Providers - Provider Manual

Healthy U is a managed care health plan exclusively for Medicaid patients. The information provided in this section is designed to assist Healthy U providers in recognizing Medicaid patients and the services that must be accessible to Medicaid patients.

Fee Schedule Updates

Healthy U defines the published date of the state Medicaid fee schedule as the first day of the first month following the quarter. For example, the published date of the state Medicaid’s July fee schedule is defined as August 1st.

Service Area

Healthy U is available to eligible Medicaid enrollees throughout the state of Utah.

Use of Primary Care Providers

All Healthy U enrollees are encouraged to choose a Primary Care Provider (PCP) to manage and coordinate all of their care. A PCP is defined as a generalist in any of the following areas:

• Family Practice
• General Practice
• General Internal Medicine
• Obstetrics/Gynecology
• Pediatrics

A PCP can be a Medical Doctor (MD), Doctor of Osteopathic Medicine (DO), Nurse Practitioner, Resident or Physician Assistant. The enrollee may also select a Clinic to act as their PCP.

Receiving Care

Referrals – Healthy U members may consult a specialist without obtaining a referral from their primary care provider.

Use of Provider Network – Except in the case of an emergency, enrollees must obtain covered services in the following manner:

• Members must receive ALL services from a Healthy U PARTICIPATING provider in order to receive coverage. Services rendered by a NON-PARTICIPATING provider will be DENIED with no payment.
• Facility services from a PARTICIPATING facility only. Services rendered by a NON_PARTICIPATING facility will be DENIED with no payment.
• Urgent Care Centers. Providers shall be reimbursed at 100% of the prevailing Medicaid Rate.

University of Utah Health Plans provides Healthy U Provider Directories to all its members upon enrollment in the plan. The most current provider directory may be viewed online

at http://uhealthplan.utah.edu/healthyU .

Directories are also made available to State Medicaid Health Program Representatives, and to participating providers upon request. Since information in the directory is subject to change, Healthy U encourages members to check provider’s participating status prior to obtaining services.

Care Management

Patients are identified at the earliest possible point for care management intervention. The mechanism for identification may be through enrollment, claims, utilization trending, medical history, survey tool or notification by provider and/or State Medicaid Representative (HPR). HIGH-RISK patients may be identified through primary care referral, specific diagnosis ICD-10 clustering, emergency room logs, referral requests, payer personnel and specialty provider contracts.

Each patient identified may be assigned a care manager from the CM Department, and followed by their case manager across the continuum of care; both in inpatient and ambulatory settings. Services may also be coordinated among social and community services, family, or specialty and primary care providers. Coordination is achieved via phone, e-mail, fax or through case conferences.

All complex case management patients, pending open and closed cases are reported to the Healthy U UM Committee on a quarterly basis.

Care Coordination will be provided through our Case Management Department for the following:

• Healthy U-Restricted patients – Please notify Healthy U if services are not provided by the Primary Care Provider (PCP)
• Obstetrical Patients - Contact U Baby Care at 801- 587-6480 and notify the plan when admitted for delivery.
• Out of area non-emergent care.
• Patients identified, by referral, from physician, patient or utilization patterns where Case Management assistance is needed.
• Patients with complex needs related to physical health and/or psychosocial issues.

General Policies Regarding Covered Services

All covered services must be medically necessary and all Healthy U plan utilization management requirements must be met for services to be reimbursed. All services must be obtained from a participating provider to be covered, except in the case of “emergency services” or when a referral has been obtained from the plan. If you have a question about whether a service or supply is covered, please contact Healthy U. You may also refer to the Utah Medicaid Provider Manual for more detailed information on covered services, including applicable definitions, regulations and limitations.

Please note: Please reference our website for current plan information.

Non-Covered Services

This list is not inclusive of all Medicaid non-covered services and supplies, but rather is intended to provide basic guidelines for determining non-covered services. Please refer to the Utah Medicaid Provider Manual for detailed information on non-covered services or contact a Healthy U Representative.

General Exclusions:

• Services rendered during a period the client was ineligible with the Healthy U Medicaid Plan.
• Services not medically necessary or appropriate for the treatment of a patient’s diagnosis or condition.
• Services that fail to meet the existing standards of professional practice are investigational or experimental.
• Services obtained out-of-network that are not emergency services, urgent care services, or where a referral was not obtained from Healthy U.
• Covered services for illnesses and injuries sustained directly from a catastrophic occurrence or disaster, including but not limited to, earthquakes or acts of war. The effective date of excluding such covered services will be the date specified by the Federal Government or the State of Utah that a Federal or State emergency exists or disaster has occurred.
• Elective services requested or provided solely due to the patient’s personal preference. Provider must notify patient in writing that service(s) is not covered and that financial responsibility will be the patient’s if the elective services are performed.
• Services for which a third party payer is primarily responsible. Healthy U will make a partial payment up to the plan’s allowable amount if the limit has not been reached by the third party.
• Services that are fraudulently claimed.
• Services that represent abuse or overuse.
• Services rejected or disallowed by Medicare for any of the reasons listed above.
• When a procedure or service is not covered for the above listed reasons or is disallowed by Healthy U, all related services and supplies, including institutional costs will be excluded for the standard post-operative recovery period.
• Cosmetic, reconstructive or plastic surgery procedures, including all services, supplies and institutional costs related to services which are elective or desired for primarily personal, psychological reasons or as a result of the aging process.
• Removal of tattoos.
• Hair transplants.
• Breast augmentation or reduction mammoplasty.
• Panniculectomy and body sculpturing procedures.
• Rhinoplasty unless there is evidence of recent accidental injury resulting in significant obstruction of breathing.
• Procedures related to trans-sexualism.
• Surgical procedures to implant prosthetic testicles or provide penile implants.
• Family planning services which are not covered include:
• Surgical procedures for the reversal of previous elective sterilization, both male and female
• Infertility studies
• In-vitro fertilization
• Artificial insemination
• Surrogate motherhood, including all services, tests and related charges.
• Abortion, except when the life of the mother would be endangered or when the pregnancy is the result of rape or incest.
• Certain services are excluded from coverage because medical necessity, appropriate utilization and cost-effectiveness of the service cannot be assured. No specific therapy or treatment is identified except for those that border on behavior modification, experimental or unproven practices. These services include:
• Sleep apnea, sleep studies, or both
• Pain management and pain clinic services
• Eating disorders.
• An inpatient admission for 24 hours or more solely for observation or diagnostic evaluation is not a covered Medicaid service.
• Miscellaneous supplies, dressings, durable medical equipment and drugs to be used as take-home supplies from an inpatient stay or outpatient service are not separately covered services.
• Surgical procedures, unproven or experimental procedures, medications for appetite suppression, or educational, nutritional support programs for the treatment of obesity or weight control are non-covered Medicaid services.

Verification of Eligibility

It is important for all Healthy U patients to show their Medicaid Identification Card BEFORE receiving any type of service. Providers must verify that the patient is eligible for Medicaid on the date of service and whether the patient is enrolled in an HMO, in a Prepaid Mental Health Plan, in the Restriction Program, or has a Primary Care Provider. This information is printed on the Medicaid Identification Card, and the information is also available through UUHP Member Services.

Since eligibility of a Medicaid member can change frequently, the provider’s office should request a copy of the member’s Medicaid Identification Card upon each visit and prior to rendering services

Provider’s offices may contact UUHP member services to verify eligibility information: Salt Lake County: 801-587-6480

Toll Free: 888-271-5870

Or providers may utilize the Medicaid Hotline: Salt Lake County: 801-538-6155

Toll Free: 800-662-9651

Lock-in or Medicaid Restriction Program

When a Medicaid recipient uses their Medicaid services unwisely, they are placed on the 'lock-in' or Restriction Program. An example of misuse includes seeing a provider or seeing several physicians in an attempt to have pain medications prescribed. Once placed in the Restriction Program, the member is required to choose a PCP, hospital and pharmacy and is restricted to using only these providers. Healthy U conducts an in-person orientation with the Restricted Medicaid member to ensure the member understands the limitations and requirements.

The Member’s Medicaid Identification Card will identify if the member is in the Restriction Program as well as list the primary care provider, hospital and pharmacy they are restricted to

use. Questions regarding this program should be directed to University of Utah Health Plans Utilization Management at 801-587-6480, option 2.

For the duration of the “Lock-in” they are required to contact the State Department of Health Restriction Program to have their primary care provider, hospital or pharmacy changed.

Restricted members are required to obtain medical services from their PCP. If, as determined by their PCP, the member is to receive services from another provider, the member must obtain and present a referral from their PCP provider. All services rendered outside the members PCP without a referral will be denied for payment.

Direct Billing of Services

Generally, health providers who agree to treat Medicaid patients are prohibited by Federal law from billing Medicaid patients directly for covered services. As such, the Provider is prohibited from billing and/or collecting from the member, except for State mandated patient responsibilities (such as co-payments & coinsurance) and/or non-covered services (see below for instructions on billing for non-covered services), any amount due to Provider by UUHP (Refer to Provider Agreement for further details), and Provider must accept Healthy U’s payment as payment in full. Failure to abide by State billing rules and regulations, and/or the Policies and Procedures of Healthy U may result in the claim(s) being denied for payment. In such cases, the Provider is prohibited from billing the member.

Healthy U members are responsible for presenting proof of Medicaid eligibility and enrollment in Healthy U at the time of service. Patients who fail to advise the provider of their Medicaid eligibility may be liable for services rendered on that date. Please refer to the Medicaid Provider Manual for additional rules and regulations.

Non-Covered Services: A provider may be reimbursed for the provision of Non-covered services if one of the two conditions are met:

• A benefit exception is obtained from Healthy U. To obtain a benefit exception, please contact the Healthy U Care Management Department. Where benefit exceptions are granted, the Provider is bound by the billing policies established above.
• The Provider has informed (in writing) the Healthy U Member that the services to be rendered are not covered under their Medicaid benefits, informs them of the total charges for which they would be liable for, and obtains the members authorization signature prior to the services being rendered. (Note – This must be done each time a non-covered service is to be rendered. A single, one-time statement covering all future services is not acceptable.)

Medically Necessary

Medically Necessary means any medical services or supplies that are necessary and appropriate for the treatment of an Enrollee’s illness or injury and for the preventive care of the Enrollee according to accepted standards of medical practice in the community in which the provider practices and consistent with practice guidelines developed and approved by Healthy

U. Covered services must meet the definition of medically necessary to be covered by the plan. Please contact the Healthy U Case Management Department for questions on medical necessity.

Emergency Services

Emergency Services means those services provided in a hospital, clinic, office, or other facility that is equipped to furnish the required care, after the sudden onset of a medical condition

manifesting itself by acute symptoms of sufficient severity (including severe pain) such that a prudent layperson, who possesses an average knowledge of health and medicine, could reasonably expect that the absence of immediate medical attention to result in:

Placing the health of the individual (or with respect to a pregnant woman, the health of a woman or her unborn child) in serious jeopardy.

Emergency providers are expected to use prudent judgment in determining whether the member requires treatment in the emergency room. Members with non-emergent conditions should be referred to their primary care physician for treatment and follow-up care.

The initial screening examination to make a clinical determination whether an actual medical emergency exits will be covered by the plan with a triage fee. All services required to stabilize the enrollee with an emergency medical condition will be covered by the plan. The Healthy U care management department should be notified within 24 to 48 hours (same day or next working day for weekends and holidays) of emergency services being rendered.

If the initial screening examination determines that the enrollee’s condition is not an emergency nor of an urgent nature, the patient should be referred to his or her Primary Care Physician for further treatment. Healthy U will reimburse a triage fee to the emergency department and attending physician for this initial assessment. If the emergency room provider provides treatment for the patient even after determining the condition is not for a medical emergency, only a triage fee for the initial screening examination will be covered by the plan.

Out-of-network

“Out-of-network” shall mean services rendered by any provider that is not a participating, contracted provider in the Healthy U Medicaid plan. Out-of-network services will only be reimbursed by the plan when they are:

• Medical necessary services that were unavailable through the Healthy U network of participating providers and are approved by the plan through the referral process.
• Services that meet the definition of “emergency services” or urgent care services.
• Court-ordered services that are Medicaid covered services and have been coordinated with Healthy U.

Translation Services

For a list of contracted translations agencies, call the Customer Service number for the member's benefits plan.

Customer Service Phone Numbers

Women’s Services

Healthy U has special programs in place to ensure that women receive the highest quality healthcare.

“U Baby Care”

Healthy U requires provider notification on all pregnant members.

The “U Baby Care” program is provided for all pregnant members upon notification of pregnancy. A case manager (RN) is on staff to take calls from members who have questions or concerns regarding their pregnancy and to provide case management services. Every member who completes the “U Baby Care” program receives a gift.

When Healthy U is notified (state report, provider notification, member notification, hospital admit) of a pregnant member, a welcome letter, risk survey, and education materials are mailed to the member. When the member returns the risk survey and has indicated a pregnancy risk, the “U Baby Care” coordinator forwards the information to the case manager (RN). The case manager contacts the member and completes a risk assessment, scoring the member low, medium, or high risk. Medium and high-risk members qualify for case management.

Healthy U offers Enhanced Services for pregnant members, including perinatal care coordination, prenatal and postnatal home visits, group prenatal and postnatal education such as Lamaze classes, nutritional assessment and counseling, and prenatal and postnatal psychosocial counseling. Providers may refer members for any of these services. Please call Healthy U’s Utilization Management Department for questions concerning enhanced services.

Information about HIV and sexually transmitted infections are provided to members of the “U Baby Care” program.

Healthy U requires providers to conduct a risk assessment on every pregnant member. Providers are encouraged to contact the “U Baby Care” case manager (RN) with any information that is pertinent to the member for coordination of care.

Healthy U honors the Newborn’s and Mother’s Health Protection Act. Mother and baby have the right to stay inpatient for 48 hours after a vaginal delivery and 96 hours after a C-Section.

For additional information please visit the University of Utah website at

http://www.dol.gov/ebsa/newsroom/fsnmhafs.html

Mammography

Mammography reminder letters and follow up calls go out to members meeting the mammogram criteria that have not had a mammogram within two years.

Mammogram screenings are covered for Healthy U members.

Cervical Cancer Screening

Healthy U recommends and covers Cervical Cancer Screening (pap test) for all female members on a yearly basis. Chlamydia Screening is also recommended and covered by Healthy U.

Family Planning Services

Family planning services are Medicaid covered services and must be made available to Healthy U patients free of charge. This includes disseminating information, counseling, and treatment-related to family planning services. Healthy U members may go to any Medicaid provider for family planning even if he or she is not a Healthy U provider.

Birth control services include information and instructions related to birth control pills, including emergency contraceptive pills; Depo Provera; IUDs; the birth control patch, the ring (Nuvaring), spermicides, barrier methods including diaphragms, male and female condoms; and cervical caps; vasectomy or tubal ligations. Office calls, examinations and counseling related to contraceptive devices are also covered and must be made available to Healthy U patients. The removal of Norplant is also a covered benefit.

Please note that elective tubal ligations and vasectomies must have the Medicaid sterilization consent form signed 30 days prior to the procedure. The form expires 180 days after consent form is signed.

Providers are expected to be familiar with the Utah “Minor’s Consent to Treatment” Law. Providing family planning services and certain other treatments for minors without parents’ consent is legal and expected of Healthy U providers. The “Minor’s Consent to Treatment” Law outlines when a provider may treat a minor without getting the consent of the minor’s parents.

The complete text of the “Minor’s Consent to Treatment” Law and forms are included in the appendix of this handbook for your convenience.

Note: Any provider participating with Healthy U who does not wish to offer family planning services because of religious or personal reasons should contact Healthy U Provider Relations at 801-587-6602, or 801-587-6480 so patients can be directed to an alternate provider.

Foster Children

A special population served by the Healthy U Health Plan is children in the custody of the State of Utah Department of Human Services. This group includes both children who have been removed from their homes by the Division of Child and Family Services (DCFS) due to suspected abuse or neglect as well as children under the direction of the Division of Youth Corrections (DYC).

A Medicaid case is routinely opened for children in these groups and they are enrolled in one of the available Medicaid health plans. Healthy U contracts with providers who have experience and training in abuse and neglect to ensure quality care for these children and is responsible to coordinate appointments with DCFS or DYC.

If a child in State custody has an established relationship with a provider contracted with Healthy U every effort will be made to ensure that child continues his or her care with that provider.

There are specific guidelines that must be adhered to when scheduling provider visits for children in State custody because of suspected abuse or neglect. In cases where the DCFS child protective caseworker suspects physical and/or sexual abuse it is the responsibility of Healthy U providers to ensure that the child have an appropriate examination within 24 hours of notification of removal from the home.

In all other cases an initial health screening by a provider must take place within five calendar days of notification of removal from the home. This exam serves to identify any medical problems or conditions that require immediate attention or that might determine the selection of a suitable placement for the child. There are occasions when a child is placed with the State and must be examined and have medical treatment before a Medicaid case is opened for the child.

Child Health Evaluation and Care (CHEC)

CHEC is the Utah Medicaid version of the federally mandated Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) with three main components: Outreach and Education, Expanded Services, and Screening and Prevention. This section of the provider manual includes information on each component, other CHEC services, and reimbursement.

Outreach and Education

Families of Medicaid eligible children are encouraged to seek early and repeated well-child health care visits beginning ideally at birth, and continuing through the child's 20th birthday. The Utah Department of Health and Healthy U provide outreach services to families to ensure they are informed of the importance of well-child care and that a visit is due. Healthy U also conducts education sessions for primary care physician’s offices to keep them up-to-date with the CHEC Medicaid program. For more information about outreach education, please call Case Management at (801) 587-6480 or 800-271-5870, option 2.

Expanded Services for Medically Necessary Health Care

Section 1905 (a) of the Social Security Act provides expanded coverage for CHEC enrollees when services are medically necessary to prevent, or ameliorate defects, and/or improve physical and mental conditions identified during CHEC screening - even when the service is not covered on the Medicaid fee schedule. Coverage is based upon a medical necessity review.

Please contact the University of Utah Healthy U Case Management at (801) 587-6480 or 800- 271-5870, option 2, with any coverage questions, or for a medical necessity review.

Screening and Prevention Services

• Comprehensive Health History:
• Health history includes an assessment of both physical and mental development obtained from the parent, guardian, or other responsible adult who is familiar with the child’s history. The Health history should include:
• Developmental History: following developmental screening tools are recommended for children up to 6 years of age:
• Child Development Review (CDR) - http://www.childdevrev.com/.
• Infant Development Inventory (IDI) - http://www.childdevrev.com/.
• Ages and Stages Questionnaire (ASQ) - http://www.brookespublishing.com/.
• Communication and Symbolic behavior Scales Development Profile – Infant and Toddler (CSBSDP) - http://www.brookespublishing.com/.
• Parents’ Evaluation of Developmental Status (PEDS) - http://www.developmentalscreening.org/screening_tools/peds.htm
• Nutritional History: Use to identify nutritional deficiencies or unusual eating/feeding habits.
• Dental History

Comprehensive Physical Examination:

A comprehensive physical examination includes:

• Physical Examination: A standardized physical examination with an assessment of all body systems and a complete oral inspection of the mouth, teeth and gums during each CHEC screening.
• Measurement of Length, Height, and Weight: Measure and lot these items (and the occipital frontal head circumference of each child two years of age and younger) on the 2000 CDC growth charts (available at http://www.cdc.gov/growthcharts/).

Vision Screening

Services include diagnosis and treatment for defects in vision, including eyeglasses. When needed, refer the child to the appropriate specialist. Further evaluation and proper follow-up is recommended for the following vision problems:

• Infants and children who show evidence of enlarged or cloudy cornea, cross eyes, amblyopia, cataract, excessive blinking, or other eye normality.
• A child who scored abnormally on the fixation test, the pupillary light reflex test, alternate cover test, or corneal light reflex in either eye.
• A child with unequal distant visual acuity (a two-line discrepancy or greater).
• A child under age five years of age with distant visual acuity of 20/50 or worse, or a child five years of age or older with distant visual acuity of 20/40 or worse.

Note: A table with the recommended vision screening protocols and intervals is available in the Utah Medicaid Provider Manual (Section 2 – CHEC Services) at http://health.utah.gov/medicaid/pdfs/chec.pdf.iv)

Hearing Services

Services include diagnosis and treatment for defects in hearing, including hearing aids. Screening should be supervised by a state-licensed audiologist.

If a newborn was not screened in the birthing facility before discharge, a screening test should be conducted as soon as possible after birth. Conduct screening exams on all children during the first CHEC exam and perform at each periodic visit if indicated by historical findings or the presence of risk factors. When indicated, Infants require screening every six months until three years of age. When needed, refer the child to an appropriate specialist.

Age-appropriate hearing screening intervals, protocols, and procedures, and screening indicators are available in the Medicaid Provider Manual (Section 2 – CHEC Services) at http://health.utah.gov/medicaid/pdfs/chec.pdf.

Speech and Language Development

Screen for appropriate development and to identify developmental delays. The CHEC program recommends using the following landmarks for screening:

• At six months a child babbles and initiates social approach through vocalization.
• At one year a child says 'mama' and 'dada' specifically and engages in vocal play.
• At two years a child begins connecting words for a purpose, such as 'me go' and ‘want cookie’.
• At three years a child holds up her fingers to show her age and has a vocabulary of 500- 1,000 words. She will use an average of three to four words per utterance.
• At four years a child's speech should be 90% intelligible. They may make some articulation errors with letters s, r, l, and v. They should use a minimum of four to five words in a sentence.
• Refer the child for a speech and hearing evaluation if you observe one or more of the following:
• Child is not talking at all by age 18 months.
• You suspect a hearing impairment.
• Child is embarrassed or disturbed by his own speech.
• Child's voice is monotone, extremely loud, largely inaudible, or of poor quality.
• A noticeable hypernasality or lack of nasal resonance.
• Child fails the screening tests.
• Recurrent otitis media.
• Speech is not understandable at age four years, especially in cases of suspected hearing impairment or severe hypernasality.
• Blood Pressure Measurements
• Measure at each exam and compare against age-specific percentiles for all children three years and older.
• Age-appropriate Immunizations
• Assess whether the child’s immunizations are up-to-date. Provide all appropriate immunizations according to the schedule in Appendix B of the Medicaid Provider Manual at http://www.immunize-utah.org/ , or on the CDC web site at http://www.cdc.gov/vaccines/.
• You may also refer the child to the local health department.
• Laboratory Testing
• Determine the applicability of specific tests for each child. Perform the following laboratory tests at the time of the CHEC screening using the recommendations of the American Academy of Pediatrics to determine the specific periodicity of each of the following tests:
  • Newborn Metabolic Disease Screening.
  • Hematocrit or Hemoglobin Screening.
  • Tuberculin Screening with annual testing for the following high risk groups:
  • American Indian and Alaskan native children.
  • Children living in neighborhoods where the case rate is higher than the national average.
  • Children from Asia, Africa, the Middle East, Latin America or the Caribbean (or children whose parents have emigrated from these locations).
  • Children in households with one or more cases of tuberculosis.
• Cholesterol Screening
• Conduct at your discretion based on the risk of the child.

• Lead Toxicity Screening

  The Centers for Disease Control and Prevention and the American Academy of Pediatrics recommend a lead risk assessment and a blood lead level test for all Medicaid eligible children between the ages of 6 and 72 months. All children in this age group are considered at risk and must be screened. This component of the CHEC screening is mandated by federal rules.

• Verbal Lead Risk Assessment:
  • Complete a verbal risk assessment for all Medicaid-eligible children ages 6 to 72 months at each CHEC screening. Beginning at 6 months of age, a verbal risk assessment must be performed at every CHEC visit. At a minimum, the following questions must be asked to determine the child’s risk for lead exposure:
  • Does the child live in or regularly visit a house built before 1978? Was his/her child care center or preschool/babysitter’s home built before 1978? Does the house have peeling or chipping paint?
  • Does the child live in a house built before 1978 with recent, ongoing or planned renovation or remodeling?
  • Do any of the child’s siblings or playmates have lead poisoning?
  • Does the child frequently come in contact with an adult who works with lead? (Examples are construction, welding, pottery, or other trades practiced in your community.)
  • Does the child live near a lead smelter, battery recycling plant, or other industry likely to release lead? (Give examples in your community.)
  • Do you or anyone give the child home or folk remedies that may contain lead?
  • Does the child live near a heavily traveled major highway where soil and dust may be contaminated with lead?
  • Does the home the child live in have lead pipes or copper with lead solder joints? Scoring the Verbal Risk Assessment:
  • Low Risk for Lead Exposure: If the answers to all questions are negative, a child is considered low risk and must receive a blood lead test at 12 and 24 months.
  • High Risk for Lead Exposure: If the answer to any question is positive, a child is considered high risk, and a blood lead level test must be obtained regardless of the child’s age. Subsequent verbal risk assessments can change a child’s risk category. If a previously low-risk child is re-categorized as high risk, that child must be given a blood lead level test.
  • Complete a blood lead level testing at required intervals:
  • At 12 and 24 months: Complete for all children regardless of verbal assessment score.
  • Between 24 and 72 months: Complete a blood lead level test if the child has not had it at 12 and 24 months regardless of the verbal assessment score. In addition, complete a test anytime the verbal assessment indicates the child is at high risk for lead poisoning.

Reportable blood lead levels:

Blood lead level samples may be capillary or venipuncture. However, a blood lead test result equal to or greater than 10 ug/dL obtained by capillary specimen must be confirmed using a venous blood sample. In accordance with the Utah Injury Reporting Rule (R386-703), all confirmed blood lead levels greater than 15 ug/dL must be reported to the Utah Department of Health, Bureau of Epidemiology which maintains a blood lead registry. Reports of children with blood lead levels of 20 ug/dL or greater will be shared with the Utah Department of Health, Bureau of Environmental Services.

Other Tests

Please consider other tests based on the appropriateness of the test. Take into account the child’s age, sex, health history, clinical symptoms and exposure to disease.

Health Education:

This is a CHEC requirement that includes anticipatory guidance. It should be provided to parents/guardians and children, and include information regarding developmental

expectations, techniques to enhance development, benefits of healthy lifestyles, accident, injury, and disease prevention, and nutrition counseling.

Note: A table with the recommended screening and prevention components and administration intervals is available in Appendix C of Utah Medicaid Provider Manual at http://health.utah.gov/medicaid/pdfs/chec2_0104.pdf.

Mental Health:

Services that support young children’s healthy mental development can reduce the prevalence of developmental and behavioral disorders which have high costs and long-term consequences for health, education, child welfare, and juvenile justice systems.

Broadly defined, screening is the process by which a large number of asymptomatic individuals are tested for the presence of a particular trait. Screening tools offer a systematic approach to this process. Ideally, tools that screen for the mental development of young children should:

• help to identify those children with or at risk of behavioral developmental problems,
• be quick and inexpensive to administer,
• be of demonstrated value to the patient and provide information that can lead to action,
• differentiate between those in need of follow-up and those for whom follow-up is not necessary, and
• be accurate enough to avoid mislabeling many children.
• Screen the child for possible mental health needs. You may use a standardized behavior checklist to do this screen. We recommend the following social-emotional screening tools for screening infants 0-12 months:
• Ages and Stages Questionnaire (ASQ)
• Ages and Stages Questionnaire: Social-Emotional (ASQ:SE)
• Parent’s Evaluation of Developmental Status (PEDS)
• Temperament and Atypical Behavior Scale (TABS)

Screening accompanied by referral and intervention protocols can play an important role in linking children with and at-risk for developmental problems with appropriate interventions.

Please refer children with suspected mental health needs for mental health assessment.

Healthy U does not cover mental health services. Services are covered by the Prepaid Mental Health Program. For information, please call the General Medicaid Program at (801) 538-6155 or 800-662-9651. Healthy U and Medicaid encourage providers to refer children with suspected mental health needs to the mental health provider listed on the Medicaid Identification card. If no provider is listed on the Medicaid card, refer the child to a Medicaid Mental Health Provider in the child’s home area. Mental Health Services, at a minimum, include diagnosis and treatment for mental health conditions. Refer to the Utah Medicaid Provider Manual for Mental Health Services, Section 2, for policy on services.

Dental Services

Dental services are not covered by Healthy U. Services are covered by the General Medicaid Program at (801) 538-6155 or 800-662-9651. The state Medicaid program covers

dental services for children including dental examinations, prophylaxis, fluoride treatment, sealants, relief of pain and infections, restoration of teeth, and maintenance of oral health. Orthodontic Treatment is provided in cases of severe malocclusions and requires prior authorization. Refer the child to a dentist as follows:

• Make the initial referral for most children beginning at age one year and yearly thereafter.
• Make a referral to a pediatric dentist at 6 months if warranted by an oral risk assessment.
• Make the referral if the child is at least four years and has not had a complete dental examination by a dentist in the past 12 months.
• Make the referral at any age if the oral inspection reveals cavities, infection, or significant abnormality.

Reimbursement for CHEC Services

The CHEC fee includes payment for all components of the CHEC exam. Services such as administration of immunizations, laboratory tests, and other diagnostic and treatment services may be billed in addition to the CHEC screening.

Please use the Preventive Medicine codes listed in the table below each time you complete a CHEC exam. Use these codes even if the child presents with a chronic illness and/or other health problem. Please avoid billing CHEC exams using Evaluation and Management codes. If you do use an Evaluation and Management code, it should be accompanied by the appropriate ICD-10 V code in the table below to identify it as a CHEC exam.

To bill for a CHEC screening electronically, enter the procedure code in loop 2400 - service line. The element is SV101-2 - Product/Service ID. In element SV111, enter a Y to indicate EPSDT/CHEC. On a paper claim, enter the procedure code in box 24-D and enter a Y in box 24-H EPSDT/CHEC.

For additional information regarding the latest in Pediatric Health, please visit the University of Utah Website at http://healthcare.utah.edu/womenshealth/ or www.ped.med.utah.edu.

Prior Authorization Reviews

Services provided that are not medically necessary may result in the provider writing off the charges.

Services deemed ‘medically necessary’ do not guarantee payment if coverage terminates, benefits change, or benefit limits are exhausted.

Notification does not guarantee payment if coverage terminates, benefits change, or services provided are not medically necessary.

Utilization review means a review and confirmation program that determines medical necessity of any care service or treatment. In general, all covered benefits are based on medical necessity and utilization review is not limited to the above list.

The UM department will actively review cases such as organ transplants, special health care needs patients, major catastrophic illnesses, highly complex case management cases, high cost cases (i.e., neonate), any referrals out of the provider network and cases involving risk management issues.

Requests are forwarded to the UM department for review. If approved, as medically necessary, the UM Department will assign a reference number. Reference notification will be sent to the provider, facility and enrollee.

If the request is denied, the UM department will send written notice via mail or fax to the requesting provider or facility and enrollee. If the requesting provider or enrollee finds the reasons given for denial insufficient, they may file an appeal to Healthy U for review (Please refer to Appeal Policy).

Medical necessity review requests can be sent to UUHP UM department via fax or mail. Internal University of Utah provider offices may send requests via EPIC.

Submit Medical Necessity Review Requests to: University of Utah Health Plans

Attn: UM Department

Box 45180

Salt Lake City, Utah 84145

Turn-around time frames for Medical Necessity review are:

• Urgent request -Same day, (weekends, holidays and off-hours will be processed the next working day)
• Routine- 3-4 business days

State Fair Hearing Process

When a Healthy U Medicaid member, provider, or other authorized party is dissatisfied with an action taken by Healthy U Medicaid, and they have completed the appeal process with Healthy U Medicaid, they may file a request for a State Fair Hearing with the Office of Administrative Hearings. The “Request for Hearing/Agency Action” form must be filed within 120 calendar days of the “Notice of Appeal Resolution” letter, from Healthy U Medicaid.

When a provider wishes to appeal a payment reflected by an Explanation of Benefits (EOB), or other remittance document issued by Healthy U Medicaid, and they have completed the appeal process with Healthy U Medicaid, they may file a request for a State Fair Hearing with the Office of Administrative Hearings.

The “Request for Hearing/Agency Action” form must be filed within 120 calendar days of the “Notice of Appeal Resolution” letter, from Healthy U Medicaid. (speaking to a service representative or other Healthy U Medicaid employee, exchanging e-mails, or having any other contact with Healthy U Medicaid about the claim or issue cannot extend or fulfill the 120 calendar day requirement).

Of note, Healthy U Medicaid “Notice of Appeal Resolution” letters are sent by mail or fax and contain information about filing a State Fair Hearing, including the time within which a hearing must be filed, and a State Fair Hearing Form.

State Fair Hearing Forms may also be obtained on the Utah Medicaid website at:

• State Fair Hearing Forms - English
• State Fair Hearing Forms - Espanol

In addition, a copy can be requested from our office by calling (801) 587-6480 or 1 (888) 271-5870.

The form must be filled out and mailed or faxed to:

Mailing Address:

Office of Administrative Hearings DIVISION OF MEDICAID AND HEALTH FINANCING

DIRECTOR'S OFFICE/FORMAL

HEARINGS BOX 143105

SALT LAKE CITY, UT 84114-3105

Street Address:

Office of Administrative Hearings DIVISION OF MEDICAID AND HEALTH FINANCING

DIRECTOR'S OFFICE/FORMAL HEARINGS288 NORTH 1460 WEST SALT LAKE CITY, UT 84114-3105 Fax: (801) 536-0143

If the member is currently receiving a service that has been reduced or denied, they may continue to receive the service, if they file a hearing request within 10 days from the date on the “Notice of Appeal” Resolution” letter. If the member decides to continue to get the service and the decision about their service/s is not in the member’s favor, the member may have to pay for the service.

The member has a right to have an attorney or other person, familiar with their case, at the hearing.