dvance care planning • Medication review

• Medication

list • Functional status assessment • P

ain screening

*Refer to the A

merican A

cademy of P

ediatrics and The Am

erican College of O

bstetricians and Gynecologists, S

ixth Edition, G

uidelines for Perinatal C

are for recomm

ended number of perinatal visits.



2012 HE

DIS

Measu

res at a Glan

ce – Children/A

dolescents ages Birth to 17 – P

reventive Care

Ag

esB

irth to

Ag

e 23 to

67 to

1011 to

17

¨C

hildhood Imm

unization Status before

Age 2

Befo

re Ag

e 2: • 4

Dtap • 3

IPV

• 1 M

MR

• 3 H

iB • 3

HepB

• 1 Varicella

Zoster Virus • 4

PC

V • 2

HepA

• 2 R

V • 2

flu vaccines

¨W

ell-Child Visits in the First 1

5 M

onths —

Six or m

ore well-care visits by age

15

months

• 6 or m

ore well care visits b

efore 15 m

on

ths o

f age

¨Lead S

creening in Children

• Capillary or venous blood test for lead b

efore ag

e 2 (Many

states require two capillary or venous tests by age 2).

Ä

nnual Dental Visit

• Refer for dental care at age 2




¨C

hildren and Adolescents’ A

ccess to P

rimary C

are Practitioners

• Patients seen at least once annually after age 1




¨W

ell-Child Visits in the Third, Fourth,

Fifth and Sixth Years of Life

• One or m

ore well care visits each year

¨W

eight Assessm

ent and Counseling

for Nutrition and P

hysical Activity for

Children/A

dolescents

• Body M

ass Index (BM

I) percentile • Counsel for nutrition

• Counsel for physical activity

• BM

I percentile • Counsel for nutrition


• BM

I percentile • Counsel for nutrition


Ïm

munizations for A

dolescents A

ges 11

-12

Befo

re Ag

e 13: • O

ne Meningococcal

• One Tdap or Td (Tetanus and diphtheria)

Ä

dolescent Well-C

are Visits • O

ne or more w

ell-care visits each year

¨C

hlamydia S

creening in Wom

en A

ges 16

or Older

• Chlam

ydia test annually if patient is sexually active

¨Frequency of O

ngoing Prenatal C

are• G

reater than or equal to 81percent of expected prenatal visits*

¨P

ostpartum C

are• P

ostpartum care visit betw

een 21 and

56 days after

delivery (not the C-section suture rem

oval appointment)

¨Tim

eliness of Prenatal C

are


(or within 4

2 days of enrollm

ent in plan)

¨H

PV

vaccine

• Three doses of HP

V before ag

e 13

2012 HE

DIS

Measu

res at a Glan

ce - Children/A

dolescents ages Birth to 17 - C

ondition Managem

ent

Ä

ppropriate Treatment for C

hildren W

ith Upper R

espiratory Infection (UR

I) A

ges 3 M

onths and Older

• Avoid antibiotic m

edication prescription for UR

I • A

void antibiotic medication prescription for U

RI

• Avoid antibiotic m

edication prescription for UR

I• A

void antibiotic medication prescription for U

RI

Ä

ppropriate Testing for Children W

ith P

haryngitis Ages 2

and Older

• Group A

streptococcus test with a diagnosis pharyngitis

and a prescribed antibiotic• G

roup A streptococcus test w

ith a diagnosis pharyngitis and a prescribed antibiotic

• Group A

streptococcus test with a diagnosis pharyngitis

and a prescribed antibiotic• G

roup A streptococcus test w

ith a diagnosis pharyngitis and a prescribed antibiotic

Ü

se of Appropriate M

edications for P

eople With A

sthma A

ges 5 and O

lder• O

ne or more form

ulary prescriptions for a preferred therapy for patients w

ith asthma

• One or m

ore formulary prescriptions for a preferred

therapy for patients with asthm

a • O

ne or more form

ulary prescriptions for a preferred therapy for patients w

ith asthma

Ä

ttention deficit hyperactivity disorder (A

DH

D) M

edication Managem

ent A

ges 6-1

2

• Follow-up visit w

ithin 30

days of prescribing an AD

HD

m

edication • Two follow

-up visits within nine m

onths• M

onitor medication com

pliance


ithin 30


HD

m



onths• M


pliance


ithin 30


HD

m



onths• M


pliance

¨M

edication Managem

ent for People

with A

sthma A

ges 5 and O

lder• M

onitor asthma controller m

edication compliance

• Monitor asthm

a controller medication com

pliance• M

onitor asthma controller m

edication compliance

Ïnitiation and E

ngagenment of A

lcohol and other drug dependence treatm

ent A

ges 13

and older

• Initiation of treatment w

ithin 14

days; engagement

of treatment w

ithin 30

days

* Refer to the A

merican A

cademy of P

ediatrics and The Am

erican College of O

bstetricians and Gynecologists, S

ixth Edition, G

uidelines for Perinatal C

are for recomm

ended number of perinatal visits.



2013 HEDIS recommended immunization schedule for children birth to age six (6)

2013 HEDIS recommended immunization schedule for children ages 7-20



4.25 Recommended Childhood Immunization SchedulesThe childhood and adolescent immunization schedule and the catch-up immunization schedule have been approved by Advisory Committee on Immunization Practices (ACIP), American Academy of Family Physicians (AAFP), and the American Academy of Pediatrics (AAP).

Bright Futures/American Academy of Pediatrics: brightfutures.aap.org/pdfs/AAP%20Bright%20Futures%20Periodicity%20Sched%20101107.pdf

Government Childhood and Adolescent Immunizations Guide: cdc.gov/vaccines/schedules/

Source: CDC and Advisory Committee on Immunization Practices

4.26 Kan Be Healthy Periodicity ScheduleScreening frequencies are based on the 2007 American Academy of Pediatrics (AAP) “Recommendations for Preventive Pediatric Health Care” as published on the AAP website, as of November 5, 2007. The first screen may be performed at any age under 21 and repeated according to ideal timeframes listed in the KBH Screening Frequencies table below. When the ideal schedule is not possible to follow, please note that KBH medical screens may be completed at any time.

Note: Every KBH visit must have all components completed and documented.

Medical Screenings

(M) Medical screens follow the KBH minimum documentation requirements which include the hearing, vision, and dental screening.

Dental Screenings

(D) Dental screens are a required component of each KBH visit based on both the Kansas State and AAPD/ADA/AAP Periodicity Schedule.

Vision Screenings

(V)VisionscreensarearequiredcomponentofeachKBHvisitbasedonboththeKansasStateandAAPPeriodicitySchedule.SchoolvisionscreeningsareaseparateanddistinctprocessandfollowtheirownperiodicityscheduleasoutlinedintheKDHEVisionScreening Guidelines.

Hearing Screenings

(H) Hearing screens are a required component of each KBH visit based on both the Kansas State and AAP Periodicity Schedule. School hearing screenings are a separate and distinct process and follow their own periodicity schedule as outlined in the KDHE Hearing Screening Guidelines and Resource Manual.



KBH Screening Frequencies

Age with Type of Screens Due

Birth:

M, V, H

Two to five days after birth:

M, V, H

One month:

M, V, H

Two months:

M, V, H

Four months:

M, V, H

Six months:

M, V, H

Nine months:

M, V, H, D

12 months:

M, V, H, D

15 months:

M, V, H, D

18 months:

M, V, H, D

24 months:

M, V, H, D

30 months:

M, V, H, D

Yearly three - 20 years:

M, V, H, D

Community Plan

M506659/13©2013UnitedHealthCareServices,Inc.