Quality Improvement

UHP has a Quality Improvement Program (QIP) that looks at the quality of healthcare and personal service our members receive. Our QIP makes sure that for every member, all care settings and services are part of our quality improvement activities.

The QIP lets UHP track improvement activities and issues over time. Each year, UHP develops a QI Work Plan for the coming year. The Work Plan includes QI activities, reporting and studies from all areas of UHP (clinical and service), and also includes timelines for getting the quality improvement plan done and reported to the QI Committee and the UHP Board. If you have any questions or are interested in participating on UHP QI committees, please contact the UHP QI Department at 1-732-476-1077.

UHP has teamed with other Medicaid managed care organizations in New Jersey to promote lead poisoning prevention awareness. UHP has specific guidelines for lead screening and testing that follows the New Jersey Department of Health recommendations. All children ages 9 months and up to six years of age should be tested for lead.

UHP also focuses on ensuring that all children and adolescents get their immunizations, and monitor well-child visits and Early, Periodic, Screening, Diagnostic and Treatment (EPSDT) exams as well.

Adolescent Immunization HEDIS rates are as follows:

HEDIS rates for Childhood Immunizations are as follows:

In review, UHP found that some of the results did not meet the intended goal. UHP will continue to outreach to members and providers hoping to increase the scores next year for Childhood and Adolescent Immunizations. UHP will also continue to reach out to members and providers to review the need for preventive healthcare. Providers may visit our website at www.uhpnet.com to obtain preventive healthcare guidelines including lead screening and immunizations recommendations and EPSDT requirements.

UHP Access and After Hours Standards

UHP’s annual PCP Access Audit was conducted in September and December 2006.  The audit sample consisted of 98 PCPs representing 2895 members. Of the 98 PCPs, 33 were Pediatricians who do not treat adult members, 36 were Internists who do not treat members less than 16 years of age, and the remaining 29 were Family Practice (FP) or General Practice (GP) treating both children and adults.

Analysis:

1)   100% of PCPs audited met the plan general standards for access.

2)   One PCP office was found to be in non compliance with Plan standards for after-hours   service.  The areas were:

• No recorded message directing the caller to a servicing or on call provider

Within three (3) days of the audit, UHP’s Provider Relations Department informed each of the two non-compliant offices of these discrepancies. Corrections were made to the after-hours messages and verified by the Plan.

To address this problem and to meet the Healthy People 2010 objective to increase to 95% the proportion of children aged < 6 years who participate in fully operational population-based immunization registry, the New Jersey Department of Health & Senior Services (NJDHSS) developed the New Jersey Immunization Information Registry (NJIIS). The NJIIS is a confidential, population-based, computerized information system that allows NJDHSS to collect and consolidate vaccination data about children within a geographic area. Registries are an important tool to increase and sustain high vaccination coverage by consolidating vaccination records of children from multiple providers, generating reminder and recall vaccination notices for each child, and providing vaccination history documents, and vaccination coverage assessments.

The NJIIS allows providers to obtain a complete and accurate immunization history for a new or continuing patient, produce immunization records, reduce paperwork, manage vaccine inventories, introduce new vaccines or changes in the vaccine schedule, interpret the complex immunization schedule, and provide immunization coverage data for your office, health plans, and other national organizations. Major health care organizations, including the American Academy of Pediatrics, American Medical Association, American Osteopathic Association, the American Association of Health Plans and the American Public Health Association, have endorsed immunization registries as an important tool in the delivery of vaccine.

For additional information on NJIIS: http://njiis.doh.state.nj.us/njiis/

What is HIPAA Level 5 Compliance?

• Applies to inbound 837 transactions (electronic claims and encounter submissions.)
• Validates code sets and ensures that the usage is appropriate for a particular transaction and to the coding guidelines which apply to the specific code sets.
• Validates external tables, such as CPT, ICD-9, CDT, NDC, status codes, adjustment reason codes and their appropriate use within the transaction.

In addition, if an inappropriate code set is used within a transaction, only the particular claim will be rejected; not the entire file as would have occurred under HIPAA Level 4. UHP currently employs several edits that allow acceptance of files that may not meet HIPAA level 4 standards; these edits will be removed effective May 1, 2009. This means that claims that do not meet HIPAA Level 4 compliance will be rejected.

If you have questions, please contact us at:

• The UHP/Centene EDI Help Desk at 1-800-225-2573, extension 25525
• The UHP/Centene EDI Help Desk at EDIBA@centene.com

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• Communicating With Patients
• About Ambulatory Medical Records
• Your Telephone Protocol

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• Get to Know Your Member Benefits