Upper Peninsula Health Plan
Upper Peninsula Health Plan

UPPER PENINSULA HEALTH PLAN

Messages from the Clinicians....

March 2000

In This Issue....

Facility Site Visits                                                     Oral Contraceptives on Formulary
Pharmacy Update                                                               Case Management Services
PCP/Specialist Communication                                             AFIX-Record Assessment
Billing Clarification                                                         Secondary Medicaid Coverage
CEO Corner                                                  

Year 2000 Provider Facility Site Visits

As most of you already know, the state requires that we perform two medical record audits per year.

We will make every attempt to painlessly complete this requirement by giving you as much notice as possible and by being as unobtrusive, cooperative and efficient as we can during the process. This year, we are required to do some additional HEDIS (Health Plan Employer Data and Information Set) audits in addition to the routine medical audits. The HEDIS audit will begin as soon as out third party administrator is able to tell us which records have to be audited. The timeline that we have  to do this is short. We expect to be contacting you to pull the required records by the 1st two weeks of March and arranging a day for the audit in your office in the first few weeks of April.

If you have any questions regarding this audit, please feel free to call Marcie Jones, Carolyn Hilden or Tina Peterson.           Top

Oral Contraceptives on Formulary

The oral contraceptives on our formulary include Necon, NOR-QD, Trivora, Zovia, Levora, Mircette, Loestrin, Estrostep and Desogen. These oral contraceptives are the most cost effective for our formulary, however, the health departments may have other brand that are more cost effective for their formulary.                                           Top

Case Management

UPHP is in the process of developing a more comprehensive case management program. We will be providing coordination of services for beneficiaries with complex medical conditions, inappropriate utilization of health care services, noncompliance with treatment plans, and other as referred to the program. We would like to ask you to think about your current UPHP Medicaid caseload, and to refer any patients that you feel would benefit from case management services. These services are provided at no cost to the provider, and will hopefully demonstrate improved outcomes for out patients and providers.                          Top

Communication Between PCP & Specialist

Communication between the PCP and specialist is important to the beneficiary’s plan of care and continuity of treatment. Please remember this when dictating consultation and treatment notes, and copy the PCP in a timely manner to facilitate optimal treatment and outcomes.                                    Top                                                          

Pharmacy Update

Medications prescribed for ADD/ADHD now require a one time only prior authorization (PA) in accordance with state requirements. Information needed to obtain authorization includes the patient name and Medicaid ID number, the diagnosis ADD or ADHD and the physicians signature on the PA form.                                                       Top

Secondary Medicaid Coverage

Members who have Medicaid as their secondary coverage require prior authorization for in-plan or out-of-plan referrals. This includes members who have Medicare Prim.                                       Top

The Michigan Department of Community Health Immunization Record Assessment...AFIX

Providers want healthy patients. To safeguard health and well being, patients must be immunized.
What is AFIX?
AFIX is a set of strategies designed to improve immunization rates when implemented.

  • ASSESSMENT of immunization coverage levels at the clinical level.
  • FEEDBACK of information to providers and staff.
  • INCENTIVES, recognition for participation and increasing coverage.
  • EXCHANGE of information to learn what strategies have worked.

Have you thought about taking advantage of a FREE immunization assessment service but were afraid that...

  • It would take too much time? Do you have 10 minutes for the initial call?
  • It would be disruptive to your office routine? We schedule at your convenience.
  • It will give results you do not want to see? Results are confidential.

To set up a FREE personalized immunization assessment, contact:
Stephanie Sanchez, Assessment Coordinator at the Michigan Department of Community Health, phone (517) 335-9011.
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CEO Corner

Sharing Risk with Primary Care Givers
In the next few months a contract addendum will be going out to all primary care givers including family physicians and internal medicine specialists providing primary care services. This addendum will include a withhold on approximately 65 Clinical Procedure Codes (CPT) related to primary care services. The withhold amount will be offset by an increase in reimbursement for these CPT’s so there will be no change in actual reimbursement to affected providers. The Plan has tried to avoid risk sharing with our partners, but the Insurance Commissioner has made it a condition of our license going forward. Additional details will accompany the addendum. If there are any questions, please contact William Streur at the Plan.
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Messages From the Billing Liaison...

Modifier LT - cannot be processed by the Wausau system. Instead of using LT, use modifier 50 or 51 as appropriate. TR is accepted by the Wausau system

Dental - as a rule, dental services in a clinic/facility setting are not a benefit of the UPHP. Due to a shortage of dentists, UPHP will reimburse for dental pain when billed with these codes only. Billing these codes take effect 2/1/2000.

  1. Clinic = 99212
  2. Facility = Z9525
  3. Physician = 99281
    • No other code will be reimbursed for these services.
    • Diagnostic code 521 WILL NOT BE ACCEPTED.

POS (place-of-service) code - Urgent care in a facility (Z9525) must have POS cod 02 or 22 on HCFA billing.

Clinic Authorizations - for in-plan or out-of-plan referrals, if its a multi-physician office, authorize the clinic/office, not one particular physician. If one particular physician is specified and authorized and a different physician in the same office, same TIN renders services, claim will deny.

Correct Claims - all corrected claims MUST be hard copy. The corrected claim must have written in BOLD letters “/corrected claim”.

  1. If the claim submitted had 6-digits and the corrected claim was cross-walked to the matching 5-digit, same charge listed, no documentation required. IF the corrected claim has changed diagnostic code or CPT-4/MUPC-documentation is required.
  1. Up-coding and whiteout on any submitted form will not be accepted and will be returned for resubmission.

ICD-9 - HCFA provides specific guidelines to aid in the standardizing coding practices across the United States. One of the guidelines specifies:

  1. Code to the highest degree of specificity. Carry the numerical code to the fourth of fifth digit where applicable. Remember, there are only approximately 100 valid 3-digit codes: all other ICD-9 codes require additional digits.
  2. Claims rejected for incorrect ICD-9 will be ANSI code 47 “Diagnosis code is invalid.” Please refer to the Corrected Claims section for resubmission.

Billing Requirement of 23-Hour Observation - For reimbursement of 23-hour observations, concurrent authorization must be obtained and the following codes must be utilized. 99234, modifier - 26 on HCFA 1500 form 99234 on UB92 form.

Claims Status - All requests for claim status must go through WIC. All mailed requests and faxed requests will be mailed to WIC; phone messages will not be forwarded.

CPT-4 ~ IPD-9 ~ HCPCS: - These tools used every day for billing. Each office should have a copy of the most current version.

Interpretive Services - ALWAYS use modifier -26 in block 24 d., HCFA 1500.

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