Quality Focus

Quality Improvement Initiatives

Proactively insuring the highest-quality of care for our members.

Chronic Disease Management
Dean Health Plan has been establishing standards for preventive care for our members diagnosed with chronic illnesses such as Diabetes and Cardiovascular Disease. These standards are reviewed every 2 years and distributed to all Dean Health Plan practitioners.

Member education is a primary focus. Dean Health Plan:

• Routinely provides information to our help educate our members, allowing them to work more effectively with their primary care practitioner.
• Sends reminder letters regarding the importance of screenings and regular flu vaccines.
• Sends educational mailings and risk-assessment surveys to appropriate members.
• Surveys members annually to help identify future educational programs that may be beneficial.

Proactive and Preventive Health Management
Dean Health Plan recognizes that all our efforts in quality improvement and preventive care rely heavily on our members taking a proactive approach to their own health care. We also understand that our members need a little reminder now and then to keep them on track.

Preventive screenings are one of the fastest and easiest ways for members and practitioners alike to assure the appropriate level of care is being provided.

• Dean Health Plan sends out reminders to our patients when screenings are due, such as Colorectal
  Cancer screenings, Breast Cancer screenings and Cervical Cancer screenings.
• Reminders are also sent out to parents to keep their children up to date with immunizations.

Dean Health Plan has set the following goals:

• 85% for women 50 years of age and over receive a mammogram screening at least every two years.
• 85% of women age 21 years of age and over are screened for cervical cancer at least every three years.
• 90% of all children and adolescents receive all recommended immunizations.

Utilization Management

Dean Health Plan is committed to providing the best value and care to our members. Our Utilization Management Program was developed to support our commitment and ensure appropriate utilization of medical resources to maximize the effectiveness of care provided to you. This program implements a systematic and organized approach to assess, plan, implement, coordinate, monitor, evaluate, promote and improve high-quality member care.

High-quality care means the clinical management you receive is effective and appropriate, and that it is available and accessible when you need it. It also means care should be delivered in a timely manner, respectful and caring from the member's perspective, effective, safe, efficient and well coordinated over time across practitioners and settings.

The objectives of the Program are to:

1. Comply with state and federal regulations including the National Committee for Quality Assurance (NCQA).
     This includes the screening and monitoring of written requests for prior authorization, referral requests for
     selected outpatient care and services as well as performing concurrent review of selected inpatient hospital
     admissions and outpatient care and services, and performing retrospective review for selected inpatient and
     outpatient care and services. Behavioral health care is included in these activities.
2. Conduct case management of high utilization, catastrophic and complex cases, including disease
     management for members with targeted chronic disease states.
3. Screen and monitor written referral and prior authorization requests for services both within and outside the
     DHP network. Monitor and evaluate the consistency of utilization management (UM) decision making.
4. Coordinate care and services with non-contracted or out of network services.
5. Conduct technology assessments on both new medical technologies and new applications of
     existing technologies.
6. Meet established turnaround time standards for UM decisions.
7. Participate in the evaluation of Customer and Practitioner Satisfaction measures and make
     appropriate improvements.
8. Evaluate the appropriateness of UM criteria and guidelines for decision-making.

The UM Program is provided across all DHP product lines. For more information about the prior authorization and referral requirements of specific products, please refer to the Schedule of Benefits accompanying the Member Certificate (policy).

Questions about the UM Program may be directed to DHP's Customer Service department at (608) 828-1301 or (800) 279-1301.

HIPAA Transactions

Transaction Companion Guides

DHP supports all HIPAA compliant electronic transactions.

Please click here for Dean Health Plan's Claim Adjustment Reason Codes. The Claim Adjustment Reason Codes will be updated quarterly. To ensure you are referencing the correct reason codes, please download this file on a quarterly basis and discard all earlier documents.

Transaction	Transaction Number	Companion Guide
Health Care Claim Institutional and Professional	837	Companion Guide    400 kb PDF
Health Care Payment/Advice	835	Companion Guide    1.1 meg PDF
Health Care Eligibility/Benefit Inquiry and Response	270/271	Companion Guide    1.2 meg PDF
Health Care Claim Status Request and Response	276/277	Companion Guide    1.1 meg PDF
Health Care Services Review – Request for Review and Response	278	Companion Guide    2.7 meg PDF
Benefit Enrollment and Maintenance	834	Companion Guide    1.2 meg PDF
Payroll Deducted and Other Group Premium Payments	820	Companion Guide    1.2 meg PDF

Steps for Getting Started with Electronic Data Interchange (EDI)
Trading partners interested in submitting electronic transactions to DHP can download and complete an EDI set up form. Please complete the form and e-mail or fax to the DHP EDI team at dhpedi@deancare.com or (608) 836-6335. Trading partners can also call (866) 481-3421 to request an EDI set up form.

EDI set up Form - PDF 55 kb PDF

EDI set up Form - Word Doc 1.4 meg Word Doc

All trading partners will be required to sign a Trading Partner Agreement (TPA). Please click here to download the form. Please complete the form and mail two signed copies to the following address:

Dean Health Plan
Attention: EDI Department
1277 Deming Way
Madison, WI 53717

DHP will mail a signed copy of the TPA back to each trading partner.

Transaction Testing Process
DHP will test all trading partner transactions prior to moving into a production environment. Below, please find the steps DHP will take when testing a transaction.

1. Create test folder on FTP server for trading partner
2. Test trading partner files with Claredi® to ensure that transactions are valid.
3. Work with trading partner to eliminate all Claredi® identified errors
4. Process transaction in test environment to ensure accurate results
5. Set up production folder for trading partner on FTP Server.

Contact Us
If you have any questions, please contact the DHP EDI team at dhpedi@deancare.com or (866) 481-3421.

HIPAA Information Links
Centers for Medicare and Medicaid Services
Washington Publishing Company
Workgroup for Electronic Data Interchange
Strategic National Implementation Process
WS FTP Pro

Wisconsin Medicaid and BadgerCare Coding Updates

Fraud Awareness

Together, we can work to help control the cost of health care.

The first step is education. The new Special Investigative Unit (SIU) brochure, Fraud Awareness: Helping to Control Health care Costs is one way we are working to educate Dean Health Plan agents, groups and members. The brochure highlights the following areas:

• What is "health care fraud and abuse"?
• How does it affect not only existing, but also potential groups and members?
• What are fraud warning signs?

View the Brochure:

Download English version
Download Spanish version

If you would like to report a suspected fraud, you may do so by downloading the form and mailing it to:

Dean Health Plan
C/O SIU
1277 Deming Way
Madison, WI 53717