A partir del 1 de marzo de 2010, University Health Plans, Inc. (UHP) ya no participará en el programa NJ FamilyCare/Medicaid. Esto significa que un nuevo plan de salud, también llamado una Organización de mantenimiento de la salud (Health Maintenance Organization) (HMO), se hará cargo de su cobertura de atención médica a partir del 1 de marzo de 2010. UHP está trabajando con miras a que éste sea un cambio sin problemas para usted. No habrá interrupción en su cobertura de atención médica.

En febrero, usted recibirá una nueva tarjeta de identificación de su nueva HMO.  Sírvase comenzar a usar su nueva tarjeta de identificación el 1 de marzo de 2010. Debe seguir usando su tarjeta de identificación de UHP y consultando con sus proveedores de UHP hasta el 28 de febrero de 2010.  Su nueva HMO le enviará un Manual para Miembros que incluye sus beneficios y procedimientos para obtener servicios, junto con su tarjeta de identificación y Paquete de bienvenida antes de su fecha de entrada en vigencia. Pedimos que revise el manual y llame a su nueva HMO si tiene preguntas o inquietudes adicionales.  

Miembros voluntarios

Los miembros elegibles pueden seleccionar Pago por servicios (Fee-for-Service) de Medicaid si no quieren ser un miembro de otro plan de salud. Si elige hacer esta transferencia, comuníquese con el Coordinador de Beneficios de Salud del Estado llamando al 1-866-472-5338 (TTY 1-800-701-0720).

 Continuación del cuidado:

Si recibe servicios de un proveedor de la red de UHP que también participa en la red de su nueva HMO y sus servicios no requieren autorización previa de su nueva HMO, puede seguir recibiendo esos servicios sin comunicarse con su nueva HMO. Si su proveedor no está en la red de su nueva HMO, su nueva HMO le ayudará a mover sus servicios a un proveedor dentro de la red.  Sin embargo, hay ciertas circunstancias en las que puede continuar tratamiento con este proveedor.  Si actualmente lo(a) trata este proveedor por las siguientes condiciones, puede continuar el tratamiento como sigue:   

•  Para cuidado posoperatorio, puede continuar consultando con este proveedor hasta por seis (6) meses;
• Para cuidado oncológico (cáncer), puede continuar consultando con este proveedor hasta por un (1) año;
• Para cuidado psiquiátrico, puede continuar consultando con este proveedor hasta por un (1) año;
• Si está embarazada, puede continuar consultando con este proveedor hasta por seis (6) semanas después del parto.

 Si está inscrito(a) en un programa de UHP de manejo de casos/atención médica/enfermedad, estaremos contentos de discutir su caso con su nueva HMO. 

 Si está en el hospital en la fecha en que UHP se retire del programa NJ FamilyCare/Medicaid, UHP seguirá siendo responsable por servicios hasta que se le dé de alta del hospital.

 Si tiene preguntas con respecto a esta información o tiene comentarios o inquietudes acerca de sus necesidades de atención médica, llame a UHP al 1-800-564-6847 (TTY/TDD 1-800-852-7897. 

 UHP se ha complacido en servirlo(a).  Le deseamos buena salud y felicidad siempre.

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Provider Report_Fall 2009_Web Referenced Articles

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Provider Report_Fall 2009

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University Health Plans, Inc. (UHP) would like to make you aware of some important information. UHP is currently going through a process to become officially “accredited” by the National Committee for Quality Assurance (NCQA). NCQA requires UHP to send certain information to its providers. This letter addresses how we operate our business and includes a short synopsis of our Quality Improvement (QI) programs. In the future, you will see and hear more about UHP and NCQA in letters we send you, items posted on our website or in the provider newsletter.

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.

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Approximately 95% of all U.S. children begin the recommended series of vaccination, but only about 75% complete the series by 2 years of age– a critical period for childhood disease prevention. Ensuring that children complete the recommended series of immunizations at the appropriate time is the main problem facing immunization programs. However, since many children receive vaccines from more than one provider and since many parents do not maintain accurate records of their children’s immunizations, it is difficult to evaluate the immunization status of individuals. Without this information, efforts to identify and aggressively pursue children who are incompletely immunized are severely hampered.

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/

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University Health Plans, Inc. is in the process of accepting test files from the major clearinghouses (such as Emdeon) as well as our direct-connect providers to assure that all inbound 837 transactions are HIPAA Level 5 compliant by May 1, 2009.

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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Provider Report – Winter 2009 (PDF)

Newsletter Highlights

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

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Healthy Moves – Winter 2009 (PDF)

Newsletter Highlights

• Is It Time to Renew?
• Get to Know Your Member Benefits

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