Messages from the Clinicians....

October 2000

Upcoming Changes At UPHP

Effective January 1, 2001, UPHP will be transitioning to a new TPA (Third Party Administrator) for claims reimbursement. During this transition, clinical services will be limiting authorizations through December 31, 2000. All authorization requests for January 1, 2001 and beyond may be faxed or called in beginning January 1, 2001. Your patience is appreciated during this process.

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Provider Manuals

Revised edition of UPHP Provider manuals were distributed during the August 23 and 24, 2000 Billing Seminars. You may obtain a copy by contacting UPHP’s Customer Service Representative. Future updates will be mailed directly to each provider office. It will be the responsibility of that office to place the revisions in the office manuals.

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Hospital Readmissions

Below is an excerpt from the MSA Hospital Bulletin, chapter VIII, Section 2, page 13, dated 04-01-00 Hospital 00-05.

Readmissions

Readmissions within 15 days for a related condition, whether to the same or a different  hospital, are considered part of a single case/episode for payment purposes.

If the readmission is to a different hospital, full payment is made to the second hospital. The first hospital’s payment is reduced by the amount paid to the second hospital. The first hospital’s payment is never less that zero for the episode.

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Do You Have a Member Who is Trying to Quit Smoking?

UPHP will cover a three-month supply of Zyban and Nicotine Patches per twelve-month period. Prior authorization confirms benefit limitations. We also participate in the local Health Department’s smoking cessation programs. If you have a patient who is a member of UPHP and is trying to quit, please refer them to their local Health Department or UPHP’s Customer Service Representative for more information.

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Prevnar Vaccine

Prevnar is the pneumococcal vaccine recommended for children under the age of five. Prevnar is included in the Vaccines for Children Program (VFC) in which the state program reimburses the cost of the vaccines. UPHP recommends contacting your local Health Department to receive the vaccine for your clinic. UPHP will reimburse an administrative cost for Prevnar at the same rate as other vaccines. Medical guidelines for Prevnar can be obtained from UPHP if desired.

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Emergency Room Follow-up Care

All specialist referrals originating from Emergency Rooms must obtain authorization within 24 hour of the initial follow-up office visit. Refer to your provider manual for more information of contact the Clinical Services Department at 1-800-835-2556 extension 2082.

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How to Verify Member Eligibility

When you as a provider see a UPHP member, you must ensure the member’s eligibility by following the procedure below:

• Request to see UPHP identification and Medicaid card.
• If a current Medicaid card is not available, call Medifax at 1-888-696-3510 to verify Medicaid and UPHP enrollment status.
• If the member is eligible for services by UPHP:
     -Print the member identification
     information on any appropriate
     forms.
     -Return the member identification
     card to the member and render
     services to the patient.
• If the member is NOT eligible for services by UPHP
     -Advise the person that he/she is
     not eligible for services through
     UPHP and that he/she will be
     financially responsible for any
     care rendered.

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NOTE: Health Care Guidelines for Pap smear screening recommendations have been adjusted.