2021 HEALTHY REWARDS PROGRAM - QUALITY CARE. BETTER HEALTH - CAREFIRST MEDICARE ...
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Quality Care. Better Health.
2021
Healthy Rewards Program
H8854_21_DRS_2029_OE_M DRS: 8/27/2020
The start to a
healthier and happier you.
At University of Maryland Health Advantage, we believe that
preventive care plays an important role in staying healthy.
That is why we encourage you to participate in our
Healthy Rewards Program for a healthier and happier you!
Earn a $15 reward card when you complete any
of these screenings or exams.
• Health Risk Assessment
• Annual Wellness Visit
• Annual Flu Shot
• Post-Hospitalization Physician Visit
• Colorectal Cancer Screening
• Mammogram (Breast Cancer Screening)
• Diabetes HbA1c and Urine Protein
Screening (Microalbumin)
• Diabetic Retinal Eye Exam
A Foreign Transaction Fee of 3% of the purchase value is charged for foreign transactions. If your card is lost or
stolen, a $5 Replacement Card Fee will be charged to replace your card. The OmniCard Visa Reward Card is issued by
MetaBank®, Member FDIC, pursuant to a license from Visa U.S.A. Inc.Earning your
reward card is easy.
1 2 3 4 5
Call your doctor to Take this booklet During your Write your Ask the office
schedule the with you to your appointment, ask full name staff to fax the
preventive appointment. the doctor or office and member completed form
screening, exam, staff to fill out, sign identification to University of
or vaccination you and date the form number (located Maryland Health
need. If you prefer, that relates to that on the front of Advantage at
we can assist you appointment. your member ID 410-779-3957.
in scheduling your card) on the form.
visit, just call our
Member Services
number.
To receive eligible rewards, all services must be completed by December 31, 2021
and all completed forms must be submitted to the plan by January 31, 2022.
Any forms received after January 31, 2022 may not be eligible for a reward card.
Member Services:
410-779-9932 (TTY: 711)
or toll free 1-844-386-6762
8 am - 8 pm EST | 7 days a week | October 1 - March 31
8 am - 8 pm EST | Monday - Friday | April 1 - September 302021
Health Risk Assessment
Health Risk Assessments (HRAs) are used to help identify any health risks that could
impact your health. After you answer each question, your case manager at University
of Maryland Health Advantage will use this and other health information to create a care
plan personalized to your health care needs.
University of Maryland Health Advantage mails the care plan to you and your Primary
Care Provider (PCP). The care plan includes goals and actions for you to improve your
health. University of Maryland Health Advantage encourages you to talk to your PCP
about your care plan at every visit.
To receive this reward, members must complete the HRA within the first 90 days of
their enrollment with the plan, and/or annually thereafter. University of Maryland Health
Advantage will reach out to you when you are due for your HRA.
You complete this assessment in your own home. You do not have to go to the doctor to
do it. There are two (2) ways to take the assessment:
1 2
Complete it over the phone If you prefer to take the HRA at
when we call you! home, ask the representative
It’s quick and confidential. on the phone for a mailed copy.
We will mail it to you with a
postage-paid envelope.
All HRA results are confidential. Every HRA is offered at no charge to Medicare members. A member of
our case management team will call you to discuss your HRA results and develop a personalized care
plan shortly after we receive your completed HRA. Conversations with the case management team does
not count as a completed HRA, you must complete the brief survey to be eligible for the reward card.
The HRA must be completed prior to December 31, 2021 for you to be eligible to receive a reward card.
Your reward card will arrive in the mail within six (6) to eight (8) weeks after we receive your HRA. Reward
cards cannot be used to buy tobacco or alcohol. Reward cards cannot be converted to cash. You can
only receive one (1) reward card per HRA.2021
Annual Wellness Exam
University of Maryland Health Advantage encourages all members to get an annual
wellness exam once every 12 months.
The visit is offered to all Medicare members one (1) time each year at no cost. This
visit must be completed during 2021 in order for you to be eligible for a reward card.
During this visit, your doctor will check on your health. The doctor will work with you
to develop a care plan made just for you.
During your annual wellness exam, remember to:
• Educate yourself about the screenings you may need.
• Ask questions about your health numbers (Blood Pressure/Body Mass Index).
• Share information with your doctor about any pain you may have.
• Inform your doctor about any physical or mental changes you are experiencing.
• Engage your doctor in a talk about any over-the-counter drugs you take to
check and see if they are safe to take along with any prescription medicine
prescribed to you.
• Reduce the risk of falls by talking about how to prevent them.
• Discuss advance care planning with your doctor. Advance care planning is
making decisions about the care you would want to receive if you become
unable to speak for yourself.2021
Annual Wellness Exam
Getting your reward card is easy.
1 2 3 4 5
Call your doctor to Take this booklet During your Write your Ask the office
schedule the with you to your appointment, ask full name staff to fax the
preventive appointment. the doctor or office and member completed form
screening, exam, staff to fill out, sign identification to University of
or vaccination you and date the form number (located Maryland Health
need. If you prefer, that relates to that on the front of Advantage at
we can assist you appointment. your member ID 410-779-3957.
in scheduling your card) on the form.
visit, just call our
Member Services
number.
Your reward card will arrive in the mail within six (6) to eight (8) weeks after we receive the completed form from your doctor and have verified
the services. Reward cards cannot be used to buy tobacco or alcohol. Reward cards cannot be converted to cash. All preventive measures must
be completed during the 2021 calendar year. You can only receive one (1) reward card per form.
PROVIDER OFFICE USE:
• Review the patient’s medical record and complete the form.
• Make sure the form is signed and dated. By signing the form, you are attesting to the accuracy of the
information.
• Make sure the patient’s name and University of Maryland Health Advantage member identification number are
included.
• File a copy of the form in the patient’s medical records.
• Fax the Annual Wellness Exam assessment form and any office visit notes to University of Maryland Health
Advantage at 410-779-3957 or mail it to the following address:
University of Maryland Health Advantage
Attn: Quality Dept.
1966 Greenspring Drive, Suite 100
Timonium, MD 210932021
Annual Wellness Exam
Provider: This form is two sided. Please complete all fields and fax this
form and proof of service to University of Maryland Health Advantage at
410-779-3957 so your patient can redeem their reward card.
Name: _____________________________________________________________________
Member ID: _____________________________ Date of Birth: __________________________
Name of Provider: _____________________________ Date of Visit: ______________________
Practice Name: __________________________________ NPI: __________________________
Address: _____________________________________________________________________
Phone: __________________________________ Fax: ________________________________
Measures:
Blood Pressure: ________/________ Weight: __________lbs. Height: __________ BMI: _______
Activities of Daily Living: Does the patient require assistance with any of the following?
Bathing YES NO N/A
Dressing YES NO N/A
Eating YES NO N/A
Walking YES NO N/A
Using the toilet YES NO N/A
Transferring (ex. getting in & out of chairs) YES NO N/A
Can the patient perform all activities of daily living independently? YES NO N/A
Physical Activity: Did you discuss the patient’s level of physical activity
YES NO N/A
and provide advice to start, increase, or maintain levels as appropriate?
Balance/Falls: Does the patient have any trouble walking or standing? YES NO N/A
Fallen in the last 12 months? YES NO N/A
If yes, discuss treatment options. _______________________________________________
Urine Leakage: Any urine leakage? YES NO N/A
Does it interfere with sleep or daily activities? YES NO N/A
If yes, discuss treatment options. ______________________________________________
Smoking: Does the patient smoke? YES NO N/A
Did you advise smoker to quit? YES NO N/A
Did you discuss smoking cessation medication and/or strategies? YES NO N/A
Medication Review: Is the patient taking medication? YES NO N/APlease list all medications, including OTC and herbal or supplemental therapies prescribed or attach a signed and dated
copy of the medication list.
TYPE MEDICATION DOSE/FREQ.
Cholesterol
Diabetes
Blood Pressure
Did you assess for non-adherence (missing more than one dose/week and
YES NO N/A
address any barriers)?
Has the patient been diagnosed with rheumatoid arthritis? YES NO N/A
If yes, is the patient on a DMARD? YES NO N/A
If no, why not? _________________________________________________________________________
Comprehensive Pain Assessment: Does the patient have pain? 0: Does not hurt 10: Hurts the most
Indicate level of pain for the head/neck 0 1 2 3 4 5 6 7 8 9 10 Freq. _______
Indicate level of pain for the chest 0 1 2 3 4 5 6 7 8 9 10 Freq. _______
Indicate level of pain for the muscles 0 1 2 3 4 5 6 7 8 9 10 Freq. _______
Indicate level of pain for bones/joints 0 1 2 3 4 5 6 7 8 9 10 Freq. _______
Indicate level of pain for other _____________ 0 1 2 3 4 5 6 7 8 9 10 Freq. _______
Is the pain under a pain management plan? YES NO N/A
Annual Preventive Measures: Has the patient completed the following important screenings?
Mammogram (for women 50-74 years of age) YES NO N/A
Colorectal Cancer Screening (for patients 50-75 years of age) YES NO N/A
Dilated Retinal Eye Exam (for diabetic patients up to 75 years of age) YES NO N/A
Annual Flu Vaccine (for all patients) Date completed: ____________ YES NO N/A
Advanced Care Planning: Does the patient have evidence of advanced
YES NO N/A
care planning directives in the medical record?
Name of Office Staff Member Completing Form: ______________________________________________________
Provider’s Signature: __________________________________________________________________________
Provider Use Only: Please use the following coding guidance to document the annual wellness visit:
Annual Wellness Visit: G0438 or G0439 (HCPCS Code)
BMI: Z68.20-Z68.24 or Z68.51-Z68.54
Functional Status: 1170F or 99483
Pain Assessment: 1125F, or 1126F2021
Annual Flu Shot
Annual Flu Shot:
Healthcare Professional: Please sign and date this form, then
fax it and proof of service to 410-779-3957. Please note, all data
An annual flu shot is offered at no fields must be completed in order for your University of Maryland
cost to all Medicare members. It Health Advantage patient to receive their reward card.
must be completed during 2021
in order for you to be eligible to
receive a reward card. Name of Healthcare Professional:
_______________________________________________
According to the Centers for
Disease Control and Prevention, Practice/Pharmacy Name: __________________________
it is not possible to predict what Practice/Pharmacy Phone: __________________________
any flu season will be like. The
timing, severity, and length of the Practice/Pharmacy Fax: ____________________________
flu season usually varies from one NPI: ___________________________________________
year to the next.
Location/Address: _________________________________
University of Maryland Health _______________________________________________
Advantage encourages members
Today’s Date: ____________________________________
to get a flu shot. Human immune
defenses become weaker with age. I confirm that I administered a flu shot to:
The flu can be serious for people
Member Name: __________________________________
age 65 and older or with other
health risk factors. Member ID: _____________________________________
Member Date of Birth: _____________________________
Call your doctor today to schedule
your flu shot. Some pharmacies Please sign: _____________________________________
can also give members a flu shot at
no cost to the member. Be sure to
ask if your pharmacy can give you
a shot at no cost.
Provider Use Only: Please use one of these codes
for influenza administration codes:
90654, 90656, 90658, 90661, 90662, 90673, 90674, 90682,
90686, 90688, 90689, or G00082021
Annual Flu Shot
Getting your reward card is easy.
1 Call your doctor to schedule an annual flu shot. If
you prefer, we can assist you in scheduling your visit,
just call our Member Services number.
2
Take this booklet with you to your appointment.
3 During your appointment, ask the doctor or office
staff to fill out, sign and date the form that relates to
the appointment.
Write your full name and member identification 4
number (located on the front of your member ID
card) on the form.
5 Ask the office staff to fax the completed form to
University of Maryland Health Advantage at
410-779-3957 or mail to the address below.
University of Maryland Health Advantage
Attn: Quality Dept.
1966 Greenspring Drive, Suite 100
Timonium, MD 21093
Your reward card will arrive in the mail within six (6) to eight (8) weeks after we receive
the completed form from your doctor and have verified the services. Reward cards
cannot be used to buy tobacco or alcohol. Reward cards cannot be converted to cash.
You can only receive one (1) reward card for one (1) flu shot in 2021.
HEALTHCARE PROFESSIONAL USE:
• Please fill in all data fields (including member name and ID). Sign
and date the form.
• Fax the form to University of Maryland Health Advantage at
410-779-3957.2021
Post-Hospitalization
Physician Visit
Post-Hospitalization
Physician Visit: Provider: Please sign and date this form, then
fax it and proof of service to 410-779-3957. Please note,
The post-hospitalization visit is all data must be completed in order for your University
of Maryland Health Advantage patient to receive their
offered at no cost to Medicare reward card.
members who were hospitalized.
If you complete your post-
Member Name: __________________________________
hospitalization visit within 30 days
of leaving the hospital, you will be Member ID: _____________________________________
eligible to receive a reward card. Member Date of Birth: _____________________________
University of Maryland Health Hospital Discharge Date: ____________________________
Advantage understands that it can Provider Appt. Date: _______________________________
be tough going home after being in
the hospital. You may have left the
hospital with multiple Name of Office State Member Completing Form:
follow-up instructions. You may
______________________________________________
have many medicines to take. You
may also want more medical help Practice Name: __________________________________
and support in the weeks following
Name of Provider: ________________________________
your hospital stay.
Practice NPI: ____________________________________
This visit may be with a primary Address: ________________________________________
care provider or specialist. During
this visit, your doctor will go over _______________________________________________
the instructions that you got at the Phone: _________________________________________
hospital. Your doctor will see if you
need to adjust any medication, Fax: ___________________________________________
follow-up on test results, and Provider’s Signature: ______________________________
discuss future treatments.
Today’s Date: ____________________________________2021
Post-Hospitalization
Physician Visit
Getting your reward card is easy.
1 Call your doctor to schedule your post-
hospitalization visit. If you prefer, we can assist
you in scheduling your visit, just call our Member
Services number.
2
Take this booklet with you to your appointment.
3 During your appointment, ask the doctor or office
staff to fill out, sign and date the form that relates to
that appointment.
Write your full name and member identification
4
number (located on the front of your member ID
card) on the form.
5 Ask the office staff to fax the completed form to
University of Maryland Health Advantage at
410-779-3957.
Your reward card will arrive in the mail within six (6) to eight (8) weeks after we receive the
completed form from your doctor and have verified the services. Reward cards cannot be
used to buy tobacco or alcohol. Reward cards cannot be converted to cash. You can only
receive one (1) reward card for one (1) post-hospitalization visit in 2021.
PROVIDER USE:
• Review the patient’s medical record and complete the form.
• Make sure the form is signed and dated. By signing this form, you
are attesting to the accuracy of the information.
• Make sure the patient’s name and Member ID are included.
• Please file a copy of the completed form in the patient’s medical records.2021
Colorectal Cancer
Screening
Colorectal Cancer Provider: Please sign and date this form, then
Screenings (iFOBT, Colonoscopy, or fax it and proof of service to 410-779-3957. Please note, all
data must be completed in order for your University of Maryland
Flex Sigmoidoscopy):
Health Advantage patient to receive their reward card.
Medicare covers 3 colorectal cancer
screenings when ordered by a doctor – iFOBT, Colonoscopy, or Flexible Sigmoidoscopy
Colonoscopy, Flexible Sigmoidoscopy,
There are three (3) ways to be screened for colorectal
and an iFOBT stool-based test. There
cancer. You will only receive one (1) reward card for one (1)
is no age requirement for members to screening. Once completed, you are not eligible to receive
receive a colonoscopy, but you must another reward card through the Healthy Rewards Program
be over the age of 50 to complete a for any additional colorectal cancer screenings during 2021.
Flexible Sigmoidoscopy or an IFOBT
stool-based test. The screening must Please check off which ONE test you used for screening:
be completed within the recommended
time frame in order for you to receive a
reward card.
□ iFOBT kit (test for blood in stool)
Date mailed kit to lab: _________________________
According to the Centers for Disease
Control and Prevention, regular □ Colonoscopy
screening is key to preventing Date of test: __________________________________
colorectal cancer.
□ Flexible Sigmoidoscopy
University of Maryland Health
Date of test: __________________________________
Advantage encourages you to talk with
your provider about when to begin
If you complete either the Colonoscopy or Flexible
screening for colorectal cancer, what Sigmoidoscopy, please have your provider complete the
test to have, and how often to have it. information below.
Colorectal cancer screenings can detect
problems before any symptoms occur. Name: _________________________________________
Your provider will take into account
Member ID: ______________ Date of Visit: ____________
your age, medical history, family history,
and general health to determine which Member Date of Birth: ______________________________
screening is right for you.
Name of Provider: _________________________________
It is recommended that individuals
get an iFOBT stool-based tests every Practice Name: ___________________________________
12 months, a Flexible Sigmoidoscopy
every five (5) years, or a Colonoscopy NPI: ____________________________________________
every 10 years. Address: ________________________________________
Note: Members will only earn a reward
card for completing one (1) of three (3) _______________________________________________
tests. Phone: ___________________ Fax: __________________2021
Colorectal Cancer
Screening
Getting your reward card is easy.
Colorectal Cancer Screening (iFOBT)
Complete an iFOBT colorectal cancer screening kit before
1 December 31, 2021. Use the kit as instructed.
Mail your sample to the lab to be processed. Instructions
2 on how to do this will be included in your kit.
3 Fill out the form in this Healthy Rewards Program
booklet.
4 Fax or mail the completed form to University of Maryland
Health Advantage.
FAX: 410-779-3957
MAIL: University of Maryland Health Advantage
Attn: Quality Department
1966 Greenspring Drive, Suite 100
Timonium, MD 21093
Colorectal Cancer Screening
(Colonoscopy or Flexible Sigmoidoscopy)
1 Talk with your provider to schedule an appointment for your
colorectal cancer screening before December 31, 2021.
2 After you’ve completed your screening, have your
provider fill out the form in this Healthy Rewards
Program booklet.
3 Fax or mail the completed form to University of Maryland
Health Advantage.
FAX: 410-779-3957
MAIL: University of Maryland Health Advantage
Attn: Quality Department
1966 Greenspring Drive, Suite 100
Timonium, MD 21093
Your reward card will arrive in the mail within six (6) to eight (8) weeks after we receive
the completed form from your doctor and have verified the services. Reward cards
cannot be used to buy tobacco or alcohol. Reward cards cannot be converted to cash.
You can only receive one (1) reward card for one (1) colorectal cancer screening in
2021 within the recommended time frames.2021
Mammogram
(Breast Cancer Screening)
Mammogram (Breast Cancer
Screening): Mammogram Screening Center: Please fill out this
form, then fax it and proof of service to 410-779-3957.
Mammograms are offered at no cost Please note, all data fields must be completed in order for
your University of Maryland Health Advantage patient to
to all female Medicare members
receive their reward card.
over the age of 40. This screening
must be completed between October
1, 2019 and December 31, 2021 in Member Name: __________________________________
order for you to be eligible to receive Member ID: _____________________________________
a reward card.
Member Date of Birth: _____________________________
Mammograms check for breast Date of Mammogram: _____________________________
cancer even if a woman does not
have any signs or symptoms. Today’s Date: ____________________________________
Name of Mammogram Center: ________________________
During this screening, x-ray images
_______________________________________________
are taken of each breast. The x-ray
images look for lumps or tumors that Location Address: _________________________________
cannot be felt.
_______________________________________________
Mammograms can also see other Location Phone: ___________________________________
problems that may indicate breast Location Fax: _____________________________________
problems.
Name of Office Staff Member Completing this Form:
Some imaging centers may require _______________________________________________
a referral. Be sure to ask when you
call to make your appointment. If a
referral is needed, your primary care
provider will provide one for you. Mammogram Screening Center Use Only: Please use
one of these codes for the mammogram:
Talk with your provider if you have
77055, 77056, 77057, 77061, 77062, 77063, 77065, 77066,
any questions.
77067, G0202, G0204, or G02062021
Mammogram
(Breast Cancer Screening)
Getting your reward card is easy.
1 Make an appointment for your mammogram breast
cancer screening at a mammogram screening center.
If you prefer, we can assist you in scheduling your
visit, just call our Member Services number.
2
Take this booklet with you to your appointment.
3 Ask a staff member at the mammogram screening
center to fill out the form after you get your
mammogram.
Write your full name and member identification 4
number (located on the front of your member ID
card) on the form.
5 Ask the office staff to fax the completed form to
University of Maryland Health Advantage at
410-779-3957.
Your reward card will arrive in the mail within six (6) to eight (8) weeks after we receive
the completed form from your doctor and have verified the services. Reward cards
cannot be used to buy tobacco or alcohol. Reward cards cannot be converted to cash.
You can only receive one (1) reward card for one (1) mammogram between October 1,
2019 and December 31, 2021.
PROVIDER USE:
• Please fill in all data fields on the form.
• Make sure the form is signed and dated. By signing this form, you
are attesting to the accuracy of information.
• Make sure the patient’s name and Member ID are included.
• Please file a copy of the completed form in the patient’s medical records.
• Please share a copy of the results with the patient’s PCP as appropriate.2021
Diabetic Screenings
Provider: Please fill out this form, then fax it and proof of
service to 410-779-3957. Please note, both tests and all data
Diabetic Screenings: fields, including the results, must be completed in order for your
University of Maryland Health Advantage patient to receive their
reward card.
HbA1c and Urine Protein Screening
(Microalbumin) are recommended Member Name: ___________________________________
for members who have a diagnosis Member ID: ______________________________________
of diabetes. Member Date of Birth: ______________________________
Date of HbA1C: __________________ Value:____________
These tests are offered at no Date of Urine Protein Screening (Microalbumin): __________
cost to Medicare members who Value: ____________
need them. These tests must be
completed during 2021 in order Yes No Not Prescribed
for you to be eligible to receive a ACE Inhibitor or ARB
Diabetes Medication(s)
reward card.
Cholesterol Medication(s)
If you have kidney disease and are Today’s Date: _____________________________________
under the care of a nephrologist, Does the patient see a nephrologist? If yes, date of last visit:
you may not need to have the urine
_______________________________________________
protein test completed. In this case,
you may provide evidence of a visit Name of Provider/Practice: __________________________
with your nephrologist during 2021. Location/Address: _________________________________
_______________________________________________
Note: Members must complete Location Phone: ___________________________________
both screenings to be eligible for a
Location Fax: ________________NPI: _________________
reward card.
Name of Office Staff Member Completing this Form:
_______________________________________________
Provider Signature: ________________________________
Provider Use Only: Please use one of these codes for diabetic tests:
HbA1c: 83036, 83037 (CPT Codes), 3044F, 3046F, 3051F, 3052F (CPT II)
Nephropathy Screening: 3066F or 4010F (CPT II)2021
Diabetic Screenings
Getting your reward card is easy.
1 Call your provider to schedule your diabetic
screenings. If you prefer, we can assist you in
scheduling your visit, just call our Member Services
number.
Take this booklet with you to your appointment.
2
3
At your appointment, ask your provider to complete
the form, sign, and date it.
Write your full name and member identification
4
number (located on the front of your member ID
card) on the form.
5 Ask the office staff to fax the completed form to
University of Maryland Health Advantage at
410-779-3957.
Your reward card will arrive in the mail within six (6) to eight (8) weeks after we receive
the completed form from your doctor and have verified the services. Reward cards
cannot be used to buy tobacco or alcohol. Reward cards cannot be converted to cash.
You can only receive one (1) reward card for the completion of both the HbA1c and
Microalbumin in 2021.
PROVIDER USE:
• Review the patient’s medical record and complete the form.
• Make sure the form is signed and dated. By signing this form, you
are attesting to the accuracy of information.
• Make sure the patient’s name and Member ID are included.
• Please file a copy of the completed form in the patient’s medical records.2021
Diabetic Retinal
Eye Exam
Provider: Please fill out this form, then fax it and proof of service
to 410-779-3957. Please note, all data fields must be completed
in order for your University of Maryland Health Advantage patient
to receive their reward card.
Diabetic Retinal Eye Exam:
Member Name: __________________________________
It is recommended that members
Member ID: _____________________________________
with diabetes have a retinal eye
exam once a year. According to Member Date of Birth: _____________________________
the National Institute of Health, Date of Eye Exam: _________________________________
between 40 and 45 percent of
Americans diagnosed with diabetes Result: _________________________________________
have some stage of diabetic Today’s Date: ___________________________________
retinopathy.
Name of Provider/Practice: __________________________
This eye exam is offered at no cost _____________________________________________
to Medicare members who need it.
It must be completed during 2021 Location Address: _________________________________
in order for you to be eligible to _______________________________________________
receive a reward card.
Location Phone: ___________________________________
Location Fax: _____________________________________
Signature of Eye Care Professional:
_______________________________________________
Provider Use Only: Please use one of these codes
Diabetic Retinal Screening: 67028, 67030, 67031, 67036, 67039,
67040 to 67043, 67101, 67105, 67107, 67108, 67110, 67113,
67121, 67141, 67145, 67208, 67210, 67218, 67220, 67221, 67227,
67228, 92002, 92004, 92012, 92014, 92018, 92019, 92134, 92225-
28, 92230, 92235, 92240, 92250, 92260, 99203-05, 99213-15,
99242-45, S0620, S0621, or S3000
Diabetic Retinal Screening Negative in Year Prior: 3072F (CPTII)
Eye Exam with Evidence of Retinopathy: 2022F, 2024F, or 2026F
Eye Exam without Evidence of Retinopathy: 2023F, 2025F, or 2033F2021
Diabetic Retinal
Eye Exam
Getting your reward card is easy.
1 Call the ophthalmologist or optometrist to schedule
your retinal eye exam. If you prefer, we can assist
you in scheduling your visit, just call our Member
Services number.
2
Take this booklet with you to your appointment.
3 During your appointment, ask the eye care
professional to complete the form, sign, and date it.
Write your full name and member identification 4
number (located on the front of your member ID
card) on the form.
55 Ask the office staff to fax the completed form to
University of Maryland Health Advantage at
410-779-3957.
Your reward card will arrive in the mail within six (6) to eight (8) weeks after we receive
the completed form from your doctor and have verified the services. Reward cards
cannot be used to buy tobacco or alcohol. Reward cards cannot be converted to cash.
You can only receive one (1) reward card for one (1) eye exam visit in 2021.
PROVIDER USE:
• Review the patient’s medical record and complete the form.
• Make sure the form is signed and dated. By signing this form, you
are attesting to the accuracy of information.
• Make sure the patient’s name and Member ID are included.
• Please file a copy of the completed form in the patient’s medical records.
• Please share a copy of the results with the patient’s PCP.2021
Medical Information
Name: ___________________________________ Pharmacy:
Date of Birth: ______________________________ Name: ___________________________________
Phone #:__________________________________ Phone #:_________________________________
Primary Care Provider: Other Doctors:
Name: ___________________________________ Name: ___________________________________
Phone #:_________________________________ Specialty: ________________________________
Phone #:_________________________________
Emergency Contact:
Name: ___________________________________ Name: ___________________________________
Relationship: ______________________________ Specialty: ________________________________
Phone #:__________________________________ Phone #:_________________________________
Allergies: _________________________________ Medical Conditions: ________________________
_________________________________________ ________________________________________
_________________________________________ ________________________________________
_________________________________________ ________________________________________
_________________________________________ ________________________________________
_________________________________________ ________________________________________2021
Medication Record
Use this page to keep track of all medications you
take. This includes prescription drugs, over-the-counter
medications, herbal supplements, and vitamins. Share this
information with your provider and pharmacist during all visits. Remember to
use a pencil so you can make any changes if necessary.
You should review this record when starting or stopping a new medication,
changing your dosage, or visiting with your provider.
Start/Stop Date Notes,
Name of Form (pill, patch, How Much Use (regularly or
Dosage (1/10/21 - 5/10/21 Directions,
Medication injection, etc) and When occasionally)
1/10/21 - ongoing) Reasons for Use
1.
2.
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4.
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6.
7.
8.
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11.
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15.2021 Notes
The Healthy Rewards Program is offered to all
University of Maryland Health Advantage members at no cost.
For assistance in scheduling a screening or test, or if you have
questions about the program, please call a Member Services
representative for assistance.
Member Services:
410-779-9932 (TTY: 711)
or toll free 1-844-386-6762
8 am - 8 pm ET | 7 days a week | October 1 - March 31
8 am - 8 pm ET | Monday - Friday | April 1 - September 30
Remember to register for University of Maryland
Health Advantage’s online and secure member portal at
www.UMMedicareAdvantage.org.
University of Maryland Health Advantage is an HMO-SNP plan with a Medicare contract and a State of Maryland Medicaid
contract. Enrollment in University of Maryland Health Advantage depends upon contract renewal.You can also read
