UnitedHealthcare of Georgia of Georgia UnitedHealthcare GASCO - - PowerPoint PPT Presentation

UnitedHealthcare UnitedHealthcare of Georgia

• f Georgia

GASCO University Administrators GASCO University Administrators’ ’ Association Association December 3, 2008 December 3, 2008

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Our Mission is to help people live healthier lives

We seek to enhance the performance of the health system and improve the overall health and well-being of the people we serve and their communities. We work with health care professionals and other key partners to expand access to high quality health care so people get the care they need at an affordable price. We support the physician/patient relationship and empower people with the information, guidance and tools they need to make personal health choices and decisions.

Our Mission

Administrative Simplification = Provider Satisfaction and leads to Affordable Healthcare

Provider Advocates…Who are we? A New Partnership with Physicians A New Partnership with Physicians

• UHG Navigational Specialist
• Face to Face contact
• Maximize the ability to interact with UHC
• Your Provider Advocate is to be your resource for issue

resolution and relationship.

Responsive, Proactive, Reliable and Simplistic! Responsive, Proactive, Reliable and Simplistic!

UHG

Provider Advocate

Physicians

Other Health Care Providers

Claim Process Flow Claim Process Flow

Resolving claim issues

Follow standard processes to submit a reconsideration of a claim (online, phone, paper.)

• Allow 30 days for claim to
• process. If you do not receive a satisfactory

response within 30 days follow the steps below:

First Step

• Call the United Voice Portal (UVP) for

resolution at 1-877-842-3210 (have your tracking number available – B plus 16 digits).

• If you do not receive a satisfactory

response within 30 days

Second Step

• Call your Provider Advocate

Self Service via the Provider Web Portal Self Service via the United Voice Portal Assisted Service from a Provider Phone Rep. Escalated Service Line- Rapid Resolution Expert Contact your Provider Advocate

Provider Phone Representative Provider Web Portal Escalated Service Line- Rapid Resolution Expert United Voice Portal

Issue Resolution Engagement

Oncology Oncology Initiatives Initiatives

A dedicated team with cancer expertise

Leader is a board certified oncologist Address both quality of cancer care and affordability of care Research experience to find the problems Clinical and business skills to find solutions

Oncology Line of Service

UHC Customer Service

Dedicated Call Center Team for Oncology Clinics

Phone number: 1-877-842-3210

• Providers are transferred to dedicated team after

entering TIN

• Contractually, some ASO customer related calls must be

transferred to client dedicated team

Dedicated Claims Processing Team for Chemotherapy Claims

• Chemotherapy claims (J 9000 claims) to be processed

by specialized team.

Oncology Initiatives

Change in UHC Herceptin Policy

Effective 01/01/2009, UHC removing the requirement to submit a pathology report to obtain coverage for Trastuzumab.

Claim Submission Hematocrit Level Popup

During a Claim Submission users will now receive a Pop-up box to remind them when Hematocrit (HCT) Level is required based upon the procedure code(s) entered on the claim.

KRAS Testing Required

Spring 2009, UHC is launching a KRAS requirement for coverage

• f Cetuximab and Pantumimab for Colorectal Cancer. Enrollees with “wild-

type” KRAS gene will be eligible for coverage for Cetuximab and Pantumimab therapy. Requirements: Submission of a pathology report documenting the type

• f KRAS gene.

State Health Benefit Plan State Health Benefit Plan

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State Health Benefit Plan (SHBP)

Renewed SHBP contract effective 01/01/2009 United Healthcare administers the following State Health Benefit Plan (SHBP):

Options PPO Choice HMO Indemnity High Deductible Health Plan Definity CDHP *Important to remember: For SHBP claim issues or benefit questions, contact the Customer Service number on the back of the member’s ID card. UHC SHBP members have 1 single group number – 702030. SHBP product type will be listed at the bottom of the front of the member ID card. SHBP does not require prior notification on radiology services.

Standard Notification Requirements Standard Notification Requirements

Notification Requirements

Effective December 3, 2007, Providers are responsible for Advance Notification for certain planned services.

• Notification is required at least five (5) business days prior to the

planned service date (unless otherwise specified within the Notification List in Administrative Guide).

• Notification for home health services is required within forty-eight hours

after physician's order.

• If services are planned less than five (5) business days prior to the

service date, notification is required as soon as the service is scheduled. Note: Physicians who have received the UnitedHealth Premium quality and efficiency of care designation are exempt from the Advance Notification requirement for certain services as indicated on the Advance Notification List.

Predeterminations Predeterminations

What is a Predetermination?

• What is a predetermination?

Voluntary requests for coverage of services that may or may not be covered under the plan Voluntary requests for coverage of services that do NOT require prior notification

• How are they submitted and who submits them?

Faxed to the RMO at (801) 233-9580 Mailed to the address on the members card Visiting unitedhealthcareonline.com click on Claims and Payments/Claim Estimator Providers submit clinical notes, codes and any documentation regarding why the patient needs the treatment

Urgent Pre-D Requests How do I escalate a Predetermination?

• Fax an urgent predetermination issue to

UnitedHealthcare and and email your Provider Advocate

• Provider Advocate will escalate to Pred

Escalate Mailbox

• The Pre-D Unit will respond to the Provider

Advocate stating that they received the issue and it is being worked.

UnitedHealthcareOnline.com UnitedHealthcareOnline.com Going Green in 2008

Tools for Administrative Simplification

Our Physician Focused Tools:

• Simplify the administrative process before the patient even steps

into the office, through point of service and beyond

• Reduce the amount of paper coming in and out of your office
• Help the environment stay green

Use UnitedHealthcareOnline.com to:

Check Eligibility, Benefits & Claims Status Submit & Adjudicate Professional Claims with real time adjudication Submit and verify Status of Notifications Submit a Pre-Determination of Benefits

Electronic Claim Submission Products:

• Real Time Adjudication through UnitedHeatlhcareOnline.com
• Submit claims through Ingenix EDI Solutions or the clearinghouse
• f your choice
• Connectivity Director – direct connection to UnitedHealthcare

UnitedHealthcare ID Cards: Swipe Card Technology

• Verify member eligibility and co-payment information
• Speed patient check-In
• Reduce the risk of claim denials

A day in the life of a practice

Our tools can simplify the administration process before the patient even steps into the office, through point of service and beyond. They reduce the amount of paper coming in and out of your office, ultimately helping the environment stay green.

Meet Patty Patient…

Pre Visit Tools Post Visit Activities Follow Up Tools Administrative Tools

Prior to or at arrival Day of visit or after Post claim submission Anytime Patient makes an appointment, schedules surgery or comes to the ER:

• Do a pre-determination of

benefits

• Check eligibility
• View the Patient Personal Health

Record Clinical portion of visit is complete:

• Use claim estimator to

check bundling logic

• Submit the claim

Claim has been submitted:

• Get paid electronically via

EPS

• Submit an adjustment if

necessary Access administrative resources, right at your fingertips:

• Review the admin guide
• Check on a medical policy

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UnitedHealthcareOnline.com

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Additional services available on UnitedHealthcareOnline.com

Updated 2008 UnitedHealthcare Administrative Guide UnitedHealthcare’s Reimbursement Policies UnitedHealthcare’s Medical Policies Notification Requirements Electronic Payments and Statements information Claim Cost Estimator Tool UnitedHealthcareOnline Available Services (cont)

Getting Started

Need your own user ID & Password? Register Online - Login box

• All users can register by clicking on the ‘New User’ link and following the prompts. In most

cases you are able to obtain a user id & password instantly!

Did an employee leave your organization? Manage Users

• User ID and Password Management allows an Administrator or the Password Owner to manage

individual users' accounts as well as establish the appropriate levels of access

Want a single sign-on for all of your TINs? Multi-TIN Access

• Billing companies can now link multiple Tax IDs together with a convenient single sign-on
• Are you an organization that uses a billing company? You have the ability to approve the billing

company access to your tax ID

Need Instruction? Help

• Quick Reference Cards
• Step by Step help
• Online Tutorials

Get started using UnitedHealthcareOnline.com today!

Why Electronic Payments & Statements (EPS)? EPS is the standard way for UnitedHealthcare to pay claims EPS reduces administrative costs Reduces postage/paper costs Eliminates lockbox/check deposit fees Reduces manual work EPS is secure

Did you know that one tree can produce 8,333 pieces of paper* (16 reams)? In 2006 UnitedHealthcare generated 80 million paper EOBs/Checks, using 9,600 trees! *source: dolphinblue.com UnitedHealthcare: Averages two EOBs per check Inserts one check per envelope Creates hundreds/thousands of envelopes/checks for you to track and deposit manually.

EPS Payments

Email notification of each deposit Electronic payments made at least once per week

• Into your checking account

We cannot debit your account for claim overpayment, unless we obtain your permission If you need payments split into multiple accounts, we can do this based on NPI New in 2008

• Payments for Evercare and Secure Horizons will now be part of

your direct deposit – this is rolling out gradually throughout the country – you will be notified first!

• EPS is going multi-payer. Soon you will be able to get

payments from other entities

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Key Message Summary

A New UnitedHealthcare Expanded Provider Relations Team Nine (9) Provider Advocates – Deployed Statewide Five (5) Market Service Agents – Deployed Statewide Claims Resolution Service Mode Administrative Advisory Committee Specialized Oncology Line of Service Administrative Simplification – Go Green Real Time Adjudication Online Notification Submission ID Card Swipe Card Technology Electronic Payments & Statements Voice of the Physician & Practice Administration is critical

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Questions and Answers

Q & A

Thank you for attending!