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UniCare Health Plan of West Virginia, Inc.A true partnership with our provider communityUniCare Health Plan of West Virginia, Inc.Medicaid Managed Care

Welcome!We would like to thank everyone for taking time out of their busyschedule to be here today! Thank you for the dedicated care andtime you provide our UniCare members each day.UniCare Health Plan of West Virginia, Inc.2

UniCare facts Plan historyo Operational November 2003o Four counties, 700 members Marketplaceo Statewideo Enrollment 143,000 o One of four managed care organizations(MCOs)o Largest Medicaid MCO No Commercial productUniCare Health Plan of West Virginia, Inc.3

UniCare facts (cont.) Productso Mountain Health Trusto Vendor relationships for dental (adultemergency/children), pharmacy andvisiono Behavioral healtho West Virginia Health Bridge (Affordable CareAct expansion)o Social Security Income effective January 1, 2017UniCare Health Plan of West Virginia, Inc.4

Provider educationResources available

Provider Orientation Webinars UniCare offers a monthly provider orientation webinar thethird Tuesday of each month from 12:00 p.m.--1:00 p.m. Topic coveredo Who we areo Health Care Management Serviceso Case Managemento Community Outreacho Resources Availableo Many more topics.UniCare Health Plan of West Virginia, Inc.6

Provider Online Reporting Tool UniCare’s new web base reporting tool to retrieve yourmonthly member rosters Upcoming Educational Webinaro April 19, 2017 12:00 p.m.--1:00 p.m. Topic coveredo How to registero Basic Navigationo Resource Available Requirement: Active Availity accountUniCare Health Plan of West Virginia, Inc.7

Prenatal Risk ScreeningInstrument (PRSI) Effective January 1, 2017, UniCare is discontinuing ourpregnancy notification form and adopting the WestVirginia Prenatal Risk Screening Instrument(PRSI) The PRSI is intended to promote early and accurateidentification of prenatal risk factors. Submit PRSI to UniCare within seven days of the firstprenatal visit.o Email the completed form [email protected]. Please type “SECUREPRSI” in the subject line.o Fax the completed form to 1-877-833-5729.UniCare Health Plan of West Virginia, Inc.8

Precertification Lookup Tool(PLUTO) A tool to assist with determining a code’s precertificationrequirements Finding PLUTO:o Go to www.unicare.com.o On the top menu bar, under OTHER UNICAREWEBSITES, select Providers.o Under Resources for:, select State Sponsored Plans onthe right side of the page.o Select West Virginia – Medicaid Managed Care.o On the resulting Provider Resources page, find theAuthorization and Preservice Review section.o Select Precertification Look UP Tool (PLUTO).UniCare Health Plan of West Virginia, Inc.9

PLUTO (cont.) Once in PLUTO:o Select West Virginia in the Market drop-downo Select Medicaid/SCHIP/Family Care in the Line ofBusiness drop-down.o Enter your data into the CPT/HCPCS Code or CodeDescription field.o Choose Submit once done.UniCare Health Plan of West Virginia, Inc.10

Prior Authorization Effective April 1, 2017, UniCare will no longer accept andreview claims with medical records attached in place ofrequired prior authorization(PA). If a claim for service requiring a prior authorization is receivedwithout the appropriate PA, the claim will be denied for lack ofPA. Once you have received a PA, remember to include the PA onthe claim you submito CMS-1500: PA number in field 23o CMS-1450: PA number in field 63UniCare Health Plan of West Virginia, Inc.11

Utilization ManagementPeer-to-PeerWhen to request a Peer-to-Peer?o A request is denied as not medically necessary and youwish to discuss with our peer clinical reviewer (PCR)o Call the Peer-to-Peer Line at 1-866-902-4628, option 3 This process allows attending, treating and orderingphysicians to discuss their case with the PCR who made theinitial adverse determination as well as offer additionalinformation for reconsideration Peer-to-Peer review must be requested within 24 hours of thedenial notification Peer-to-Peer review is not an appealUniCare Health Plan of West Virginia, Inc.12

Utilization Management Appeals Appeals are accepted for up to 90 days after a denial isissued. A physician clinical review specialist of same or similarspecialty who was not involved in any previous level of reviewor decision making reviews the provider appeal. The physician specialist may not be the subordinate of anyperson involved in the initial determination. The physician specialist reviews the case and contacts theprovider as necessary to discuss appropriate alternatives,render a decision and document a decision.UniCare Health Plan of West Virginia, Inc.13

PCP changes Members have the ability to change their PCP at any time. Members can check eligibility before each visit. PCP selection form can be found here:o Go to www.unicare.como On the top menu bar, under OTHER UNICAREWEBSITES, select Providers.o Under Resources for:, select State Sponsored Plans onthe right side of the page.o Select West Virginia – Medicaid Managed Care.o On the resulting Provider Resources page, find the Formsand Tools section.o Select Forms Library from the list.UniCare Health Plan of West Virginia, Inc.14

Appointment availabilityrequirementsType of appointmentStandardEmergency examinationsImmediate access during office hoursUrgent (sick) examinationsWithin 48 hours of requestNonurgent (sick) examinationsWithin 72 hours of requestNonurgent routine examinationsWithin 21 days of requestSpecialty referralsWithin three weeks for routine referrals;within 48 hours for urgent referrals15

Appointment availabilityrequirements (cont.)Type of appointmentStandardFirst trimester (use the Pregnancy NotificationWithin 14 calendar days of requestReport found on the provider site)Second trimester (use the PregnancyAssessment Form Second Trimester —Reassessment found on the provider site)Within seven calendar days ofrequestThird trimester (use the PregnancyAssessment Form Third Trimester —Reassessment found on the provider site)Within three business days ofrequestHigh-risk pregnancyWithin three business days ofidentification or immediately if anemergency existsPostpartum exam (use the PostpartumCheckup found on the provider site)Three to eight weeks after deliveryof appointment standard16

After-hours care Members will have access to quality, comprehensive healthcare services 24/7. Members can receive help with emergency calls. System is in place to ensure that members can reach the PCPor an on-call provider. Members can also call the 24/7 Nurse Line (1-888-850-1108) Suggested text for answering machines:o “Hello, you have reached [physician/office name]. If this is anemergency, hang up and dial 911 or go to the nearest hospitalemergency room. If this is not an emergency and you have amedical concern or question, please call [insert contact phone orpager number]. You will receive a return call from the on-callphysician within [time frame].”UniCare Health Plan of West Virginia, Inc.17

Provider changes UniCare requires all providers, including hospitals, to send anyadministrative change requests to us so that we have correctinformation in our system. This includes changes in your practice or facility name,address, fax and email information, tax identification number(TIN), and other similar changes. All providers with the exception of hospital-based providersmust be credentialed. Submit the information via:o Fax: 1-877-608-6752o Email: ssbdatamanagemen[email protected] Health Plan of West Virginia, Inc.18

Provider changes (cont.) The Provider Profile Update Form can be found here:o Go to www.unicare.como On the top menu bar, under OTHER UNICAREWEBSITES, select Providers.o Under Resources for:, select State Sponsored Plans onthe right side of the page.o Select West Virginia – Medicaid Managed Care.o On the resulting Provider Resources page, find the Formsand Tools section.o Select Provider Profile Update Form.UniCare Health Plan of West Virginia, Inc.19

Availity Web Portal Expansion of our provider website services through Availityo Availity Web Portal (https://www.availity.com), amulti-payer website that gives physicians, hospitals andother health care professionals access to multiple payerinformation with a secure, single log-ino Availity’s Web Portal offers a variety of online functions tohelp providers reduce administrative costs by eliminatingpaperwork and phone callso Target date for Access Point retirement: 2017UniCare Health Plan of West Virginia, Inc.20

Availity Web Portal (cont.) Multiple payers, one website, one log-ino Claim status inquiry and claims submissiono Eligibility and benefits checko Remittance advices retrievalo Monthly member rosters accesso 24/7 availability from any computer with internet accesso Real-time information exchange means highest accuracyof informationo Free services for providersUniCare Health Plan of West Virginia, Inc.21

Availity Web Portal (cont.) Simple to useo The portal has a consistent look and feel.o Expert client service representatives and free training areavailable to you.o To register for the Availity Web Portal, go tohttps://www.availity.com.o If you have questions or need additional registrationassistance, contact Availity Client Services at1-800-AVAILITY (1-800-282-4548).UniCare Health Plan of West Virginia, Inc.22

Important Contact InformationResources available

Customer Care Center services Dedicated to UniCare’s Medicaid Managed Care Programo Assistance for providerso Eligibility verificationso Claims inquirieso PCP assignment and changeso Benefit informationo Interpreter serviceso Provider website navigation Call 1-800-782-0095 or TTY: 1-866-368-1634.UniCare Health Plan of West Virginia, Inc.24

Utilization review resources Authorizationso Phone: 1-866-655-7423o Fax: 1-855-402-6983 (Medical prior authorization)o Fax: 1-855-402-6985 (Medical concurrent review)o Fax: 1-855-325-5556 (Behavioral health inpatient)o Fax: 1-855-325-5557 (Behavioral health outpatient) Pharmacy prior authorizations (PA)Review turnaround timeso Phone: 1-877-375-6185PA general — 7 daysPA urgent — 3 dayso Fax: 1-855-875-3627Current inpatient admission — Grievance/appeal fax24 hoursExpedited appeals — 3 dayso Fax: 1-866-387-2968Routine appeals — 30 daysUniCare Health Plan of West Virginia, Inc.25

Utilization review resources (cont.) Continued stay reviewo Phone: 1-866-655-7423o Fax: 1-855-402-6985 Customer Serviceo Phone: 1-800-782-0095 Peer-to-Peer Lineo Phone: 866-902-4628, option 3UniCare Health Plan of West Virginia, Inc.26

Submitting claims Submit via EDI:o EDI Payer ID #80314o Technical Support: Phone: 1-800-470-9630 Email: [email protected] Live chat: www.unicare.com/edi Submit paper claims to:o UniCare Health Plan of West Virginia, Inc.P.O. Box 91Charleston, WV 25321-0091UniCare Health Plan of West Virginia, Inc.27