Messages from the Clinicians....

July 1999

MSS/ISS, Well-Child, Family Planning

UPHP is currently undertaking an initiative to increase the appropriate utlilization of these services. We are working closely with UP Health departments to accurately identify qualified enrollees and to assure appropriate assessments and interventions are completed. If you or your staff have any questions regarding these services, or if you need a copy of the criteria for these programs, please contact our Quality Assurance Department.

We urge you to work with your local health department in helping our members access the array of services available to them.
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DME Update

In a continued effort to streamline the DME authorization process, the Upper Peninsula Health Plan is giving  notice to an immediate change.

Effective 6/23/99, NO PRIOR AUTHORIZATION is required for DME under $500.00 or orthotics under $1,000.00 for ANY AGE.

All DME items linked to the Penny Fee Screen, under $500.00, any age, MUST have an itemized invoice attached to the claim. Reimbursement rate will be based on YOUR cost of the item, not retail.

If you have any questions, please contact our Provider Relations Department.       Top

Newborn Deliveries

Please note that newborn deliveries, regardless of the primary insurance payor, need to be authorized by the Clinical Services department by calling
 (800) 835-2556 WITHIN 24 HOURS OF BIRTH. This is a reporting requirement of the state.                                                 Top

CEO Corner

Per our medicaid contract with the State of Michigan, UPHP must conduct two medical record audits per year, at the provider’s offices. The audits will include medical record documentation and compliance, facility review, a selected health care evaluation study and a possible HEDIS validation sample. We are in the process of beginning the first round of audits. Your office will be contacted within the next two months to arrange a mutually agreeable time and date to complete these audits. We will provide a list of specific records that will be audited, and UPHP staff will complete the audits at your facility. If you have any questions or concerns about this, please call our Clinical Services Department.                                            Top

Clinical Practice Guidelines

Our Clinical Advisory Committee (CAC) is in the process of gathering clinical practice guidelines for the treatments of conditions affecting our enrollee populations. These guidelines will be recommended by the UP physicians and approved by the UPHP CAC. Once this process is finalized., the guidelines will be bound and distributed to all UPHP providers for use in the care of our enrollees. If you have any suggestions for guidelines to be used or would like to participate in this process, please call our Medical Director. We hope to have these guidelines approved and distributed by 9/1/99.                                                      Top

Secondary Medicaid Coverage

Members that have Medicaid as their secondary coverage still require prior authorization for out-of-plan referrals if the member is requesting Medicaid benefits. (i.e., pharmacy or medically necessary transportation.)                                   Top

Claims Information

Effective immediately, any submitted claims missing the “M” in front of the Medicaid ID# will be denied or returned. Returned claims will ask for the SSN#, resubmit the claim with the “M” followed by the eight digit recipient ID number. No “corrected claim” indicator is needed at the bottom of the form.

Per our medicaid contract with the State of Michigan:

• You have one year from date of service or discharge to file a claim.
• 30 to request authorization.
• If the claim is rejected by UPHP, further activities on the part of the provider must occur on that claim within 120 days from the date of the rejection or that claim is no longer eligible for payment (see provider manual page 3.8).       Top

Health Education Newsletters

In accordance with our state Medicaid contract, UPHP will soon begin to distribute health education newsletters to our enrollees. Some topics include wellness, prenatal care, and appropriate use of emergency rooms. If you have particular issues that you feel should be addressed in these newsletters, please call us with your suggestions.                  Top