UPPER PENINSULA HEALTH PLAN

In This Issue....

Clinical Services Report                                                                             MCIR
Thank You                                                                                 MIChild Referral
Home Health Facts                                                                             New PCPs
Pharmacy Claims                                                             Restricted Drug Classes
PCP Verifications                                                                 Diabetes Videotapes
Claim Notes

Provider Notes

Quality Management
The following graphs Member Satisfaction with Providers; Care of Children and Care of Women; Diabetes Care depict the outcome of the most recently completed Health Plan Employer Data and Information Set (HEDIS) and External Quality Review (EQR) reports. Upper Peninsula Health Plan (UPHP) participation in HEDIS is required by the Michigan Department of Community Health (MDCH), and the results are compared to other Michigan health plan results. EQR is a review that MDCH contracts with the Michigan Peer Review Organization (MPRO) to complete as a federal requirement for Medicaid managed-care plan evaluation.
We have selected to report those areas that are specifically used for comparison and are identified as targeted performance standards by MDCH. Overall, we did very well; we obtained the third highest scored in the state, which is commendable for you. The major areas of current concern are immunizations, prenatal and postpartum care, well-child office visits, and diabetes.
To continue providing services to the Medicaid population we need to address these areas; eligibility for contracting will be based in part on these scores. MDCH may also assess financial penalties to those plans not meeting minimal standards. We are implementing several interventions to improve these rates, which include contacting members who need services and informing provider offices of members who require the identified services.
Often we find the service is being provided; it just may not be captured on claims data due to coding issues. We will soon be sending your office managers a coding guide that will assist in the proper coding for HEDIS and EQR audit components.

Clinical Practice Guidelines
The Upper Peninsula Health Plan (UPHP) Clinical Advisory committee (CAC) recently reviewed and approved updated guidelines for the treatment of respiratory tract infections, prenatal care, and asthma care. If you visit the UPHP Web site and uphp.com, click on Provider Link, and then click on Clinical Practice Guidelines, you will be able to access these updated guidelines. You will also find guidelines on the treatment of depression, diabetes, and acute coronary syndrome on this Web site. If you would like a copy of these guidelines, please contact Clinical Services. The UPHP CAC also is embarking on a comprehensive study and education project regarding the treatment of respiratory tract infections. You will soon receive further information on this project.

Utilization Management Criteria
On September 11, 2001, the UPHP Clinical Advisory Committee approved a change to the use of Interqual criteria for utilization review. Most of you should be familiar with these criteria, as they are used by Blue Cross and Blue Shield of Michigan (BCBS), the Health Care Financing Administration (now the Centers for Medicare/Medicaid Services), the U.S. Department of Veterans Affairs, more than 750 licensed health plans, and more than 2000 hospitals nationwide to facilitate the utilization review process. Interqual has been in existence for more than 25 years.
Interqual criteria address inpatient, outpatient, home health, rehabilitation, and skilled nursing facility utilization. All licensed health plans must use written criteria based on sound clinical evidence when performing utilization review.
If you would like information on Interqual criteria, the utilization management program, or HEDIS and EQR reports, or have questions regarding the RTI project or the clinical practice guidelines, please contact UPHP Clinical Services Director Marcie Jones, R.N., B.S.N.

We utilize both MICR and claims data to verify immunization status. If vaccines are accurately updated in the MCIR, we may not have to request a medical record from your office to verify information for out required audits! In addition, for any providers using CPT codes 90471 (Immunization Administration) or 90472 (Additional Vaccines), please be sure to submit all of the antigen-specific codes as well. This allows us to appropriately identify, by claims data, the vaccines given. Your reimbursement for these claims will be facilitated in a more timely fashion when the complete claim information is present.
The Upper Peninsula Health Plan will soon send letters to providers requesting follow-up action when MCIR has not been updated. We thank you for your attention to this most important issue.
If you have questions regarding the MCIR system, contact Region 6 MCIR Coordinator Julie Clark at 906-786-4111, extension 182, or the MCIR Help Desk at 888-217-3905.

UPHP Customer Service 1-800-835-2556 or 906-225-7500

THANK YOU!
We would like to thank our provider offices for their timeliness in sending the numerous medical records we have requested in the past few months. This is a time-consuming task, and we appreciate your prompts submissions. We are currently striving to reduce the number of medical records we must request by capturing as much data as possible from accurate claims submissions.
Many times medical records are requested when we believe a service has taken place, but was not coded as such. In June 2001, we sent out a detailed listing of specific well-child services with corresponding codes that we, as well as our state auditors, use to determine utilization of services. We will also soon be sending a coding guide to your office (as mentioned under the Quality Management section). If you would like more information, please call Clinical Services at 225-7500 or 888-904-7526.

Do Not Refer MIChild Members to
County Health Department for Immunizations

MIChild members have full coverage with the Upper Peninsula Health Plan (UPHP) for all immunizations recommended by the American Academy of Pediatrics. Immunizations are covered from birth to age 19 with no copayments.
Since UPHP MIChild members receive full coverage for immunizations, they are not eligible to receive free immunizations from the county health departments. Offices that participate in the Michigan vaccine replacement program cannot provide free immunizations to MIChild members. UPHP physicians should not refer MIChild members to the county health departments for any immunizations.
UPHP physicians should administer necessary immunizations in their offices and submit the claims to UPHP. If your office does not maintain a supply of vaccines, please refer the MIChild members to another UPHP physician in the community who does provide immunizations.

Facts You Should Know About Home Health Care

UPHP Clinical Services can provide assistance in determining the most cost-effective and appropriate setting for your member to obtain care. A letter was recently sent to all home health providers indicating the parameters for utilization of home health services. These parameters, provided from the Medical Services Administration Home Health Manual, will be available in the next provider manual update and upon request. Please contact Clinical Services at 800-835-2556 or locally at 225-7774 (Centrex) with any questions.

UPHP Helps Members Find New PCPs

When your office chooses to dismiss one of our members from care, the Upper Peninsula Health Plan (UPHP) can help by ensuring that the member changes his or her primary care provider (PCP) within the allotted time frame. UPHP asks  that you send or fax our Customer Service department a copy of the written notification your office sends to the member. If the member does not contact UPHP within the specified amount of time, we will automatically assign a new PCP to the member. We will then notify the member of the change. For more information, please call Customer Service at 800-835-2556.

Pharmacy Claims Go to Merck-Medco

ProVantage officially changed to Merck-Medco July 1. As of that date, all pharmacy claims must be submitted to Merck-Medco through Paid Prescriptions. When doing so, please be sure to use UPHPINC as the group number, 001 as the person code, and the member’s eight-digit recipient identification number.
Copayments should now be submitted to Merck-Medco on a Universal Claim Form to: Paid Prescriptions, L.L.C., Attention: Mailstop 7, Pharmacy Claims, Merck-Medco, 339 Jefferson Road, Parsipany, New Jersey 07054.
If you have questions, contact Merck-Medco at the following telephone numbers. For the Paid Prescription Pharmacy Help Desk (pharmacies only), call 800-922-1557. For all prior authorizations, call 800-753-2851. For customer service, call 800-784-0881.
If you have difficulty running a claim and do not find any resolution through Merck-Medco, call UPHP Customer Service at 800-835-2556.

RESTRICTED DRUG CLASSES LISTED ON NEW FORMULARY

Upper Peninsula Health Plan (UPHP) providers recently received the new formulary listing the restricted drug classes. The list should guide your product selection within the therapeutic categories. Your assistance in making this initiative a success is greatly appreciated. On September 11, 2001, the UPHP CAC Pharmacy and Therapeutics Committee approved the addition of Axert tablets and Imitrex tablets for migraine headache treatment. These medications are subject to coverage limitations based on quantity limits or length of therapy.
For a copy of the formulary and specifications, refer to our Web site: www.uphp.com Click Provider Link; then click UPHP Formulary. You can also contact UPHP Customer Service at 800-835-2556, or locally at 225-7500. For prior authorization, call Merck-Medco at 800-753-2851.

CLAIM NOTES

Obstetrics Delivery Rate - Effective October 1, 2000, the obstetrics delivery rate was increased an additional $75. The increase was reflected in payments for dates of service that began August 1, 2001. For any deliveries between October 1, 2000, and August 1, 2001, we will reimburse you the $75. Each delivery must be listed on a spreadsheet, including the mother’s name and Medicaid identification number, the date of delivery, your name, and the billing address to which you want the check mailed. Please mail, fax, or e-mail this list to Marie Stewart at the Upper Peninsula Health Plan (UPHP). Mail: 228 West Washington Street, Marquette, MI 49855; fax: 906-225-7690; e-mail: mstewart@uphp.com Requests must be received by December 13, 2001.
Urgent Care - If you bill urgent care on the HCFA-1500 form, please put UC of GJ in block 24b.
UPHP Carve-Outs - Correction to the Provider Office Manual: effective for claims submitted to Lake Forest, Illinois.
For Dental Services: When billing on the UB-92, use RV451 for facility and RV981 for physician. When billing on the HCFA-1500, use 99212. The diagnosis must fall within the 521.0-524.60 range.
For Substance-Abuse Services: When billing on the UB-92, use RV451 for facility and RV 981 for physician. When billing on the HCFA-1500, use 99212. The diagnosis must fall within the 303.00-305.93 range.

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Upper Peninsula Health Plan - 228 W. Washington Street - Marquette, MI 49855

1-800-835-2556 or  906-225-7500