Unity Member Guide - Unity Health Insurance

Transcription

M E M B E R
G U I D E
Welcome
to Unity Health Insurance
Keep This Guide for Future Reference
Know Your Health Plan
The Member Guide is for informational
purposes only. It is only a partial, general
description of Unity features and benefits.
It is not a contract nor any part of one. The
complete terms of your health plan are in
your Policy documents, which includes your
Certificate of Coverage, Schedule of
Benefits, and any Benefit Riders. If there
are any differences between this Member
Guide and your Policy documents, your
Policy documents are the controlling
documents.
Before seeking any health care under
your Unity health plan, please review the
following resources very carefully. Together,
they will provide the information you need
to know to make the most of your health
plan benefits –
Member Guide
Commercial Network Provider
Directory*
Medicare Select Provider Directory*
(Medicare Select members only)
State of Wisconsin UW Health
Provider Directory* (State of
Wisconsin Local and Government
Participants only)
State of Wisconsin Community
Network Provider Directory*
(State of Wisconsin Local and
Government Participants only)
BadgerCare Plus Provider Directory*
(BadgerCare Plus Participants only)
Certificate of Coverage
• Riders (if applicable)
Schedule of Benefits or Summary of
Benefits and Coverage
It’s Your Choice materials
(State of Wisconsin and Local
Government Participants only)
Most of the information in this Member
Guide pertains to all Unity members;
however, POS and PPO members will
also find information that applies just to
them on pages 25 – 27.
Unity Health Insurance
Customer Service
If you have any questions about your
benefits, send a message to Unity
Customer Service through MyChart at
unitymychart.com. You may also call
(800) 362-3310. Our representatives are
available weekdays from 7 a.m. to 7 p.m.
Email is checked during normal
business hours.
(800) 362-3310 (toll-free)
(608) 643-2491 (local)
(608) 643-2564 (fax)
(608) 643-1421 (hearing impaired)
Pharmacy Services: (800) 788-2949
If you are unable to contact Unity during
normal business hours, you may call and
leave a voicemail message including your
name, subscriber number, telephone
number where you can be reached and
the best time (any time day or night) for a
customer service representative to return
your call. Unity monitors email and chat
during normal business hours. Unity
customer service representatives will
gladly assist you in getting answers to
your health care coverage questions.
Other Sources of Information
Read our quarterly newsletter, Pulse, for
updates to this guide.
Visit unityhealth.com/members for
information on the following topics –
• How to Get Care
• How Insurance Works
• Pharmacy Benefits
– Programs and Policies
– Choice90
– Choosing a Pharmacy
Find A Doctor
• Interactive look-up of Unity providers
Health & Wellness
• Preventive Health
• Managing Your Health
– Asthma
– Emotional Wellness
– Diabetes
– Health Appointment Planning
– Health Coaching
– High Blood Pressure
– Living Well with
Chronic Conditions
– Lower Back Pain
– Medication Adherence
– Pregnancy & Childbirth
– Tobacco Cessation
• Wellness Rewards
• Interactive Tools
MyChart, secure online portal that gives
you access to –
• View benefit information
• Check claims status
• Contact a customer service
representative
• Receive electronic Explanation of
Benefits (EOB)
• Take a Health Risk Assessment
• Review Prior Authorizations
• Plus, if you receive care from
UW Health you can view portions
of your UW Health medical
information
Unity Health Insurance is a Qualified Health Plan issuer in the Health Insurance Marketplace.
Unity Health Insurance does not discriminate on the basis of basis of race, color, national origin, disability, age, sex, gender identity, sexual orientation, or health status in
the administration of the plan, including enrollment and benefit determinations.
* Providers are independent contractors and not employees of Unity Health Plans Insurance Corporation.
Contents
2 Welcome to Unity Health Insurance
4 Understanding the Concept
of Managed Care
• What is Managed Care?
• Why Choose Managed Care?
5 Enrollment & Eligibility Information
• New Member Enrollment Information
• Your Subscriber / Member
Identification Card
• Changes to Your Enrollment
Information
• Dependent Information
• Other Insurance Coverage
• Continuation and Conversion Plans
9 Accessing Primary Care
• How to Obtain Information about
Practitioners and Providers
• Why Choose a Primary Care
Physician (PCP)?
• How to Choose Your PCP
• Tips for Selecting a PCP
• MyChart
• How to Change Your PCP
• Making an Appointment for
Routine Care
• After-Hours Clinic Care
• Accessing Care Away From Home
• Well-Child Care
12 Accessing Specialty Care
• Specialty Care Services
• Procedures and Equipment
Requiring Prior Authorization
• Dental / Oral Surgery, Optometric,
Chiropractic and OB / GYN
• Behavioral (Mental Health / AODA)
Health Care Services
• Maternity Care
• Hospital Care
15 Accessing Urgent & Emergency
Care Services
• Urgent Care Services
• When You Need Urgent Care
• Emergency Care Services
• What To Do In Case of An
Emergency
• Follow-up Care for Urgent
and Emergency Care Services
17 Pharmacy Benefits & Services
• Prescription Drug Benefit
• Prescription Drug Formulary
• How is the Formulary Developed?
• Medication Prior Authorization
• Generic Drugs
• Why Choose a Generic?
• Unity’s Generic Substitution Policy
• Vacation Supply of Drugs
• Step Therapy Program
• Emergency Drug Supply
• New Member Drug Supply
• Choice90 Extended Supply Program
• Specialty Pharmaceuticals Program
• Half-Tab Program
• RX Outcomes
• Refill Policies
21 Medical & Complex Case
Management
• Guidelines for Care
• Complex Case Management
23 Claims & Payment Information
• Claims Submission
• Out-of-Pocket Expenses
25 Information for POS Members
• How POS Plans Work
• POS Member Information
27 Information for PPO Members
• How the PPO Plan Works
• PPO Member Information
28 Member Rights & Responsibilities
• Special Needs
• Complaints and Grievance
Resolution
• Member Rights
• Member Responsibilities
• Confidentiality and Privacy Policies
• Women’s Health and Cancer
Rights Act
32 Quality Improvement Programs
• NCQA Accreditation
• HEDIS® Reporting
• Member Satisfaction
• Evaluation of New Medical
Technology
• Ensuring Quality Practitioners
and Providers
34 Glossary of Commonly Used
Managed Care Terms
If you need language assistance, please see the contact information below.
unityhealth.com
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Welcome
to Unity Health Insurance
Welcome to Unity Health Insurance. Our goal is to keep our members healthy
while managing the cost of care. We provide programs and services to meet
your health care needs. We work to provide you with attentive service and
access to quality care through our large network of participating providers. We
strive to offer convenient access to health care within our service area.
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Mission
Health Plan Options
Unity is a growing, financially strong organization that provides
managed health insurance products and services. We promote quality
health care for our members and deliver value to our customers and
strategic partners.
“Health plan” refers to the type of coverage you have.
Unity offers a number of health plan options –
The cornerstones of this mission are –
Choice
A variety of benefit options and a broad choice of providers.
Access
Health care delivered by local, community-based providers with
access to state-of-the-art specialty and tertiary care.
Value
Competitive pricing, administrative efficiency and customer
satisfaction.
Quality
Measurement and improvement of health care processes and
outcomes.
Vision
Unity will be the preferred managed health insurance partner of
employers, members, providers and the communities we serve.
Customer Service Philosophy
Providing excellent customer service is a company-wide goal at
Unity. Every employee is dedicated to ensuring members have a high
level of satisfaction with their Unity health plan. Unity employees
follow a philosophy that helps us provide the high level of service
our members deserve.
Our Philosophy
We strive to –
Provide prompt and accurate member services
Keep our promises and commitments to our customers
Exceed our customers’ expectations in everything we do
Health Management Organization (HMO) Plan
Members who have this plan agree to obtain all
non-emergent health care services through a defined
network of doctors, hospitals and other medical
professionals.
POS Plan
This plan allows members flexibility in seeking medical
care, with options to stay “in plan” or go “out-of-plan”
to seek health care services. Refer to page 25.
PPO Plan
The PPO Plan allows members to access care from
providers throughout the United States. See page 27
for more information.
HSA-Qualified High Deductible
Health Plans (HDHP)
High Deductible Health Plans are plans with federally
defined deductible limits. By having a HDHP, the
subscriber is eligible to open a Health Savings
Account (HSA), a tax savings vehicle.
Individual Health Insurance Plan
Unity offers health plans for individuals and families.
Members with coverage under a Unity individual
product should contact Unity Customer Service when
this Member Guide refers to “Your Employer’s Benefit
Administrator.”
Medicare Select Plan
Unity offers supplemental health insurance plans
for individuals who are currently enrolled in Medicare
Part A and B.
Please visit unityhealth.com for more
information about these plan types.
unityhealth.com
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Understanding the Concept of Managed Care
What is Managed Care?
The philosophy of managed care is to provide members with
preventive services in order to keep them healthy. Healthy
members are less likely to need more expensive medical care.
Managed Care Organizations (MCOs) attempt to reduce
costs by creating provider networks through which all
members receive their health care. Unity Health Insurance
works with its network of providers to help ensure members
receive timely and appropriate medical care and that
unnecessary or untested services are not provided.
Unity and its participating providers develop programs to
improve member use of preventive health care services. By
focusing on prevention of illness and management of chronic
disease, members have more control over their health.
Why Choose Managed Care?
Managed care empowers members to proactively seek
preventive health care services. It better suits today’s active
lifestyle because of these features –
Convenient Access
Unity’s service area covers southwestern and south central
Wisconsin. Participating provider clinics are situated to
provide you and your family with accessible health care
services.
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Streamlined Administration
You are virtually free of hassles and follow-up paperwork
when you use an in-network provider and follow
any applicable referral requirements. In most cases, your
practitioner will submit claims directly to Unity.
Coordination of Care
Your relationship with your Primary Care Physician (PCP)
is important. Your PCP works with you to coordinate all of
your health care services.
Care Management
Doctors and nurses in Unity’s care management program,
working with your PCP, review treatment plans and
requests to coordinate your care.
Health Education and Wellness
Unity has partnerships with a variety of community
providers that offer health education classes and services
that can improve your health and well-being.
Preventive Health Care
Unity has adopted a Preventive Health Care Guideline to
help you and your family plan routine visits to your PCPs.
This guideline promotes preventive health care services
such as age appropriate physical exams, well-child care,
cervical cancer screenings, mammograms and many other
services to help keep you and your family healthy.
Enrollment and Eligibility Information
New Member Enrollment Information
You will receive your new member materials when you
enroll. This includes your ID cards and other information
about using your health plan including how to access
information online at unityhealth.com.
We encourage you to read your enrollment information
thoroughly. Please note that in the future you will receive a
letter with information directing you to MyChart to review
your Schedule of Benefits (SOB) or Summary of Benefits and
Coverage (SBC.) You can always contact Customer Service to
request free, printed copies. If you misplace an item or have
questions, log into MyChart or contact Customer Service.
Note: State of Wisconsin and Local Government Participants should refer to the
It’s Your Choice materials for more information.
Your Subscriber / Member
Identification Card (ID Card)
Your new member information includes two ID cards.
These cards identify you (the subscriber) and your covered
dependents, your group number, a PCP for each family
member (if applicable), your provider network and health
plan (see page 3). For additional or replacement ID
cards, login to unitymychart.com or call (800) 548-6489.
MyChart allows you to print your ID card or you can request
a new one be mailed to your home. Your new ID cards will
be sent to you within five to seven business days.
Unity Health Insurance knows that privacy is very important
to you which is why your member ID number is a randomly
assigned number.
There is important information on the front and back of
your member ID card. Do not tear it in half—you will need
the top and bottom portions to present at your clinic or
pharmacy when you seek services. Always have your member
ID card with you each time you access services from an
in-network health care provider or when contacting Unity
Customer Service.
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The front of your Unity Health Insurance member ID card includes the following information –
Your Network – Use this to search for providers at
unityhealth.com/findadoctor:
• Individual Health Insurance member ID cards will indicate “BeloitOne, Elite or
Prime” in the “Your Network” section of the HMO ID card.
• State of Wisconsin health insurance program member ID cards will indicate
“State / Local” and then either “UW Health or Community” based on the network
chosen in the “Your Network” section of the HMO ID card.
• Medicare Select and Personal Options member ID cards will indicate “Unity” in
the “Your Network” section of the HMO ID card.
• HMO member ID cards will indicate “Unity, Beloit One, Elite or Prime” in the
“Your Network” section of the HMO ID card.
• PPO member ID cards will indicate “MultiPlan PHCS or HealthEOS Plus+” in
the “Your Network” section.
• BadgerCare Plus member ID cards will indicate “BadgerCare Plus” in the
“Your Network” section.
Subscriber Name – Full name of the subscriber.
Subscriber # – The subscriber number is a unique number
assigned to each individual subscriber.
Group # – The group number identifies the subscriber’s
employer group and is usually the same for all members
and their dependents within that employer group.
Member Name – Each member / dependent is listed under
“member name,” along with each individual member’s PCP
name, clinic name and telephone number.
Person Code – Each member / dependent is identified by a
person code. This person code is the last two digits of the
member’s identification number. The subscriber will always
have person code “00.” Please include the appropriate person
code whenever you contact Unity regarding a specific
member.
PCP – The clinic and Primary Care Physician (PCP) for each
member is listed, along with the clinic phone number. Each
member shown on a card can have a different PCP.
Note: There may be certain circumstances when this information may not be listed.
The back of your Unity Health Insurance member ID card also contains important information –
be sure to read it before using your card.
Remember the following –
Verify the information on your ID card right away.
Notify Customer Service if any changes are needed.
It is necessary to present your ID card every time you
receive medical care. This includes services at a pharmacy
(if applicable).
Please note: State of Wisconsin and Local Government participants should use
their Navitus Health Solutions LLC ID card at the pharmacy. BadgerCare Plus
members should use their Forward or ForwardHealth card.
Notify Customer Service immediately if you lose your
ID card or if it is stolen.
Do not allow anyone else to use your ID card unless they
are insured under your Unity policy.
HMO / Individual
840 Carolina Street
Sauk City, WI 53583-1374
HOW TO OBTAIN CARE
BENEFIT INFORMATION: Can be found within MyChart at
unityhealth.com. Simply request an account at unitymychart.com.
PROVIDER NETWORK: Please use Find a Doctor at unityhealth.com.
PRIOR AUTHORIZATION: Your participating doctor, hospital staff
or provider must call Unity Customer Service. You are responsible for
this notification when using an out-of-network provider. Please use
the Prior Authorization list at unityhealth.com for further information.
URGENT AND EMERGENCY CARE: If you have a serious medical
problem where care clearly cannot be delayed, call 911 or obtain care
from the nearest medical site. Notify Unity Customer Service.
Customer Service
(800) 362-3310
TDD (608) 643-1421
Fax (608) 643-2564
unityhealth.com
Members Send Claims to:
PO Box 610
For members with
Unity drug coverage,
pharmacies may use:
BIN# 003585
PCN#/Rx Group# 51050
24-hour pharmacy:
(800) 788-2949
This card is for identification purposes only
and does not constitute proof of eligibility
Unity Health Plans Insurance Corporation
Front
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unityhealth.com
Back
POS
Point of Service (POS)
840 Carolina Street
Your Network:
HOW TO OBTAIN CARE
problem where care clearly cannot be delayed, call 911 or obtain care
from the nearest medical site. If you are unsure of the urgency of the
situation, call your primary care clinic for instructions.
For after-hours care, contact your PCP clinic. Your clinic is required
to provide you with instructions for after-hours care. If you use
out-of-network providers, you may have additional costs and you
will be responsible for obtaining Prior Authorization.
PROVIDER NETWORK: Please use Find a Doctor at unityhealth.com.
PRIOR AUTHORIZATION: Your participating doctor, hospital staff
or provider must call Unity Customer Service at least three days
prior to any non-emergency hospitalization. You are responsible
for this notification when using an out-of-network provider.
BENEFIT INFORMATION: Benefit information is available within
MyChart. Simply request an account at unitymychart.com. An
activation code will be mailed to your home. Once you receive your
activation code, follow the instructions to activate your account.
PHARMACY: For members with Unity drug coverage, pharmacies
may use:
BIN# 003585
Unity 24-hour pharmacy: (800) 788-2949
Customer Service
(800) 362-3310
TDD (608) 643-1421
Fax (608) 643-2564
unityhealth.com
Send Claims to:
PO Box 610
Front
Back
PPO
840 Carolina Street
Your Network:
HOW TO OBTAIN CARE
Subscriber Name
Subscriber #
problem where care clearly cannot be delayed, call 911 or obtain care from
the nearest medical site. If you are unsure of the urgency of the situation,
call your primary care clinic for instructions. For after hours care, contact
your PCP clinic. Your clinic is required to provide you with instructions for
Carolina
840may
after-hour care. If you use out-of-network providers, you
incur Street
Sauk
WI 53583-1374
additional costs and you will be responsible for obtaining
PriorCity,
Authorization.
Group #
Your Network:
Subscriber Name
Member Name
Subscriber #
Group #
Person Code
Member Name
Person Code
PROVIDER NETWORK: For care OUTSIDE of Wisconsin, call PHCS at
(866) 680-7427
HOW TO OBTAIN CARE
For care IN Wisconsin, call MultiPlan
at (888)AND
342-7427
URGENT
EMERGENCY CARE: If you have a serious medical
You may also use Find a Doctor atproblem
unityhealth.com
where care clearly cannot be delayed, call 911 or obtain care from
the
nearest
medical
site.
If youPrior
are unsure of the urgency of the situation,
PRIOR AUTHORIZATION: To view a list of services requiring
call your primary
clinic for for
instructions.
For after-hours care, contact
Authorization, please visit unityhealth.com.
You arecare
responsible
this
your PCP clinic. Your clinic is required to provide you with instructions for
notification when utilizing any provider.
after-hours care. If you use out-of-network providers, you may have
BENEFIT INFORMATION: Benefit
information
is and
available
within
MyChart. for obtaining Prior Authorization.
additional
costs
you will
be responsible
Simply request an account at unitymychart.com. An activation code will be
PROVIDER NETWORK: For care IN Wisconsin, call HealthEOS at
mailed to your home. Once you receive your activation code, follow the
(800) 279-9776.
instructions to activate your account.
For care OUTSIDE of Wisconsin, call MultiPlan at (888) 342-7427
drugalso
coverage,
pharmacies
use:
PHARMACY: For members with Unity
You may
use Find
a Doctor atmay
unityhealth.com
BIN# 003585
PCN#/Rx
Group# 51050
PRIOR
AUTHORIZATION:
To view a list of services requiring Prior
Authorization, please visit unityhealth.com. You are responsible for this
notification
utilizing
Send when
Claims
to: any provider.
HealthEOS by Multiplan
BENEFIT INFORMATION: Benefit information is available within MyChart.
PO Box 6090
Simply request an account at unitymychart.com. An activation code will be
De Pere, WI 54115-6090
mailedFax
to your
Once you receive your activation code, follow the
(262)home.
879-0876
instructions
to activate
your account.
EDI Payor
# (Emdeon):
36326
Customer Service
(800) 362-3310
TDD (608) 643-1421
Fax (608) 643-2564
unityhealth.com
PHARMACY: For members with Unity drug coverage, pharmacies may use:
BIN# 003585
Customer
Service
and does not constitute
proof
of eligibility
Unity Health Plans
Insurance
Corporation
(800)
362-3310
TDD (608) 643-1421
Fax (608) 643-2564
unityhealth.com
Send Claims to:
HealthEOS by Multiplan
PO Box 6090
De Pere, WI 54115-6090
Fax (262) 879-0876
EDI Payor # (Emdeon): 36326
Front
Back
unityhealth.com
7
Changes to Your Enrollment Information
If your enrollment status changes, you must contact –
Your employer’s Benefits Administrator / Human
Resources Manager if you are on a group plan
Unity Health Insurance Customer Service if you purchased
an individual plan directly from Unity
HealthCare.gov if you purchased an individual plan through
the Health Insurance Marketplace (HIM).
Notify them of the following changes as soon as possible –
• Name, address and / or phone number change
It is very important you also let Unity know about these
changes as quickly as possible. You may do so by logging
into MyChart or calling (800) 548-6489.*
• Choosing or changing your PCP
See “Accessing Primary Care,” page 9.
• Your marriage
As the policy subscriber, you must add your spouse to your
policy within 31 days if you’re on a group plan and 60 days
if you’re on an individual plan following the date of your
marriage if you want your spouse insured. Adding a spouse
may change your monthly premium. You may be able to
add your spouse by logging into MyChart or calling
Customer Service (800) 362-3310. If you do not add your
spouse within the timeframe specified in your plan, your
spouse may be subject to a waiting period.*
• New baby
Enroll your newborn under your policy within 60 days
following the child’s date of birth. Adding a newborn may
change your monthly premium. You may be able to add
your dependent by logging into MyChart. If not, contact
Customer Service to obtain an enrollment application.*
Note: A newborn of a dependent (grandchild) may be added only if the
dependent parent is under the age of 18. Coverage for the grandchild ends the
day the parent turns 18 years of age.
• Divorce
Notify Customer Service when your divorce is final. You
must fill out the necessary paperwork to have your former
spouse / stepchildren removed from your policy. Your
former spouse / stepchildren may be eligible to continue
coverage for a period of time. You may be able to remove
them from your policy by logging into MyChart. If not,
contact Customer Service at (800) 362-3310.*
• Death of a member
Contact Customer Service to complete the necessary
forms.*
• Termination of employment
You may be eligible to continue your coverage through
your employer group when you leave your job. Contact
your former employer’s Benefits Administrator for
continuation information.
Note: State of Wisconsin and Local Government Participants should refer to
the It’s Your Choice: materials for more information about enrollment
changes.
Dependent Information
Adopted children, children placed for adoption, stepchildren
Legally adopted children, children placed for adoption or
stepchildren who live with you may be eligible for coverage.
Contact Customer Service for details.*
Adult children
Your adult child is eligible for coverage under your plan
until age 26 or if the child is a full time student and was
under 27 years of age when called to federal active duty.
This only applies if he / she was a full time student when
called to active duty and returned to full time student status
within 12 months after fulfilling his / her active duty.
Contact Unity Customer Service for further details.
Disabled dependents – Intellectually or physically disabled
dependents may be eligible to continue coverage under your
policy. Contact Unity Customer Service for further details.
Other Insurance Coverage
You must inform Unity if or when you have other
health insurance coverage. This information ensures your
claims will be submitted and processed correctly. Unity
coordinates benefits with your other insurance plan.
Always give copies of your health insurance identification
cards to the providers you see for health care services.
If you have any questions regarding the coordination
of benefits, contact Customer Service. To inform us of
other coverage, please complete the Other Insurance
Questionnaire at unityhealth.com/memberforms by
selecting Other Insurance Questionnaire.
Continuation and Conversion Plans
If you leave your job, are widowed, experience a divorce or
separation or your dependent child is no longer eligible for
coverage through your employer, then you, your spouse
or your child may be eligible for continuation benefits.
Please talk with your employer about continuation.
When you are no longer eligible for your employer’s coverage
or when your continuation coverage runs out, you may be
able to convert to Unity’s conversion product or apply for an
individual plan.
*Individuals who bought their health plan through the Health Insurance Marketplace (HIM) must contact them directly with these changes.
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Accessing Primary Care
How to Obtain Information
About Practitioners and Providers
The Unity Health Insurance provider directories list
participating primary care physicians (PCPs), specialists,
chiropractors, pharmacies, hospitals and urgent care facilities
by city. Unity Customer Service can assist you in locating a
PCP / clinic in your area.
Your PCP clinic can assist you with specific questions
regarding the board certification status, residency and
educational background of a particular provider.
Note: PPO members, please visit unityhealth.com for more information
about the PPO network.
Our online Find A Doctor feature
allows you to search for providers by
their name, city, specialty type or facility.
Visit unityhealth.com/findadoctor.
Why Choose a PCP?
All Unity members must select or be assigned a participating
PCP. A PCP is a physician who manages your health care
and helps ensure you receive continuous, quality care in an
efficient, cost-effective manner. Your PCP coordinates your
medical care through Unity’s network of specialty care
providers.
To effectively manage care and help you obtain an optimal
level of health, it’s beneficial for you to have a close
relationship with your PCP. There is also an established
working relationship between your PCP and Unity.
Your PCP should –
Know your medical history and help coordinate all of your
health care needs, including working with medical /
surgical specialists and behavioral health (mental health /
AODA) practitioners
Monitor and coordinate your care if you have a medical
condition such as asthma or diabetes
Recommend you seek regular preventive health services,
such as immunizations, age appropriate physicals and
screenings
Refer you to participating specialists as needed
There are many advantages to having a PCP –
The most consistent care is received when one physician
has a total history of your health care and can coordinate
your care
Referrals will be made when needed
You will not have to worry about hospital
pre-authorization or filing claim forms
Out-of-pocket costs can usually be minimized
Note: PPO members do not need to select a PCP.
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How to Choose Your PCP
Tips for Selecting a PCP
All Unity Health Insurance members must select or be
assigned a PCP. Each of your family members has the right
to select his / her own participating PCP. The PCP(s) you
select for you and your family members may be a –
Family Practice Physician (FP)
Family Practice with Obstetrics (FP / OB)
General Practice Physician (GP)
Geriatric Physician (Ger)
Internal Medicine Physician (IM)
Pediatrician (Peds)
OB / GYN Physician (OB / GYN)
It is important to take time to select PCPs for your family.
PCPs are trained to serve as a person’s primary doctor for the
long term.
It is very important you read the introductory section of
your provider directory or the help information within
Find A Doctor prior to selecting a PCP or PCP clinic.
For provider updates, visit unityhealth.com/findadoctor
or contact Customer Service.
You should verify the PCP you select is accepting
new patients. You can call the clinic directly, visit
unityhealth.com/findadoctor or contact Customer
Service to obtain this information.
UW Health Welcome Center
If you are looking for a PCP at a UW Health clinic and need
help selecting one, contact the UW Health Welcome Center
at (800) 552-4255 weekdays from 8 a.m. to 5 p.m. You can
also send an email to [email protected].
In addition to helping you select a PCP, the UW Health
Welcome Center will –
Work with you to transfer your medical records from your
previous health system
Gather your medical history
Discuss any chronic and / or preventive issues or needs
you may have
Help you schedule an appointment at the Welcome Center
clinic, if needed
Assist you with connecting to community resources if
needed
Note: PPO members please see page 27.
Look for a PCP who –
Is highly recommended by your friends, family
or co-workers
Has the training and background that meet your needs
Takes steps to help you prevent illness—for example, talks
to you about quitting smoking
Has admitting privileges at the hospital of your choice
Encourages you to ask questions
Listens to you
Explains things clearly so you can understand
Treats you with respect
MyChart
If you have a UW Health PCP, sign up for MyChart to view
portions of your health information, schedule appointments
and communicate with your primary care team. For more
information and to sign up, visit unitymychart.com.
How to Change Your PCP
You can change your PCP by logging into MyChart or calling
(800) 548-6489. If you receive care from UW Health, you can
also change your PCP at your clinic. The change will be
effective on that day unless you request a future date.
Note: If you do not notify Unity Customer Service before visiting a new PCP clinic,
you may have to pay for the services that you or a family member received.
Making an Appointment for Routine Care
Contact your PCP clinic when you need non-emergency
services (if you have a UW Health PCP you can schedule an
appointment through MyChart). It is important each
member of your family works with his / her chosen PCP to
receive recommended preventive health care, routine
screenings and immunizations.
When calling your PCP or PCP clinic, keep in mind
you may be able to see a Nurse Practitioner (NP) or a
Physician’s Assistant (PA) instead of waiting for an
appointment with your PCP. NPs and PAs are licensed,
highly-qualified professional health care providers who
work in partnership with physicians. They are available to
assist you with physical exams, urgent or problem visits
and follow-up of ongoing health care.
Always show your member ID card to the office staff when
you arrive at your appointment.
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After-Hours Clinic Care
If you need medical attention after your primary care clinic’s
normal business hours, call your primary care clinic. Follow
the instructions provided by the clinic’s messaging system
(even when you are outside the service area). In a medical
emergency, go to the nearest emergency room.
Refer to page 15 for more information on urgent / emergent care.
Accessing Care Away from Home
(Out-of-Area Care)
It is important you understand how to obtain health care
when you are away from home. We have separated it into
two categories: emergency and urgent care and routine
specialty care.
The information on pages 15 and 16 will help you
understand the process for obtaining emergency and urgent
care. Please follow this process whenever you feel you are in
need of emergency or urgent care, whether you are near your
home, away at school or on vacation.
Routine, follow-up and specialty care should always be
obtained when you arrive home. Listed below are some
common situations and what you need to know to correctly
obtain care –
Specialty care as follow-up after an emergency or urgent
care admission – All care received as follow-up to an
emergency or urgent care admission must be provided by
or arranged by your PCP or participating specialist. See
page 16 for more information.
Vacation – When on vacation you may need to access
emergency or urgent care. You should follow the steps
on page 15 and 16. Follow-up appointments after
emergency or urgent care and other routine / preventive
care must be obtained from your PCP or from a
participating specialist.
Students away at school – If your child is a covered
dependent living away from home while attending school,
that child can obtain emergency or urgent care, as needed,
where his / her school is located. HMO subscribers who
have dependents that are full-time students over age 18
attending post secondary school outside of the Unity
Health Insurance service area can receive coverage for
non-emergency and non-urgent care that is medically
necessary and prior authorized. All non-emergent care
must be prior authorized through Unity Medical
Management at (888) 829-5687 before care is received in
order for services to be covered. For covered services,
Unity will pay non-participating providers located outside
Unity’s service area 50 percent of usual, customary and
reasonable charges, as determined by Unity, up to the
maximum benefits stated on the Schedule of Benefits.
Note: The enhanced HMO benefit for full-time students is not available to
State of Wisconsin and Local Government Participants.
Winter away from home – Many Unity members spend
several of the winter months in a warmer climate. While
you can obtain emergency or urgent care at your winter
destination as needed, you must obtain routine and
follow-up care from your PCP or a participating specialist.
If you are planning extensive travel, you should speak with
your PCP to discuss how to obtain necessary medical care
while you are away.
It is important you are aware of the specialists and facilities
that are “participating” for you and each member of your
family so you can correctly obtain routine and follow-up care
as necessary. Please refer to unityhealth.com/findadoctor or
the front of your provider directory for more information
about the providers available to you. Out-of-area care is
limited to usual, customary and reasonable charges.
POS and PPO members should see pages 25 – 27 to
understand how their benefits will pay if they obtain routine,
specialty or follow-up care from a provider that is not
participating under their Unity plan.
Well-Child Care
Your child’s health and well-being are assessed during wellchild exams. In addition, this is a time to discuss disease
prevention and health care promotion with your child’s
PCP. This includes age appropriate immunizations that
are a good way to prevent many diseases which can affect
young children and adolescents. Children should receive
vaccinations according to the recommended schedule in the
Preventive Health Care Guideline. The Preventive Health
Care Guideline is reviewed at least every two years and can
be viewed and printed at unityhealth.com/preventive. You
can also request a paper copy by calling (800) 548-6489.
unityhealth.com
11
Accessing Specialty Care
Specialty Care Services
Your PCP is responsible for providing primary care
services and for coordinating your health care needs.
In most cases, your PCP can provide the medical care you
need; however, when necessary, your PCP can also refer you
to a participating Unity specialist for specialty care. Unity
Health Insurance does not require HMO members to
receive a referral from their PCP prior to accessing specialty
care; however, it is beneficial to have a strong working
relationship with the PCP.
Out-of-plan referral requests will be reviewed only for
services that are not available from our participating providers.
Services are subject to medical necessity, all benefit maximums,
policy limitations and exclusions and eligibility requirements
and are covered up to usual, customary and reasonable
charges. For a description of your covered benefits, please
refer to your Policy documents.
Note: State of Wisconsin and Local Government Participants should refer to the
It’s Your Choice materials for more information.
For hospital services, your admitting physician must contact
Unity for approval and prior authorization. For elective or
planned hospital services, you must use a participating
hospital. Contact Customer Service to see if your plan
requires Prior Authorization.
Note: If you are a POS or PPO member, see pages 25 – 27.
12 unityhealth.com
Procedures and Equipment Requiring
Prior Authorization
Some medical procedures and equipment require Prior
Authorization. This means that in order for the procedures
or equipment to be covered, your physician must obtain
approval from Unity.
On the next page you will find a list of categories requiring
Prior Authorization. For a complete list of services that require
Prior Authorization, please visit unityhealth.com/priorauth
or contact Unity Customer Service.
Note: POS members are responsible for obtaining Prior Authorization for
services received from an out-of-network provider. PPO members, please visit
unityhealth.com to see what services require Prior Authorization under your plan.
Please note: The procedures and equipment requiring prior authorization may
not be covered benefits under your health insurance plan.
Members will need Prior Authorization
(PA) for procedures that fall into these
categories –
Cosmetic procedures
Durable Medical Equipment
Experimental and Investigational Treatments
Genetic Testing including Pharmacogenetics Testing
Home Health Care including home infusion services
Hospice Care
Inpatient Admissions
Out-of-Network services or supplies
Pharmacy / Medications
Surgical Procedures
Therapies
Other Therapies
TMJ Surgical Treatment
Transplants
Uvulopalatopharyngoplasty / Somnoplasty /
Uvulectomy LAUP – Laser assisted
uvulopalatopharyngoplasty / somnoplasty
Warm Water Therapy
X Stop Interspinous Implant
See a full list at unityhealth.com/priorauth
Pharmacy Prior Authorization is required for
some clinic-administered injectable medications.
Visit unityhealth.com/priorauth for the list.
Dental / Oral Surgery, Optometric,
Chiropractic and OB / GYN
Review your Schedule of Benefits (SOB) or Summary
of Benefits and Coverage (SBC) for specific coverage
information for these services or contact Customer Service.
If you have coverage, simply contact a participating provider
to schedule an appointment. Although referrals are not
necessary for these services, all benefits are subject to review
for medical necessity and to plan limitations and maximums
and certain provider limitations.
Members should review their Policy documents, as these services may not be
covered under all policies.
Behavioral (Mental Health / AODA)
Health Care Services
Unity Health Insurance members can seek services with a
participating mental health or alcohol and other drug abuse
(AODA) practitioner without a referral from their PCP.
Unity’s network includes psychiatrists, psychologists,
licensed clinical social workers, licensed professional
counselors, certified addiction counselors and specialty
facilities to meet your behavioral health care needs.
Note: There are certain practitioner limitations for mental health or AODA
services.
Members in need of behavioral (mental health care / AODA)
health care services can call UW Health – Behavioral Health
Care Management at (800) 683-2300 for assistance in getting
an appointment with a behavioral health practitioner.
UW Health – Behavioral Health Care Management
connects you with staff who will determine the correct type
of behavioral health practitioner who can best meet your
needs and will assist you in getting an appointment in a
timely manner.
unityhealth.com 13
For emergency care that is life threatening, please call 911.
If your need is not life threatening and you have a behavioral
health provider, please call your provider’s office. They will
assist you. If do not have a behavioral health provider please
call UW Health – Behavioral Health Care Management at
(800) 683-2300 for assistance.
Maternity Care
Good prenatal care is important for you and your baby.
Services for prenatal care, delivery and postpartum care are
provided while you are a Unity member according to the
terms of your policy.
PCPs provide a full range of care, including prenatal and
postpartum care. Your PCP can confirm your pregnancy
and will advise you on the prenatal and postpartum care you
need. You may also see a participating OB / GYN specialist,
but an authorization may be required for OB / GYN services
in specific circumstances.
14 unityhealth.com
Enroll in 9 Months & More, the Unity Health Insurance
prenatal and postpartum program, to receive educational
materials and guidance throughout your pregnancy and the
delivery of your baby. As part of the program you can sign
up for text4Baby, a free mobile information service that
provides pregnant women and new moms with information
to help them care for their health and give their babies the
best possible start to life. For more information, visit
unityhealth.com/pregnancy.
Hospital Care
You or a family member may require care and services
in a hospital setting for non-emergency (elective / planned)
surgery, treatment or tests. For elective or planned hospital
services, you must use a hospital that participates in Unity’s
network. For all elective or planned hospital services, the
admitting physician must obtain Prior Authorization from
Unity for your hospital admission and stay.
Note: If you are a POS or PPO member, see pages 25-27.
Accessing Urgent and Emergency Care Services
Urgent Care Services
When You Need Urgent Care
Some medical problems are not life-threatening but do need
prompt attention. These include –
Most broken bones
Sprains
Minor cuts
Minor burns
Non-severe bleeding
Ear infections
1. Contact your PCP first. Your PCP will tell you how to get
appropriate care. Do this even when you are outside the
service area. (Unity Health Insurance requires all
participating PCPs to have 24-hour call coverage available
for you.)
Urgent Care Centers are not emergency rooms nor a
replacement for your PCP’s office.
Visit unityhealth.com/healthtopics to
check your symptoms to help you determine
if you need urgent or emergent care.
2. If your PCP tells you to seek care at an urgent care facility,
show your member ID card to the staff.
If you visit an Urgent Care Center, you will be responsible
for the urgent care copayment or any deductible (refer to
your Schedule of Benefits (SOB) or Summary of Benefits and
Coverage (SBC)). In addition to a copayment or deductible,
coverage for services received from an out-of-network
Urgent Care Center, may be limited to usual, customary and
reasonable charges. You should work with your PCP if you
need any follow-up care.
If your PCP tells you to seek services somewhere other than
at an urgent care facility, you will need an approved referral
from Unity, before you obtain care that is covered by Unity.
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Accessing Urgent and Emergency Care Services
Unity Health Insurance will consider payment for
out-of-area urgent care services if you experience a sudden
and unexpected illness or injury and all of the following
are true –
You urgently needed the care, AND
You could not have foreseen the need for care prior to
leaving the service area, AND
You did not specifically leave the service area to obtain
care, AND
You could not have delayed care until you were able to
return to the service area.
Your plan will not cover care provided by out-of-area
providers if you can safely return to the service area to obtain
the care needed. Contact your PCP for all follow-up care.
Note: If you are a POS or PPO member, see pages 25-27.
Emergency Care Services
An emergency medical condition is one that manifests itself
by acute symptoms of sufficient severity, including severe
pain, to lead a prudent layperson who possesses an average
knowledge of health and medicine to reasonably conclude
that a lack of immediate medical attention will likely result in
any one of the following –
Serious jeopardy to the person’s health or, with respect to a
pregnant woman, serious jeopardy to the health of the
woman or her unborn child.
Serious impairment to the person’s bodily functions.
Serious dysfunction of one or more of the person’s body
organs or parts.
Some examples of emergencies include
(but are not limited to) –
Heart attack
Stroke
Acute asthmatic attack
Acute hemorrhage (bleeding)
In these instances, seek emergency services at the nearest
emergency facility.
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What To Do In Case Of An Emergency
1. Go to the nearest hospital or call 911. (Whenever possible,
use a participating hospital.)
2. Have someone show your member ID card to the
emergency room hospital staff.
3. Notify your PCP of your emergency care. Your PCP will
help coordinate any necessary follow-up services.
If you visit an emergency room (ER), you will be responsible
for the ER copay or deductible (see your Schedule of Benefits
(SOB) or Summary of Benefits and Coverage (SBC)). You
may also have other charges such as lab and X-ray charges, as
the result of an ER or urgent care visit. Ambulance
transportation may be subject to a copayment or deductible
and coinsurance. Depending on your plan, coverage may be
limited to usual, customary and reasonable charges.
See your Policy documents for additional information.
Follow-Up Care for Urgent and Emergency
Care Services
Follow-up care is care you receive after the initial treatment
of the urgent or emergency condition. Follow-up care is
NOT urgent or emergency care. If an ER physician refers you
to a specialist for a follow-up visit, call your PCP before
seeing the specialist. Your PCP must provide or arrange for
your follow-up care. All follow-up care must be provided
within the Unity service area. Out-of-area referrals for HMO
members require Prior Authorization from your PCP and
approval by Unity.
Note: You may have some out-of-pocket expenses if you use an emergency
room or an urgent care facility. Refer to your Policy documents for a detailed
explanation of your benefits or contact Unity Customer Service. (If you are
a POS or PPO member, see pages 25-27.)
Pharmacy Benefits and Services
Prescription Drug Benefit
Prescription Drug Formulary
The next few pages contain information about the Unity
Health Insurance Prescription Drug Benefit. You should also
read the following documents, which provide detailed
information about Unity’s Prescription Drug Benefit –
The purpose of a formulary is to promote use of safe, effective
and cost-effective medications. A formulary is an important
tool to help Unity meet its goal of providing coverage for safe
and effective medications in an affordable manner.
Prescription Drug Benefit brochure
Unity’s formulary is made up of formulary medications,
a list of non-preferred medications and a list of restricted
medications.
Formulary medications are cost-effective drugs covered by
Unity.
Formulary medications can either be generics (Tier 1) or
brand (Tier 2)
Non-preferred medications are either Brand or Generics
and covered at Tier 3.
Non-preferred medications are those that have suitable
alternatives on the formulary or those that are considered
less effective or less safe for most patients.
Non-formulary – Medications that are not covered.
Restricted medications are those for which you must
obtain Prior Authorization from Unity before you can
receive coverage. Restricted medications may be preferred
or non-preferred.
Excluded medications are not listed on the formulary.
These are medications that your prescription benefit plan
specifically excludes from coverage. Examples of commonly
excluded medications include hair loss medications, sexual
dysfunction medications, most over-the-counter (OTC)
medications and cosmetic medications. Your specific benefit
exclusions are listed in the Exclusions section of your Unity
Prescription Drug Benefit Rider or your Certificate of
Coverage.
Unity’s Prescription Drug Formulary
Prescription Drug Benefit Rider
Some Unity groups and individual plans do not have a
prescription drug benefit. Refer to your new member
materials or contact Customer Service if you have questions
about your drug coverage.
Note: Pharmacy information does not apply to members covered under the State
of Wisconsin Health Benefits program or BadgerCare Plus members.
The Unity Health Insurance formulary
and a list of participating pharmacies are
available at unityhealth.com/pharmacy
unityhealth.com
17
How is the Formulary Developed?
Generic Drugs
The Unity Health Insurance Pharmacy & Therapeutics
(P&T) Committee is responsible for creating and
maintaining the prescription drug formulary. The committee
is made up of physicians and pharmacists who provide care
for Unity members in our community. The P&T Committee
meets monthly to review medications and determines the
formulary status and restriction status of each medication.
They consider a variety of factors such as safety, side effects,
drug interactions, how well the drug works, dosing schedule
and dose form, appropriate uses and cost-effectiveness. To
view the drug formulary, visit unityhealth.com/formulary.
A generic drug contains the same active ingredient (the
specific chemical ingredient that makes the drug work) as
the brand drug. It must have the same dosing and labeling
as the brand drug and must meet the same standards for
purity and quality. The United States Food and Drug
Administration (FDA) must approve generic drugs as
equivalent to the brand before allowing them to be marketed
as interchangeable. Because the FDA has determined the
generic to be equivalent, your pharmacist can dispense the
generic version of your medication without a new
prescription from your physician.
Medication Prior Authorization
Why Choose a Generic?
Some medications on Unity’s Prescription Drug
Formulary, as denoted with “PA”, require an approved
Prior Authorization prior to coverage through Unity.
To see which medications need Prior Authorization, refer
to Unity’s formulary. To request Prior Authorization,
members, providers or authorized representatives can send
request via the web, fax, mail or telephone. Unity strongly
recommends that you ask your health care practitioner to
initiate the prior authorization request process on your
behalf. This is because your healthcare practitioner will be
able to include the medical history necessary for us to make
a timely decision based on all of the relevant information.
Requests are reviewed by pharmacists based on criteria set
by the P&T Committee. You and your practitioner will
receive written notification of the decision. If your Prior
Authorization Request is approved, your copay will match
the formulary and brand / generic status of the drug. If
your Prior Authorization Request is denied, you will have
no coverage for the medication under your Unity
Prescription Drug Benefit.
Notifications for denials will include the reasons
for the denial
If you would like additional details about the reasons for
denial, you can call the UW Health Pharmacy Benefit
Management Program staff, who manages the pharmacy
program on behalf of Unity Health Insurance at
(888) 450-4884
You can still purchase the drug with a prescription, but
you will have no insurance coverage for the prescription
You can also discuss with your practitioner the
possibility of changing to another appropriate drug that
may be covered under your Unity Prescription Drug
Benefit. For more information, visit
unityhealth.com/priorauth
Why would you want to choose the generic drug over the
brand drug? By choosing a generic, you can save money
without losing quality. Generic drugs are not advertised or
marketed as much as brand drugs, so generic drugs usually
cost less. This allows you to get the generic at a lower copay.
18 unityhealth.com
Unity’s Generic Substitution Policy
Unity’s Generic Substitution Policy states that when FDA
approved equivalent generics are available, coverage of the
brand product is only provided with an approved Prior
Authorization.
If the active ingredient is on the formulary, coverage for
the generic is provided at the Tier 1 copay
If a Prior Authorization has been approved, coverage for
the brand is provided at the Tier 3 copay
A trial of a preferred therapeutic alternative may be
required before approval of brand name product with a
generic equivalent
If your prescription is written for the brand drug, with
your permission, your pharmacist can dispense the
equivalent generic product without a new prescription.
The purpose of this policy is to ensure you receive an
effective drug at the lowest cost
Certain drugs on Unity’s Prescription Drug Formulary are
exempt from the Generic Substitution Policy since even
slight differences between brands or brands and generics
could cause differences in the effect of the drug. These
medications are sometimes called Narrow Therapeutic Index
medications. To see which medications are exempt from the
generic substitution policy, refer to Unity’s Prescription Drug
Formulary. Drugs denoted with “NTI” are exempt.
Vacation Supply of Drugs
Emergency Drug Supply
Members who are planning to travel should ensure they have
adequate supplies of their medications while they are
traveling.
There are three ways to make sure you have what
you need –
If you have an urgent need for medication that requires a
Prior Authorization and you need the medication before
the Prior Authorization can be reviewed, your pharmacy
can contact Pharmacy Services at (800) 788-2949 to receive
coverage for a five-day emergency supply of that medication.
1. Call Pharmacy Services at (800) 788-2949 to receive
approval for coverage for an extra 30-day supply to take
with you. (Applicable copays apply.)
For more information on the emergency drug supply, visit
unityhealth.com/pharmacy and select Pharmacy Programs
and Policies.
2. Make arrangements with your local pharmacy to send your
medications to wherever you’ll be staying when they are
needed.
New Member Drug Supply
3. Go to a Unity Health Insurance participating pharmacy
located where you’re staying. Unity has a national network
of participating pharmacies from which you can receive
medications. Use Unity’s Find a Pharmacy tool at
unityhealth.com/findapharmacy or contact Unity
Pharmacy Services for help identifying participating
pharmacies in the area where you’re traveling. To receive
your prescription at one of these national pharmacies, you
need to call ahead and provide the chosen pharmacy with
the name and phone number of the pharmacy where you
last filled the prescription so they can call and transfer the
remaining refills.
Step Therapy Program
Certain medical conditions can be treated using a variety of
medications. In some cases, there is a very large difference in
cost among the medications, but a very small difference in
the way the medications work.
Unity’s Step Therapy Program is approved by the P&T
Committee and requires a member to try the more costeffective medications before receiving coverage for (or
“stepping up to”) the more expensive medications. Many
members find the first medication very effective and never
need to step up.
For more information about Unity's Step Therapy Program,
unityhealth.com/pharmacy and select Pharmacy Programs
and Policies.
Members new to Unity may be taking medications that
require Prior Authorization for coverage. New members
may also be in the process of identifying and making
appointments with new primary care physicians.
To assist in making this transition, Unity provides new
members with coverage for up to 90 days (in 30 day
increments at the usual copayment) of their current
medications that usually require Prior Authorization.
When the 90 days is complete, a Prior Authorization is
required before the member can receive additional coverage.
To request a “New Member Override,” you or your
pharmacy can contact Unity Pharmacy Services at
(800) 788-2949 within the first 90 days of being a Unity
member.
Choice90 Extended Supply Program
Choice90, a convenient option for your prescription
maintenance medications.
Choice90 makes it easy to make sure you have a supply of the
medicine you take most often. You can get a 90-day supply
of certain medicines from your local pharmacy. Unity offers
a Choice90 program to allow for coverage of a 90-day supply
of selected medications, which differs from typical mail-order
pharmacy programs. Most pharmacies in Unity’s Wisconsin
pharmacy network participate in the Choice90 program.
This program offers greater flexibility and expands pharmacy
choices in Wisconsin to include more than 1,000 pharmacies.
unityhealth.com 19
Your medicine may be covered in the Choice90 program if –
The medication is considered to be a maintenance
medication in national databases
You have been on the same medication at the same dose
for the past 90 days
The medication does not cost more than a certain dollar
amount for a 90-day supply
You will keep your coverage with Unity Health Insurance
for the next 90 days
All other benefit requirements have been met* (restrictions
and exclusions apply)
* The program is not available for Unity members with drug coverage
through Navitus or BadgerCare Plus or those who do not have a drug benefit.
Medications that are excluded from coverage are not eligible for Choice90.
Medications that require Prior Authorization must have a valid prior
authorization in place before Choice90 will process.
For more information about the Choice90 Program, visit
unityhealth.com/choice90.
Specialty Pharmaceuticals Program
Medications denoted by “SP” are required to be obtained
from a pharmacy participating in the Unity Specialty
Pharmaceuticals Program for coverage through Unity.
The UW Health Pharmacy is currently participating in the
Unity Specialty Pharmaceuticals Program. Once you have an
approved prior authorization for the medication, you can
contact the UW Health Pharmacy at (866) 894-3784 to make
arrangements for receiving the medication (by mail or pickup at one of the pharmacy locations). Because of the types of
medications dispensed in the Specialty Program, additional
contact with Specialty Pharmacists are included as part of
the program.
For more information about the Specialty Pharmaceuticals
Program, visit unityhealth.com/pharmacy and select
Pharmacy Programs and Policies.
Half-Tab Program
Unity’s Half-Tab Program is designed to help maintain
the affordability of prescription drug benefits while
providing coverage for the same high quality medications.
The program is completely voluntary and it decreases your
copayment by half for certain medications when you split a
higher strength tablet in half and take half a tablet daily for
the same total daily dosage. Medications denoted by “H”
on the formulary are eligible for the Half-Tab Program.
For more information about Unity’s Half-Tab Program,
visit unityhealth.com/pharmacy and select Pharmacy
Programs and Policies.
RX Outcomes
Unity’s RX Outcomes benefit provides a lower copay for
selected medications on a Value Tier that have a greater
impact on medical outcomes. Medications included in the
Value Tier are in a special category that provides an incentive
for staying on therapy by reducing the copayment to five
dollars. Medications in the Value Tier are noted by an
asterisk* on the formulary listing. For more information,
visit unityhealth.com/pharmacy and select Pharmacy
Programs and Policies.
Refill Policies
Time to Refill
For maintenance medications, Unity requires that 75 percent
of the supply of a medication be used before providing
coverage for refills. This means that approximately three
weeks must elapse after receiving a four-week supply of
medications before you are eligible for coverage of a refill.
Refill Too Soon
If you need a refill of your medication earlier than usual
because your practitioner has modified your dosage,
your pharmacy may contact Unity Pharmacy Services at
(800) 788-2949 for a “Refill Too Soon” authorization.
For more information about your pharmacy benefits
and services including important phone numbers to
call, visit unityhealth.com/pharmacy.
20 unityhealth.com
Medical and Complex Case Management
Guidelines for Care
Unity carefully reviews treatment plans and requests
submitted by participating practitioners. This process of
medical management—sometimes called care management
or utilization management—is conducted by nurses with the
support of physicians. This process also helps ensure
expensive services are not overused so health care can remain
affordable for everyone.
Medical management staff work with your PCP to
coordinate your care at three stages –
Pre-service review – before you receive care or services
Concurrent review – while care or services are being
provided
Post-service review – after care or services have been
provided
The care recommended for you by your health care
practitioner is compared to your member certificate and / or
nationally, scientifically based care criteria. These criteria,
developed and refined with input from hundreds of
physicians and applied in the cases of thousands of patients,
involve review of your condition and symptoms to identify
the treatment strategies which are most likely to be beneficial
to you. The criteria are further subjected to a thorough
annual review by physicians and other medical experts in
our own community and are modified as necessary to meet
local needs.
The provisions of your member certificate and the
guideline-based system eliminates reviewer subjectivity and
guides decisions about clinical appropriateness that support
cost-effective, appropriate level of care decisions. The medical
management teams can provide you with copies of the care
guidelines and specific criteria used to make our decisions
upon request. You may request the guideline criteria by
contacting the appropriate medical management team.
UW Health (UWMF) Medical Management
(888) 829-5687 for medical coverage determinations
(800) 683-2300 for behavioral health and substance abuse
coverage determinations
unityhealth.com
21
Medical and Complex Case Management
The guideline / criteria show how health care providers
across the United States are practicing. They are supported
by evidence-based clinical care and are not considered
financially-derived utilization controls. Unity Health
Insurance monitors the utilization management (UM)
decision-making processes to ensure appropriate utilization
and prevent inappropriate denials. In addition, Unity’s
Utilization Management / Technology Assessment Committee
(UM / TAC) consists of plan physicians who oversee
UM activities.
Unity’s participating physicians and medical management
staff make utilization management decisions based only on
the appropriateness of care and service and the existence of
coverage. Unity does not specifically reward practitioners or
other individuals for issuing denials of coverage. Financial
incentives for utilization management decision makers do
not encourage decisions that result in the under-utilization
of health care services.
Medical management staff and the behavioral health
groups are available at least eight hours a day during normal
business hours to receive and return calls regarding medical
management issues. After normal business hours, calls are
answered by an answering machine or service and are
returned the next business day. Staff members identify
themselves by name, title and organization when receiving
or returning calls relating to medical management issues.
A toll-free number is also available to accept and address
medical management concerns. The numbers to call are –
UW Medical Foundation
(608) 821-4200 (Local)
(888) 829-5687 (Toll-free)
(608) 282-8270 (Local)
(800) 683-2300 (Toll-free)
(608) 643-2491 (Local)
(800) 362-3309 (Toll-free)
22 unityhealth.com
Complex Case Management
Unity Health Insurance will coordinate services for members
with a serious, complicated medical problem or a diagnosis
that requires an extensive use of resources. Our team of
nurses, social workers and licensed professional counselors
work with you and your health care team to coordinate care.
They navigate the health system and community resources,
connecting you to services to best meet your needs. Our goal
is to help you regain optimum health or improve your health
to the greatest degree possible.
The case manager will interview you and work with you to set
goals important to you. Unity’s case management staff, located
in the UW Health Patient Resources Department, may become
involved with you based on your / family request, a request by
your doctor / health team or if we receive notification that
you have had a critical event or a diagnosis for a complicated
problem. To contact us, please call (608) 821-4819 or email
[email protected]. You may also complete the
form online at unityhealth.com/complexcase.
Claims and Payment Information
Claims Submission
Sometimes a participating provider may bill you by
mistake even though we ask them to bill us directly.
If you believe you have received a bill in error, please
contact Customer Service.
It may be necessary for you to submit a claim if you receive
services from an out-of-network provider. To do this, you
must complete the member claim form which can be found
by going to unityhealth.com/memberforms. Send Unity
Health Insurance this form along with an itemized bill with
a receipt to show payment within 90 days from the date the
services were provided. The itemized bill should include –
Member Name
Date of Birth
Date of Service
Diagnosis Codes (if applicable)
Procedure Codes (if applicable)
Billing Amount
Provider Name and Address
(If you are a PPO member, see page 27.)
Unity recognizes that circumstances beyond your control
may not allow you to submit the claim within 90 days. If this
is the case, we will process your claim if you submit it within
the next 12 months.
If you receive medical care in another country, you must
provide an English translation of the claim and include
supporting documentation so that we can process the claim.
Keep copies of this information and send the originals to us.
If you receive a statement from a provider indicating the
provider has filed a claim with Unity, you do not have to do
anything. Unity will process the claim. Keep the statement
for your records. Claims for reimbursement of prescription
medicines should include the information previously listed
(except diagnosis and procedure codes), as well as the
following information –
Name of the medication
Quantity of the medication
ID number of the medication (NDC)
ID number of the pharmacy (NABP)
ID number of the practitioner prescribing the
medication (DEA)
You can usually find this information on the receipt you
received from the pharmacy.
You can also fill out a Prescription Claim Form by going to
unityhealth.com/memberforms.
unityhealth.com 23
Claims and Payment Information
Unity Health Insurance generally processes claims within 30
days after the provider has submitted complete information.
For pharmacy-related claims or questions, call our pharmacy
services representatives directly at (800) 788-2949. They are
available 24 hours / day, seven days / week.
Out-of-Pocket Expenses
You may have to pay some costs when you receive
covered medical or pharmacy services. These costs are
called “out-of-pocket expenses.” They include –
Copayment (“Copay”) – A fixed dollar amount you
are responsible for paying to the practitioner, facility
or pharmacy when you receive medical services.
Coinsurance – The percentage of the fee for a service
for which you are responsible, as listed in your Schedule
of Benefits (SOB) or Summary of Benefits and Coverage
(SBC). Coinsurance amounts apply after any deductible
is satisfied.
Deductible – A fixed amount of money a member or
family must pay before Unity will make a payment
toward a covered service.
Usual, Customary and Reasonable – The amount
covered by Unity based upon the customary charges of
all providers within a given geographic area for the same
or similar service.
Fee Schedule – The maximum amount of money Unity
will reimburse non-contracted PCPs, specialists and
hospitals for covered services rendered to My Choice
members.
You are responsible to pay for services excluded under your
Unity insurance plan. Review your Policy documents for a
description of excluded services or call Unity Customer
Service.
State of Wisconsin and Local Government Participants should refer to the It’s
Your Choice materials for a list of excluded services.
24 unityhealth.com
If you have out-of-pocket expenses, Unity provides you with an
Explanation of Benefits (EOB) that explains the amount that is
your responsibility to pay to the provider. An EOB is not a
bill—the provider who performed the service will send you a
bill. For confidentiality purposes, Unity mails an EOB to the
family member who received the service (i.e., your child will
receive an EOB in his / her name). EOBs will not be mailed
when the out-of-pocket expense is only a copayment. If you
receive EOBs electronically, you will receive EOBs for your
dependents under 12.
To receive your EOBs electronically, simply request a
MyChart account at unitymychart.com. All members 18
and older should have their own account. You can send a
message to Unity Customer Service through the message
center within MyChart to obtain a copy of a claim profile
for any family member. This profile includes –
Date(s) of service
Provider’s name
• Amount of claim(s)
• Amount(s) paid by Unity
• Any copay / deductible amounts for which the member
is responsible
Profiles will be sent in separate envelopes addressed to the
particular person whose profile is requested.
Note: If you are a POS or PPO member, see pages 25 – 27.
Information for POS Members
How Point-of-Service (POS) Plans Work
As a POS member, you can choose your level of flexibility and payment each time you seek medical care. You have a choice as
to whether you access health care services within or outside your network of providers. When you receive care from a provider
not listed in your network you are responsible for submitting a claim form to Unity Health Insurance within 90 days from the
date the services were received. We will still process your claim if you submit it within the next 12 months.
POS members must select or be assigned an in-network
Unity PCP. However, you are not required to seek services
with or through your PCP, although your PCP can help
ensure you receive coordinated health care.
Your health care services are subject to medical necessity,
all benefit maximums, policy limitations and exclusions
and eligibility requirements. If you receive services from
out-of-network providers, coverage may be limited to
usual, customary and reasonable charges.
You must notify Unity of any inpatient services you receive
from an out-of-plan provider; failure to inform Unity may
result in a financial penalty.
Not all services are covered when they are performed by an
out-of-plan provider. In addition, some services require Prior
Authorization when performed by an out-of-plan provider;
failure to receive the necessary Prior Authorization may result
in a monetary penalty. Review your Policy documents for
more information.
unityhealth.com 25
Information for POS Members
POS Member Information
The POS plan is a Point-of-Service product. This means the amount of coverage you receive depends on the “point” at
which you access care. You will receive the highest level of coverage (In-Plan level) by utilizing in-network practitioners
and providers. “Participating” for POS members refers to the practitioners and providers available to you based on
unityhealth.com/findadoctor with the exception of certain specialty clinics if you have a PCP in Dane County (excluding
the communities of Cambridge and Mazomanie).
You have two ways to access care –
In-Plan
Out-of-Plan
In-network through your participating PCP
OR
Specialist available from your section at
unityhealth.com/findadoctor with the exception
of certain specialty clinics if you have a PCP in
Dane County (excluding the communities
of Cambridge and Mazomanie)
Certain specialty clinics within Unity’s
provider network that are not available to you
if you have a PCP in Dane County (excluding the
communities of Cambridge and Mazomanie)
OR
Provider not listed in the directory or
at unityhealth.com/findadoctor
Provides preventive and primary care services
Provides preventive and primary care services
Coordinates specialty care and hospitalization
prior authorization for you
Coordinates specialty care and hospitalization
prior authorization for you
You receive the highest level of benefit
coverage available under your plan
You contribute more toward
your health care costs
In-Plan – You seek care from your participating
PCP or from any specialist available to you based on
unityhealth.com/findadoctor with the exception of certain
specialty clinics if you have a PCP in Dane County (excluding
the communities of Cambridge and Mazomanie).
26 unityhealth.com
Out-of-Plan – You receive services from a provider who is
not part of the Unity Health Insurance provider network or
from certain specialty clinics if you have a PCP in Dane
County (excluding the communities of Cambridge and
Mazomanie).
Information for PPO Members
How the Preferred Provider Organization (PPO) Plan Works
As a PPO member, you have access to a wide variety of providers. Unity Health Insurance contracts with HealthEOS and
PHCS (Multiplan), preferred provider organizations, to serve as the provider network. HealthEOS providers include hospitals,
clinics and physicians throughout Wisconsin. PHCS (Multiplan) includes providers throughout the United States.
HealthEOS and PHCS (Multiplan) providers can be found at unityhealth.com/findadoctor. You have a choice to either
access participating providers or providers outside the network. If you receive care from an in-network provider, the
provider will submit the claim on your behalf. When you receive care from an out-of-network provider, you are responsible for
submitting a claim form to HealthEOS or PHCS (MultiPlan) within three months from the date the services were received.
PPO Member Information
The PPO plan offers two different benefit levels –
In-Network – You obtain services from providers in the
HealthEOS or PHCS (Multiplan) networks. You receive the
highest level of coverage (In-Network) when you see
participating providers.
Out-of-Network – You receive services from providers
outside the HealthEOS and PHCS (Multiplan) networks.
Your health care services are subject to medical necessity,
all benefit maximums, policy limitations and exclusions and
eligibility requirements. Coverage for services received from
out-of-network providers may be limited to usual, customary
and reasonable charges.
Not all services are covered when they are performed
by an Out-of-Network provider. In addition, some services
require Prior Authorization. Failure to receive the
necessary Prior Authorization will result in a monetary
penalty. Review your Certificate of Coverage for more
information.
unityhealth.com 27
Member Rights and Responsibilities
Special Needs
Unity Health Insurance is dedicated to assisting you in
locating practitioners able to meet your special care
needs. We encourage you to contact Customer Service at
(800) 362-3310 regarding your special care needs. Your
request will then be assessed by the appropriate staff.
Unity also provides interpretation services in other
languages for members.
Complaints and Grievance Resolution
Unity is dedicated to providing quality service to its
members. To continuously improve care and services,
Unity looks to you for comments or suggestions.
There may be a time when you have a complaint or concern
regarding Unity benefits or service. As a member, you have
the right to voice a complaint or appeal a decision made by
Unity and to receive a prompt and fair review.
If you have a complaint you would like addressed, please
contact Unity Customer Service at (800) 362-3310. Unity’s
customer service representatives are dedicated to resolving
your complaint in a timely fashion. If Unity Customer
Service is unable to resolve your complaint, a member
advocate will assist you.
Unity’s grievance process includes a comprehensive review
of your grievance by a member advocate and review by
qualified medical personnel and the Reconsideration
Committee when needed.
28 unityhealth.com
The Reconsideration Committee was established to assure
you receive all the benefits your contract entitles you to as
well as a fair and impartial hearing of your grievance. This
committee also provides you the opportunity to share
information concerning your grievance in person.
For certain types of claims, you are entitled to request an
independent, external review of the Unity Health Insurance
decision. For details please see your Certificate of Coverage.
If your claim is not eligible for independent external review
but you still disagree with a denial, your state insurance
regulator may be able to help to resolve the dispute.
For questions about your rights or for assistance, you can
contact –
Office of the Commissioner of Insurance
PO Box 7873
Madison WI 53707-7873
Fax: (608) 264-8115
Phone: (800) 236-8517 or (608) 266-0103
Email: [email protected]
Or, if coverage is group health plan coverage the Employee
Benefits Security Administration at (866) 444-EBSA (3272).
For more information about your appeal rights, visit
unityhealth.com/appeals.
Unity is dedicated to providing quality customer service and
access to quality health care. Problems can be solved only
when they have been identified. We thank you in advance
for your cooperation.
Confidentiality and Privacy Policies
The following is a brief summary about how Unity
uses and protects member information. For additional
information see Unity’s Notice of Privacy Practices at
unityhealth.com/privacy.
General Policy
Unity has policies and procedures designed to safeguard
the confidentiality of personally identifiable member
information. These policies and procedures establish
guidelines for the proper handling of records and
information used to administer health plan benefits.
When responding to a request for information, Unity’s
policy is to release only the information necessary to
respond to the request.
Authorization for Release of Information
Unity does not need authorization to obtain or disclose
member information for treatment, payment or health
care operations. For other purposes, Unity will ask the
member to sign an authorization form that gives permission
to release the information.
Authorization must be obtained when information is to be
used for the following purposes –
Release of information to a family member, power of
attorney, employer or lawyer
Release of information that could result in another
company contacting you for marketing purposes
Release of information for research (if the disclosure
includes personally identifiable member information)
In instances where a member is unable to provide necessary
authorization, Unity may require a valid court order or other
written proof of legal authority prior to releasing information.
Member Access to Medical Records
Unity does not maintain original medical records.
Members may access their medical records by contacting
their practitioner’s office or the provider of care (such as
a hospital). Members must follow the practitioner’s or
provider’s procedures for accessing medical information.
Member Access to Unity Records
Members may request access to their Unity records, such
as claim and billing information. Unity requires members
to complete a written request for access. Members can call
Unity Customer Service at (800) 362-3310 to request a copy
of the written request form and learn more.
Disclosure of Information to Employers
Unity provides certain types of information to employers
as part of standard health insurance processes. Disclosure
of information to employers is limited to summary health
information or the information the employer needs to
administer the health plan, depending how your employer
has chosen to administer their health benefit plan. However,
employers must agree not to use the information to make
employment-related decisions (for example, promotion,
hiring, lay-off) or to administer other benefit plans (for
example, life and disability plans). The employer must
identify persons or positions that may have access to the
information and must ensure there are measures in place
to prevent unauthorized access.
Note: If you are covered by a Unity individual plan, we do not release information
to your employer without a signed authorization from you.
unityhealth.com
29
Take a moment to review your Member Rights and Responsibilities so you can continue to take a more active
role in managing your family’s health care –
Member Rights
Member Responsibilities
To choose: Members have the right to choose a personal
physician from the Unity Health Insurance network of
Primary Care Physicians (PCPs).
To choose a personal physician: Members have a
responsibility to choose a personal physician from among
Unity’s network of PCPs and to establish a relationship
with that physician.
To obtain information: Members have the right to
receive information about their rights and responsibilities
as a member of Unity. Members have the right to make
recommendations regarding Unity’s Member Rights and
Responsibilities Statement. Members have the right to
obtain information about Unity and information relating
to covered and excluded health plan benefits. Members
have the right to obtain information on available primary
and specialty care practitioners and providers. Members
have the right to receive preventive care information and
information about their illnesses and treatment options.
Members have the right to obtain information about how
to file a complaint, appeal or grievance.
To have privacy and confidentiality: Members have the
right to privacy and confidentiality in communications
and records about their care.
To participate in their care: Members have the right to
be active in decisions about their treatments. Members
have the right to have a candid discussion of appropriate
or medically necessary treatment options for their
conditions, regardless of cost or benefit coverage.
Members have the right to obtain information about the
risks and benefits of treatment. Members also have the
right to refuse care.
To present a complaint, appeal or grievance: Members
have the right to voice concerns and to receive a prompt
and fair review of their concerns.
To be treated with respect and dignity: Members have
the right to be treated with respect and dignity regardless
of their race, age, gender, sexual orientation or creed.
30 unityhealth.com
To know their benefits and requirements: Members have
a responsibility to understand their health plan benefits
and limitations and to follow required procedures.
Members also have a responsibility to know how to
use Unity’s provider network and to ask questions about
things they do not understand.
To provide accurate information: Members have a
responsibility to provide accurate and complete
information about their health history, their eligibility,
and their enrollment. Members have a responsibility to
show their ID card each time they receive services and
to pay any out-of-pocket expenses they incur.
To participate in their care: Members have a
responsibility to participate in their care by asking
questions about their health. Members also have a
responsibility to follow the recommended and agreed
upon treatment plan for their illness and to make healthy
lifestyle choices to maintain their health or manage their
illness.
To keep their appointments: Members have a
responsibility to keep their appointments or to give
early notice if they must cancel.
To show consideration and respect: Members have a
responsibility to show consideration and respect to health
plan staff and health care providers.
Treatment Setting
Practitioners and providers are expected to implement
confidentiality policies and procedures that address the
disclosure of medical information, patient access to medical
information and the storage and protection of medical
information. Unity Health Insurance reviews practitioner
confidentiality processes during pre-contractual site visits for
primary care physicians and certain specialty care
practitioners.
Quality Improvement
Data for quality improvement measures are collected from
claims, pharmacy and member medical records. Unity
protects confidential information by reviewing records in
non-public areas and excluding member identifiable
information from written reports.
Opting Out of Information Sharing or Gathering
You may have received notices from other organizations
that allow you to “opt out” of certain disclosures. The most
common type of disclosure that applies to “opt outs” is
the disclosure of personal information to a non-affiliated
company so that company can market its products or
services to you. As a health plan, we must follow many
federal and state laws that prohibit us from making these
types of disclosures. Because we do not make disclosures that
apply to “opt outs,” it is not necessary for you to complete an
“opt out” form or take any action to restrict such disclosures.
Women’s Health and Cancer Rights Act
On October 21, 1998, Congress passed a law entitled the
“Women’s Health and Cancer Rights Act of 1998.” The Act
requires all health plans offering mastectomy coverage to also
provide benefits for the following services –
Reconstruction of the breast on which the mastectomy was
performed
Surgery and reconstruction of the other breast to produce
a symmetrical appearance
Prostheses and treatment of physical complications at all
stages of the mastectomy, including lymphedema
Unity provides breast reconstruction benefits consistent
with this law. Coverage for these services is subject to all of
the same limitations, exclusions and cost-sharing provisions
that apply generally to all other services provided under your
health insurance plan. The copayment and deductible
amounts that apply to your policy’s surgical benefit also
apply to the mastectomy and breast reconstruction benefits
outlined above. Please consult your Certificate of Coverage
and / or Schedule of Benefits or Summary of Benefits and
Coverage for specific information.
Questions about your health insurance benefits can be
directed to Unity Customer Service at (800) 362-3310.
The Unity Health Insurance privacy and confidentiality
policies protect member privacy and address the following
topics –
Routine use and disclosure of member health information
Use of authorizations for non-routine disclosure of
member health information
Procedures used to monitor access to information
Protection of information disclosed to external entities
You may access Unity’s Notice of Privacy Practices online at
unityhealth.com/privacy. If you would prefer a printed copy,
please call Unity’s Privacy Official at (800) 362-3309, Ext.
1852 or email [email protected].
unityhealth.com
31
Quality Improvement Programs
Unity Health Insurance works to continuously improve
the products and services it offers. In addition, Unity
collaborates with its providers to improve the quality of care
you receive and measures your satisfaction with the services
it provided. Unity’s success depends on your satisfaction.
Visit unityhealth.com for more information on
the Unity Health Insurance quality initiatives.
NCQA Accreditation
Unity’s goal is to give members the kind of service they need
and deserve—excellent service. This means offering access to
physicians in many communities, rewarding members for
working out and getting fit, providing information to help
members make the most of their health plan benefits and
answering the phones quickly when members call.
In recognition of our ability to achieve our service goals,
Unity Health Insurance first became accredited by the
National Committee for Quality Assurance (NCQA) in 2002.
Since then, Unity has maintained an Excellent Accreditation.
NCQA is an independent, not-for-profit organization
dedicated to measuring the quality of America’s heath care.
The NCQA accreditation process is a nationally recognized
evaluation system that purchasers, regulators and consumers
can use to assess managed care plans. NCQA evaluates health
plans on more than 60 standards, which fall into five broad
categories –
Access and Service
Qualified Providers
Staying Healthy
Getting Better
Living with Illness
32 unityhealth.com
Quality Improvement Programs
Achieving an Excellent rating means Unity Health Insurance
meets or exceeds rigorous requirements for consumer
protection and quality improvement. NCQA accreditation
is a reflection of Unity’s ongoing collaborative efforts and
strong working relationship with its partner organizations.
It shows Unity is dedicated to maintaining partnerships that
are critical to the delivery of great health care.
treatments; however, your physician may decide a new
technology is medically necessary to treat your condition. In
this instance, your physician should contact Unity to request
a medical review and to obtain additional information about
the process. Unity’s Medical Director will begin a thorough
investigation. Unity’s Technology Assessment Committee,
made up of in-house resources and experts in the medical
field, will review the information.
HEDIS® Reporting
This process takes the following criteria into account when
reviewing new treatments or procedures –
If government agencies have approved the technology or
therapy for your specific disorder or condition
If studies show the therapy improves overall health and is
as good as other treatments
Whether or not benefits of the new treatment or procedure
are possible outside the research setting
Whether or not the new treatment or procedure is in the
testing stage or is part of a research study
®
HEDIS (pronounced hee-dis) stands for Healthcare
Effectiveness Data and Information Set. HEDIS® measures the
quality of care and service a health plan delivers. HEDIS® is a
set of 76 measures that health plans use to measure their
improvement from year to year. HEDIS® measures
performance in the following areas –
Member health and use of preventive services
Members’ ability to see the practitioners they need to see
Member satisfaction with services received from Unity and
medical care received from its providers
Members’ ability to achieve good health
Unity uses HEDIS® results to identify clinical areas needing
improvement. Programs to improve immunization rates and
breast and cervical cancer screenings rates are a few of
Unity’s preventive health projects. Unity also develops
programs to help members with chronic diseases, such as
asthma, diabetes and depression.
The National Committee for Quality Assurance (NCQA)
sponsors, supports and maintains HEDIS®.
* HEDIS® is a registered trademark of NCQA.
For specific information about NCQA, Unity’s results and HEDIS® results,
please visit www.ncqa.org.
Member Satisfaction
Unity identifies service areas needing improvement from
member surveys and calls received by Unity Customer
Service. Unity conducts monthly and annual member
surveys. Unity also documents member phone calls.
This information is used to identify opportunities to
improve service.
Evaluation of New Medical Technology
The health care industry changes rapidly. The medical
community develops new treatments and procedures
regularly. Unity reviews new medical technologies (which
includes new drugs) and new applications of existing
technology to ensure members receive safe and effective care.
Unity does not cover experimental or investigational
After the review, the Technology Assessment Committee
determines –
If the service or treatment is experimental and / or
investigational (as defined by Unity)
If it is medically necessary
If it is not excluded from coverage
The Technology Assessment Committee then makes a
decision regarding use of the experimental treatment or
procedure for your condition. Unity will notify the member
and his / her physician when a decision has been made.
Unity members have the right to file a grievance (see page
28). The outcome is used by doctors and nurses who serve on
Unity’s Utilization Management Committee as guidelines to
consider when they review future requests for coverage and
benefits.
Ensuring Quality Practitioners and Providers
Unity works to ensure participating practitioners and
providers are properly trained and licensed. This process
is called credentialing. Credentialing means gathering and
verifying information on a practitioner’s medical license,
education, hospital privileges and work experience. A
trained professional also conducts a site visit and medical
record review at PCP clinics and some specialty clinics.
Practitioners must be credentialed before they treat
Unity members. Credentialing is an important part of
Unity’s quality program.
unityhealth.com 33
Glossary of Commonly Used Managed Care Terms
Access – A patient’s ability to obtain medical care as determined by
factors such as the availability of medical services, his / her
acceptability, the location of health care facilities, transportation,
hours of operation and cost of care.
Ambulatory Care – Health services delivered on an outpatient
basis such as when a patient makes the trip to the doctor’s office or
surgical center for treatment.
Ancillary Care – Additional health care services performed, such as
lab work and x-rays.
Authorization – The approval of care, such as hospitalization; preauthorization may be required before admission takes place or care
is given by specialty care providers.
Behavioral Health – Diagnosis and treatment of mental health and
/ or substance abuse disorders.
Credentialing – Examination of a health care practitioner’s
qualifications to determine admittance into a participating provider
network or receipt of clinical privileges at a hospital.
Deductible – A fixed amount of money a member or family must
pay before Unity will make a payment toward a covered service.
Dependent – An individual who receives health insurance through
a spouse, parent or other family member.
Disease Management – Also called “Health Management” –
Helping members with an illness (usually chronic in nature)
maintain their highest quality of life and utilize their health care
resources in the best manner possible.
Dual Choice – The opportunity for a consumer within an employer
group to choose from two or more different arrangements for the
prepayment of health care services (usually a limited time each
benefit plan year).
Benefit – Specific health services provided to plan members as
described in the employer group or subscriber contract, which
could include primary care, hospitalization, outpatient care,
ambulatory or emergency services.
Eligible Employee – An employee who meets the requirements
specified within the employer group contract to qualify for health
benefit coverage.
Benefit Year – The 12-month period during which deductibles,
out-of-pocket expenses and limitations accumulate.
Employee Contribution – The portion of the insurance premium
paid by the employee for their health benefit coverage.
Capitation – A per-member, monthly payment to a provider that
covers contracted services and is paid in advance of its delivery.
Enrollment – The process by which a health plan signs up
individuals or groups as subscribers.
Care Management – The process whereby a health care
professional supervises the administration of medical or ancillary
services to a patient or plan member.
Fee-for-Service – Traditional provider reimbursement in which the
physician is paid according to the service performed (system used
by conventional indemnity insurers).
Certificate of Coverage – Member Certificate issued to the plan
subscriber of coverage which defines the benefits available to
members (usually through their employer group contract) and the
essential terms and conditions affecting eligibility, coverage
conditions and termination of coverage. For members covered
under the State of Wisconsin Health Insurance Program, the It’s
Your Choice materials contains the complete description of their
benefits.
Fee Schedule – The maximum amount of money Unity will
reimburse non-contracted PCPs, specialists and hospitals for
covered services rendered to My Choice members.
Claim – Information submitted by a provider or covered member
to establish that medical services were provided to a covered
member from which processing for payment to the provider or
covered member is made.
Coinsurance – The percentage of Unity’s fee for medical services
that are paid by the subscriber.
Complaint – An expression of dissatisfaction about an insurer, a
health benefit plan or an insurer’s participating providers that is
expressed to the insurer or the insured’s authorized representative.
Copayment – A fixed amount paid by the subscriber for each office
visit or pharmacy prescription filled.
Covered – See Benefit.
34 unityhealth.com
Formulary – A tool used by participating medical practitioners
and pharmacists that lists quality, effective, safe and affordable
prescription drugs covered by the health plan for those who have
drug coverage. A formulary assists physicians and pharmacists in
the management of drug solutions and promotes proper use of
prescription drugs.
Generic Drug – A chemically equivalent copy designed from a
brand-name drug whose patent has expired (typically less expensive
and sold under the common name).
Grievance – Any dissatisfaction with the provision of services or
claims practices of an insurer offering a health benefit plan or the
administration of a health benefit plan by the insurer that is
expressed in writing to the insured by or on behalf of an insured.
Glossary of Commonly Used Managed Care Terms
Group – A body of subscribers eligible for insurance by virtue of
some common identifying attribute, such as a common employer,
or a membership in a union, association or other organization.
Group Contract – The application and addenda, signed by both
the health plan and the group, which constitutes the agreement
regarding the benefits, exclusions and other conditions between the
health plan and the enrolling unit. (A contract is usually limited to
a 12-month period and subject to renewal thereafter.)
High Deductible Health Plan (HDHP) – A plan with federallydefined minimum deductible levels for single and family policies.
Health Insurance – A contractual relationship whereby an
insurance company (the insurer) agrees to reimburse the insured
for health care costs in exchange for a premium. The contract
(policy) generally stipulates the type of health care benefits covered
as well as costs to be reimbursed.
Health Maintenance Organization (HMO) – A form of health
insurance in which members prepay a premium for health services
and which generally includes a defined set of services made
available through a defined panel of physicians for enrollees at a
preset price. (For the member, it means reduced out-of-pocket costs
and limited paperwork.)
Hospital Affiliation – A contractual agreement between an HMO
and one or more hospitals whereby the participating hospital(s)
provide the hospital care benefits offered by the plan.
Health Savings Account (HSA) – A tax advantaged savings vehicle
subscribers can establish when they have a High Deductible Health
Plan.
Practitioner – An individual who supplies health care services, i.e.,
physician, psychologist, nurse practitioner.
Preferred Provider Organization (PPO) – A health insurance plan
in which members pay lower out-of-pocket costs when they receive
care from providers participating in the network.
Premium – A fixed periodic payment for insurance coverage. Also
referred to as “rate.”
Preventive Care – Health care emphasizing priorities for
prevention, early detection and early treatment of conditions,
generally including age appropriate physical examinations,
immunizations and well-person care.
Primary Care – Basic level of health care usually provided by
family practice physicians, general practice physicians, internal
medicine physicians, pediatricians, OB / GYN physicians and / or
geriatric physicians. Usually provided in clinic settings (emphasis is
on patient’s general health needs).
Preventive Services – Routine health care that includes screenings,
check-ups and patient counseling to prevent illnesses, disease or
other health problems.
Prior Authorization – Approval from a health plan that may be
required before you get a service or fill a prescription in order for
the service or prescription to be covered by your plan.
Provider – A supplier of health care services, i.e., pharmacies,
hospitals or other health care facilities that provide services to
members.
Inpatient – A patient admitted to a hospital who is receiving
services under the direction of a physician for at least 24 hours.
Schedule of Benefits (SOB) – A definition of health care benefits
specifically identified as available to the enrolled member which
includes the limit or degree of service that member is entitled to
receive based upon his or her contract with a health plan or insurer.
Medical Management – An integrated working relationship
between the managed care organization and the health care
providers whereby medical protocols are established for the delivery
of quality health care and the most positive clinical outcomes. Also
known as care management or utilization management.
Specialty Care – Health care services provided by medical
specialists who generally do not have the first contact with patients,
but instead are referred to them by primary care and family
physicians.
Member – One who is enrolled within a prepaid health program
for health services through an individual or group contract
(includes both subscribers and their enrolled dependents).
Subscriber – The eligible person in whose name a health insurance
contract or insurance policy is held.
Network – A defined group of providers, typically linked through
contractual arrangements, which supplies a full range of primary
and acute health care services.
Summary of Benefits and Coverage (SBC) or Schedule of
Benefits (SOB) – An easy-to-read summary that lets you make
apples-to-apples comparisons of costs and coverage between health
plans.
Out-of-Pocket Expense – Portion of health services or health costs
that must be paid for by the plan member, including deductibles,
copayments and coinsurance.
Usual, Customary and Reasonable (UCR) – The allowable dollar
amount for the same or similar services and supplies provided
by health care providers within a geographic area.
Outpatient – Services provided outside of a hospital, skilled
nursing facility or other health care institution at the time services
are accessed; or services provided at a health care facility but
without being kept for 24 hours.
Utilization Review – The process of evaluating the necessity,
appropriateness and efficiency of the use of medical services,
procedures and facilities.
unityhealth.com 35
In recognition of our ability to acheive our service goals,
Unity Health Insurance first became accredited by the
National Committee for Quality Assurance (NCQA) in 2002.
Since then, Unity has maintained an Excellent Accreditation.
See page 32 for more information.
Commercial
HMO and POS
840 Carolina Street
Sauk City, WI 53583
unityhealth.com
Unity Customer Service
(800) 362-3310
UH00248 (0416)
U N I T Y H E A LT H . C O M

Unity Member Guide - Unity Health Insurance

Transcription

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