The Department of Managed Care is pleased to announce that it is hosting the first program in a series of Continuing Medical Education programs for referring physicians on Tuesday, December 5, 2000 at the Molecular Biology Research Building.

In partnership with UnitedHealthcare, invitations have been extended to primary care physicians in their network. We believe this a good opportunity to showcase the Medical Center, it’s fine reputation for patient care services, and it’s faculty and staff.

The program is entitled Advances in Cardiovascular Medicine in a Managed Care Environment and will be presented by the Cardiology Service Line with Dr. Peter Buttrick and Dr. Alexander Geha. A copy of the invitation in PDF format is attached for your information. Registration and program information is included in the invitation.

Please feel free to join us in the auditorium of the Molecular Biology Research Building at 8:00 a.m. There is no registration fee. If you or members of your staff would like to attend, please return the registration form to our department. A continental breakfast will be served. Questions may be directed to the managed care office at X5.3713.

Roger Carlson

Director, Managed Care

Effective 1 January 2001, the University of Illinois at Chicago Medical Center and Physicians Group will participate in the Cigna Healthcare of Illinois Network. Cigna, the Chicago area’s third largest health plan, offers Health Maintenance Organization (HMO), Preferred Provider Organization (PPO), and Point-of-Service (POS) products to over 500,000 members state-wide.

Provider orientations will be held throughout the month of December. Please note that Cigna Healthcare requires the use of Quest Laboratories for outpatient lab work. Outpatient care providers can schedule an orientation session with Quest Labs by calling Patricia Shennan at 1.800.323.5917, extension 4001. They will be happy to review their procedures with you. Questions about the Cigna contract or its implementation should be directed to Vince Savickis at X3-0286 or savin@uic.edu .

The Apex (Metro) web site has undergone a few cosmetic changes to help you navigate to the UICMC eligibility data. Apex has updated its web page to be more consistent with other pages on the Web. In addition to the cosmetic update, Apex has added the Office Visit (OV) and ER (ER) Co-Pay fields to the "PCPinfo" and "HMOinfo" eligibility screens.

You can access the Apex web page through the UICMC Intranet from the Managed Care web site, or by accessing www.apexmso.com.

With your helpful comments and suggestions, we will continue to work with Apex to make this site easier to use.

Effective 1 November 2000, a new revision of the handbook for providers of medical services, Chapter 100, will apply. While it contains no major policy changes, the new handbook:

• Explains the KidCare Program
• Incorporates materials previously released in Provider Bulletins & information notices
• Reflects the 1997 reorganization of State government
• Incorporates some materials that were previously found in Chapter 200
• Updates other information for all medical program providers

The new Chapter 100 is available on the IDPA website. The Internet address to access Chapter 100 is http://www.state.il.us/dpa/medical provider handbooks.htm.

Questions regarding this notice should be directed to the Bureau of Comprehensive Health Services at (217) 782-5565.

Under our current contract with Humana, physicians are paid based on a fee schedule Based on Medicare rates in place in 1995. Humana’s continued use of this outdated schedule has resulted in low reimbursements and frequent discrepancies between billed CPT codes.

Effective 1 December 2000, Humana has agreed to reimburse physicians at 104 percent of the current Medicare fee schedule. They have also agreed to update this rate annually.

This increase is estimated to provide our physicians with an average reimbursement increase for covered CPT codes of 25 percent. Should you have any questions or issues regarding the fee increase from Humana please contact Vince Savickis at X5.4271 or savin@uic.edu.

Humana has a preferred vendor, Daimer and Cartwright, for the drug Lupron. When ordered through Daimer and Cartwright, Humana is financially liable for the cost of the drug. If Lupron is obtained through UICMC pharmacy, the cost is charged back to UIC Physician Group. Since the Humana HMO contract is a capitated risk product, all clinics ordering Lupron should use Daimer and Cartwright to avoid this expense being charged to the physician group.

Lupron will be delivered directly to the clinic within 24 hours. The phone number for Daimer and Cartwright is 1.800.793.2637. You may also fax your order locally to 312.332.6141. Please contact Barbara Rabin in the Managed Care office for a copy of the order form.

Please remember that when administering Lupron as a chemotherapy agent for Humana members, a referral is required from their referral services department.

Please be aware that the University of Illinois Physician Group has no contract with Private Health Care Systems Inc. (PHCS). After reviewing some Explanation of Benefits (EOB) received by some Departments, it was noted that some of PHCS clients had taken unapproved discounts. Because we have no contract with PHCS these patient are responsible for 100% of billed charges.

The managed care office has notified PHCS requesting that they inform their clients to cease taking inappropriate discounts. Should you have any questions or concerns about PHCS please contact the managed care office.

Information about referral procedures for health plans contracted with the University of Illinois is now available at the managed care web site. The information in this new section can help guide individuals in properly completing referral forms. We hope this information will assist you in expediting the referral process. Information includes plan benefits and services, financial (J) codes, as well as key phone numbers and contacts for each health plan. Questions can be referred to Barb Rabin at X5.5766 or brabin@uic.edu.

A recent newsletter for providers included the following information about when to charge their members a co-payment:

Follow-up Care after Surgery: Co-payments may be charged for follow-up office visits,

even if the office visit occurs during the designated follow-up period. The physician co-payment applies for each visit during which the patient receives a clinical service in the office from a physician, nurse, or other clinical provider.

Direct Access GYN Care: If a member visits a participating OB/GYN for routine gynecologic services, a specialist co-payment should be charged. If a member visits her primary care physician for routine gynecologic services, the primary care co-payment applies.

Obstetrics: Obstetricians should charge one co-payment at the initial visit.

Infertility: The gynecologist or fertility specialist should charge one co-payment per visit. However, if a member has a two-year authorization to an infertility specialist, one co-payment for the two-year period applies. Contact the Member Services toll-free number on the member ID card for specific plan information.

Please note that for a member to receive comprehensive infertility care, referrals and coordination for care must be obtained through the Infertility Program at 1.800.575.5999. Coverage policy bulletins (#327 – Infertility Coverage) can be found at the Aetna web site, www.aetnaush.com/cpb/index.html .

Aetna has also announced that precertification is no longer required for Lupron and Zoladex. However, Lupron and Zoladex must be ordered from one of the participating specialty pharmacies listed below:

Chronimed

Phone: 1-800 636-1133

Fax: 1-800-322-9674

Nova Factor/Hemophilia Health Services

Phone: 1-888-221-2443

Fax 1-888-286-8954

Priority Healthcare/Pharmacy Plus

Phone: 1-888637-8338

Fax: 1-888-637-8776

For more information regarding coverage of injectable medications, including Lupron and Zoladex, visit Aetna’s company web site, www.aetnaushc.com. Please note that Lupron and Zoladex used for infertility is not a covered benefit in most plans.

Starting October 1, 2000 UnitedHealth Group (UHG) is implementing a new Maximum Frequency per Day Policy to ensure efficient and consistent adjudication of claims for services submitted with multiple units. UnitedHealth Group has analyzed all CPT and HCPCS codes and determined the most common frequency of units billed by a single provider for one member on a single date of service for each code and has set a maximum frequency per day (MFD). UHG will reimburse claims up to and including the MFD value for each individual CPT or HCPCS code. If claims have multiple units above the MFD, the additional units will be denied with assumption there was a data entry error or that the procedural codes and/or units were incorrect. This policy will apply to members in all products and to all providers, both network and non-network.

This new policy will provide a consistent payment policy to providers for service to UnitedHealthcare members for all products. It will also expedite at least partial payment of claims for reimbursable benefits. It was initiated primarily as a screen to identify coding errors or data entry errors. Units exceeding the MFD will be denied as "typical daily frequency exceeded."

Denial may be appealed by providing supporting documentation for the number of services provided. If the appeal review indicates incorrect billing or coding on the original claim, then a corrected claim will need to be submitted. The MFD values for each code will be reviewed at least annually. This new MFD policy will avoid the need to pend claims while documentation is requested, and allow more timely reimbursement of claims.

Questions may be directed to Jacqueline Petersen at X5.4359 or at japeter@uic.edu .

We don’t want to be the last to know…Help us keep our lists up to date. Please let us know when a new physician (with active admitting privileges) joins your department or leaves the medical center.

While we work closely with the Medical Staff Office to coordinate this information, having up-to-date information quickly will allow us to work through administrative issues more confidently. We are working hard to keep participating physician information accurate and appreciate any assistance you can give us. Any updates can be directed to Barb Rabin at X5-5766 or Brabin@uic.edu .

It is with mixed feelings that the members of the managed care department say good-bye to Ron Plemmons, who has so ably handled our information and web-based projects over the past several years. We will miss his enthusiasm and dedication and wish him every success at Baxter Healthcare, where he will become the Midwest regional manager for electronic data services. The following is a brief note from Ron.

"Effective Tuesday, November 28, 2000 I will be leaving the Managed Care office for a position outside of the University. This decision was not an easy one, and involved many days of thoughtful consideration.

"I want to take this time to thank everyone I have worked with for the professional relationship and leadership you have provided during my tenure here. I have thoroughly enjoyed the work environment and atmosphere provided by all of you and the University.

"I wish everyone continued success and I want to thank all of you for allowing me to be a part of your team."

Ron Plemmons

Our best wishes go with you!! Please note that we will be distributing our newsletter by e-mail until we find someone who can fill Ron’s shoes!

The Editor