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Unicare Health Plan of WV, Inc
A true partnership with our provider community UniCare is an Anthem Company. UWVPEC
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Welcome! We would like to thank everyone for taking time out of their busy schedule to be here today! Thank you for the dedicated care and time you provide our UniCare Health Plan of West Virginia, Inc. (UniCare) members each day.
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Today’s Objectives Our goal today is to share with you some of the following information you need to know about UniCare as a valued health care provider: Who we are Our role in ensuring quality health care for UniCare Medicaid recipients The specific resources that are available to you and your patients The processes we have in place that affect you
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UniCare Plan History Membership Operational November 2003
Four counties, 700 Members Membership 80% of membership < 19 years of age Approximately 5,000 deliveries annually High rates of emergency room (ER) utilization, substance abuse and NICU cases Provider Network More than 5,100 providers 68 hospitals 957 ancillary locations 20 Rural Health Centers (RHC) and 28 Federally Qualified Health Centers (FQHC) >150 sites Marketplace Statewide Enrollment 130,000+ 1 of 4 managed care organizations (MCO) Largest Medicaid MCO Products Mountain Health Trust Vendor relationships for dental (adult emergency/children), pharmacy and vision Behavioral Health West Virginia Health Bridge (ACA expansion) Network Dynamics No commercial product Demographics of UniCare members 10% pregnant women 10% adults with children 80% under 19 years of age ¼ of the state’s population receive Medicaid benefits Ethnicity of West Virginia population: 95% non-Hispanic white
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UNICARE Contracted Counties
UPSHUR LEWIS RANDOLPH BARBOUR PLEASANTS WYOMING RALEIGH WOOD RITCHIE WIRT WAYNE BRAXTON HARRISON SUMMERS MONROE MERCER ROANE KANAWHA CLAY PUTNAM CABELL PRESTON WEBSTER POCAHONTAS HANCOCK BROOKE UNICARE Contracted Counties OHIO MARSHALL MONONGALIA WETZEL MARION MORGAN TYLER BERKELEY MINERAL TAYLOR HAMPSHIRE DODDRIDGE JEFFERSON GRANT TUCKER HARDY CALHOUN GILMER JACKSON MASON PENDLETON NICHOLAS LINCOLN BOONE FAYETTE GREENBRIER Contracted Not Contracted MINGO LOGAN MCDOWELL
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Medicaid Managed Care Benefits
Covered and Carved Out Services
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Services Covered by UniCare
Office visit and physician services Specialty services Hospital services Prenatal services Initial evaluation for mental health diagnosis by primary care physician (PCP) Family planning services Members may use any Medicaid qualified provider Early and Periodic Screening, Diagnosis and Treatment (EPSDT) Limited to children under 21 Pharmacy Dental (pediatric) Diagnostic service (e.g., lab and radiology) Behavioral Health Services
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Services Covered by UniCare
Vision Service: Vision Service Plan Adults limited to medical treatment only Children’s benefits include exam, lenses, frames and needed repair every 12 months Pharmacy Services: Express Scripts, Inc.® Dental Services for Children: Scion Under 21 years old Dental Services for Adults: Emergency extractions only Express Scripts, Inc. is a separate company that provides pharmacy services and pharmacy benefit management services on behalf of health plan members.
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Carved Out Services Covered by Bureau for Medical Services (BMS)
Carved out services include*: Intellectual and Developmental Disabilities (I/DD) waiver Long-term care Non-emergency/Non-ambulance medical transportation Transplants *Medicaid beneficiaries have coverage for these services; however, UniCare does not pay for them.
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Provider Education Resources Available
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Provider Changes UniCare requires all providers, including hospitals, to send any administrative change requests to us so that we have correct information in our system. This includes changes in your practice or facility name, address, fax and information, tax identification number (TIN) and other similar changes Provide specific instructions for your change request Submit this information Fax:
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Appointment Availability Requirements
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After Hours Care Members will have access to a quality comprehensive health care services 24/7 Emergency calls System in place to ensure that members can reach the PCP or an on-call provider Members also can call MedCall® Suggested text for answering machines: “Hello, you have reached [physician/office name]. If this is an emergency, hang up and dial 911 or go to the nearest hospital emergency room. If this is not an emergency and you have a medical concern or question, please call[insert contact phone or pager number]. You will receive a return call from the on-call physician within [time frame].
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Clinic Days UniCare is launching a quality initiative designed to improve our compliance rates for preventive services. Our HEDIS results indicate a significant number of members are not receiving timely preventive services. Clinic Day is an initiative that brings members and providers together to improve access to care and patient compliance. In partnership with our network providers, we will host a series of Clinic Days for UniCare members who have not received well-child visits or immunizations. Clinic Day can also target members who are due for diabetes care or postpartum care. Members will be directed to the office of the provider identified as their PCP. UniCare will coordinate appointment scheduling with the provider and member.
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UniCare Care Disease Management
Clinical and Non-clinical Wellness & Health Promotion Weight management, smoking cessation, low acuity outreach, seasonal outreach, homeless outreach, Healthcare Effectiveness Data and Information Set (HEDIS®)/quality improvement initiatives Member health education materials and newsletters Development and approval process in support of all health plan and corporate partners Call for member referral to Disease Management. *HEDIS is a registered trademark of the National Committee for Quality Assurance (NCQA). Disease Management Conditions Covered: Asthma Diabetes Congestive heart failure COPD Hypertension Coronary artery disease HIV/AIDS Major depressive disorder Schizophrenia Bipolar disorder Substance abuse
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UniCare Case Management
Complex case management Stabilization case management Discharge planning Facility/field visits High-risk obstetric case management Social worker intervention Case Management Referral (option 1)
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UniCare Utilization Review Resources
Authorizations Phone: Fax : (Medical) Fax: (Behavioral Health Inpatient) Fax: (Behavioral Health outpatient) Continued Stay Review Phone: Fax: Customer Service Phone: Peer-to-Peer Line Phone: Grievance/Appeal fax Fax: Pharmacy Prior Authorizations Phone: Fax:
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Customer Care Center Services
Dedicated to UniCare’s Medicaid Managed Care Program Phone: (TTY) Assistance for providers Eligibility verifications Claims inquiries PCP assignment and changes Benefit information Interpreter services Provider website navigation
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UNICARE HEALTH PLAN of WV, Inc.
UPSHUR LEWIS RANDOLPH BARBOUR PLEASANTS WYOMING RALEIGH WOOD RITCHIE WIRT WAYNE BRAXTON HARRISON SUMMERS MONROE MERCER ROANE KANAWHA CLAY PUTNAM CABELL PRESTON WEBSTER POCAHONTAS UNICARE HEALTH PLAN of WV, Inc. TERRITORY MAP As of 9/12/16 Terri Roush Network Relations Manager (304) HANCOCK BROOKE OHIO Carrie Blankenship 304) Chris Bates (304) Beth Roach Cell: (304) Office: (804) MARSHALL WETZEL MONONGALIA MARION MORGAN TYLER BERKELEY MINERAL TAYLOR HAMPSHIRE DODDRIDGE JEFFERSON GRANT TUCKER HARDY JACKSON CALHOUN GILMER MASON PENDLETON Angie Richards (304) Jill Miller (304) Mary Straface (304) Beth Daniel (304) NICHOLAS LINCOLN BOONE FAYETTE GREENBRIER MINGO LOGAN MCDOWELL
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UniCare ID Card
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UniCare ID Card Members receive their UniCare ID card upon enrollment
The UniCare ID number has a “W” prefix The member will not receive a UniCare ID card each month BMS will still issue a Medicaid eligibility card ID cards will only be reissued to the member for the following reasons: Member change of address Change of PCP Upon member request
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Submitting Claims 365 days from the date of service Paper Electronic
Submit paper claims: UniCare Health Plan of West Virginia, Inc., P.O. Box 91, Charleston, WV Electronic Data Interchange (EDI) Fast, inexpensive and secure Shorter Claims turn around Expedited payment EDI Payer ID # 80314 Technical Support: Phone: Live Chat:
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Provider Updates- Availity
Expansion of our provider portal services through Availity Availity Web Portal, a multi-payer portal (website) at availity.com that gives physicians, hospitals and other health care professionals access to multiple payer information with a secure single sign-on Availity’s Web Portal offers a variety of online functions to help providers reduce administrative costs by eliminating paperwork and phone calls. Target date for Access Point retirement end of 1st quarter 2017 The services are free to providers! Provider Bulletin Updates To register for the Availity Web Portal go to availity.com If you have questions or need additional registration assistance, contact Availity Client Services at Availity( )
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FQHC/RHC Reminders Services included in the FQHC and RHC Encounter Rate must be billed using the UB-04 claim form Providers must bill all encounters using the encounter code T1015 along with the appropriate modifier Claims must list the actual CPT/HCPCS procedure codes and appropriate revenue codes, as defined by Medicare, to identify services included during the encounter visit. The FQHC and RHC may indicate the actual charge or a zero for the CPT/HCPCS codes listed on the claim for encounter data purposes, but MUST include the encounter rate for the T1015 encounter code for payment. Indicate the appropriate type of bill when submitting corrected claims to ensure properly processing. The third digit of “7” in the three digit type of bill defines a replacement/corrected claim. Behavioral Health group therapy reimbursed at the fee-for-service rates 90853 90853-AJ
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Questions?
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Thank you for your Participation today!
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