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practicemattersMassachusetts | Summer 2015

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Practice Matters: MA - Summer 2015 Provider Services Center: 888-735-5842

Important information for health care professionals and facilities

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In This Issue...• Frail Elder Waiver Requirements Reminder

• Claims Filing Limit

• Introducing the ICD-10 Coding Practice Tool

• Tips on the Claim Resubmission and Correction Process

• Reviews Help Ensure Patients Receive Proper Care

• Coordination of Care among Primary Care Physicians and Specialists

• New Information Needed for Institutional Claims Submissions

• Summertime is the Time for Satisfaction Survey

We hope you enjoy the summer edition of Practice Matters. In this issue, you can read about frail elder waiver requirements, a new ICD-10 coding practice tool, tips on the claim resubmission and correction process, and much more. Happy summer!

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Important information for health care professionals and facilities

FeaturesThe Physician ICD-10 Coding Practice Tool allows providers to practice selecting ICD-10 codes for various clinical scenarios across 35 medical specialties. Each clinical scenario for commonly used diagnosis codes includes a medical example, medical history and office notes; and users can compare codes used by peer physicians within each specialty.

Clinical ScenariosThe clinical scenarios included in the tool were chosen based on the number of claims submitted by the most common clinical specialties, including:

Allergy/Immunology OphthalmologyAudiology OptometryCardiology Orthopedic SurgeryChiropractic Care OtolaryngologyDermatology Pediatric Medicine

Emergency Medicine Physical Medicine and Rehabilitation

Endocrinology Physical Therapy

Family Medicine Plastic and Reconstructive Surgery

Gastroenterology PodiatryGeneral Practice PsychiatryGeneral Surgery Psychology, ClinicalHematology PsychologyHematology-Oncology Pulmonary MedicineInfectious Disease Radiation OncologyInternal Medicine RheumatologyNephrology Thoracic SurgeryNeurology UrologyObstetrics & Gynecology Vascular SurgeryOccupational Therapy

Frail Elder Waiver Requirements ReminderAs a UnitedHealthcare Senior Care Options care provider for the Frail Elder Waiver (FEW) population, we would like to remind you that the Massachusetts Office of Long Term Services and Supports requires your compliance with requirements outlined in Appendix C of the 1915(C) Home- and Community-Based Services FEW program. Some of the requirements are:

• Meeting provider qualifications and training • Criminal Offender Record Information checks of staff • Training employees in mandated reporting and

identifying elder abuse

For more information, please contact your Senior Provider Relations Advocate.

Claims Filing LimitImportant reminder: Our claims filing limit for providers is 90 days from the date of service.

Introducing the ICD-10 Coding Practice ToolOct.1, 2015 signals the effective date for transition to ICD-10 coding to replace ICD-9 — the coding system used by physicians and health care professionals to record and identify diagnoses and procedures for claims payments.

ICD-10 affects diagnosis coding and inpatient procedure coding only. It does not affect current procedural terminology (CPT) coding for outpatient procedures.

To assist physicians with the transition to ICD-10, we developed the Physician ICD-10 Coding Practice Tool, an online self-service tool available as of July 29 at UnitedHealthcareOnline.com under Quick Links. Click ICD-10 and Regulatory Outreach. The tool is specific to physicians and their office staff to practice the new coding. It is not intended for facilities.

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Important information for health care professionals and facilities

Example scenarioScenario (aligned with Medical History and Office Visits Notes)Patient in for weekly B12 injection Medical History Member is currently under treatment for severe B12 deficiency; no other medical history. Office Visit Notes Member was given 1000 mcg. Vitamin B 12 Intramuscular in her left deltoid for severe B12 deficiency. Patient tolerated injection without complications; Patient to return to office in one week.

Access and RegistrationTo access the tool, please register at UnitedHealthcareOnline.com > Tools & Resources > Health Information Technology > ICD-10. When you register, you’ll get a username and password for secure access to the tool. You can then access the tool as often as you would like. If needed, you also can pick-up where you left off from a previous session the next time you access the tool.

ResourcesFor assistance using the Physician ICD-10 Coding Practice Tool, a link to the How to Guide will be available and accessible via the Services & Support page of the tool. If you need technical assistance, call 855-819-5909 during the following hours:

Monday-Friday, 6 a.m. to 10 p.m. CTSaturday, 6 a.m. to 6 p.m. CTSunday, 9 a.m. to 6 p.m. CT

Tips on Claim Resubmission and Correction ProcessHealth care professionals can resubmit or correct professional (CMS 1500) and institutional claims (UB-04) by making the necessary changes in their practice management system for the corrected claim to be printed or submitted electronically or by making the necessary corrections to the original submitted paper claim. Please check your UnitedHealthcare Community Plan Provider Manual and reimbursement policies to reconfirm billing types allowed for reconsideration.

Please resubmit the entire claim as originally submitted — even line items that were previously paid correctly. Under National Uniform Billing Committee (NUBC) claim frequency guidelines, when sending a replacement or voided claim, the entire original or previous submission must be replaced or voided.

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Practice Matters: TX - Summer 2013 Customer Service Center: 888-362-33683

Community Plan

Practice Matters: MA - Summer 2015 Provider Services Center: 888-735-58423

Important information for health care professionals and facilities

How to make a resubmission or corrected claim request:

• Online: Visit UnitedHealthcareOnline.com or access OptumCloud Dashboard. (Resubmissions with attachments can only be done via OptumCloud Dashboard).

• Mail: Print the UnitedHealthcare Claim Reconsideration form available at UnitedHealthcareOnline.com > Tools & Resources > Forms > Claim Reconsideration Request Guide.

– Complete the Claim Reconsideration Request form as instructed and mark the box on Line 4 for Corrected Claims. Continue to the comments section and list the specific changes made and rationale or other supporting information.

– Enter the words “Corrected Claim” in the comments field on the claim form.

– Filling in CMS 1500:• Original claim number in Box 22• Enter the appropriate claim frequency code

left-justified in the field.7 – Replacement of prior claim8 – Void/cancel of prior claim

– Filling in UB 04:• Bill type in Box 4• Enter the appropriate claim frequency code in

the third position of the Type of Bill7 – Replacement of prior claim8 – Void/cancel of prior claim

Please double check claims for errors prior to submitting the first time and make sure to send your claims directly to the UnitedHealthcare Community Plan address on the back of the member’s identification card or as outlined in your state’s Provider Manual.

For more information on completing your claim, go to:• nucc.org or nubc.org• CMS Claims Processing Manual at

cms.hhs.gov/Manuals/IOM/list.asp and refer to the CMS-1450 and CMS-1500 data sets

• For electronic claim submissions, refer to the Health Insurance Portability and Accountability Act Implementation Guides at wpc-edi.com.

Reviews Help Ensure Patients Receive Proper CareUnitedHealthcare Community Plan performs concurrent reviews on inpatient stays in acute, rehabilitation and skilled nursing facilities, as well as prior authorization reviews of selected services. A list of services requiring prior authorization is available in the Provider Manual. A physician reviews all cases in which the care does not appear to meet guidelines.

Decisions regarding coverage are based on the appropriateness of care and service, and benefit coverage. We do not provide financial or other rewards to our physicians for issuing denials of coverage or for underutilizing services.

The treating physician has the right to request a peer-to-peer review with the reviewing physician and copy of the criteria used in the review. The denial letter contains information on how to request materials and contact the reviewer. Members and practitioners also have the right to appeal denial decisions. Information on requesting an appeal is included in the denial letter.

Appeals are reviewed by a physician who was not involved in the initial denial decision and is of the same or similar specialty as the requesting physician.

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Practice Matters: MA - Summer 2015 Provider Services Center: 888-735-58424

Important information for health care professionals and facilities

Coordination of Care among Primary Care Physicians and SpecialistsPrimary care physicians (PCPs) and specialists share responsibility for communicating essential patient information with each other regarding consultations and referrals. Non-communication affects quality of care and can negatively affect health outcomes.

Relevant information that the PCP should provide to the specialist includes the patient’s history, diagnostic tests and results, and the reason for the consultation. The specialist is responsible for timely communication to the PCP of the results of the consultation, and ongoing recommendations and treatment plans.

Information exchange among health care providers should be timely, relevant and accurate to facilitate ongoing patient care management. The partnership between the PCP and specialist is based on the consistent exchange of clinical information, and this communication is a key factor in providing quality patient care.

New Information Needed for Institutional Claims SubmissionsAll institutional claims (uniform billing) submitted by paper or electronic transactions must now include the individual attending physician’s first and last name with a valid National Provider Identifier (NPI).

This edit helps ensure that we maintain compliance with State Medicaid guidelines. Please continue to include the appropriate taxonomy code for billing and attending providers.

Summertime is the Time for Satisfaction SurveyEach year, we ask for your participation in our Physician Satisfaction Survey. The survey provides insights about your experiences working with us. Your opinions help identify opportunities to enhance our services to align with your practice’s needs.

The next survey will be fielded in August to a random sample of physicians. Invitations will be distributed by fax. Please complete the survey if you receive a request. Your feedback is important to us.

© 2015 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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