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Articles ofImportance to Read:

Page 1• Important Information: Getting Ready for5010/ICD-10Page 2• UnitedHealth Group is First to AchieveCAQH Core Certification Using 5010 TestingPlatformPage 3• Wellness Includes Emotional, Mental andPhysical Health – They All Work Together toMake Your Patients Feel BetterPage 5• Immunization Code Information• Medical Record Criteria• All Choices Providers UpdatePage 6• HCBS In-home Services Providers UpdatePage 7• Disease Management ProgramsPage 8• Knowing Your Resources for National DrugCodes (NDC)Page 9• Preventive Health Care Screening Reminders• TENNderCare Screenings and ComponentsPage 10• UnitedHealthcare Community Plan Online(formerly AmeriChoice Online)Enhancements

• Encourage Your Patients Who areUnitedHealthcare Members to Get the FluVaccine, Not the Flu!

• Pneumococcal Disease Prevention throughVaccinationPage 11• Important Information Regarding The DeficitReduction Act of 2005 and The Federal andState False Claims ActsPage 12• UnitedHealthcare Community Plan AddsMilliman to Behavioral Health Inpatient Levelof Care

Important information from UnitedHealthcare for physicians and other health careprofessionals and facilities serving UnitedHealthcare Medicaid members

Important Information:Getting Ready for 5010/ICD-10

The federal government has mandated thatall covered entities (including health careproviders, clearinghouses and health plans)must transition to the latest version of the Health InsurancePortability and Accountability Act (HIPAA) electronic transactionstandards and code sets.

Two key dates are:• Jan. 1, 2012 – The 5010 version of the electronic transactionsstandards will replace the current 4010 version.

• Oct. 1, 2013 – The International Classification of Diseases 9thRevision, Clinical Modification (ICD-9-CM), the current codeset for reporting diagnosis, will be replaced by ICD-10-CM.

UnitedHealthcare encourages physician practices and facilities tobegin the preparation for these two important changes as soon aspossible to streamline the process and reduce administrative burdensand potential rework.

If you are not familiar with 5010 and/or ICD-10 and what it maymean to your practice, a number of resources are available fromindustry groups like the American Medical Association (AMA),The American Academy of Professional Coders (AAPC), and theMedical Group Management Association (MGMA) that can helpin educating you and your staff on the electronic transactionstandards and code sets.

Summer 2011

www.UnitedHealthcareOnline.com

An important message to health care professionals and facilities

I Summer 2011 2 Provider Service Center: 1-800-690-1606

It is an industry accepted standard that the firststeps to a 5010 implementation plan is to speakwith your practice management software vendorto ensure your system will be compliant with theupcoming changes. The Medical GroupManagement Association (MGMA) hasdeveloped a list of vendor-specific questions toassist you in this discussion. To view thequestions, please visit the MGMA website. Onceyou determine that your systems are compliant,the next step is to ensure that testing isconducted of your practice management andelectronic medical record system with yourvendor and/or clearinghouse.

At UnitedHealthcare, our 5010/ICD-10implementation plan is underway, and we areactively engaged in 5010 Trading PartnerTesting. For ICD-10, we plan to be “code ready”six to nine months in advance of the 2013mandate. (Please note that we will not ask ournetwork participants to comply with anymandates early; rather, these timelines ensurethat UnitedHealthcare has the ability to supportyour needs and conduct a thorough TradingPartner Testing program.) We want to assureyou that we will be ready and we are eager toconsult with our provider and facility network asthey begin their implementation planning.

Have you started external testing ofversion 5010?All HIPAA-covered entities that submittransactions electronically are required toupgrade from Version 4010/4010A to Version5010 transaction standards by Jan. 1, 2012.Westrongly suggest you develop a plan for testing(both internally and with external businesspartners) in preparation for the Jan. 1, 2012,deadline.

Testing transactions using Version 5010standards will ensure that you are able to sendand receive compliant transactions effectively.Testing early will allow you to identify any

potential issues and address them in advance.Here are key dates to know to ensure you areready for the Version 5010 and ICD-10transitions:

• Jan. 1, 2011 – Begin external testing of Version5010 for electronic claims.

• Dec. 31, 2011 – External testing of Version5010 for electronic claims must be complete toachieve Version 5010 compliance.

• Jan. 1, 2012 – All electronic claims must useVersion 5010; Version 4010 claims are nolonger accepted.

• Oct. 1, 2013 – Claims for services provided onor after this date must use ICD-10 codes formedical diagnoses and inpatient procedures;CPT® codes will continue to be used foroutpatient services.

Additional HIPAA 5010 and ICD-10 resourcesare posted on the UnitedHealthcare Online®website.

UnitedHealthcare Plan of the River Valley, Inc.("UnitedHealthcare") encourages physicianpractices and facilities to begin the preparationfor these two important changes as soon aspossible to streamline the process and reduceadministrative burdens and potential rework.

UnitedHealth Group is First to AchieveCAQH Core Certification Using 5010Testing Platform

• 5010 data transactions include patienteligibility/verification and claim status

• Faster and more predictable administrativetransactions enable doctors and hospitals tospend more time caring for patients

CAQH and UnitedHealth Group (NYSE:UNH) announced on April 12, 2011 thatUnitedHealth Group had completed theCommittee on Operating Rules for InformationExchange® (CORE®) Phase I and II testing



process. This process certifies that UnitedHealthGroup can deliver more efficient and predictablepatient-eligibility and claims-verificationinformation to doctors, hospitals, physicianoffices and other care providers, according tooperating rules developed by CORE.

UnitedHealth Group is the first health careorganization to complete certification using theupdated platform, which builds on non-mandated aspects of the Health InsurancePortability and Accountability Act (HIPAA)version 5010 requirements. This is an importantmilestone in the company’s efforts to streamlinepatient-eligibility and claims status transactions,so that care providers can spend less time onadministrative functions and more time treatingpatients.

The CORE operating rules streamlineadministrative information exchanges andimprove provider access to patient benefitscoverage and financial information at the point-of-care. CORE is a multi-phase, collaborativehealth care industry initiative aimed atimproving access to electronic patientadministrative and payer information for careproviders before or at the time of service, usingany technology. Each phase expands the availabledata criteria and augments the functionalrequirements for electronic data exchange.

“CORE certification reflects UnitedHealthGroup’s commitment to streamliningadministrative processes with doctors, hospitalsand other care providers so they can spend moretime providing quality care for their patients,”said Timothy Kaja, senior vice president,UnitedHealth Group Provider and NetworkService Operations. “By becoming COREcertified, UnitedHealth Group is demonstratingthat the concept of operating rules as mandatedby the Patient Protection and Affordable CareAct (ACA) is an important part of makinghealth care work better.”

“We are pleased that UnitedHealth Group isCORE certified. The operating rules will ensurean effective flow of administrative data betweenus,” said Murray E. Fox, M.D., FACOG, aPlano, Texas-based practicing physician andfounder, president and CEO of Patient PhysicianNetwork, a 650-physician member networkwhose primary goal is to respond to thechanging health care environment in the Dallas-Fort Worth area. “Being able to rely onUnitedHealth Group for consistent and accurateelectronic information about benefits coverageand financial obligations enables us to streamlineour internal processes and offer complete andtimely information to our patients.”

Robin Thomashauer, executive director ofCAQH, said: “We are pleased to seeUnitedHealth Group join the growing numberof companies that have become CORE certifiedand the first to become CORE certified in a5010 format. Advances such as this are essentialto establishing the foundation for trueadministrative simplification, leading toimproved transparency and reduced cost inhealth care. Continued advances in COREoperating rules and adoption by companies suchas UnitedHealth Group and its physicianpartners will accelerate our nation’s progress tothat end.”

Wellness Includes Emotional, Mentaland Physical Health – They All WorkTogether to Make Your Patients FeelBetter

In treating your patients, mental health is asimportant as physical health. The rich onlineresources at liveandworkwell.com can assist youand your patients to improve overall wellness. Itcan assist manage benefits, use interactive toolsand find clinician reviewed information tosupport wellness and deal with life’s challenges.Patients and their families have convenient,confidential information and support to help



cope with stress, emotional/mental health,substance abuse/addictions and grief or trauma.We also provide support for people living withchronic conditions such as diabetes, asthma, orarthritis.

Support is available online 24/7 atliveandworkwell.com to you and your patients.Try it…you’ll find something new that you needto know (screen shot on the back!):

• Mental Health Clinician SearchTool

• My Claims & Coverage: self-manage andmonitor your behavioral benefit coverage,visit certification and claims any time

• Interactive self-help programs to addressdepression, anxiety, stress, alcohol, drugs andsmoking

• Behavioral health and wellness newsfeeds

• Extensive information and resources:

– 28 Mental Health Condition Centers:Depression, ADHD, Autism, Dementia,Bipolar Disorder, Personality Disorders,Abuse, Anger, Alcohol and DrugDependency, Anxiety, Post-traumatic Stress, Grief, EatingDisorders and more

– Coping with Stress Center as wellas child and teen specific stresscenters

– Care giving and Living withChronic Disease Centers: guides,information, search tools andresources

– Nutrition and Fitness Centers foradults, kids and teens

– Drug information, drug interactionchecker, alternative medicine andhealth database

– Age-appropriate kid and teen health and lifeinfo and games

– Videos, podcasts and self-paced Webinars(see Multimedia area)

• Available in English and Spanish

How to use the site:Go to liveandworkwell.com• Patients with UBH behavioral healthcoverage can register/login directly foraccess to all resources, or

• You can enter anonymously by selecting“click here to enter with only an AccessCode” then enter “Clinician” and utilizethe resources available in your practiceand with patients

The information and therapeutic approaches inthis content are provided for informationaland/or educational purposes only. They are notmeant to be used in place of professional clinicalconsultations for individual health needs. Certaintreatments may not be covered in some benefit



Immunization Code Information

The UnitedHealthcare Employer &Individual Frequently Asked Questions(FAQ) document has recently beendiscussed in regards to the 2011 immunizationcodes changes. The staff of the UnitedHealthcareCommunity Plan Payment Policy team has beenhard at work researching the differing Statespecific regulations, the Vaccines for Children(VFC) requirements related to these new codes,and gathering information from health planrepresentatives in order to determine how eachmarket should be billing for immunizations withrespect to these new codes. After much research,state specific FAQ documents have been drafted,based on the differing methods ofreimbursement being utilized by the differentmarkets. For those markets utilizingimmunization administration cost on VFCserum codes, nothing has changed, and thus nonew document was drafted. For the remainingmarkets, these documents will be forwarded tothe health plan representatives to be dispersed toproviders for educational purposes. If you wouldlike more information on the 2011immunization code changes, please contact yourProvider Advocate.

Medical Record Criteria

UnitedHealthcare is contractually obligated tosubmit accurate, detailed and complete encounterdata to the states. Consequently,UnitedHealthcare participating providers arerequired to submit accurate, detailed andcomplete claims data and to maintain andprovide, when requested, medical recorddocumentation to support the claims. Here is ashort checklist for your office to maintainmedical records:

• Medical records must include: history &physical; allergies and adverse reactions;problem list; medications; preventive

services/screening; and documentation ofclinical findings for each visit

• All medical records are to be stored securely

• Only authorized personnel should have accessto medical records

• Staff receive periodic training in patientconfidentiality

• Medical records are organized and stored in amanner that allows easy retrieval

Please call your Provider Relations Advocate ifyou have any questions regarding medical recordscriteria. Resources are available to you atUnitedHealthcareOnline.com > ClinicianResources > Patient Safety Resources > MedicalRecord Tools & Templates.

All Choices Providers Update

Your provider advocate will be sending out aProvider Compliance Checklist in order todetermine if you have all the necessary polices inplace. This will be addressed during yourassessment review and will include the following:

• Deficit Reduction Act of 2005 (DRA) &Federal and State False Claims Acts

• State Medicaid letter – Medicaid providers toscreen for exclusions

• Disclosure of criminal conviction, ownershipand control interest

• Limited English Proficiency (LEP) andinterpretation services

• Non-discrimination

• Grier posters

• Advance directives

• Cultural competency

• Program integrity, fraud and abuse



The UHC Compliance Checklist can be found:https://www.uhcrivervalley.com/downloads/provider/AmeriChoice/ProviderComplianceChecklist.pdf

The policy, as well as the State and Federal FalseClaims Act are available at:https://www.uhcrivervalley.com/10provider/01americhoice/integrityofclaims.asp.

HCBS In-home Services ProvidersUpdate

The next Sandata update is scheduled for5/16/2011. Sandata users please note that allupcoming release notes are available in thedocumentation library. There are also manyhelpful guides including the “ExceptionHandling Guide”.

The steps to access the TennesseeDocumentation Training Library:

1) Type in the url:http://nhwebtraining.sandata.com/tenncare

2) User Name: nhtraintn

3) enter Password: 3stars

Nursing FacilitiesCorrected Claims:

Nursing Facility Providers will only use bill type667 or 217 in field locator 4 of UB04 claim formwhen the monetary value on the claim isimpacted, i.e. correction of units, revenue codes,dates of service, etc.

• FL 45 must have a from and to date. If not,please leave blank so that the claim defaults tothe statement date.

• If you need to submit a correction fordiagnosis codes you will continue to use 663 or213 as your bill type.

Patient Liability:

• In order for UHC to calculate patient liabilityaccurately it is best to bill charges on amonthly basis instead of split billing i.e. bi-weekly, weekly etc.

• This will cut down on claims being processedwith underpayments and overpayments of“pennies”

• It will also prevent the providers in having tosubmit corrected claims on multiple claimsinstead of one claim

Enhanced PAE’s:All enhanced levels of care require authorization

• 192 plus CPT Code 94004 – Chronic Vent

• 192 plus CPT Code 94004 w/Modifier 22 –Vent Weaning

• 192 plus CPT Code 94004 w/Modifier 52 –Trach Suction

• Enhanced PAE’s should be faxed to LashandraWhite at 877-360-7548 in order to receive anauthorization for services

Adult Care Homes Level II• In June of 2009 the Tennessee Senateunanimously approved legislation thatauthorizes adult care homes, small residencesoperated for two to five people.

• The initiative was based on similar adult carefoster homes in Oregon

• The design is for ventilator-dependent andbrain-damaged Tennesseans.

• Each home must have a properly licensedprofessional who lives on the premises as a“resident manager” and have a professionalcaregiver on duty 24 hours a day

• The resident is responsible for room and boardcharges in Vent and TBI Critical Adult CareHomes



• Member will be allowed to keep $100 ofhis/her monthly personal needs allowance forpersonal expenses.

• Facility will be responsible for collecting roomand board payment from the resident andbilling MCO the difference between the perdiem rate of $450 or $217(as applicable) andthe room and board amount due.

• Facility is also responsible for collecting anypatient liability amount—in addition to roomand board.

For more information providers in Middle andWest Tennessee please contact:Bryan Boles at 931-372-1892 [email protected]

For providers in East Tennessee please contact:Judy Lane at 865-981 1596 [email protected]

Disease Management Programs

UnitedHealthcare Community Plan’s DiseaseManagement Programs (DM) serve to optimizethe health and well being of members withchronic illness, or at high risk for adversemedical outcomes. To accomplish this,UnitedHealthcare Community Plan hasdeveloped comprehensive DM Programs that aremember-centered and facilitate collaborationbetween members and their health care teams.The DM programs also promote self-management, active decision-making, andparticipation in health care interventions andoutcomes.

UnitedHealthcare Community Plan currentlyprovides DM Programs for the following:• Diabetes

• Asthma

• COPD

• Heart failure

• Coronary artery disease

• Childhood obesity

• Major depression

• Schizophrenia

• Bipolar disease

• Maternity management (Healthy First Steps)

Disease Management is based upon the premisethat collaboration between the member, supportsystems, and health care professionals result inthe development of partnerships that promotetargeted interventions and health care goals, thatcontribute to improving health care outcomes.This coordination of care provides anopportunity for improvement in the quality ofcare continuum.We strive to empower themember to become successful in managing theirchronic disease or condition. UnitedHealthcareCommunity Plan understands how difficult itcan be to change behavior.We have developedproprietary strategies to maximize success for ourmembers. Members in our DM Programs receiveongoing disease-specific education and coachingregarding lifestyle changes, as well as holisticsupport to address situations that may impedethe member from reaching health care goals.Moreover, designated clinical staff, social workersor educators are assigned to these members. Theone-on-one relationship built during regularcontact between the member and the healthprofessionals creates a strong bond thatencourages compliance and active participation.Eligible members of UnitedHealthcareCommunity Plan do not have to enroll; they areautomatically enrolled when we identify them aspregnant or living with a chronic illness.We willinform you of their participation. If you wouldlike to enroll a UnitedHealthcare CommunityPlan member who is not currently enrolled inthe program, please let us know.We will workcollaboratively with you and your patients to



identify and prevent complications, promoteoptimal health and ensure quality health care. Ifyou have any additional concerns or questions,please let us know.This will allow us to supportyour treatment plan for your patients. A DiseaseManagement Program representative can bereached by calling 800-690-1606.

Knowing Your Resources for NationalDrug Codes (NDC)

United Healthcare Community Plan oftenreceives feedback on struggles with usingNational Drug Codes (NDC) and how exactlythese codes are billed. A large part of thisstruggle is identifying the resources available tohelp educate providers and their staff of thebackground and changes to the NDC program.

The United States Food and DrugAdministration provide a thorough backgroundof the NDC numbering system.The DrugListing Act of 1972 requires all pharmaceuticalmanufacturers to register all prepared,propagated, compounded or processed drugswith the FDA using a three-segment number,which we know as the NDC number.

The NDC Directory, published by the FDA, is avaluable resource for any office to be familiarwith. The directory is comprised of prescriptiondrugs and insulin products manufactured forcommercial distribution, and are organized intoten categories which leave providers severaloptions for searching for a drug.

This background information and the NDCDirectory can be found at:www.fda.gov/cder/ndc/database. (The release ofthe new NDC Directory has been delayed toJune 1, 2011. The FDA asks all providers to visitthe website in May for test data files and datadefinitions.)

The NDC number is a sequence of ten numbersin either the 4-4-2, 5-3-2, or 5-4-1configurations. The first set-up numbers is thelabeler code, which is provided by the FDA.Thesecond set of numbers is the product code, whichidentifies a specific strength, dosage form andformulation. The final set up numbers is thepackage code, which indentifies the package sizeand package types.

Because HIPPA requires an 11-digit NDC code,you may see an asterisk in the manufacturersNDC code. This acts simply as a place holder forthe eleventh required digit.When billing anNDC code, you must place a zero (0) in theplace holder in order to be compliant withHIPPA regulations. Make sure attention is paidto the drug manufacturer’s configuration of theNDC code to ensure your success in billing thedrug code.

The Center for Medicare and Medicaid Services(CMS) also provides several resources thatprovider offices can educate themselves with.Providers who have questions about theappropriate quantities to report, or providers whowould like to review the 2011 codes, can refer tothe alpha-numeric HCPCS manual and thetable of drugs manual found at:http://www.cms.hhs.gov/HCPCSReleaseCodeSets/ANHCPCS/list.asp.

United Healthcare Community Plan is requiredby the Federal Deficit Reduction Act of 2005 tocollect claims data for physician administereddrugs for use in drug rebate programs. As of June1, 2007, all professional claims for physicianadministered drugs are required to have theNDC number on each CMS 1500 form.

Visit the United Healthcare Community PlanProvider University website to find our NDCTricksand Tips flyer available at:https://www.uhcrivervalley.com/10Provider/01AmeriChoice/ProviderUniversity/CourseDocuments.asp



If you have any further questions, please contactyour Senior Provider Advocate [email protected].

Preventive Health Care ScreeningReminders

Recommended preventive health care service forTENNderCare members is covered by UnitedHealthcare Community Plan. Adult screenings

are equally asimportant asperformingTENNderCare exams.The preventive benefitshelp both children andadults detect problemsearly and take an activerole in maintaininggood health.

These general guidelines list the types of carescreenings and exams needed at particular ages.

• For infants and young children, the guidelinestypically focus on physical and mentaldevelopment, immunizations, nutrition, andsafety.

• For children and young adults, the focus isusually on maintaining or developing healthylifestyle habits and eliminating high-riskbehaviors.

• For adults, the focus continues to be oneliminating high-risk behaviors; however,screening for chronic and/or life-threateningdisease becomes more important.

The choices our members make about the waythey live are important to their health. As theprovider, please talk to the member about theimportance of preventive services and theservices they might need. Remind them that itis important to follow your advice aboutcheckups, healthy lifestyle choices andmedications that prevent health problems.

Always encourage regular screenings and assist inkeeping our members healthy.

TENNderCare Screenings andComponents

UnitedHealthcare Community Plan wants towork with our providers to ensure members arereceiving the proper TENNderCare screenings.Regular preventive health screenings inconjunction with completion of the sevenscreening components are important inmaintaining the health of the your patients whoare UnitedHealthcare Community Planmembers.

What are the seven required screeningcomponents?

1. Comprehensive health history (includingdevelopmental and behavioral)

2. Comprehensive unclothed or suitablydraped physical examination

3. Appropriate laboratory tests, according toage and health history

4. Vision screening

5. Hearing screening

6. Immunizations in accordance with currentAAP recommendation

7. Health education/anticipatory guidance

All TENNderCare members under the age of21yrs should be screened according torecommendations of Bright Futures/AmericanAcademy of Pediatrics (AAP) periodicityschedule - the "Recommendations for PreventiveHealth Care." Please be sure to perform regularcomprehensive TENNderCare screeningsincluding the seven components.



UnitedHealthcare Community PlanOnline (formerly AmeriChoice Online)Enhancements

United Healthcare's innovative online providerportal, UnitedHealthcare Community PlanOnline (formerly AmeriChoice Online), hasbeen updated with new features in 2011.

One new enhancement offers the provider theoption to search by member for both theTENNderCare EPSDT Screening MeasuresReport and the Preventive Health ScreeningMeasures Report. Click on either the"TENNderCare EPSDT Report by Member"link or "PHM Report by Member" link, to viewan individual report for a member enrolled inyour panel. Providers can search for anindividual member by UnitedHealthcareCommunity Plan member ID number ormember name, last name and date of birth.Searching by member ID number is the fastestand most accurate search method.

Another enhancement allows the provider tocontact the health plan through the online portalwith questions regarding data on theTENNderCare EPSDT or Preventive HealthMeasures report, such as dates of screening. Thegoal is to facilitate communication relating toreports that are available for providers. Tosubmit a query or comment to the health plan,providers will only have to click the notify planlink, enter and submit forminformation/comment relating to theTENNderCare EPSDT Screening or PreventiveHealth Screening Measures Report. An emailwill be sent to the EPSDT/Preventive Healthand Education Department and providers willreceive a reply within 3-5 business days.

Please visit www.uhccommunityplan.com to viewthe new features. If you have any additionalquestions regarding the new features ofUnitedHealthcare Community Plan Online,please contact your Provider Advocate.

Encourage Your Patients Who areUnitedHealthcare Members to Getthe Flu Vaccine, Not the Flu!

The seasonal flu vaccine continues to be themost effective method for preventing flu virusinfection and its potentially severe complications.UnitedHealthcare Community plan encouragesour doctors and nurses to begin vaccinating theirpatients as soon as flu vaccine is available in theirarea. Everyone six months of age and older arerecommended to get the flu vaccine, whichincludes even the healthiest adults. Vaccination isespecially important for people at higher risk ofserious influenza complications or people wholive with or care for people at higher risk forserious complications.

You can help reduce the transmission of theseasonal flu and serious complications by usingevery office visit as an opportunity torecommend the member take advantage of theannual seasonal flu shot benefit covered byMedicare. And don’t forget, health care providersand their staff can spread the highly contagiousflu virus to their patients. Persons working inhealth care settings also should be vaccinatedannually against influenza. Vaccination of healthcare professionals has been associated withreduced work absenteeism. Don’t forget toimmunize yourself and your staff.

Source:http://www.cms.gov/MLNMattersArticles/downloads/SE1031.pdf

Pneumococcal Disease Preventionthrough Vaccination

Invasive pneumococcal disease, caused byStreptococcus pneumoniae (pneumococcus),remains a leading cause of serious illness inchildren and adults worldwide.

Despite the fact that the vaccine has consistentlybeen recommended by ACIP, the AmericanAcademy of Pediatrics, the American College of



Physicians and the American Academy ofFamily Physicians, the vaccine remainsunderutilized. Because infection withStreptococcus pneumoniae bacteria can lead tomeningitis, deafness, brain damage and otherhealth problems, providers should encourage thevaccination for those who do not have acontraindication to the vaccine.

Most healthy adults who get the vaccine developprotection to most or all of these types within 2to 3 weeks of getting the shot. And remember, asclinicians, parents see you as the most trustedsource of information about vaccines. So helpprevent pneumococcal infections, throughvaccination. Vaccination clearly offers the bestprotection against pneumococcal disease.

Resources:http://www.cdc.gov/mmwr/preview/mmwrhtml/00047135.htmhttp://www.cdc.gov/vaccines/pubs/vis/downloads/vis-pcv.pdf

Important Information Regarding TheDeficit Reduction Act of 2005 and TheFederal and State False Claims Acts

The Deficit Reduction Act (DRA) of 2005contains many provisions reforming Medicareand Medicaid, which are aimed at reducingMedicaid fraud. Under Section 6032 of theDRA, every entity that receives at least fivemillion dollars in Medicaid payments annually(i.e., UnitedHealthcare Community Plan) mustestablish written policies for all employees of theentity, and for all employees of any contractor oragent of the entity. This information shouldprovide detailed information about false claims,false statements, whistleblower protections andrecoveries under applicable federal and state falseclaims laws. As a contracted provider orsubcontractor with UnitedHealthcareCommunity Plan, you and your staff are subjectto these provisions.

The UnitedHealth Group/UnitedHealthcareCommunity Plan policy, titled “Integrity ofClaims, Reports and Representations toGovernment Entities” can be found at thewebsite link shown below.This policy detailsUnitedHealth Group’s commitment tocompliance with federal and state false claimsacts, provides a detailed description of these actsand the mechanisms in place within ourorganization to detect and prevent fraud, wasteand abuse. Posted along with the policy is theTennessee Medicaid False Claims Act whichprovides additional detail regarding theprotections afforded whistleblowers under thestate False Claims Act as well as the recoveries awhistle blower may be entitled to receive. Thisdetailed information about whistle blowersshould be included in the educational materialprovided to your employees.

The policy and the state False Claims Act areavailable at the following link:https://www.uhcrivervalley.com/10provider/01americhoice/integrityofclaims.asp.

In addition, CMS issued guidance regardingcompliance with Section 6032 which you mayreference on-line at:

http://www.cms.hhs.gov/smdl/downloads/SMD032207.pdf

http://www.cms.hhs.gov/smdl/downloads/SMD032207Att1.pdf

http://www.cms.hhs.gov/smdl/downloads/SMD032207Att2.pdf

UnitedHealthcare Community Plan policyrequires that during its on-site visits withproviders, provider outreach staff will verifyprovider’s compliance by reviewing the DRAalong with providers’ evidence of compliance.Providers will also be asked to attest to theircompliance by completing a DRA Attestationform.



Should you have questions regarding yourresponsibilities to educate your employees underSection 6032 of the Deficit Reduction Act,please contact your legal counsel or theUnitedHealthcare Community Plan ComplianceOfficer, Andrea M. Fitzgerald, CHC at 615-493-9532.

UnitedHealthcare Community PlanAdds Milliman to Behavioral HealthInpatient Level of Care

UnitedHealthcare Community Plan is excited toannounce the addition of Milliman CareGuidelines for Behavioral Health InpatientLevel of Care (LOC). In March of 2011, ourBehavioral Health Utilization Managers beganusing Milliman criteria in reviewing all initialand concurrent clinical reviews. Millimanprovides an excellent, evidence-based, qualitymeasured tool to guide care managers in clinicaldecision-making. Often we see our most chronic,complex members being treated in psychiatrichospitals across the state. As a result of Paritylegislation and associated expectations aroundbenefit administration, including utilizationreview activities, we have adopted the samecriteria set currently being used for our PhysicalHealth Inpatient LOC.

Milliman Care Guidelines are some of the mostwidely utilized criteria sets; due to the fact thatthey are annually updated and are evidence-based clinical guidelines. Milliman has reviewedmore than 100,000 abstracts, articles and othersources of evidence, and chosen more than14,000 unique citations in order to build theirevidence-based authorization criteria, carepathways, and other care management tools. Inaddition, Milliman incorporates qualitymeasurement tools from such nationallyrecognized organizations such as NCQA,HEDIS and Joint Commission.

Beginning March 15th, 2011, Behavioral HealthUtilization Care Management staff began usingMilliman Care Guidelines for all Mental HealthInpatient Level of Care requests with greatsuccess. For all stays that were admitted underthe prior level of care guidelines (LOCGs),concurrent reviews continued under thoseLOCGs until members were discharged frominpatient services. For inpatient substance abuseservices (including co-occurring disorders) wecontinue to utilize ASAM PPC-2R at this time.

As we look forward, we envision Milliman CareGuidelines better standardizing our concurrentreviewing process and helping us serve ourmembers in a more standardized, evidence basedway.We encourage providers to embrace theMilliman Care Guidelines to aide organizationalefficiency and address quality-of-care issues, aswell as to partner with UnitedHealthcareCommunity Plan in serving our members in themost efficacy based, effective way.

Based on the positive outcomes of utilizingMilliman Criteria thus far, we continue toconsider using Milliman Care Guidelines formultiple levels of behavioral health care atUnitedHealthcare Community Plan.Weencourage you to familiarize yourselves withMilliman at http://www.careguidelines.com/ andsee what a positive impact these care guidelinesmay have on your organization.

Provider Service Center: 1-800-690-1606

Practice Matters is a periodic publication for physicians and other health care professionals and facilitiesin the UnitedHealthcare network.

UnitedHealthcare Plan of the River Valley, Inc

M47507TN 6/11

8 Cadillac Dr., Ste. 100Brentwood, TN 37027

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