Messages from the Clinicians....

In This Issue....

Associate Medical Director Notes                                     Congratulation UPHP Providers!
ADA Diabetes Guidelines                                                         UPHP Formulary Decisions
Prior Auth Process Changes                                                             Out-Of-Plan Referrals
Immunization Timing                                                                   When Services are Denied
Claim Notes

Provider Notes

Notes From the Associate Medical Director

Upper Peninsula Health Plan Associate Medical Director, Robert J. Lorinser, M.D.

I would like to explain three issues on which the Upper Peninsula Health Plan (UPHP) is currnetly focusing attention:

1. Physician Profiling - Physician profiling is due to be completed by July 2002 and will be sent to the primary care providers throughout the plan. The issues of this profiling will center on:

• Quality of health care indices utilizing HEDIS measurements (i.e., mammogram completion, immunization rates, diabetes management, etc.). These will provide comparisons to the Upper Peninsula best practices by other primary care physicians.
• The financial aspects of providing medical care, which will be adjusted fro disease severity and will provide you with an “efficiency of care index.”
• Pharmaceutical prescribing patterns

The development of this profile has been very resource intensive. UPHP wants to be able to stand behind the profile’s accuracy and utility for providers.

2. Clarification of the Pharmacy Program - I apologize for any challenges you may have recently experienced with the state’s formulary changes. It was the state’s fee-for-service Medicaid patients who were moved to the new state formulary administered by the pharmacy benefit manager (PBM) First Health. The state had considered mandating that all health plans switch to this formulary program as well. The state has now reconsidered this initiative, however, and, in all likelihood, there will be no changes for UPHP members for the foreseeable future.

The following rules apply to UPHP members:

• UPHP will maintain its own formulary under the restricted drug classes as previously published* (the one-page list). An exception is the psychotropic carve-out explained below.
• The psychotropic medications will follow the fee-for-service formulary as mandated by the state of Michigan. Medco Health Solutions and UPHP handle these drug prior authorizations for UPHP members-not First Health.
• Our pharmacy benefit manager is still Medco Health Solutions (Merck-Medco) - not First Health.
• Medco Health Solutions does all of our drug prior authorizations-not First Health.
• Call UPHP or Medco Health Solution-not First Health-for any concerns related to our Formulary.
• Directly call UPHP Customer Service regarding any complaints or misunderstandings to help us resolve these issues.

The Michigan Department of Community Health “Michigan Pharmaceutical Products List” is applicable only to fee-for-service Medicaid and not UPHP members. Members of Great Lakes Health Plan are also not included under our formulary.

**We will soon be revising our formulary list to reflect the changes with psychotropic medications. If you would like another copy of the UPHP restricted drug classes, please check out Web site under Provider Link/UPHP Formulary or call Customer Service.

3. UPHP Pharmacy and Therapeutics Committee - This last issue involved the development of an Upper Peninsula (UP) Pharmacy and Therapeutics Committee. This committee is being formed to integrate the concerns of the various healthcare providers: the healthcare systems; the hospitals; the payors (mainly Blue Cross and UPHP); and the patients and customers whom all of these entities serve. The initial meeting of the UP Pharmacy and Therapeutics Committee will be scheduled for May 2002. Each hospital and healthcare network will be asked to participate by sending a pharmacist and physician representative. We will provide more information about this committee soon.

Thanks - I would also like to add that I feel fortunate to be involved as a provider with UPHP in addressing the medical care of our UP population. I am impressed with the dedication of the administrative and clinical staff of UPHP, and I am proud to be part of this organization. If you have any further questions about the issues discussed in this section , please call me at UPHP or at my practice (Family Care Doctors: 906-225-3867). Thank You.

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Congratulations to UPHP Providers!
Summary of 2001 Customer Assessment of Health Plans Study (CAHPS)

This report’s results are based on two member-satisfaction surveys conducted from February through May 2001. The Upper Peninsula Health Plan (UPHP) was one of 19 Medicaid Quality Health Plans in Michigan surveyed. UPHP’s survey response rate 47%, the highest response rate of all health plans.
UPHP is a strong performer for most satisfaction measures, with care delivery as a particularly exemplary area of performance. The plan does an exceptional job of providing its members with a personal physician or nurse, and these providers receive high ratings (10, 9 and 8 on an 11-point scale) from an above average 81% of members. Overall health care is also highly rated.
The following are just a few highlights of this report. If you would like more information about this report or about our 2001 Provider Survey results (reported in the July 2001 Provider Notes), please contact UPHP Customer Service.

• Member Responses:
• Smoke cigarettes = 49% (+,H)*
• Advised to quit smoking by their doctor = 64%*
• Went to doctor’s office for care 3 or more times = 48%
• Saw a specialist doctor = 34% (-)
• Got a new prescription or refill = 82% (+)
• Gave their personal doctor/nurse a rating of 8-10 on an 11-point scale, where 10 is “best doctor/nurse possible” = 81% (+) and 78% for child’s doctor/nurse
• Getting needed care is “not a problem” = 82% (+) for adult and 83% (+) for child
• Waited more than 7 days for regular/routine care = 18% (-) for adult and 16% for child
• Doctors/providers always or usually communicate well = 91% (+) for adult and 92% (+) for child
• Office staff always or usually courteous and helpful = 94% (+) for adult and 92% for child

(+) or (-) indicates statistically significant differences from the average of all plans: + is higher than the average, and - is lower than the average. (H) indicates a statistically significant (higher) difference from HEDIS/CAHPS 2.0H data reported in 2000.

*UPHP has initiated a quality improvement project to address this concern. Your input is always welcome on this and any other projects. If you have questions regarding this project, please contact Customer Service, who will direct your call.

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ADA Diabetes Clinical Practice Guidelines

The UPHP Clinical Advisory Committee met in March and reviewed the changes to the American Diabetes Association (ADA) Diabetes Clinical Practice Guidelines. They adopted the current revisions for the 2002 Clinical Practice Recommendations. You can find this link on the UPHP Web site under Provider Link/Clinical Practice Guidelines/Diabetes Care Guideline or you can request a copy by calling Clinical Services.

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UPHP Formulary Decisions

There were no additions or deletions made to the UPHP formulary at the March 12, 2002 quarterly Clinical Advisory Committee meeting. The committee, however, voted to deny Clarinex formulary status. The rationale for this decision was that there is no clinical benefit over existing nonsedating formulary antihistamines. Claritin is expected to be released in an over-the-counter form this fall or next winter.

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Prior Authorization Process Changes

In-Plan Services
The Upper Peninsula Health Plan (UPHP) is amending its authorization process to a prenotification process for select services. This process requires providers to notify UPHP Clinical Services to obtain a notification number for claims processing. Please use the appropriate prenotification forms posted on our Web site, or contact Clinical Services to obtain them.
Services requiring prenotification are as follows:

• In-plan home health care
• In-plan referrals
• In-plan MRI/MRA
• In-plan outpatient dental surgery
• In-plan outpatient physical, occupational, and speech therapy
• In-plan sterilization services

For Prior Authorization: Authorization requirements remain the same for other services identified in your provider manual on page 3.2. Please place this article in your UPHP Provider manual for future reference.

Behavioral Health
The requirement for prior authorization for mental health services changed March 15, 2002. Mental Health providers are no longer required to obtain prior authorization to provide our members’ mental health needs. The 20-visit limit per calendar year remains unchanged. Mental health providers are now responsible for assuring the appropriateness of care under the UPHP benefit versus the Community Mental Health Service Provider (CMHSP) behavioral health carve-out through the state of Michigan. All mental health services will be subject to retrospective review to determine benefit eligibility. Remember, the UPHP mental health benefit is for acute, short-term services only. If you have any questions about this change, please call Clinical Services.

Prior Authorization for Ultram
Ultram is nonformulary for UPHP. Providers may request prior authorizations through Medco Health Solutions at 800-753-2851.

Out-Of-Plan Referrals
To streamline the out-of-plan referral request process, we are making some changes. Updates to your provider manual will be sent soon. Meanwhile, the new form and request procedure will be available on the UPHP Web site. You can also request a copy by calling Clinical Services.
Here is a brief outline of some of the changes. As the current procedure states, all out-of-plan referrals must have prior authorization.

1. All out-of-plan referral prior authorization requests are to be made by fax or mailed to UPHP Clinical Services. Out-of-plan referral prior authorization requests by telephone will not be accepted.
2. All clinical documentation supporting medical necessity for the out-of-plan referral must accompany the referral request.

Thank you in advance for your cooperation!

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Immunization Timing
The current Michigan Childhood Immunization Registry (MCIR) review of immunizations indicates that there are some children who are due for “extra” immunization doses. These “extra” doses are indicated when the child has received previous vaccine doses outside of acceptable timing ranges (Example: third HepB given before 6 months of age or varicella vaccine before 12 months of age even if only one day early).
We urge you to double-check your records for these timing issues. Using the MCIR to review immunizations will allow you to avoid timing errors. MCIR specifies the earliest date a child may receive the required dose of any antigen. No one likes to tell a parent that “we have to give another shot because a previous dose was given at the wrong time.” All current immunization reviews, whether through UPHP, MCIR, or the school systems, will view these children as not being up-to-date. Although the Centers for Disease Control may acknowledge a “grace period” of a few days for some timing issues, the state of Michigan does not.
Another immunization resource is the Web site www.immunize.org You can find a link to this on the UPHP Web site under Links/Immunization Action Coalition. They have a two-page Summary of Rules for Childhood Immunizations that lists all the relevant guidelines. If you do not have access to the Internet and would like a copy, call UPHP and leave a message for Clinical Services, Quality Department staff.

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When Services Are Denied....

A physician-to-physician consult to discuss utilization determinations is available to all practitioners by contacting UPHP Clinical Services nursing staff at 800-835-2556, Monday through Friday, from 8 a.m. to 5 p.m. (eastern time).

UPHP Customer Service * 1-800-835-2556

CLAIM NOTES

Revenue Code RV361-  Per the Medical Services Administration manual, Revenue Code RV361 (Treatment Room) must be billed with CPT-4 code. For UPHP claims billed on the UB-92, the claim must be filed as follows:
Facility..................................RV361 + CPT-4
Physician...............................RV361 + CPT-4 + TC (modifier)
HCFA-1500.........................CPT-4 + TC (modifier)

If you have claims that were previously submitted and denied, please resubmit them as corrected claims

Series Billing - When you are billing for a series of events (i.e., therapies, etc.), please indicate individual dates for each CPT-4 code billed. To avoid duplicate denials, do not indicate a span of time for an individual CPT-4 code. Only one unit will be paid per CPT-4 code per day.

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