Provider Manual hawk-i Community Plan

Transcription

Community Plan
2014 UnitedHealthcare hawk-i Iowa
Physician, Health Care Professional, Facility and Ancillary
Provider Manual
UHCCommunityPlan.com
Table of Contents
Welcome to UnitedHealthcare Community Plan.................................................................... 1
Key Contact Information........................................................................................................... 3
Identification Cards/Eligibility Verification............................................................................. 4
Administrative Functions.......................................................................................................... 5
Claims Billing Procedures....................................................................................................... 10
Reimbursement........................................................................................................................ 15
Member Cost Share Responsibility....................................................................................... 17
Provider e-Services.................................................................................................................. 19
Emergent and Urgent Services............................................................................................... 20
Credentialing............................................................................................................................. 23
Covered Benefits...................................................................................................................... 26
Coverage of Abortions............................................................................................................. 29
Member Rights and Responsibilities.................................................................................... 30
Care After Hours....................................................................................................................... 33
Health Services......................................................................................................................... 34
Prior Authorization Guidelines............................................................................................... 38
Referral Procedure................................................................................................................... 39
Medical Record Charting Standards...................................................................................... 40
Member Access and Availability............................................................................................ 42
Utilization Care Management Programs............................................................................... 45
Timing of Utilization Management Decisions...................................................................... 48
Medical Hospital Utilization Management........................................................................... 50
Care Management.................................................................................................................... 53
Disease Care Management..................................................................................................... 54
Preventive Health and Clinical Practice Guidelines............................................................ 55
Practitioner Education – Sanction Policy Summary............................................................ 58
Denied Payment Authorization Decisions............................................................................ 60
Quality Improvement................................................................................................................ 61
Member Complaint and Appeal Process.............................................................................. 65
Glossary of Terms..................................................................................................................... 66
Forms Appendix....................................................................................................................... 68
Welcome to UnitedHealthcare Community Plan
UnitedHealthcare Community Plan
(UnitedHealthcare), a division of UnitedHealth
Group, provides services to the Healthy and Well
Kids of Iowa hawk-i program under the brand
“UnitedHealthcare Community Plan”. This Provider
Manual contains information related to this specific
program. If you are also a network provider for
UnitedHealthcare commercial and Medicare
products, you can access those Administrative
Guides at UHCOnline.com.
If you have any questions about the information or
material in this manual or about any of our policies
or procedures, please do not hesitate to contact
Provider Services at 888-650-3462. This toll-free
number is conveniently located at the footer of
each page in this manual.
Healthy and Well Kids in Iowa hawk-i offers free or
low-cost health insurance for children under 19 years
old. UnitedHealthcare Community Plan partners
with the Iowa Department of Human Services to
participate in the hawk-i program across the state.
UnitedHealthcare is one of the participating health
plans that families can choose.
Important Information Regarding
the Use of This Guide
We greatly appreciate your participation in our
program and the care you provide to our members.
In the event of a conflict or inconsistency between
your state Regulatory requirements and this manual,
the provisions of the regulatory requirements will
control, except with regard to benefit contracts
outside the scope of that Regulatory requirement.
This manual is designed as a comprehensive
reference source for the information you and
your staff need to conduct your interactions and
transactions with us in the quickest and most
efficient manner possible. Much of this material,
as well as periodic updates and some additional
electronic tools, is available on our website
at UHCCommunityPlan.com.
Additionally, in the event of a conflict or inconsistency
between your contract and this manual, the provisions
of your contract will control except for State of Iowa or
Centers for Medicare and Medicaid Services (CMS)
required language for provider contracts.
Communications to Providers
Our goal is to ensure that our members have
convenient access to high-quality care provided
according to the most current and efficacious
treatment protocols available. We are committed
to working with and supporting you and your staff
to achieve the best possible health outcomes for
our members.
UnitedHealthcare Community Plan Provider Manual 2/14
From time to time, there may be important
information about policies and protocols that must
be communicated to all participating providers.
These communications may be done through
Network Bulletins or through the Practice Matters
Provider Newsletter. If the information communicated
through these methods is a change to any protocol
set forth in this Manual, you will see the updated
information in this Manual upon the next provider
manual revision notification.
1
UnitedHealthcare hawk-i provider services: 888-650-3462
Network Bulletin – The Network Bulletin is a
bimonthly publication (6 times a year) posted to
UHCOnline.com. This bulletin contains information
and updates as well as administrative changes for all
providers, not just Medicare, Medicaid, and CHIP.
Articles located in this bulletin that are specific to
hawk-i providers will also be communicated through
the Provider Newsletter called Practice Matters.
Practice Matters – Practice Matters is the Provider
Newsletter published quarterly specific to the hawk-i
product within UnitedHealthcare Community Plan.
This newsletter includes any policy changes and
communicates any clinical topics or reminders.
Articles regarding policy or administrative updates
will be included in this publication but may also be
found in the Network Bulletin as specified above.
The Practice Matters newsletters are posted on the
UHCCommunityPlan.com provider website. They can
be found at: http://www.UHCCommunityPlan.com/
health-professionals/IA/provider-news.
2
Key Contact Information
UnitedHealthcare hawk-i Provider Service
888-650-3462
(TDD 711)
UnitedHealthcare hawk-i Member Services
800-464-9484
Inpatient Care Authorization
866-604-3267
Pharmacy Program (Pharmacist)
877-305-8952
Prescription Prior Authorization (Physician)
800-310-6826
Epic Hearing
866-956-5400
OptumHealth Behavioral Services
800-510-5145
Routine vision services are managed by Block Vision. Verification of
eligibility and authorization for routine vision services are available online at
www.blockvision.com or through Block Vision’s Voice Response Unit
at 866-819-4298
800-428-8789
OptumHealth NurseLine
877-244-0408
State of Iowa hawk-i Customer Service (Member)
800-257-8563
Delta Dental
Delta Dental contracts directly with the State of Iowa hawk-i program to
cover routine dental services.
800-544-0718
3
Identification Cards/Eligibility Verification
the health plan’s website or by phone 24 hours a day.
This procedure is essential because:
Identification Cards - Eligibility Verification
UnitedHealthcare hawk-i members should receive
a new membership Identification (ID) card prior to
his/her effective date. However, if a member does
not receive an ID card prior to their effective date,
using provider e-services, you can access member
eligibility information on the health plan website
at UHCCommunityPlan.com or contact Provider
Services to verify eligibility.
• Member may no longer be eligible.
• Benefits may change.
• Fraudulent use may occur.
Steps to Verify Eligibility
• Ask members to present their UnitedHealthcare
hawk-i ID card.
The ID card does not guarantee eligibility. It is for
identification purposes only. Eligibility must be verified
every time services are received. The most recent
member eligibility information can be accessed on
• If unable to determine eligibility using the provider
website eligibility tool, contact Provider Services.
Sample Plan ID Card - Information is subject to change, therefore you should check the member
ID card at every appointment.
Note: hawk-i is located in the lower right hand side on the front of the ID card, so members can be
identified as UnitedHealthcare hawk-i.
Printed: 04/23/12
Printed: 04/23/12
Health Plan (80840) 911-95378-08
Health Plan (80840) 911-95378-08
Member ID: 999999999
Member ID: 999999999
Member:
Member:
SUBSCRIBER M BROWN
SUBSCRIBER M BROWN
DHS11
DHS11
Payer ID
87726
95378
Payer
ID
95378
Group Number:
Group Number:
Rx Bin:
Grp:
Rx Bin:
PCN:
Rx Grp:
Rx PCN:
0APU
0APU
Unauthorized use of non-plan providers may result in benefits denial.
www.uhccommunityplan.com.
Unauthorized use of non-plan providers may result in benefits denial.
TDD 711
800-464-9484
For
Members:
www.uhccommunityplan.com.
877-244-0408
NurseLine:
TDD 711
800-464-9484
For Members:
800-510-5145
Mental
Health:
TDD 800-486-7914
877-244-0408
NurseLine:
711
800-510-5145
Mental Health:
TDD 800-486-7914
For Providers:
www.uhccommunityplan.com
888-650-3462
P.O. Box 5220, Kingston, NY 12402-5220
Medical
Claim Address: www.uhccommunityplan.com
For
Providers:
888-650-3462
Medical Claim Address: P.O. Box 5220, Kingston, NY 12402-5220
610494
hawki
610494
9999
hawki
9999
hawk-i
Administered by UnitedHealthcare Plan of the River Valley,
Inc.
hawk-i
Administered by UnitedHealthcare Plan of the River Valley, Inc.
Pharmacy Claims: OptumRx, PO Box 29044, Hot Springs, AR 71903
For Pharmacist:
877-305-8952
Pharmacy
Claims: OptumRx,
PO Box 29044, Hot Springs, AR 71903
For Pharmacist: 877-305-8952
4
Administrative Functions
Regulatory Compliance
for compliance with the obligations that govern our
federal and state programs.
Introduction
As a business segment of UnitedHealth Group,
UnitedHealthcare implements and is governed by the
UnitedHealth Group Ethics and Integrity Program.
UnitedHealthcare is dedicated to conducting
business honestly and ethically with members,
providers, suppliers and governmental officials
and agencies. The need to make sound, ethical
decisions as we interact with physicians, other health
care providers, regulators and others has never
been greater. It’s not only the right thing to do, it is
necessary for our continued success and that of our
business associates.
Ethics and Integrity Program activities support
the following seven key elements that facilitate
prevention, early detection and remediation of
violations of law and UnitedHealthcare policies.
1. Written Standards, Policies and Procedures
2. High Level Oversight – Governance
3. Effective Training and Education
4. Effective Lines of
Communication/Reporting Mechanisms
5. Enforcement and Disciplinary Guidelines
The Ethics and Integrity Program promotes
compliance with applicable legal requirements,
fosters ethical conduct within UnitedHealthcare and
provides guidance to its employees and contractors.
Additionally, the Ethics and Integrity Program focuses
on increasing the likelihood of preventing, detecting,
and correcting violations of law or UnitedHealthcare
policy. The implementation of such a program,
however, cannot guarantee the total elimination of
improper employee or agent conduct. If misconduct
occurs, UnitedHealthcare will investigate the matter,
take disciplinary action, if necessary, and implement
corrective measures to prevent future violations.
Preventing, detecting and correcting misconduct
safeguards UnitedHealthcare’s reputation, assets and
the reputation of its employees.
6. Auditing and Monitoring
7. Response to Identified Issues
Examples of applicable regulations and requirements
include but are not limited to – Medicaid: Title
42 CFR Part 438 Managed Care, and executed
state contracts.
Federal Health Insurance Portability and
Accountability Act of 1996 (“HIPAA”) and state
health information privacy laws; Federal and State
False Claims Acts.
UnitedHealthcare has compliance program staff,
led by the Chief Medicaid Compliance Officer,
which is responsible for oversight and management
of the Ethics and Integrity Program. A compliance
committee, consisting of senior managers from each
of our key organizational functions provides direction
and oversight for the Program. UnitedHealthcare
also has compliance officers or compliance contacts
located in each health plan or business unit who
report to the senior management of their
assigned entity.
Ethics and Integrity Program
The Ethics and Integrity Program incorporates
recommended compliance program guidance from
the Department of Health and Human Services Office
of the Inspector General (“OIG”), the Centers for
Medicare and Medicaid Services (“CMS”), and the
Federal Sentencing Guidelines for Organizations
(revised and amended, 2010). The purpose of the
Ethics and Integrity Program is to ensure operational
accountability and to provide standards of conduct
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Reporting and Auditing
investigate and recover money it has paid for fraudulent,
wasteful or abusive claims through evolving policies and
initiatives to detect, prevent and combat fraud, waste
and abuse.
Any unethical, unlawful or otherwise inappropriate activity by
a UnitedHealthcare employee which comes to the attention
of a provider should be reported to a UnitedHealthcare
senior manager in the health plan or directly to the Ethics
and Compliance Help Center at 800-455-4521.
UnitedHealthcare will also appropriately refer suspected
fraud, waste and abuse (FWA) cases to law enforcement,
regulatory, and administrative agencies pursuant to
state and federal law. UnitedHealthcare seeks to protect
the ethical and fiscal integrity of the company and its
employees, members, providers, government programs,
and the public, as well as safeguard the health and wellbeing of its members.
An important aspect of the Ethics and Integrity Program is
assessing high-risk areas of UnitedHealthcare operations
and implementing periodic reviews and audits to
ensure compliance with law, regulations, and contracts.
When informed of potentially irregular, inappropriate or
fraudulent practices within the plan or by our providers,
UnitedHealthcare will conduct an appropriate investigation.
Providers are expected to cooperate with the company
and government authorities in any such inquiry, both by
providing access to pertinent records (as required by the
Participating Provider Contract) and access to provider
office staff. If activity in violation of law or regulation is
established, appropriate governmental authorities will
be advised.
UnitedHealthcare is committed to compliance with its
Anti-fraud, Waste and Abuse Program and all applicable
federal and state regulatory requirements governing its
Anti-fraud, Waste and Abuse Program. UnitedHealthcare
recognizes that state and federal health plans are
particularly vulnerable to fraud, waste and abuse and strives
to tailor its efforts to the unique needs of its members and
Medicaid, Medicare and other government partners.
If a provider becomes the subject of a governmental
inquiry or investigation, or a government agency requests
or subpoenas documents relating to the provider’s
operations (other than a routine request for documentation
from a regulatory agency), the provider must advise
UnitedHealthcare of the details of this and of the factual
situation which gave rise to the inquiry.
All suspected instances of Fraud, Waste and Abuse
in any way and in any form is thoroughly investigated.
In appropriate cases, the matter is reported to law
enforcement and/or regulatory authorities, in accordance
with federal and state requirements. UnitedHealthcare
cooperates with law enforcement and regulatory agencies
in the investigation or prevention of Fraud, Waste
and Abuse.
Fraud, Waste and Abuse
The Deficit Reduction Act of 2005 (DRA) contains many
provisions reforming Medicare and Medicaid that are
aimed at reducing fraud within the health care programs
funded by the federal government. Under Section 6032 of
The DRA, every entity that receives at least $5 million in
Medicaid payments annually must establish written policies
for all employees of the entity, and for all employees of
any contractor or agent of the entity, providing detailed
information about false claims, false statements and
whistleblower protections under applicable federal and
state fraud and abuse laws.
UnitedHealthcare’s Anti-fraud, Waste and Abuse
Program focuses on proactive prevention, detection, and
investigation of potentially fraudulent and abusive acts
committed by providers and plan members. A toll-free
Fraud, Waste and Abuse Hotline (866-242-7727) has been
set up to facilitate the reporting process of any questionable
incidents involving plan members or providers.
Through the Anti-fraud, Waste and Abuse Program,
UnitedHealthcare’s mission is to prevent paying fraudulent,
wasteful and abusive health care claims, as well as identify,
6
conduct business electronically are required to do
so utilizing the standard formats adopted under
HIPAA or to utilize a clearinghouse to translate
proprietary formats into the standard formats for
submission to UnitedHealthcare.
As a contracted provider with UnitedHealthcare,
you and your staff are subject to this provision.
The UnitedHealth Group policy, titled “Integrity of
Claims, Reports and Representations to Government
Entities” can be found at UHCCommunityPlan.com.
This policy details our commitment to compliance
with the federal and state false claims acts, provides
a detailed description of these acts and of the
mechanisms in place within our organization to
detect and prevent fraud, waste and abuse, as
well as the rights of employees to be protected
as whistleblowers.
2. Unique Identifiers
HIPAA also required the development of unique
identifiers for health care providers for use in
standard transactions.
Providers
The National Provider Identifier (NPI) is the standard
unique identifier for health care providers. The NPI
is a 10-digit number with no embedded intelligence
which covered entities must accept and use in
standard transactions. While the HIPAA regulation
only requires that the NPI be used in electronic
transactions, many state agencies require the
identifier on fee-for-service claims and on encounter
submissions. For this reason, UnitedHealthcare
requires the NPI on paper transactions.
HIPAA and Compliance/
Provider Responsibilities
Health Insurance Portability and
Accountability Act
The Health Insurance Portability and Accountability
Act (HIPAA) of 1996 is aimed at improving the
efficiency and effectiveness of the health care
system in the United States. While the portability and
continuity of insurance coverage for workers and
greater ability to fight health care fraud and abuse
were the core goals of the Act, the Administrative
Simplification provisions of HIPAA have had the
greatest impact on the operations of the health care
industry. UnitedHealthcare is a “covered entity” under
the regulations as are all health care providers who
conduct business electronically.
The NPI number is issued by the National Plan and
Provider Enumeration System (NPPES) and should
be shared by the provider with all impacted trading
partners, such as providers to whom you refer
patients, billing companies, and health plans.
3. Privacy of Individually Identifiable
Health Information
The privacy regulations ensure a national floor of
privacy protections for patients by limiting the ways
that health plans, pharmacies, hospitals and other
covered entities can use patients’ personal medical
information. The regulations protect medical
records and other individually identifiable health
information, whether it is on paper, in computers or
communicated orally.
1. Transactions and Code Sets
These provisions were originally added because of
the need for national standardization of formats and
codes for electronic health care claims to facilitate
electronic data interchange (EDI). From the many
hundreds of formats in use prior to the regulation,
nine standard formats were adopted in the final
Transactions and Codesets Rule. All providers who
7
The major purposes of the regulation are to
protect and enhance the rights of consumers by
providing them access to their health information
and controlling the inappropriate use of that
information. In addition, the regulation is designed
to improve the efficiency and effectiveness
of health care delivery by creating a national
framework for health privacy protection that builds
on efforts by states, health systems, and individual
organizations and individuals.
CFR, Part 455, Subpart B. This disclosure of criminal
convictions related to the Medicare and Medicaid
programs is required by CMS. These requirements
hold that individual physicians and other health care
professionals must disclose criminal convictions,
while facilities and businesses must additionally
disclose ownership and control interest.
Medical Review Hours
The health plan staff is available for medical review
Monday through Friday, 8 a.m. to 5 p.m.
4. Security
The Security Regulations required that covered
entities meet basic security objectives.
Medical review is available during standard business
hours. Emergency medical services do not require
prior authorization.
1. Ensure the confidentiality, integrity and
availability of all electronic PHI the covered entity
creates, receives, maintains and transmits;
**The health plan offices are closed on the following
holidays: New Year’s Day, Martin Luther King, Jr.
Day, Memorial Day, Independence Day, Labor Day,
Thanksgiving Day, Day after Thanksgiving Day and
Christmas Day. Refer to the website for additional
holiday observances.
2. Protect against any reasonably anticipated
threats or hazards to the security or integrity of
such information;
3. Protect against any reasonably anticipated
uses or disclosures of such information that
are not permitted or required under the Privacy
Regulations; and
Change Notification
Any change in your provider information should be
reported as soon as possible. Some examples of
these changes are practice location, Tax Identification
Number or practice status regarding acceptance of
new patients. Please call the UHG VETSS line at
877-842-3210 or Provider Service at 888-650-3462
to communicate any changes.
4. Ensure compliance with the Security
Regulations by the covered entity’s workforce.
UnitedHealthcare expects all network providers
to be in compliance with the HIPAA regulations
that apply to their practice or facility within the
established deadlines. Additional information on
the HIPAA regulations can be obtained from the
website: www.cms.hhs.gov.
If terminating your participation, you must submit
a termination notification to us in the time frames
stated in your provider contract. All notices must
be in writing and delivered either personally or sent
by certified mail with postage prepaid. If mailed,
such notice shall be deemed to be delivered
when deposited in the United States mail, at the
UnitedHealthcare respective address as it appears
on the signature sheet of your provider contract.
Disclosure of Criminal Conviction,
Ownership, and Control Interest
Prior to payment for any services rendered to
UnitedHealthcare members, the provider must have
completed and filed with the health plan disclosure
information in accordance with requirements in 42
8
If services covered by the contract agreement are
added or discontinued, the provider is responsible for
notifying the health plan prior to such discontinuation
or addition. The health plan will review the changes
requested to ensure adequacy of member access for
service. If the need for additional service exists, the
provider must comply with health plan credentialing
requirements for that new service. A current provider
contract will not automatically include a new location.
Each request will be evaluated on an individual basis.
for claims payment or medical management. The
provider may charge the member for records
provided at the member’s request. Providers are not
allowed to charge the health plan or the member for
records provided when a member moves from one
primary care provider to another.
Pro-Children Act
The Plan must comply with Public Law 103-227, Part
C Environmental Tobacco Smoke, also known as the
Pro-Children Act of 1994 (Act). This Act requires
that smoking not be permitted in any portion of any
indoor facility owned or leased or contracted by an
entity and used routinely or regularly for the provision
of health, day care, education, or library services
to children under the age of 18, if the services are
funded by federal programs either directly or through
State or local governments. Federal programs
include grants, cooperative agreements, loans
or loan guarantees, and contracts. The law also
applies to children’s services that are provided in
indoor facilities that are constructed, operated, or
maintained with such federal funds. The law does
not apply to children’s services provided in private
residences; portions of facilities used for inpatient
drug or alcohol treatment; service providers whose
sole source of applicable federal funds is Medicare or
Medicaid; or facilities (other than clinics) where WIC
coupons are redeemed.
Locum Tenens
In instances when a network physician has a locum
tenens covering for a short period of time (less than 60
days), it will be the network provider’s responsibility to
ensure appropriate licensure, malpractice insurance
and other pertinent information is validated prior to
allowing the locum tenens to treat patients.
Claims should be submitted under the network
physician’s name and NPI.
Allied Health Professional Billing
If your office employs an “Allied Health Professional”
(e.g., Nurse Practitioner, Physician Assistant) who
is providing services to members, the claim must
be submitted to the health plan with the NP/PA’s
assigned provider identification number. These
claims should not be filed under the supervising
physician’s number.
The Plan further agrees that the above language will
be included in any subawards that contain provisions
for children’s services and that are subgrantees shall
certify compliance accordingly. Failure to comply with
the provisions of this law may result in the imposition
of a civil monetary penalty of up to $1000 per day.
Records and Patient Information for
Claims and Medical Management
Medical records and patient information shall
be supplied at the request of the health plan or
appropriate regulatory agencies as required for
claims payment and medical management. The
provider is not allowed to charge the health plan or
the member for copies of medical records provided
9
Claims Billing Procedures
Electronic Data Interchange (EDI)
Contact your software vendor or clearinghouse with
any questions regarding placement of information on
your system.
EDI is our preferred choice for conducting business
transactions with contracting/participating physicians
and healthcare industry partners.
Electronic Funds Transfer (EFT)
EFT can reduce administrative costs, simplify
bookeeping, and offer greater security. EFT can
significantly reduce reimbursement turnaround time
and funds are available as soon as they are posted to
your account. To enroll in EFT for UnitedHealthcare
Community Plan, please visit the EDI section of your
state home page on UHCCommunityplan.com.
EDI tools
We offer an array of EDI tools designed to help
you save time and money by automating several of
your daily office administrative and reimbursement
functions. Please refer to the UnitedHealthcare
Community Plan published Companion Guides
for the required data elements. Companion
guides are available for viewing or download
within the EDI section of your state home page
at UHCCommunityplan.com.
Electronic Remittance Advice (ERA)
ERA allows a provider to obtain an electronic version
of the Explanation of Payment (EOP). Depending on
your system’s capability, the data may be uploaded
directly to the ledger of your practice computer
system. ERA can potentially replace the tedious
process of Guide EOP reconciliation, posting and
data entry. This transaction is available only in the
HIPAA ANSI X1 2 835 format.
EDI claims/encounters
EDI claim is the preferred method of submission
for contracted physicians and health care providers.
You may submit all professional claims and/or
encounters electronically for UnitedHealthcare
Community Plan. The HIPAA ANS1 X1 2 837 format
is the only acceptable format for submitting claims/
encounter data.
Electronic eligibility inquiry/response
One of the primary reasons for claims rejection is
incomplete or inaccurate eligibility information. This
EDI transaction is a powerful productivity tool that
allows providers to instantly obtain Customers’
eligibility and benefit information in “real-time,” using
a computer instead of the phone, prior to scheduling
and confirming the patient’s appointment. The HIPAA
ANSI X1 2 270/271 format is the only acceptable
format for this EDI transaction.
Claims requiring medical record attachments will
require paper submission. However, do not submit
medical record attachments unless instructed to do
so by UnitedHealthcare Community Plan.
Secondary Claims
Please refer to the 837 Companion Guide located
within the EDI Section of UHCCommunityPlan.com
for technical requirements. Do not send paper
claim backup for claims that have already been
submitted electronically.
Electronic claims status inquiry/response
This EDI transaction allows a provider to send
and receive in “real-time” an electronic status of
a previously submitted claim using a computer.
Claims with missing or inaccurate information can be
resubmitted, which greatly enhances the provider’s
receivables and cash flow cycle. The HIPAA ANSI X1
276/277 format is the only acceptable format for this
To set up Carrier Tables within your Software
Set your system payer tables for UnitedHealthcare
Community Plan to generate electronic claims instead
of paper claims. Make sure the Payer ID for the plan
is spelled correctly and setup is consistent.
10
EDI transaction. Some software vendors
and/or clearinghouses, may also offer Electronic
Claims Status and Inquiry transaction services.
The following claims may be submitted electronically
without specific rules:
• 59 Modifier.
Please refer to the UnitedHealthcare Community Plan
Companion Guides for the data elements required for
these transactions. Companion guides are available
for viewing or download at UHCCommunityplan.com.
Paper claim specific rules include:
Claims Format
• Corrected claims may be submitted electronically;
however the words “corrected claims” must be in
the notes field. Your software vendor can instruct
you on correct placement of all notes.
All claims for medical or hospital services must
be submitted using the standard CMS 1500
(formerly known as HCFA 1500), UB-04, or
respective HIPAA-compliant format. The health
plan recommends the use of black ink when
completing a CMS 1500. Black ink on a red CMS
1500 form will allow for optimal scanning into the
claims processing system.
• Unlisted procedure codes may be submitted
with a sufficient description in the notes field.
Your software vendor can instruct you on correct
placement of all notes. If sufficient information
cannot be submitted in the notes field, paper must
be submitted. X-ray, lab and drug claims with
unlisted procedure codes should be submitted
electronically with notes.
No matter which format you use to submit the claim,
ensure that all appropriate secondary diagnosis
codes are captured and indicated for line items.
This allows for proper reporting on encounter data.
• Occupational Therapy, Speech Therapy,
Physical Therapy, Mental Health/Substance
Abuse and dialysis claims require the date of
service by line item.
The health plan does not accept span dates for
these types of claims.
Claim Processing Time
• Secondary COB claims may be submitted if the
following “required” fields are included on the
electronic submission:
Please allow 30 days before inquiring about claims
status. The standard turn-around time for clean
claims is 10 business days, measured from date
of receipt.
– Institutional: Payer Prior Payment, Medicare
Total Paid Amount, Total Non-Covered Amount,
Total Denied Amount.
Claims Submission Rules
– Professional: Payer Paid Amount, Line Level
Allowed Amount, Patient Responsibility, Line
Level Discount Amount (Contractual Discount
Amount of Other Payer), Patient Paid Amount
(Amount that the payer paid to the member not
the provider).
The following claims MUST be submitted on paper
due to required attachments:
• Timely filing reconsideration requests.
• CCI edit reconsideration.
• Unlisted procedure codes if sufficient information
is not sent in the notes field.
– Dental: Payer Paid Amount, Patient
Responsibility Amount, Discount Amount
(Contractual Discount Amount of Other Payer),
Patient Paid Amount (Amount that the payer paid
to the member not the provider).
Please do not send claims on paper or
with attachments unless requested by the
health plan.
11
Balance Billing
Effective Date / Termination Date
The balance billing amount is the difference between
the allowed charge and the provider’s actual charge
to the patient. UnitedHealthcare members cannot be
balance billed for covered services in accordance
with the federal law prohibition found at 42 U.S.C.A.
§ 1395cc and 42 U.S.C.A § 1396a(p).
Coverage will be effective on the date the member
is effective with the health plan. Coverage will
terminate on the date the member’s benefit plan
terminates with the health plan. If a portion of the
services or confinement take place prior to the
effective date, or after the termination date, an
itemized split bill will be required.
Services to members cannot be denied for failure to
pay copayments. If a member requests a service that
is not covered by UnitedHealthcare, providers should
have the member sign a release form indicating
understanding that the service is not covered by
UnitedHealthcare and the member is financially
responsible for all applicable charges.
Please be aware that effective dates for members
can be revised. You should verify eligibility at each
visit, to assure coverage for services.
Overpayments
The best way to handle a potential overpayment is
to call Provider Service. Be sure to have the Claim
Number or Member ID and Date of Service available.
The health plan’s claim processing system will
automatically deduct any overpayment made from the
next remittance advice.
Federal and State law prohibit a provider who
participates in the Medicaid program from billing
members for covered services. Additionally, section
403 of the Children’s Health Insurance Program
Reauthorization Act of 2009 (CHIPRA) applies
Medicaid-managed care requirements to CHIP, which
includes the Iowa hawk-i program. This section
further explains that providers are prohibited from
balance billing a member for service(s) in excess
of the contracted amount, other than approved
copayments and/or deductibles.
If an overpayment is identified, contact Provider
Service to submit an overpayment request. Checks
should not be sent to the health plan for overpayment
related issues unless specifically requested.
Subrogation
Span Dates
The health plan will not override timely filing denials
based on decisions received from third-party carriers
on subrogation claims. At the time of service, please
submit all claims to the health plan for processing.
Through recovery efforts, we will work to recoup
dollars related to subrogation. In addition, if your
office receives a third-party payment, notify the health
plan’s Customer Service and the overpayment will
be recouped.
Exact dates of service are required when the claim
spans a period of time. Please indicate the specific
dates of service in Box 24 of the CMS 1500, Box
45 of the UB-04, or the Remarks field. This will
eliminate the need for an itemized bill and allow
electronic submission.
12
Timely Filing and Late Bill Criteria
The following are not acceptable
forms of documentation for timely filing
payment reconsideration:
Timely filing improves cash flow for your office.
It enables the health plan to settle fund accounts
accurately and to intervene earlier in cases requiring
case management to improve patient outcomes.
Claims must be submitted and received by us in
accordance with the time frames outlined in your
provider contract. Claims that are filed untimely will
be denied. The claims filing deadline is based on the
date services were rendered, or the date when the
provider identifies us as the primary health payer, or
receives a claim response from the primary payer.
Secondary claim submissions can be submitted
electronically or with a copy of the primary health
payer’s remittance. If we receive a claim and return it
to the provider for additional information, the provider
must resubmit the claim within the time frame outlined
in the provider’s contract.
• Screen prints showing dates of a claim previously
submitted to the health plan.
• Electronic reports stating vendor or clearinghouse
has accepted the claim.
• CMS or UB form with “print” date located in Box
31 or Box 86, respectively.
• Electronic report stating the health plan has
rejected the claim.
Provider Claim
Reconsideration Requests
Step 1: Claim Reconsideration. You must submit
your Claim Reconsideration within 12 months
from the date of the Explanation of Benefits (EOB)
or Provider Remittance Advice (PRA). A Claim
Reconsideration request is typically the quickest
way to address any concern you have with how we
processed your claim. With a Claim Reconsideration
request, we review whether a claim was paid
correctly, including if your provider information and/or
contract are set up incorrectly in our system,
which could result in the original claim being
denied or reduced.
Claims submitted after the claims filing period will
be denied as NOT ALLOWED – DO NOT BILL
THE PATIENT.
If a claim has been denied for timely filing, the
following are acceptable forms of documentation for
payment reconsideration:
• EOB or EOMB from primary health payer dated
within the claims filing period of claim submission
to the health plan.
UnitedHealthcare acknowledges that providers
remain eligible to file claims reconsiderations,
resubmissions, disputes or appeals as permitted
under the terms of their participation agreement or
this manual. A request for claims reconsideration is
intended solely for convenience and administrative
ease. In the event this claims reconsideration process
conflicts in any way with your participation agreement
or this manual, the terms and conditions of the
participation agreement or this manual shall govern.
Providers are encouraged to review their participation
agreement and this manual to understand all other
available claims reconsideration, resubmission or
appeals remedies.
• Confirmation of denial from believed health payer
within the claims filing period of claims submission
to the health plan.
• Copy of billing statement to patient showing
dates of bills or provision of patient’s health plan
insurance information.
• Documentation proving the health plan contributed
to the filing delay.
• Electronic report states the health plan has
accepted the claim.
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Below is the method for submitting Claim
Reconsideration Requests.
Paper Claim Reconsideration Request
The paper Claim Reconsideration Request form can
be downloaded from:
• UnitedHealthcareonline.com Claim Reconsideration
– Paper Claim Reconsideration instructions
Where to send Claim Reconsideration Requests:
UnitedHealthcare
P.O. Box 5220
Kingston NY 12402-5220
Claim Dispute
If you do not agree with the outcome of the Claim
Reconsideration decision in Step 1, you may submit
a formal claim dispute. You must submit your appeal
to us within 12 months (or as required by law or
your participation agreement), from the date of the
Explanation of Benefits (EOB) or Provider Remittance
Advice (PRA).
The provider dispute form can be found on
UHCCommunityPlan.com. Forms should be
mailed to:
P.O. Box 31364
SALT LAKE CITY UT 84131
Or the form can be faxed to (801) 994-1082.
A copy of the claim and supporting documentation
will be required for review.
14
Reimbursement
To align with federal mandates regarding enforcement
of Correct Coding Initiatives (CCI) and Fraud, Waste
and Abuse Prevention tools, the health plan performs
coding edit procedures. These Program Integrity
activities are referred to as reimbursement policies.
contract documents, the enrollee’s benefit
coverage documents, and the Provider Manual
all may supplement or in some cases supersede
these policies.
Reimbursement policies are based on external
sourcing including:
Provider Claim Editing Tools
iCES Clearinghouse from Ingenix:
UnitedHealthcare Community Plan utilizes a
customized version of the Ingenix Claim Edit
System known as iCES Clearinghouse (v2.5.1)
iCES-CH is a clinical edit system application that
analyzes health care claims based on business rules
designed to automate UnitedHealthcare Community
Plan reimbursement policy and industry standard
coding practices. Claims are analyzed prior to
payment to validate billings in order to minimize
inaccurate claim payments.
• CMS National Correct Coding Initiative.
• CMS National/Local Coverage Determinations
(NCDs/LCDs).
• Current Procedural Terminology (CPT).
• Specialty Societies including, but not limited to:
– American Society of Anesthesiologists (AMA).
– American College of Cardiologists (ACC).
– American College of Obstetrics and
Gynecology (ACOG).
Facility Claim Editing: UnitedHealthcare
Community Plan utilizes an edited system application
for claims for outpatient and inpatient services
provided to Medicaid/CHIP beneficiaries. The Facility
Editor is a rules-based software application that
evaluates claims data for validity and reasonableness.
The edits are based on CCI guidelines and other
CMS rules established for government programs.
• National Physician Fee Schedule (NPFS)/Relative
Value File.
Reimbursement policies are available online
at UHCCommunityPlan.com. Reimbursement
policies may be referred to in your agreement with
UnitedHealthcare Community Plan as “payment
policies.” UnitedHealthcare Community Plan may
revise/update or add to these policies on occasion.
As a participating provider, you agree to abide by
these policies. UnitedHealthcare Community Plan is
committed to notifying providers who are impacted by
policy changes/additions.
Outpatient Code Edits
These reasonableness tests incorporate the
Outpatient Code Edits (OCE) developed by the CMS
for hospital outpatient claims. The Facility Editor
will be used to examine outpatient facility-based
claims prior to payment to validate billings in order to
minimize inaccurate claim payments.
Payment of a claim is subject to our payment policies
(reimbursement policies) and medical policies, which
are available to you online or upon request to your
Network Management contact.
The CMS OCE edits that will be applied by the
Facility Editor include:
NOTE: Policies do not cover all issues related
to reimbursement for services rendered to
UnitedHealthcare Community Plan enrollees as
legislative mandates, the physician or other provider
1. Basic field validity screens for patient demographic
and clinical data elements on each claim.
15
2. Effective-dated ICD-9-CM, CPT-4 and HCPCS
Level II code validation, based on service dates
and patient clinical data.
The inpatient edits are sourced to:
Medicare Code Editor (MCE) which include (but are
not limited to) the following edit rules:
3. Facility-specific National Correct Coding
Initiative edits. The NCCI edits identify pairs of
codes that are not separately payable, except
under certain circumstances. NCCI edits were
developed for use by all health care providers; the
Facility Editor incorporates those NCCI edits that
are applicable to facility claims. The NCCI edits in
the Facility Editor are applied to services billed by
the same hospital for the same beneficiary on the
same date of service. There are two categories of
NCCI edits:
• Data Validation Edits.
Multiple Services on Same Visit:
In certain situations, providers can bill for both
evaluation and management (E&M) and preventive
medicine (PM) on the same office visit. PM codes
must be billed with one of the following E&M codes:
99211, 99212, or 99213 for an unrelated diagnosis.
If the PM code is billed in any other combination
of E&M codes, it will not be payable. The E&M
code must be filed with a –25 modifier in
these circumstances.
a. Comprehensive code edits, which identify
individual codes, known as component codes,
which are considered part of another code and
which are designed to prevent unbundling; and
Immunization Administration
The health plan will pay for immunization
administration in conjunction with an E&M or P&M
visit. Providers should use code 90471 for the first
injection and 90472 for subsequent injections.
b. Mutually exclusive code edits, which identify
procedures or services that could not
reasonably be performed at the same session by
the same provider on the same beneficiary.
4. Other OCE edits for inappropriate coding,
including incorrect coding of bilateral services,
evaluation and management services, incorrect
use of certain modifiers, and inadequate coding
of services in specific revenue centers are also
included in the Facility Editor.
Note: the hawk-i program does not participate
in the Vaccines for Children (VFC) program.
Vaccinations are reimbursed according to your
provider contract fee schedule.
Inpatient Code Edits
The inpatient editing rule sets are also developed by
the CMS for hospital inpatient claims. As with the
outpatient edits, the claims editing tool will review
claims prior to payment to validate billings to minimize
inaccurate claims payments.
16
Member Cost Share Responsibility
Cost-Sharing for Members
• Non-plan services when not a result of an emergency
or in absence of a prior authorization – member is
responsible for the costs of those service(s).
hawk-i members are only responsible for the costs
allowed under the Rules and Regulations as valid
cost sharing responsibilities. A contracted provider
cannot refuse to provide Medically Necessary
Services for a member’s failure to pay.
• Services without prior authorization where one is
required – member is responsible for the cost of
those service(s).
• Services outside of their benefit plan.
A network provider shall collect from the member
any applicable costs. Reasonable efforts to collect
should include, but are not limited to, referral to a
collection agency and, where appropriate, court
action. Documentation of the collection efforts must
be maintained and made available to the health plan
upon request.
• For questions, please contact Provider Services.
For more information about hawk-i benefits, refer to
the Covered Benefits section in this manual.
Non-payment of Copayment
hawk-i Copayments
When a member does not pay the applicable
copayment at the time services are rendered, the
physician has the following options:
hawk-i members have no copayments for most
services, exceptions include but not limited to:
• Render the service, and pursue member payment
of cost sharing at a future time.
• Dental – member must use dental carrier’s
schedule of benefits, contact Delta Dental
for details.
• Reschedule the appointment (unless the visit is for
urgent/emergent care).
• Non-emergent – member will have a $25
copayment for any non-emergent visits to an
emergency room.
Contact Provider Service for assistance if the
member refuses to pay copayments.
• Hearing – member can have one audiometric exam,
one hearing aid evaluation, and one hearing aid
per ear every 36 consecutive months. Costs for
services above these benefits are the responsibility
of the member.
Coordination of Benefits
Coordination of Benefits (COB) is designed to avoid
duplicate payment for covered services. COB is
applied whenever the Member covered by the health
plan is also eligible for health insurance benefits
through another policy. The health plan recommends
the copayment not be collected until the second
payer has paid the claim in order to prevent a
possible overpayment.
• Prescription – member will pay the full contracted
price of any brand prescription filled when an
equivalent generic is available on the Preferred
Drug List (PDL).
• Vision – member may receive 1 eye exam every
12 consecutive months and has a $100 material
allowance per calendar year, they are responsible
for any amount in excess of these limits.
17
As a network provider you agree to cooperate with
the health plan toward the effective implementation
of COB procedures, including identification of
services and individuals for which there may be a
financially responsible party other than the health
plan, and assist in efforts to coordinate payments
with those parties.
How to file:
• When the health plan is primary, submit directly
to us.
• When the health plan is secondary, submit to
primary carrier first, then, submit the EOB with
the claim to the health plan for consideration. EOBs
can be submitted to the health plan electronically.
Refer to “Claims Submission Rules” in this manual.
Reminder: The Contract Agreement between
UnitedHealthcare and the State of Iowa states: “in
the event a hawk-i child is enrolled with other health
insurance coverage, the other insurance plan shall
be the primary payer and hawk-i shall be the payer
of last resort.” Therefore, if the member is eligible for
services or benefits under another policy, including
Medicare, coverage under that plan will be primary.
The only exception is in rare instances that the
member also has Medicaid coverage. In these cases,
Medicaid is the payer of last resort.
18
Provider e-Services
Provider e-Services can be accessed from the health
plan website at UHCCommunityPlan.com. Offering
online features is just another way the health plan
is working to strengthen our relationships
with providers.
• Reduce the number of claims rejected due to
inaccurate eligibility information.
Provider Registration
• Determine if your claims have been received by
the health plan.
How to Obtain a Username and Password
• To register for e-Services provider portal, go to
UHCCommunityPlan.com. Then click on Health
Professionals and select the state of Iowa under
“Already Part of Our Network”. Choose “Claims
and Member Information” from the navigation
buttons on the left side of the screen, under
UnitedHealthcare hawk-i, click “Access secure
provider website”. This will bring you to the log in
page for the online provider portal.
• Know if your claim is pended, denied or paid
within seconds.
Claim Status/Review
Allows you to locate specific claims and obtain claim
summary and line item detail information.
• Reduce your cost of duplicate claims submission
and reduce administration cost.
• Submit online request for claim review and receive
answer within 48 hours.
• From the Community Plan Online Provider Portal
log in page, you will see a prompt to register for an
account. Once you click on “register”, it will direct
you to a page to set up your log in information.
• To access the non-secured portion of the provider
website, go to UHCCommunityPlan.com and click
on Health Professionals and select the state of
Iowa under “Already Part of Our Network”. This
brings you to the general home page. Here you can
access our policies (including the Reimbursement
Policies), Provider Manual, handouts, forms, and
recent newsletters.
e-Services
Verify Patient Eligibility
• Verify the eligibility of your patients before you
see them.
• Know patients’ copayments that you can collect at
time of service.
• View deductibles, out-of-pocket maximums and
co-insurance of patients.
19
Emergent and Urgent Services
Post-stabilization Care Services are:
Members are encouraged to receive Emergency
Services from their Primary Care Provider (PCP) or a
network hospital or facility.
Covered services, related to a medical emergency
that are provided after a member is stabilized in order
to maintain the stabilized condition to improve or
resolve the member’s condition.
The health plan covers Emergency, Post-stabilization,
and Urgently Needed Services without prior approval
whether the member is in or out of the service
area or if the care is provided by network or nonnetwork providers. All non-emergency services must
be provided or coordinated by network providers.
Members who are present at an emergency room
should be screened to determine whether a medical
emergency exists. Prior authorization is not required
for the medical screening.
Claim coverage decisions are based upon the
severity of symptoms at the time of presentation.
Post-stabilization services, including all medical health
services that are necessary to assure there is no
likely material deterioration of the member’s condition
after discharge or during transport to another facility,
are also covered based upon the prudent layperson
standard. If either the member’s PCP or the health
plan directs the member to the emergency room,
emergency screening services and other medically
necessary emergency services will be reimbursed,
whether or not the member’s condition meets the
prudent layperson definition of a medical emergency.
A member is encouraged to contact their PCP
as soon as possible, preferably within 24 hours
after an Emergent/Urgent Service Procedure. The
member’s PCP is expected to work with the member
to coordinate any followup care. As a participant in
a managed care health plan, the PCP is responsible
for the emergency medical direction of members 24
hours a day, 7 days a week.
Urgently Needed Services
Urgently Needed Services are Covered Services that
are not emergency services provided when:
A Medical Emergency is defined as—A physical
or behavioral condition manifesting itself by acute
symptoms of sufficient severity (including severe
pain) that a prudent layperson, who possesses an
average knowledge of health and medicine, could
reasonably expect the absence of immediate medical
attention to result in the following:
• The Member is temporarily absent from the
UnitedHealthcare hawk-i Service Area, and
• When such services are Medically Necessary and
immediately required:
1. As a result of an unforeseen illness, injury, or
condition; and
• Placing the health of the individual (or, with respect
to pregnant women, the health of the woman or her
unborn child) in serious jeopardy;
2. It is not reasonable given the circumstances to
obtain the services through a UnitedHealthcare
network provider.
• Serious impairment of bodily functions; or
• Serious dysfunction of any bodily organ or part.
Under unusual and extraordinary circumstances,
services may be considered urgently needed
services when the Member is in the service area, but
the UnitedHealthcare hawk-i provider network is
temporarily unavailable or inaccessible.
20
After Hours/Provider Availability
Emergency Inpatient Admission
PCPs shall provide coverage 24 hours a day, 7 days
a week. When a network provider is unavailable to
provide services, he or she must ensure that another
network provider is available.
Should the attending physician proceed and admit
the member, the health plan must be notified no
later than the end of the next working day. Once
the member’s condition is stabilized, the health plan
requires notification for hospital admission and follow
up care. Should the hospital fail to notify the health
plan within 10 calendar days following a member’s
presentation for emergency services, charges
deemed not medically necessary by the health
plan’s Medical Director, could become the financial
responsibility of the hospital.
The Member should normally be seen within 30
minutes of a scheduled appointment or be informed
of the reason for delay (e.g., emergency cases) and
be provided with an alternative appointment.
After-hours access shall be provided to assure a
response to urgent and emergency phone calls occur
within 15 minutes. Individuals who believe they have
an emergency medical condition should be directed
to immediately seek emergency services.
Billing for Hospital Observation Beds
Used for the purpose of determining whether a
patient requires admission or other treatment.
Emergency Services in the
Emergency Room
• Outpatient observation is limited to up to 24 hours
for medical observation.
The health plan covers all emergent services
necessary to stabilize members, without
pre-certification of the services, where a prudent
layperson, acting reasonably, would believe that a
medical emergency existed. Screening services to
determine whether a medical emergency exists are
covered services.
• When a member is admitted after an outpatient
observation, the health plan will consider the date
the member entered outpatient observation as the
first day of the inpatient admission.
Coverage Updates
The health plan routinely meets to review changes
and advances in health care treatment as they
occur. Changes in the health plan’s coverage and
payment are posted online. These changes are
also maintained in the online version of the provider
manual that can be accessed using the health plan
provider website at UHCCommunityPlan.com.
If there is disagreement regarding the member’s
stabilized condition at the expected time of discharge
or transfer, the decision of the attending physician will
prevail. The health plan may arrange for a network
physician with appropriate emergency room privileges
to assume the attending provider’s responsibilities to
stabilize, treat and transfer the member. This situation
can only occur when the arrangement does not delay
the provision of emergency services.
You may also contact Provider Services with
any questions related to coverage and
payment guidelines.
21
Encounter Data Element Collection
All data required for Encounter collection and
reporting is drawn from submitted claims. Should your
office have a capitation arrangement with the health
plan, encounters must be submitted with the same
level of required information as fee-for-service claims.
22
Credentialing
Provider Credentialing
certified nurse midwives. When an office site check
is required, a health plan representative will contact
the provider’s office to schedule the site visit.
Providers wanting to participate in the health plan
must contact the National Credentialing Center by
calling 877-842-3210 and provide specific information
regarding their credentials and practice arrangements.
When a decision is made to offer a provider an
opportunity to be considered for participation,
the provider will receive application submission
instructions via fax. The application process includes
submission of a completed signed application and
supporting documents to the UnitedHealthcare
National Credentialing Center by utilizing the Council
for Affordable Quality Healthcare’s (CAQH) Universal
Credentialing Datasource.
Nondiscrimination in
Network Participation
The health plan does not deny or limit the participation
of any clinician or facility in the health plan network,
and/or otherwise discriminate against any clinician or
facility based solely on any characteristic protected
under state, federal, or local law.
The health plan wishes to assure its provider(s) and
facilities that it has never had a policy of terminating a
clinician or facility because he or she:
Provider Recredentialing Process
1. Advocated on behalf of a member;
All providers are recredentialed at least every
36 months. At the time of recredentialing, the
UnitedHealthcare National Credentialing Center will
notify the provider to access the CAQH Universal
Credentialing Datasource to update and re-attest
to the validity of credentialing data. The provider’s
professional license, DEA license (if applicable) and
professional liability insurance are verified prior to the
Credentialing Committee review. Each provider’s file
is also reviewed for any sanctions (the health plan
and/or state/federal) and quality of care or quality of
service issues. This triennial cycle does not preclude
recredentialing for shorter time frames due to quality
issues and/or per the direction of the Corporate
Credentialing Committee.
2. Filed a complaint against the health plan;
3. Appealed a decision of the health plan; or
4. Requested a review or challenged a
termination decision.
The health plan has not, and will not, terminate any
clinician or facility from its network based on any of
the four grounds enumerated above. Nothing in the
health plan’s clinician or facility contracts should be
read to contradict or in any way modify this longstanding practice.
Public Release of Physician/
Clinician Specific Information
The health plan does not release any individual
clinician-specific utilization management information
to entities outside of the health plan except as
permitted or required by law.
Office Site Review
Office site checks are required as a part of the
credentialing process for primary care, obstetrician/
gynecology providers. Office site checks are
also required for physician assistants and nurse
practitioners, who practice primary care, as well as
23
Written Notification and
Correction of Information
A request for arbitration must be in writing. At
any time a provider’s participation status changes
with the health plan, the provider shall provide all
necessary information in a timely manner to ensure
continuity of care for the members.
If, during the process of credentialing or
recredentialing, the health plan discovers information
that varies substantially from that which was initially
provided, the health plan will notify the clinician
or facility and offer an opportunity to correct the
information. Provider(s) and facilities are given
10 business days to respond. Responses must
be made in writing to the health plan. Once the
corrected information is verified, it becomes part
of the clinician’s or facility’s file and is maintained
in the same manner as all other credentialing and
recredentialing material. Provider(s) or facilities have
the right to review information submitted to support
their credentialing application; the right to correct
erroneous information; the right to be informed of
their credentialing or recredentialing status, upon
request; and the right to be informed of their rights.
Please note that it is essential that you provide
updated demographic information as changes occur.
The Health Care Quality Improvement Act of 1986,
as amended, requires that health care entities (e.g.,
hospitals, health maintenance organizations, group
medical practices) report to the National Practitioner
Data Bank/Health Integrity and Protection Data
Bank and State Medical and Dental Boards specific
information when adverse actions occur.
Member Notification of Provider
Suspension/Termination
The health plan’s members will be notified when
a provider’s participation status has been suspended
or terminated regardless of cause. The health
plan will notify members affected by the termination
of providers.
Altering Participation Status
Organizational Provider
Credentialing Program
When a provider is identified with performance,
license or sanction issues, the health plan has the
right to restrict, suspend or terminate the provider’s
participation status. Providers who are subject to an
adverse action will be offered an appeal of the health
plan’s decision.
The Organizational Provider Credentialing Program
includes the credentialing of network hospitals,
ambulatory surgery centers, home health/infusion
agencies, and skilled care facilities according to
company and external review standards.
The process follows established policies and
procedures approved annually by the health plan’s
Corporate Quality Improvement Committee. The
purpose of the program is to select and monitor
organizational providers.
Appeals will be presented to a credentialing appeals
panel. The network provider will be given the
opportunity to present evidence and discuss the
adverse decision with the credentialing appeals panel
by telephone or in person. The panel’s decision will
be by majority vote. The network provider will be
notified by certified mail of the panel’s decision.
If the network provider disagrees with the decision
of the credentialing appeals panel, he/she has days
from the date of the decision to request arbitration.
24
Facility
In some instances the health plan may elect to
delegate organizational provider credentialing. In
these instances the delegate must comply with
the health plan’s organizational provider
credentialing standards.
Application Process
A Provider must submit a complete, signed
application and supporting documentation for
review by the UnitedHealthcare National
Credentialing Center. This includes copies of
the following as applicable:
Ambulatory Record Review
Standard Guidelines
• Accreditation certificate/letter.
Provider’s office medical records will be reviewed
against the health plan, NCQA and regulatory
guidelines relating to structure and content. It is
expected that all medical records be in substantial
(≥85%) compliance with these standards.
• State license.
• Certificate of professional liability insurance.
• Laboratory certification.
• Information regarding any license sanctions and/or
insurance denials.
Medical record standards for physical health
providers are located in the Medical Record
section of the manual.
• A listing of all subcontracted patient care services
(required in order to confirm the use of plan,
accredited providers).
It is the policy of the health plan to contract with only
accredited facilities unless otherwise determined by
business need.
If the need is so determined the health plan may
conduct an on-site facility audit.
At the request of the health plan, an organizational
provider must provide evidence of license for any
personnel employed that are legally required to be
licensed in the state in which they practice and that
each is practicing within the scope of the license.
Organizational providers are recredentialed on a
36-month basis; facilities are triennial (3-year) basis.
The recredentialing process includes the collection
of an updated application and supporting documents.
Utilization and quality issues are also reviewed at the
time of recredentialing.
Between credentialing and recredentialing, providers
are required to notify the health plan within 15 days
of any material changes in their Network Applications
and supporting documentation.
25
Covered Benefits
UnitedHealthcare hawk-i Covered Benefits
Benefits Chart
The following benefit information is a summary. Some procedures, including certain medical services or benefits
provided, require prior authorization by UnitedHealthcare before rendering services. Call Provider Services to
check benefit coverage for hawk-i members.
Service
Benefit Limit
Preventive Care Services
Includes, but is not limited to, initial and periodic evaluations, family planning
services, prenatal care, laboratory services and immunizations in accordance
with rules and regulations.
EPSDT Screenings
Covered as medically necessary, except that the screenings do not have to
be medically necessary. Children may also receive screenings in-between
regular checkups if a parent or caregiver believes there is a problem.
Screening, interperiodic screening, diagostic and follow-up treatment
services as medically necessary in accordance with federal and state
requirements.
Inpatient Hospital Services
As medically necessary, including rehabilitation hospital facility.
Outpatient Hospital Services
As medically necessary.
Physician Inpatient Services
Physician Outpatient Services/
Community Health Clinic Services/
Other Clinic Services
Lab and X-ray Services
Hospice Care
As medically necessary with a prior authorization. Must be provided by a
Medicare-certified hospice.
Dental Services
Dental Services are provided by the Dental Benefits Manager. Benefits
available through State Dental Plan with Delta Dental.
Delta can be contacted at 800-544-0718 or visit their website at
www.deltadentalia.com.
Routine Vision Services
Routine Vision Services are provided by
Block Vision.
Routine annual assessment, evaluation, or screening of normal eyes and
examinations for the purpose of prescribing fitting or changing eyeglass
and/or contact lenses are covered through Block Vision.
Medical eye care, meaning evaluation and management of abnormal
conditions, diseases, and disorders of the eye (not including evaluation
and treatment of refractive state), are covered as medically necessary as a
medical benefit through UnitedHealthcare.
Home Health Care
As medically necessary. Must have approved prior authorization
by UnitedHealthcare.
26
Service
Benefit Limit
Pharmacy Services
Pharmacy services shall be provided by the Pharmacy Benefits
Manager (PBM), unless otherwise described below.
• Outpatient Prescription Drugs: The health plan covers medications
when ordered by a network physician and supplied by a network
pharmacy. The pharmacy will not dispense more than a 30-day supply for
each prescription and drugs must be on the preferred drug list (PDL).
Members do not have a copayment for generic medications or brand
medications if a generic equivalent is not available. Members will pay the
full health plan contracted rate if they choose a brand drug that does have
a generic equivalent. If members have a prescription filled at a non-network
pharmacy, they must pay for the prescription at the time it is filled and
submit request for reimbursement. The health plan will consider payment
up to the contracted rate for that drug.
• Injectable Drugs provided in an office/clinic setting: The health
plan shall be responsible for reimbursement of injectable drugs obtained
in an office/clinic setting and to providers providing both home infusion
services and the drugs and biologics. The health plan shall require that all
professional claims contain NDC coding and unit information to be paid for
home infusion and J codes.
Services reimbursed by the health plan shall not be included in any pharmacy
benefit limits established for pharmacy services. The PDL and Prescription
look-up tool can be found at UHCCommunityPlan.com.
Durable Medical Equipment
As medically necessary. Specified DME services shall be
covered/non-covered in accordance with rules and regulations.
Medical Supplies
As medically necessary. Specified medical supplies shall be
covered/noncovered in accordance with rules and regulations.
Emergency Air and Ground
Ambulance Transportation
Speech Therapy*
Covered as medically necessary by a Licensed Speech Therapist to
restore speech (as long as there is continued medical progress) after a
loss or impairment. The loss or impairment must be the results of a stroke,
accidental injury, or surgery to the head or neck.
Occupational Therapy*
Covered as medically necessary when provided by a
Licensed Occupational Therapist to restore, improve, or
stabilize impaired functions.
Physical Therapy*
Covered as medically necessary when provided by a Licensed Physical
Therapist to restore, improve, or stabilize impaired functions.
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Service
Benefit Limit
Organ and Tissue Transplant and Donor
Organ Procurement
All medically necessary and non-investigational/experimental organ and tissue
transplants, as covered by Medicare, are covered. Unless noted below,
the services of United Resource Network (URN) must be used and a prior
authorization is required, please contact Provider Service for assistance.
Example of transplants include:
• Bone marrow/Stem cell;
• Cornea; (Do not require a prior authorization or the services of URN)
• Heart;
• Heart/Lung;
• Kidney;
• Kidney/Pancreas;
• Liver;
• Liver/Small bowel;
• Lung;
• Pancreas; and
• Small bowel
Reconstructive Breast Surgery
Coverage of all stages of reconstructive breast surgery on a diseased
breast as a result of a mastectomy, as well as surgical procedures on the
non-diseased breast to establish symmetry between the two breasts in the
manner chosen by the physician.
Chiropractic Services
Allowed with a UnitedHealthcare prior authorization. A network provider
must contact UnitedHealthcare in advance to request the prior authorization
to a chiropractor.
Benefits are covered for therapeutic application of chiropractic manipulative
treatment rendered to restore/improve motion, reduce pain and improve
function in the management of an identifiable neuromusculoskeletal condition.
Coverage is not available for health-related services which do not seek to
cure, or which are provided during periods when the medical condition of the
patient who requires the service is not changing.
*Maximum 60 combined outpatient treatment days per calendar year per disability.
Exclusions and Limitations
guidelines, to assist clinicians in making informed
decisions in many health care settings, including
acute and sub-acute medical, rehabilitation,
skilled nursing facilities, home health care
and ambulatory facilities.
There are exclusions and limitations to the
UnitedHealthcare hawk-i covered services.
Contact provider service to verify coverage. The
Coverage Policy Library can be located online
at UHCCommunityPlan.com. Select Billing and
Reference Guides from the left navigation buttons,
then click on Coverage Policy Library. In addition and
when appropriate, UnitedHealthcare uses Milliman®
Care Guidelines®, which are nationally recognized
clinical
Emergency Transportation
UnitedHealthcare hawk-i benefits provide for
emergency transportation. Non-emergent (routine)
transportation is not a covered benefit.
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Coverage of Abortions
Documentation Required
for Claim Payment
The health plan covers abortions pursuant to
applicable federal and state laws and regulations.
Please submit medical records detailing the
procedure with the claim. This will facilitate faster
claims payment. When coverage requires the
completion of a specific form, the form must be
properly completed as described in the instructions
with the original form maintained in the member’s
medical file and a copy submitted to the health plan.
Abortions Absolute
• State medical necessity form
• Documentation (police report statement from rape
crisis centers) to support necessity form
Abortions, Suspect or Missed
• Ultrasound report or physician’s
documentation report
Required forms for abortions are available online
• History and physical (documentation of ultrasound,
history of bleeding, open os, etc.)
Under the Hyde Amendment, the health plan is
permitted to provide reimbursement for abortions only
when one of the following circumstances is present:
• Operative report
• Pathology report
• There is credible evidence to believe the pregnancy
is the result of rape or incest.
• The abortion is medically necessary because
the mother suffers from a physical disorder,
physical injury, or physical illness, including a lifeendangering physical condition caused or arising
from the pregnancy itself, that would place the
woman in danger of death unless an abortion
is performed.
A “Certification of Medical Necessity for Abortion”
form must be completed by the physician. This
form along with supporting documentation must be
attached to the claim form.
29
Member Rights and Responsibilities
Member Rights and Responsibilities
• Be free from any form of restraint or seclusion
used as a means of coercion, discipline,
convenience or retaliation.
UnitedHealthcare hawk-i Members have the right to
timely, high quality care, and treatment with dignity
and respect. Network providers must respect the
rights of all UnitedHealthcare hawk-i Members.
Following are the member rights and responsibilities,
as provided in the Member Handbook.
• Get a copy of your child’s medical record, talk
about it with your child’s doctor, and to ask,
if needed, that your child’s medical record be
amended or corrected.
• Have your child’s medical record be kept private,
shared only when required by law or contract or
with your approval.
You and your child have the right to:
• Receive information about UnitedHealthcare, its
services, the doctors providing the care, and
member rights and responsibilities in a manner and
format that is easily understood.
• Receive respectful care in a clean and safe
environment free of unnecessary restraints.
• Receive information about physician incentives.
• Participate in decisions regarding your child’s
health care.
• Make an advance directive.
• Be told by your child’s doctor what is wrong, what
can be done and what the likely result will be in a
language you understand.
You and your child have a responsibility to:
• Learn about available options and alternatives to
treat your child.
• Give information that UnitedHealthcare and
your child’s doctor need to give proper care to
your child.
• Voice complaints or appeals about
UnitedHealthcare and the care we provide.
• Listen to the doctor’s advice, follow instructions
and ask questions.
• Suggest changes to UnitedHealthcare’s member
rights and responsibilities.
• Understand your child’s health problems and work
with your child’s doctor to develop treatment goals.
• Be cared for with respect and dignity, without
regard for health status, physical or mental
handicap, sex, race, color, religion, national origin,
age, marital status, or sexual orientation.
• Work with your child’s doctor to guard and improve
your child’s health.
• Find out how your child’s health care system
works by reading this member handbook and other
member materials.
• Be told where, when and how to get the services
you need from UnitedHealthcare.
• Go back to your child’s doctor or ask for a second
opinion if your child does not get better.
• Get a second opinion about your child’s care.
• Give your OK to any treatment or plan for your
child’s care after that plan has been fully explained
to you.
• Treat health care staff with respect you
expect yourself.
• Tell us if you have problems with any health
care staff.
• Refuse care for your child and be told what you
may risk if you do.
30
• Keep your child’s appointments. If you must cancel
or reschedule, call the doctor as soon as you can.
and ethnic backgrounds. Network providers must
cooperate with UnitedHealthcare in meeting
this obligation.
• Use the emergency room only for real emergencies.
UnitedHealthcare does not reimburse for translation
services for hawk-i members in the provider office
setting. Providers are responsible for offering
these services without charge to the member and
should not be billed to UnitedHealthcare. This is a
requirement under Title VI of the federal regulations.
• Call your doctor when your child needs medical
care, even if it is after office hours.
• Follow the rules and limitations that are explained
in this member handbook and the Evidence
of Coverage.
• Contact only UnitedHealthcare hawk-i network
providers to arrange medical care when needed.
Disease Management Member Rights
and Responsibilities
As a member of the health plan, members also have
certain rights and responsibilities specific to disease
management services they receive.
• Get a prior authorization for referral services, when
needed, as explained in your member handbook.
• Comply with the limits of the prior authorization.
• Carry and use your child’s member ID card. Always
identify your child as a UnitedHealthcare hawk-i
member before receiving medical care.
Disease Management Member Rights
1. Upon request, have access to information about
the organization’s disease management programs
and services, including those provided by a
vendor, its staff and its staff ’s qualifications and
any contractual relationships.
One of the most important responsibilities you
have is to use network providers.
The only exceptions to this rule are:
• When your child received a prior authorization from
UnitedHealthcare after working closely with their
network provider on needed care.
2. Members may decline participation or disenroll
(opt out) from disease management programs
by contacting the health plan’s disease
management department.
• When the situation is a medical emergency.
3. Members have the right to know which staff
members are responsible for managing disease
management services for the individual patient.
Remember that not all network providers in your
community are contracted with UnitedHealthcare
hawk-i. You can call the customer service number
listed on your child’s member ID card or go to
UHCCommunityPlan.com to find out if a doctor is in
the UnitedHealthcare hawk-i network.
4. Members will receive support from the health plan
in making decisions with their treating providers
regarding health care.
5. Members have the right to information, in
an understandable form, about all disease
management-related treatment options included in
provider practice guidelines, whether or not they
are covered under the member’s benefit plan, and
are encouraged to discuss treatment options with
their treating providers.
Services Provided in a Culturally
Competent Manner
UnitedHealthcare is obligated to ensure that services
are provided in a culturally competent manner to
all Members, including those with limited English
proficiency or reading skills, and diverse cultural
31
e. Obtain recommended screenings according to
the disease-specific standards of care.
6. Member’s personal identifiable data and medical
information will be kept confidential in accordance
with applicable law.
f. Have a primary care provider that plans and
coordinates your care.
7. Members will be treated privately, with courtesy
and respect.
g. Know the goals and targets you have agreed to
with your physician; know your current status
in order to make lifestyle modifications to meet
those goals and targets.
8. Members have the right to file a complaint
according to the procedure as set forth in the
appropriate benefit plan documents if they
experience a problem with any service, provider,
or with the organization.
h. Actively participate in your disease management
program by following prescribed treatments
and recommendations, reading and applying
written and verbal information provided to you,
and giving feedback to the disease management
staff and your treating provider regarding your
progress.
9. Members may have the organization act as a
patient advocate.
Disease Management
Member Responsibilities
1. Provide, to the extent possible, information needed
by professional staff in order to provide disease
management services for the member.
3. Inform all providers providing your care of
treatments and recommendations you are receiving
from other providers.
2. Following instructions, advice and guidelines
agreed upon with those providing your health
care and disease management services. The
instructions may include but are not limited to
the following:
a. Follow exercise and dietary prescriptions
b. Daily monitoring (e.g., blood glucose
monitoring, peak flow readings, blood
pressure) as prescribed.
c. Consistent use of prescribed medications.
d. Schedule and keep follow-up appointments.
32
Care After Hours
In the event of a medical emergency, a member
should seek care from the nearest doctor or hospital.
If the member has questions or needs medical
advice, they may contact OptumHealth NurseLine.
OptumHealth NurseLine Services
OptumHealth NurseLine is a service that gives
medical facts and access to health information.
NurseLine can be accessed 24 hours a day by calling
877-244-0408 and TDD (Hearing-Impaired) 711.
OptumHealth NurseLine can provide:
• Help to avoid unnecessary emergency room visits.
• Guidance to callers on appropriate
treatment settings.
• Education about the importance of healthy
lifestyle choices.
33
Health Services
Treatment Philosophy
If you need to recommend a member to a
specialist for medically necessary services, and
UnitedHealthcare does not have the needed
specialist in-network, or, should the member feel that
an in-network specialist does not meet their needs;
you must first receive approval from UnitedHealthcare
to recommend an out-of-network specialist.
Emergency services never require prior authorization.
The health plan encourages prevention and early
treatment of illness for its members and is committed
to creating and maintaining relationships with its
network providers. The health plan has established
and made available assessment, treatment planning,
and documentation guidelines and has adopted
practice guidelines to assist the providers. These
assessment guidelines recognize the importance of
a thorough assessment to screen for medical and
behavioral disorders.
Women can choose any of our network OB/GYN
or midwives to deal with women’s health issues.
Women can have routine check ups, follow-up
care if there is a problem, and regular care
during pregnancy.
Primary Care Provider
(PCP) Responsibilities
UnitedHealthcare works with members and
providers to ensure that all participants understand,
support, and benefit from the primary care case
management system.
The PCP acts as the medical home for members.
PCPs coordinate members’ medical care with all
other health care professionals and services.
Responsibilities of the PCP
Role of the PCP
In addition to the requirements applicable to all
providers (see Network Provider Requirements), the
responsibilities of the PCP include:
The PCP plays a vital role as a physician case
manager in the UnitedHealthcare system by
improving health care delivery in four critical
areas—access, coordination, continuity, and
prevention. The PCP is responsible for the provision
of initial and basic care to members, makes
recommendations for specialty and ancillary care,
and coordinates all care delivered to members.
The PCP must provide 24/7 coverage and backup
coverage when he or she is not available. The PCP is
the point of entry into the delivery system, except for
emergencies and out-of-area urgent care services.
UnitedHealthcare expects PCPs to communicate with
specialists the reason for the necessity of specialty
services by way of a prescription or note on their
letterhead. UnitedHealthcare also expects PCPs
to note the reason for the recommendation in the
patient’s medical record. UnitedHealthcare expects
a specialist to communicate to the PCP significant
findings and recommendations for continuing care.
• Offer access to office visits on a timely basis, in
conformance with the standards outlined in the
Timeliness Standards for Appointment Scheduling
section in this manual.
• Conduct a baseline examination during the
member’s first appointment.
• Treat general health care needs of members. Use
nationally recognized clinical practice guidelines
as a guide for treatment of important medical
conditions. Guidelines can be found in the
Preventive Health & Clinical Practice Guidelines
section of this manual.
34
• Coordinate each member’s overall course of care.
• Take steps to encourage all members to receive
all necessary and recommended preventive health
procedures in accordance with the Agency for
Healthcare Research and Quality, US Preventive
Services Task Force Guide to Clinical Preventive
Services, http://www.ahrq.gov/clinic/uspstfix.htm.
• Be available to members by telephone 24 hours
a day, 7 days a week, or have arrangements for
telephone coverage by another UnitedHealthcare
network PCP. No recorded messages
are permitted.
• Make use of any member lists supplied by the
health plan indicating which members appear to be
due preventive health procedures or testing.
• Respond to after-hour patient calls within 30–45
minutes for non-emergent symptomatic conditions
and within 15 minutes for emergency situations.
• Be sure to timely submit all accurately coded claims
or encounters to ensure member preventive health
lists or the PCP personal provider profile reports
are as accurate as possible.
• Educate members about appropriate use of
emergency services.
• Discuss available treatment options and alternative
courses of care with members.
• Understand PCP Provider Profiling reports and use
them to help determine what areas of practice may
need to be strengthened as compared to peers.
Profiles are already risk adjusted for the age, sex
and patient health.
• Refer services requiring prior authorization to the
Pre-Certification Department, Behavioral Health,
or Pharmacy as appropriate.
• Inform UnitedHealthcare Care Management of
any member showing signs of End Stage
Renal Disease.
• For questions related to profiles, member lists,
practice guidelines, medical records, government
quality reporting, HEDIS, etc., call Provider Services.
• Admit UnitedHealthcare members to the hospital
when necessary and coordinate the medical care
of the member while hospitalized.
• Provide all EPSDT services to members up to
21 years.
• Respect the Advance Directives of the patient
and document in a prominent place in the medical
record whether or not a member has executed an
advance directive form.
• Screen UnitedHealthcare members for behavioral
health problems, using the Screening Tool for
Chemical Dependency (a.k.a. Substance Abuse)
and Mental Health. File the completed screening
tool in the patient’s medical record.
• Provide covered benefits in a manner consistent
with professionally recognized standards of health
care and in accordance with standards established
by UnitedHealthcare.
• Make recommendations to network specialists
for health problems not managed by the PCP.
The PCP completes a prescription or a note
on a letterhead indicating the reason for the
recommendation and assists the member in making
an appointment. No formal referral form is required.
The prescription note will suffice.
• Document procedures for monitoring patients’
missed appointments as well as outreach attempts
to reschedule missed appointments.
• Transfer medical records upon request. Copies of
members’ medical records must be provided to
members upon request at no charge.
• Document the reason for a specialist
recommendation and the outcome of the specialist
intervention in the member’s medical record.
35
Communication With PCPs
and Other Health Care
Professionals - Behavioral Health
• Allow timely access to UnitedHealthcare member
medical records as per contract requirements for
purposes such as: medical record keeping audits,
HEDIS or other quality measure reporting, and
quality of care investigations. Such access does
not violate HIPAA regulations.
To appropriately coordinate and manage care
between behavioral health care clinicians and medical
professionals, the health plans asks that clinicians
attempt to obtain the member’s consent to exchange
treatment information with medical care professionals
(e.g., primary providers, medical specialists) and/or
other behavioral health care clinicians (psychiatrists,
therapists). Coordination and communication should
take place at: the time of intake, during treatment, the
time of discharge or termination of care, and between
levels of care.
• Maintain staff privileges at a minimum of one
UnitedHealthcare network hospital.
• Report infectious diseases, lead toxicity, and
other conditions as required by state and local
laws and regulations.
Coordination With Other
Service Providers/Contractors
The coordination of care between behavioral health
care clinicians and medical care professionals
improves the quality of care to our plan participants in
several ways:
Your office may contact dental, vision, pharmacy, and
mental health/substance abuse services directly on
behalf of the member, or you may contact Provider
Services for assistance with coordination, as needed.
Contact information for other covered services is
located in the front of this manual.
• Communication can confirm for a primary physician
that his or her patient followed through on a referral
to a behavioral health professional.
Coordination of care between physical, mental
health, and substance abuse providers is important
for improved outcomes in treatment. Providers
should evaluate individuals in their care for other
health care needs and refer as appropriate. If
referral information to other providers is needed,
providers may contact Provider Service. Referrals
to other providers should include, at a minimum,
the individual’s identifying information, the reason(s)
for the referral, medication(s) the individual is
currently being prescribed, diagnosis(es), current
course of treatment, and any other pertinent
information deemed appropriate by the referring
provider. All referrals should be documented in the
member’s chart.
• Coordination minimizes potential adverse
medication interactions for member’s prescribed
psychotropic medication.
• Coordination allows for better management
of treatment and follow up for members with
coexisting behavioral and medical disorders.
• Continuity of care across all levels of care and
between behavioral and medical treatment
modalities is enhanced.
• For members with substance abuse disorders,
coordination can reduce the risk of relapse.
36
The following guidelines are intended to facilitate
effective communication:
During the diagnostic assessment session, request
the patient’s written consent to exchange information
with all appropriate treatment professionals.
Following the initial assessment, provide other
treating professionals with the following information
within two weeks:
• Summary of patient’s evaluation.
• Diagnosis.
• Treatment plan summary (including any
medications prescribed).
• Primary clinician treating the patient.
• Update other behavioral health clinicians and/or
primary or referring physicians when the patient’s
condition or medications change.
At the completion of the treatment, send a
copy of the termination summary to the other
treating professionals.
• Attempt to obtain all relevant clinical information
that other treating professionals may have
pertaining to the patient’s mental health or
substance abuse problems.
Some members may refuse to allow for release of
this information and this decision must be noted in
the clinical record. Both accreditation bodies and the
health plan expect all clinicians to make a “good faith”
effort at communicating with other behavioral health
clinicians and any medical care professionals who are
treating the plan participant.
37
Prior Authorization Guidelines
Services That Require
Prior Authorization and
Contact Information
Non-urgent prior authorization requests must contain
the documentation required for each particular
procedure or device. Once all documentation has
been received, notification of the decision will be
made to the Provider within 14 calendar days.
Urgent pre-service requests will be decided and
communicated within 72 hours.
You may also contact Provider Services to request
a current list of services that require prior authorization
and a list of codes. Prior Authorization forms can be
found online at UHCCommunityPlan.com.
In the event of an adverse decision, the Provider may
discuss the case with the Medical Director, and the
member has the right to appeal as outlined in their
member handbook. For any benefit question, please
contact Provider Service at 888-650-3462.
Service Needed
Behavioral Health and Substance Abuse
Go to www.liveandworkwell.com for information about Behavioral Health services
Call 800-510-5145
Medical Services
Call 888-650-3462
Go to www.UHCCommunityPlan.com for the Coverage Policy Library, which
includes services that require prior authorization.
• Chiropractic
• Cosmetic and Reconstructive Surgery
• Durable Medical Equipment and Supplies
• Home Health
– Medication or Infusion
– All other
• Hospice
• Hospital Inpatient
– Acute
– Sub-acute
• Abortion
• Non-Contracted Provider Services (Hospital and Professional)
• Prosthetics and Orthotics
• Skilled Nursing Facility
• Transplant
• Medical Injectables Including but not Limited to
– Acthar HP
– Botulinum Toxins
– Immune Globulins
– Makena
Call 800-310-6826 or fax requests
to 866-940-7328
Pharmacy
The PDL can be found at UHCCommunityPlan.com
38
Referral Procedure
**A referral does not guarantee payment of a claim.
Certain procedures and DME equipment require
prior authorization and benefit determination as
outlined in the member’s Plan Document.
Out-of-Network Procedures for
Referral to Non-Network Providers
When services are not available from a network
physician, prior authorization for a referral to
non-network physicians or facilities is required. The
health plan must be advised of all requests for prior
authorizations (except emergencies). In the case of
emergencies, the health plan must be notified the
first working day following referral. Prior authorization
for extensions must also occur as described above.
Prior authorization is required for each follow up visit
unless otherwise indicated.
Network physicians must arrange for care by
non-network physicians or facilities prior to the
service, except in emergencies or accidents. If a
member requests authorization after the fact, please
advise them that this is against policy and refer them
to the health plan if they have further questions.
39
Medical Record Charting Standards
Medical Record Charting Standards
• Working diagnosis(es) must be documented and
must be consistent with findings.
• All pages of the record must contain patient
identification (name and identifying number).
• Plans of action/treatment must be consistent
with diagnosis(es).
• The record must contain biographical/personal
data, such as age, date of birth, sex, race/ethnicity,
and marital status/social supports as well as a
notation of cultural/linguistic needs.
• Episodes of emergency care, hospitalizations
and discharge summaries must be documented,
including follow-up care, such as home health
visits, physical therapy reports, etc.
• Each entry must have provider name, initials, or
other identification (even for solo practitioner sites).
• Each encounter must include documentation of
clinical findings and evaluation, as well as a followup plan, such as date for return visit.
• Each entry must be dated and signed.
• The record must be legible, as judged by the
auditor (illegibility of records may result in the need
for provider assistance in completing the audit).
• Each encounter must present evidence that
unresolved problems from previous visits have
been addressed.
• The record must contain a completed, up-to-date,
problem list and a list of all prescribed medications.
• Consultations documented in the record must be
appropriate given patient characteristics, history,
and presenting problems.
• Allergies and adverse reactions to medications
must be prominently displayed for patients of all
ages. Document even if no allergies exist.
• The record must document appropriate
coordination of care between the PCP and
authorized specialty physicians.
• The record must contain an appropriate and
organized medical history and physical exam.
• Consultant summaries, lab reports, imaging study
reports, operative procedures, and tissue excisions
must be noted in the chart or otherwise reflect
physician review.
• Preventive services/risk screenings must be
appropriately used and documented.
• Pediatric charting must contain a completed
immunization record and BMI charting and
anticipatory guidance documentation.
• Care must be medically appropriate.
• The record must document efforts to educate
patients, including lifestyle counseling, and disease
specific education.
• Adolescents should be screened for and counseled
on depression, substance abuse, tobacco use,
sexual activity, exercise and nutrition.
• Records should reflect the patient’s
advance directives.
• The record must document smoking habits
and history of alcohol and substance use:
negative histories also must be noted. If the
history is positive for any of these habits,
document advice to quit.
• Providers are to maintain an organized medical
record keeping system and standards for the
availability of medical records and medical
record retention.
• Lab and other studies must be signed
and documented.
• Providers are to maintain the confidentiality of all
medical records in accordance with any applicable
statutes and regulations.
• Notes must be appropriate in presenting a
problem or complaint.
40
• All medical records are to be stored securely.
Only authorized personnel are to have access to
the records and all staff should receive periodic
training on maintaining confidentiality of
member information.
• Treatment involving the care of more than
one member of a family should have separate
treatment records for each identified and
diagnosed member and billing records should
reflect the plan participant who was treated
and the modality of care.
• Problem list.
• Medication list.
• Policy for monitoring and addressing
missed appointments.
• Clinical tools for flow sheets for patients with
chronic conditions. Does the record contain
practice guidelines, prescription printouts with
safety warnings, flow sheets for monitoring diabetic
labs, etc. for patients with chronic conditions.
41
Member Access and Availability
that could seriously jeopardize the life or health
of the member or the member’s ability to regain
maximum function, based on a prudent layperson’s
judgment, or in the opinion of a practitioner with
knowledge of the member’s medical condition,
would subject the member to severe pain that
cannot be adequately managed without the care or
treatment that is the subject of the request.
The health plan has established standards for the
access and availability of network primary care,
designated specialty care practitioners and provider
services, as necessary to meet the health care
needs of the member population or demographically
significant sub-populations.
Health plan members expect, and should receive,
reasonable and timely access to health care from
network practitioners irrespective of physical, mental,
language, or cultural barriers. The health plan’s goal
is to select and retain practitioners and providers to
meet the medical health care needs of members.
• Emergency: A physical or behavioral condition
manifesting itself by an acute symptoms of
sufficient severity (including severe pain) that a
prudent layperson, who possesses an average
knowledge of health and medicine, could
reasonably expect the absence of immediate
medical attention to result in the following:
These standards allow for evaluation of practitioners’
performance in the area concerning accessibility of
appointments and scheduling times. These standards
allow for evaluation of the health plan’s performance
in the area concerning an adequate availability of
practicing practitioners and providers.
1. Placing the health of the individual (or with
respect to a pregnant woman, the health of the
woman or her unborn child) in serious jeopardy;
2. Serious impairment to bodily functions; or
3. Serious dysfunction of any bodily organ or part.
Access
Medical Appointment
Scheduling Guidelines
Accessibility guidelines are established to ensure
that members are provided with access to timely,
urgent, routine, and consult appointments, telephone
procedures, and after hours or emergent care.
• Preventive physical exam appointments on patients
with no acute problems should be scheduled within
3 weeks.
Each network practitioner/provider will provide or will
arrange to provide all necessary services to members
on a 24 hours a day, 7 days a week basis. Access
will be provided after hours through on-call coverage.
– Well childcare appointments within 3 weeks.
– General medical exams (including pelvic exams
with PAP smears) should be scheduled within
3 weeks.
• Preventive: Covered services for well exams
for adults and children and scheduled follow-up
exams. Patients are normally free of symptoms or
no acute symptoms.
– Mammograms should be scheduled within
3 weeks.
– Preventive Dental and Optometry care within
3 weeks.
• Routine: Non-urgent, non-emergent, medical or
behavioral health care.
– Lab and X-ray appointments within three
3 weeks.
• Urgent: Covered service for an illness or injury
manifesting itself by acute symptoms that are of
medical care or treatment for an illness or injury
42
• Appointments for urgent complaints that can
be handled in the office should be seen within
48 hours. Patient phones calls for urgent
complaints may result in either an appointment
to be seen within 48 hours or referral for telephone
follow-up.
• Patients scheduled for procedures (lab, X-rays)
are to be seen within 45 minutes of their
scheduled procedure.
• Emergencies are seen immediately, at the nearest
available facility, regardless of the contract.
Availability guidelines are established to meet the
health care needs of the member population or
demographically significant sub-populations.
Availability
• Referral appointments to specialty care (specialty
care includes, but not limited to: specialty
practitioner, specialty facilities, hospice care,
home health care, rehabilitation/skilled) shall not
exceed 30 days for routine care or 48 hours for
urgent care.
Availability Standards are:
• PCP and/or Extender:
– Not to exceed 30 miles (one way) or 30 minutes.
• Specialty care:
• Routine care (non-urgent, non-emergent,
symptomatic conditions) appointments with
PCP should be scheduled within three
3 weeks.
– Travel distance does not exceed 60 miles.
• 1 Hospital:
– Not to exceed 30 minutes.
• Access will be provided after hours through
on-call coverage.
• General Optometry Services:
Waiting Time Guidelines
• Lab and X-ray:
• A practitioner or his/her designee should be
available 24 hours a day, 7 days a week for
emergency care.
• Pharmacy within 30 minutes.
Continuity and Coordination of Care
• After-hours calls to the answering service for urgent
problems are to be returned within 15 minutes or
as soon as possible.
Continuity and Coordination of Care is monitored in
the following areas:
• Non-urgent phone calls to the practitioner during
regular office hours are to be returned the same
day by the practitioner or designee. The practitioner
office staff should set an expectation with the caller
as to when the call will be returned.
• Mental health and substance abuse.
• Specialty care.
• Hospital.
• Home health and other ancillary providers.
• Urgent phone calls to the practitioner during regular
office hours are to be returned by the practitioner
or his staff designee as soon as possible.
• Transplant services.
• Health departments that provide care to members.
• Patients with scheduled appointments are to be
seen by the practitioner within 45 minutes of their
scheduled appointments.
• ER use review.
43
The PCP has the overall responsibility for the
continuity of patient care and should receive treatment
information and regular care updates from specialty
providers, including mental health and substance
abuse providers.
• Medical Record Review.
• Referral and prior authorization process.
• Disease management process.
• Access and availability process.
• Cultural/linguistics process.
Specialty providers have the responsibility to provide
regular care updates to the members PCP within the
guidelines of member’s confidentiality.
Continuity and coordination of care between
members and providers delivering specialty services
such as home health, health departments, Centers
of Excellence for transplants, tertiary care hospitals
and sub-acute facilities are monitored by the case
managers and regional Care Management (CM) staff.
Continuity of care is also monitored by ambulatory
medical record review, inpatient concurrent review,
and pharmacy claims data analysis.
Member complaint information, customer service
logs, network physician input, practitioner satisfaction
surveys, concurrent review, and case management
includes some element to monitor continuity of care,
and when opportunities for improvement occur,
the health plan staff work to create interventions to
improve processes.
The CM staff work closely with providers to ensure
there is the integration of physical, mental health,
and substance abuse care. Should providers
encounter difficulties in securing medically necessary,
covered services for health plan members, the
CM and Customer Service staff are able to assist.
These individuals can be reached by contacting
Provider Services.
Providers of physical health care are encouraged
to assess patients for mental health and substance
abuse problems and refer as appropriate.
Providers of mental health services should evaluate
members in their care for physical health and
substance abuse problems.
Substance abuse providers should evaluate for
physical health and mental health problems.
All providers should refer members for services as
appropriate and acceptable to the member.
44
Utilization Care Management Programs
Goal: The goal of the Utilization Management (UM)
Program is to assure that:
payment authorization for medications that require
prior authorization.
• Care provided is the right care, for the right patient,
at the right time.
UM decisions are based on the appropriateness
of the care and services as determined by national
guidelines for best practice taking into consideration
individual patient needs as appropriate. The health
plan does not compensate or reward UM reviewers
for denials of coverage. Nor do reviewers receive
financial incentives to influence UM decisions.
• Care is provided in the most appropriate setting.
• Care is provided is by the most
appropriate provider.
• To accomplish this goal, the processes must be
sound and the application of the processes must
be consistent.
Some services, which providers may recommend,
are not covered as part of the benefit package. If you
have questions about what services or treatments are
covered, contact Provider Services.
The health plan:
• Uses CM and continuums of care principles.
• Uses guidelines for care.
• Tracks medical utilization data.
Components of UM Program
• Follows guidelines as established by all applicable
regulatory and accrediting bodies including NCQA
and CMS.
Prior Authorization – A documented process
for authorizing out-of-network care at an in-network
level of benefits as determined by the member’s
benefit plan.
• Evaluates annually the effectiveness of the health
care management programs.
Inpatient Review – A process for reviewing the
appropriateness of admission to the hospital and
ongoing inpatient care.
• The health plan reports outcomes and customer
satisfaction using the standard measures
of Medicare, Healthcare Effectiveness Data
and Information Set (HEDIS) and Consumer
Assessment of Health care Providers (CAHPS)
and Systems.
Ambulatory Review – A process for evaluating
the appropriateness of services performed in the
ambulatory setting.
Confidentiality of Physician-Specific
Information – Physician-specific information
gathered during the UM processes is confidential
and will not be released to the public or the member
without written consent of the physician.
Network providers agree to comply with the health
plan’s medical policies, QI and Medical Management
programs, and ongoing Utilization Review Program.
Our philosophy is that medically appropriate care
is cost-effective care. Inappropriate denials of
coverage is more costly to the plan than coverage
for appropriate care. The health plan seeks to avoid
under and over utilization of medical services.
Organization and Responsibility – The
development and continued improvement of the UM
Program is the responsibility of the Health Services
Process. Responsibility for ongoing monitoring of the
application of the UM Program lies with the Chief
Medical Officer.
Only qualified physicians may issue UM denials.
Only registered pharmacists or physicians may deny
45
Authority for Medical
Management Decisions
Advance Directive
The patient Self-Determination Act requires that
HMO patient records (charts) note whether or not
an advance directive has been made. If the patient
has given the physician a copy, it should be filed in
the patient’s chart. A notation that the physician has
addressed advance directives should be present on
adult (age 18 and older) patient charts.
Criteria exist which may allow a Utilization Care
Manager (UCM) to approve payment for a
treatment, physician or location of treatment. The
ultimate authority, however, for any denial of a request
for payment lies with the Physician Advisor.
The attending physician has the ultimate authority
for the medical care of the patient. The medical
management process does not override this
responsibility. If there is disagreement regarding
the appropriate intensity or location of care, the
attending physician shall be allowed to care for the
patient without any encumbrances from the medical
management process.
Advance directives are also available for members to
specify their desires for behavioral health services.
These directives are called Declarations for Mental
Health Treatment.
Services Out of Network
Members must receive routine, preventive, and
scheduled care within the UnitedHealthcare hawk-i
provider network.
Peer Review Process
Peer review is an integral part of the CM Program.
The Medical Director reviews issues relating to
quality of care and patient safety. These issues are
reviewed on a case-by-case basis and takes into
consideration individual patient circumstances.
The peer review process recognizes best practice,
community standards of care, and the local health
care systems.
Out-of-network services are only covered if: an
emergency condition exists, or an approved prior
authorization has been granted.
• Notification from network providers pertaining to
such services received by the health plan must be
directed to Health Services.
• The health plan processes service requests
for treatment authorizations under the direction
of the network provider and out-of-network
attending physician.
Technology Review Process
The health plan has a Technology Assessment
Process in which to evaluate and address the safety,
efficacy, and appropriateness of emerging and new
medical/behavioral technologies, as well as keep
pace with changes to existing medical/behavioral
health technologies and to make recommendations
regarding their use for potential inclusion in the
benefit plan. This includes medical/behavior health
procedures, devices and selected pharmaceuticals.
If you have a technology that you would like to have
reviewed, please contact Provider Services.
• The health plan, in conjunction with the network
provider and the out-of-network doctor,
coordinates the member’s transfer back to the
UnitedHealthcare hawk-i network when medically
feasible as appropriate.
• The health plan provides coverage out-of-network
for urgent or emergent stabilization services. This
will include the time he/she is stabilized in the
emergency room, prior to admission as an inpatient
or discharge from the facility.
46
• The health plan also provides coverage for poststabilization care services. Post-stabilization
care services are those that are provided after
an enrollee is stabilized in order to maintain the
stabilized condition.
• Coverage from out-of-area inpatient services
continues only as long as the member’s condition
prevents transfer to a network hospital. Transfers
should occur within 48 hours of determination of
member’s transferability.
47
Timing of UM Decisions
Medical management decisions must be made in a
timely manner. The health plan’s turnaround times are
in compliance with federal and state regulations as
well as NCQA standards.
Concurrent Review – services requiring approval
for continued authorization of a previously approved,
ongoing course of treatment over a period of time or
number of treatments. Example: concurrent inpatient,
skilled, or rehabilitation review.
Every attempt will be made to insure that all
pre-service, concurrent, and post-service
authorization decisions are made with practitioners
and members notified according to the health plan’s
policy, regulatory, and external requirements.
Post-Service-Review – for services
already incurred.
Urgent Care – request for medical service in which
application of the non-urgent review time frames may
in the opinion of a practitioner with knowledge of the
member’s medical condition result in severe pain or
loss of function.
The final decision concerning admission, referral,
and the continued medical management of the
patient will be solely the responsibility of the
attending practitioner.
Medical Necessity Health Services
Physician Responsibility for
Adequate Provider Information
To be medically necessary the service or treatment
must meet the following criteria:
Adequate provider information must be provided
by the requesting provider’s office when making
UM requests.
1. Recommended by a licensed practitioner who is
treating the member or other licensed health care
provider practicing within the scope of his or her
license who is treating the member.
Provider information provided by the requesting
physician is the supporting documentation for
whether medical necessity can be justified. The
absence of complete and adequate provider
information at the time of request and review results
in increased administrative time and work for both the
physician office staff as well as for health plan staff
and reviewing physicians.
2. Required in order to diagnose or treat a member’s
medical condition.
3. Safe and effective.
4. Not experimental or investigational.
5. The least costly alternative course of diagnosis
or treatment that is adequate for the member’s
medical condition.
Service Definitions
The requesting physician may seek the opportunity
to discuss decisions with the physician reviewer by
calling the number listed on the coverage decision
letter. For additional information, see the Medical
Necessity section of this manual.
** The health plan has adopted the NCQA
service definitions.
Pre-Service – services requiring approval for
payment, either in whole or part, by the health plan
prior to the member receiving services. Example:
out-of-network referrals and prior authorization.
48
Criteria Used for Medical
Management Decisions
Reviewers for the health plan are allowed to make
decisions to approve care based on specific criteria.
These criteria are of two types:
Externally Developed Criteria
Nationally recognized review criterion is used to
guide the Utilization Care Manager in approving
inpatient care. Review criteria will be reviewed and
approved annually by the Chief Medical Officer.
Updates occur annually or as necessary or when
provided. Other criteria may be substituted when
there is published peer reviewed literature support for
admission or continued stay criteria. All criteria are
subject to the review and approval process.
Internally Developed Approval Criteria
The health plan may develop standards for medical
appropriateness (approval criteria) e.g., Level of
Care Guidelines. These guidelines are reviewed and
revised annually utilizing a literature review search
of new articles pertaining to levels of care as well as
input solicited from providers.
Medical necessity criteria are available to
network physicians upon request by contacting
Provider Services.
49
Medical Hospital UM
Admissions are usually reviewed on the first
working day following admission, using Milliman
Care Guidelines and taking the individual enrollee
circumstance into consideration. If admission or
continued stay does not meet criteria outlined in
the guidelines and the individual enrollee
circumstance, the nurse reviewer will refer the
case to the Medical Director.
documented quality of care or service or patient
safety issues as well as any system issues with care.
Individual patient or physician issues are reviewed on
case-by-case basis with the Medical Director.
System issues identified by Health Services staff or
the Medical Director are addressed with the individual
facilities as needed. The Provider Contracting
Department will consider this information during the
contracting process.
The role of the Medical Director is to review for
appropriateness of admissions and need for
continued stay, as well as the quality of care
being provided for those cases referred by a
nurse reviewer.
Inpatient Review Program
The inpatient review program is a review process in
which admissions and hospital stays are reviewed to
assure that inpatient care is medically appropriate; to
identify quality of care concerns and opportunities for
improvement; to detect and better manage over and
underutilization. Nurse reviewers also review certain
care aspects as they relate to disease management
programs and practice guidelines. Discharge
planning and care management identification also
occurs at this time.
The nurse should call the attending physician for
further information concerning the management/
treatment plan prior to review with the Medical
Director. If the Medical Director cannot justify the
care, the attending practitioner will be notified.
If the attending wants to speak with the Medical
Director, they will be afforded that opportunity
within one business day of the request. External
Independent Review will be obtained as determined
by the health plan or by member request according to
applicable State laws.
The health plan uses Milliman Care Guidelines for
review of inpatient confinements directed by network
and out-of-network physicians.
The ultimate decision regarding medical management
of a member is solely the responsibility of the
attending physician. An attending physician is
never told he/she must discharge a patient,
only that the admission/continued stay is not
determined to be medically necessary by the
health plan.
If an admission or continued stay is determined to
be medically unnecessary, coverage for those
services will not be eligible for authorization and
payment, and the physician education/sanction
process may be applied.
Notice of Termination of
Hospital Benefits
Hospital Review Process
Include but not limited to the following:
Concurrent hospital review addresses many aspects
of a patient’s medical care in the hospital. Nurses
review the hospital record for documentation related
to: medical necessity supporting the acute inpatient
level of care, potential quality of care concerns,
• Continued hospitalization is determined to be
medically unnecessary.
50
skilled rehabilitation services would meet the daily
basis requirement when he/she needs and receives
those services at least 5 days a week. Skilled
services, however, are required and provided at least
3 times per day. Although, the frequency with which a
service must be performed does not by itself, make it
a skilled service.
• Treatment occurs that is considered experimental/
investigational and is a non-covered benefit.
If any of the situations listed above occur, the
following procedures should be followed:
• Notify health plan UM immediately.
The health plan and hospital representatives
will deliver Notice of Termination of Benefits to
the member.
The nature and complexity of a service and the
skills required for safe and effective delivery of
that service is considered in determining whether
a service is skilled. Skilled care requires frequent
patient assessment and review of the provider course
and treatment plan for a limited time period, until a
condition is stabilized or a predetermined treatment
course is completed. Skilled care is goal-oriented to
progress the patient toward functional independence,
and requires the continuing attention of trained
medical personnel.
Admission to Skilled Nursing Units
**Inpatient hospitalization is not required for a
member to be admitted to a Skilled Level of Care.
An individual that may require inpatient skilled nursing
care is defined as having had an acute illness, injury,
surgery, or exacerbation of a disease process. Skilled
nursing care is rendered immediately after, or instead
of, acute hospitalization to treat one or more specific,
active, medical conditions or to administer treatments
that must be performed by licensed professional
health personnel. In addition, services must be
ordered by a physician and be reasonable and
necessary for the treatment of the patient’s illness or
injury, (i.e., be consistent with the nature and severity
of the individual’s illness or injury, his/her particular
medical needs, and accepted standards of medical
practice.) The services must also be reasonable
in terms of duration and quantity. The patient must
be clinically stable with provider and lab findings
improving/unchanged for the last 24 hours; and
diagnosis and initial treatment plan established prior
to admission to the skilled nursing facility.
• Prior authorization must occur on all admissions to
the skilled facility (or skilled level of care within an
acute facility). Initial certification for admissions will
be authorized based upon level of care required
based upon anticipated treatment plan. The facility
must submit documented plan of care including
treatment goals, summary of services provided,
expected length of stay (LOS), and initial
discharge plan.
• Concurrent review is conducted at least weekly, or
more often if indicated. The provider (skilled facility)
is responsible for providing appropriate/adequate
documentation including changes in the level of
care. Approval for additional days of authorized
coverage must be obtained prior to the expiration
of the authorization.
The patient must require skilled services on a
daily basis (i.e., available on a 24-hour basis,
7 days a week). If skilled rehabilitation services
are not available on a 7 day a week basis, a patient
whose inpatient stay is based solely on the need for
51
• Determinations regarding levels of care must
consider not only level of service but also medical
stability of the patient. Disagreements regarding the
level of care required are discussed by the health
plan Chief Medical Officer or Medical Director in
consultation with the attending physician (managing
the patient in the skilled facility, not the transferring
attending physician). The appeal procedure can be
initiated as desired by the patient and/or authorized
representative when coverage is not authorized by
the health plan.
52
Care Management
Transplant
The Care Management Program provides
coordination of care for patients with complex,
chronic, or critical health care needs. EPSDT
services are also a focus of the Care Management
program. The program assists families, patients, and
doctors in planning care and services. This is part
of a team plan, which looks at individual health care
needs. Care Managers assist members and their
families by analyzing all options/choices available to
them within the health care delivery system.
Care management uses a proactive approach in
assisting patients and families with coordination of
transplant services.
This approach supports screening assessment and
development of an individualized treatment plan. The
primary objective is to ensure quality care in a costeffective manner through our Centers of Excellence.
These Centers of Excellence have been evaluated for
quality of care. The criteria addressed includes, but
is not limited to, volume, rejection protocols, survival
rates, and Quality Management Programs. Each
program is reviewed annually to assess continuing
compliance with criteria.
Care Managers contact these members by phone
to work cooperatively and effectively with patients
for whom some form of behavioral change and
motivational interviewing might result in better health
outcomes. The intended outcome is to empower
members to better manage their chronic conditions
and improve their use of clinical, caregiver/family
and community resources to improve their health
outcome. The role of the Care Manager is intended
to support the care prescribed for the member by the
attending physician.
Their health problems can cut them off from family,
co-workers and friends. A cycle of isolation,
depression, and a deterioration of their health
frequently sends them into a downward trend. In
a combined effort of the Care Manager, and in
collaboration with the member’s PCPs, members are
supported in ways that make the most difference to
their health. All home services must be ordered by
a physician and prior authorized before services
are rendered.
53
Disease Care Management
The health plan has developed several Disease
Care Management Programs which include a
coordinated system of health care interventions and
communications for populations with specific health
care needs. These programs help our members
better understand their conditions, provide self-care
tips, and give updates on new information about
certain diseases and preventive care. Physicians
provide input into our health management programs
to ensure that they are based on current medical
practices. Nurses manage the programs and work
with members by providing educational mailings,
newsletters, and reminder cards. Physicians also
receive information about their patients and the
services they are receiving. Participation in health
programs is voluntary.
Disease Care Management Programs include:
• Asthma.
• Diabetes.
• Pregnancy Management (Healthy First Steps).
• Weight Management.
For more information, go to UHCCommunityPlan.com.
54
Preventive Health and Clinical Practice Guidelines
Preventive Health Care Standards
(EPDST): Early and Periodic
Screening, Diagnosis, and Treatment
of Children Under Age 21
UnitedHealthcare’s goal is to partner with providers
to ensure that members receive preventive care.
Screening, diagnostic and follow-up treatment
services are covered when medically necessary in
agreement with federal regulations, including rules
and regulations, policies and procedures, and federal
requirements as described in 42 CRF Part 441,
Subpart B, and the Omnibus Budget Reconciliation
Act of 1989 for members under 21.
UnitedHealthcare endorses and monitors the practice
of preventive health standards recommended by
recognized medical and professional organizations.
Preventive health care standards and guidelines
are available at UHCCommunityPlan.com or can be
viewed at www.ahrq.gov/.
UnitedHealthcare monitors the provision of these
services through chart reviews and also through a
provider profiling system highly dependent on the
accuracy of the PCP’s submissions of claims and
encounters. Such things as: well child, adolescent
and adult visits, childhood and adolescent
immunizations, lead screening, and cervical and
breast cancer screening are included. The profile
is risk adjusted for the members’ comorbidities in
order to also profile on hospital, emergency room,
specialist and pharmacy utilization.
All children and teens under 21 should receive
regular checkups. These checkups help find health,
speech, hearing, vision, dental, mental health, and
drug or alcohol problems. UnitedHealthcare pays for
medicine and treatments needed.
Members under the age of 21 may be referred for
behavioral health services as a result of the EPSDT
screening by a health care professional. Behavioral
health providers will provide diagnostic and treatment
services in accord with the EPSDT screening or
diagnosis findings.
Clinical Practice Guidelines
for Chronic Conditions
In the event that a member under 16 years of age is
seeking behavioral health services and the member’s
parent(s), or legally appointed representative is
unable to accompany the member to the assessment,
the provider shall contact the member’s parent(s),
or legally appointed representative to discuss the
findings and inform the family of any other necessary
behavioral health treatment recommended for the
member. If the provider is unsuccessful in contacting
the parent(s) or legal representative, the provider
must inform the health plan to contact the parent(s) or
legal representative.
UnitedHealthcare strongly supports
evidence-based medicine and we have identified
sources that have received national recognition
both from the government and the health care
community. We have vetted these sources within
the UnitedHealth Group and our own network
advisory committees. Providers are encouraged
to visit the following websites for clinical practice
guidelines as they are intended as an important
resource to support and guide your clinical decision
making. Clinical Practice Guidelines can be viewed
55
Periodicity Schedule for
Check-ups and Screenings
No prior authorization is required for
screenings, members must receive services
from a network provider, for completion of the
exam or for treatment of problems discovered
during the exam.
Any time a member is in your office, you should
ask if they have had their age-appropriate physical
for that year. If they have not, this examination
should be performed, including any necessary
immunizations. A Women, Infants, Children (WIC)
visit is not considered a Care for Kids visit. It is
also very important that delivery of these services is
documented in the patient’s medical record.
The health plan sends each eligible member
reminders to schedule an exam. Please help
us assist our members in obtaining their
well-visit exams.
Infancy
Early Childhood
Middle Childhood
Adolescence
At birth
15 months old
5 years old
12 years old
2-4 days
18 months old
6 years old
14 years old
1 month old
24 months old
8 years old
16 years old
2 months old
3 years old
10 years old
18 years old
4 months old
4 years old
20 years old
6 months old
9 months old
12 months old
Recommended Childhood
Immunization Schedules
Government Quick Reference Guide:
http://www.cdc.gov/vaccines/recs/schedules/childschedule.htm#printable
The childhood and adolescent immunization schedule
for 2013 have been approved by Advisory Committee
on Immunization Practices (ACIP), American
Academy of Family Physicians (AAFP), and the
American Academy of Pediatrics (AAP).
Source: AAFP, CDC and Advisory Committee on
Immunization Practices
Medical Record Requirements
Government Childhood and
Adolescent Immunizations Guide:
There are specific components of screening
examinations that must be documented in the medical
record. Details regarding these components are
listed in the Medical Record Review section of this
provider manual.
www.cdc.gov/vaccines/recs/schedules/childschedule.htm
http://www.aafp.org/online/en/home/clinical/
immunizationres.html?navid=immunizations
56
Network practitioner’s office medical records will
be reviewed against the recommended components
of EPSDT exams. The health plan will utilize the
Audit Form for the office medical record review.
Offices are selected for audit based upon the
services billed by the Provider under defined service
codes. These codes are listed in the Billing section
of this provider manual.
Developmental Screening Component
Documentation of a visit should include a description
of the developmental behavioral screening method
used. When validated developmental screening
tests are performed in addition to the preventative
medicine service or other services, providers can
report CPT code 96110 in addition to the Preventive
Medicine Service. Examples listed in CPT include
the Denver II and the Early Language Milestones
Survey. This service is reported in addition to the
Preventive Medicine and other evaluation and
management or screening services (hearing, vision,
and laboratory) performed during the same visit.
Informal developmental checklists are considered
part of the history of the preventive medicine visit and
not reported and billed separately.
You must have a process for documenting services
declined by a parent, guardian, or mature competent
child. This documentation must include the particular
service declined, a notation of the reason why it was
declined, and whether another appointment was
offered to get the service.
If you are unable to complete all components of a
exam, or if additional questions or concerns remain
after a screening, please schedule a follow-up
appointment for the child.
Children may receive immunizations at the local
health department rather than in a provider’s office.
Administration of the immunization must be included
in the chart. The documentation should be a print-out
from the health department. This information should
include the vaccine administered, site, date, lot
number, and any reactions noted.
NOTE: Verbal reporting from a parent or
guardian is not adequate confirmation of
administered immunizations.
57
Practitioner Education – Sanction Policy Summary
be referred to the Provider Advisory Committee
between recredentialing cycles. Practitioner issues
are taken into consideration when deciding on
continued participation. Any issues warranting
restricting privileges will be referred to the
Credentialing Committee.
The Practitioner Education/Sanction Policy
has been developed to ensure physical health
practitioner compliance with utilization and quality
management policies and procedures. Practitioners
not in compliance with standards of care or policies
and procedures will be advised of the areas of
noncompliance and will be notified of their right
to appeal.
Following is a list of potential actions that may be
exercised in the issuance of a sanction in any of the
aforementioned categories: Administrative, Utilization,
Quality of Practitioner Service, Quality of Care and
Professional Conduct.
The categories subject to sanctions include:
• Administrative.
• Utilization.
Appropriate education/sanction actions may
include but are not limited the following:
• Quality of Practitioner Service.
• Quality of Care.
• Notification and education regarding
the occurrence(s);
• Professional Conduct.
• Educational material from other providers,
or literature references;
The Chief Medical Officer and Medical Director
have the authority to recommend: monetary and
non-monetary sanctions and/or to place a practitioner
on focused review.
• A documented plan for improvement from
the practitioner;
• Focused review of the practitioner’s practice;
If there is a recommendation to terminate a
practitioner for conduct falling within the scope of this
policy, it must be issued by the Chief Medical Officer
or Medical Director.
• Additional training and/or mandatory Category 1
CME. All expenses associated with training and
CME will be the responsibility of the practitioner;
• External, professional review of
relevant documentation;
When a sanction is issued, practitioners will
receive a sanction letter describing the occurrence
and notifying them of the sanction action and the
consequences that may result from additional
incidences. The physician will also be notified
in writing of any sanction issued to a mid-level
practitioner that they supervise. All practitioners are
notified in writing of their right to appeal a sanction
via the Participating Practitioner Appeal Process
for Sanctions, including the opportunity to have a
discussion with the physician reviewer.
• Summary suspension;
• Establishing a range of actions altering
practitioner participation;
• Initiation of the termination process;
• Monetary sanction.
When appropriate, sanctions will be reported
to the appropriate regulatory or licensing agency
as required.
The final decision for imposing sanctions rests
with the CEO and Chief Medical Officer or their
designee. As necessary, sanction information may
58
Professional Conduct Sanctions
Arbitration concerning recredentialing and
termination shall be conducted in accordance with
the Commercial Arbitration Rules of the American
Arbitration Association. If arbitration is utilized, the
parties must waive their right to seek remedies in
court, including their right to jury trial, except for
enforcement of the decision of the arbitrator.
Professional misconduct will be handled on a
case-by-case basis in collaboration with Chief
Medical Officer, Medical Director, legal and
other appropriate individuals. Suspension and/or
termination may result.
Appeals of Sanctions
If you elect to appeal a sanction, you must notify the
issuer of the sanction in writing within 30 days of
the date of notification of the sanction. If the initial
reviewer does not approve the appeal request, it will
be presented to another reviewer of same or similar
specialty for the decision. A decision will be made
within 30 days of receipt of all information you submit.
You will be notified in writing of the appeal decision.
Should you disagree with the appeal decision, you
will have 60 days from the date of the decision on
the appeal to request binding arbitration. The request
should be submitted in writing to the issuer of the
sanction. The health plan legal department will send
the practitioner information regarding how to initiate
arbitration with American Arbitration Association
(AAA). The practitioner’s request for arbitration must
be made to the AAA within 180 days of the decision
on the appeal. The question before the arbitrator
will be whether the decision being arbitrated should
be set aside because the decision was arbitrary
and capricious. Judgment upon the decision by
the arbitrator may be entered in any court having
jurisdiction. Each party will bear its own costs and
attorney fees. Both parties will share expenses
associated with the arbitration equally. Arbitration
shall be final and binding on all parties.
59
Denied Payment Authorization Decisions
As a network practitioner, you have the right to
submit additional information following an initial
payment authorization denial, speak to the physician
reviewer regarding medical necessity issues involved
in the denied payment authorization. As the network
practitioner, you make the final provider decision
concerning admission, referrals, and the continued
medical care of your patients. The health plan makes
the final determination concerning payment.
If the original decision is not reversed, the provider
may then pursue the denied payment authorization
through the appropriate Claim Reconsideration or
Provider Dispute Process. For denied services that
have not been rendered, the member may initiate
an appeal by contacting Customer Service at the
number on the back of their ID card. Physicians may
assist members in the Member Appeal Process.
Appeals may be expedited when the member’s
medical condition warrants, and the treating physician
signs the member’s appeal request for expedited
review.
60
Quality Improvement
The Health Plan’s Quality Management (QM)
Department monitors the performance in the
following areas:
• Cooperation with the member complaint process.
• Access to Care.
• Participation in health plan Quality Improvement
studies related to enhancing provider care or
service for health plan members.
• Response to inquiries by the health plan QM
Committee staff or health plan QM staff.
• Member Satisfaction.
• Quality Improvement/Management.
• Assisting the health plan in maintaining various
accreditations as appropriate and as requested by
the health plan.
• PCP and BH Practitioner Coordination.
• Patient Safety.
UnitedHealthcare strives to continuously improve the
quality of care and service provided by our health
care delivery system both from the clinical and
non-clinical perspective. The Quality Improvement
(QI) Program establishes goals and objectives that
encompass the quality improvement activities across
the markets we serve. Health promotion, health
management and patient safety activities are also an
integral part of the QI Program.
Upon request, the health plan makes available to
provider(s) information about its QM program,
including a description of the QM program and
a report on the health plan’s progress in meeting
its goals. The health plan examines the effect of
treatment programs using measures such as, but not
limited to, outcome measurement, re-hospitalization
rates and drug utilization reviews. Some of the
activities involving provider(s) are described in more
detail below.
Provider Participation in QM Program
Service Initiatives
Providers are encouraged to participate with the
health plan in QM activities. Our committees that
address concerns related to members, provider(s)
and the health plan are enhanced by the ongoing
participation of contracted provider(s). Our
committees include the Provider Affairs Committee
and QM Committee. Providers are encouraged
to offer feedback to the health plan on our various
QM projects and processes. In addition, health
plan network providers have agreed contractually
to comply with the health plan QM Program. The
program includes, but is not limited to:
Information gathered from a variety of sources is used
to identify service initiatives for the health plan. These
include but are not limited to complaint information,
appeals and directives information customer service
logs, member satisfaction surveys, and information
obtained in the provider satisfaction surveys. Network
Providers must participate in Quality Improvement
activities, including service initiatives as they
are identified.
• Ensuring that care is appropriately coordinated and
managed between provider(s) and the member’s
primary physician.
• On-site audits and requests for treatment records
as described below.
61
Member Satisfaction
Prospective Drug Safety Review – Patient Safety
The health plan monitors the FDA Center for Drug
Evaluation and Review (CDER) for announcements of
drug product recalls or drug product safety warnings.
The Pharmacy Director and Chief Medical Officer will
evaluate the need for action. In general, a need for
action exists when:
The health plan utilizes multiple sources for obtaining
member feedback. This includes administration of the
annual CAHPS® member satisfaction survey, member
complaints/appeals, member/provider feedback,
and information obtained from member service logs.
The information is gathered, sorted, and aggregated.
Every attempt is made to address the customer’s
issue/problem at the time of the occurrence (1st call
resolution). In addition, the information is aggregated
for tracking and trending.
• A significant safety concern is identified about a
pharmaceutical in common use.
• The likelihood exists that without intervention from
the health plan members will continue to use a
pharmaceutical with significant risks to their health.
Opportunities, typically service initiatives, are
identified and become part of the annual Health
Services Work Plan.
• The safety warning involves information not
previously known to members or providers prior to
the issuing of the warning.
Quality of Care/Quality
of Service Issues
When such a situation is determined to exist, an
immediate plan of action will be determined. This
generally involves a review of claims to identify
members currently established on the medication
with a high likelihood for continued therapy and their
prescribing physician. Depending on the urgency
of the situation, a decision will be made to notify the
members and/or their physician. Notification may take
place through direct mail or scheduled publications
(Member Newsletter, Network Bulletin and/or
Pharmacy Update), again depending on the urgency
and publication schedules.
Quality of Care and Quality of Service concerns are
member reported or discovered by health plan staff
and are investigated in collaboration with the Chief
Medical Officer or Medical Director. If a quality issue
has occurred, corrective action may include notifying
the provider, education, and request for additional
CME education for the provider, probation, summary
suspension, or termination. The health plan has
processes in place to report serious deficiencies to
the appropriate agencies and/or National Practitioner
Data Bank.
Patient Safety
Quality medical care is the core of the health plan’s
mission and Health Services program. As part of that
commitment, the health plan integrates patient safety
into the various aspects of the annual Health Services
program. The comprehensive focus on patient safety
is seen in multiple aspects of the health plan as
described below:
62
Provider Cooperation With Complaint
Investigation and Resolution
Pharmacy Programs - Patient Safety
The health plan works together to review patient
provider information, which it can use to optimize
each member’s care. Instances may exist whereby
pharmacy utilization patterns may require either
immediate intervention or detailed investigation and
analysis to determine whether provider issues exist
requiring intervention. These may be but are not
limited to:
Provider(s) are expected to cooperate with the
health plan in the quality improvement complaint
investigation and resolution process. If the health
plan requests written records for the purpose of
investigating a member complaint, provider(s) should
use their best efforts to submit these to the health
plan within 14 business days. Complaints filed by
the health plan members should not interfere with
the professional relationship between the clinician
and member.
• Potential drug disease interactions.
• Multiple prescriptions within the same
pharmaceutical class (polypharmacy).
QM staff in conjunction with Network Management
staff, will monitor complaints filed against all
network provider(s), and solicit information from
network provider(s) in order to address the
member complaints. The health plan will develop
and implement appropriate action plans to correct
legitimate problems discovered in the course of
investigating member complaints. Such action plans
may include the following:
• Under-utilization of medications to treat a specific
disease process.
• Over-utilization of medications to treat a specific
disease process.
• Utilization of medications in excess of
established guidelines.
• Suspected uncoordinated health care by
multiple practitioners.
• Suspected inappropriate/excessive controlled
substance usage.
• Require the clinician to submit and adhere to a
corrective action plan.
• Suspected fraudulent and/or illegal acquisition of
prescription medications.
• Monitor the clinician for a specified period, followed
by a determination about whether substandard
performance or noncompliance with the health plan
requirements is continuing.
Health Services monitors the above issues
and intervenes as appropriate with either the
physician or member. Members who display
drug-seeking behavior may be placed in a
“restricted access” situation.
• Require the clinician to use peer consultation for
specified types of care.
• Require the clinician to obtain training in specified
types of care.
We encourage your feedback on all guidelines and
welcome any suggestions on new guidelines to be
considered for adoption.
• Limit the clinician’s scope of practice in treating
health plan members.
• Cease enrolling or referring any new or existing
health plan members to the care of the clinician,
or reassign members to the care of another
network clinician.
63
Chart review measures include:
• Temporarily suspend the clinician’s participation
status with the health plan.
• Childhood Immunization Status.
• Terminate the clinician’s participation status with the
health plan.
• Adolescent Immunization Status.
• Cervical Cancer Screening.
HEDIS®
• Prenatal and Postpartum Care.
• Controlling High Blood Pressure.
HEDIS, the Healthcare Effectiveness Data and
Information Set, is a set of standardized measures
collected to show a health plan’s performance in
member care. HEDIS is developed (and updated
annually) with the knowledge of clinical and technical
experts and the representation of purchasers,
members, managed care organizations, providers,
and policy makers.
• Cholesterol Management for Patients with
Cardiovascular Conditions.
• Comprehensive Diabetes Care.
• Beta Blocker Treatment After a Heart Attack.
The health plan greatly appreciates providers’ efforts
in supporting the HEDIS chart review process each
year. HEDIS is compiled and submitted to NCQA
each June. Following the completion of HEDIS for
NCQA, the health plan publishes a “Report Card”
reflecting the scores we’ve reached on the
HEDIS measures.
HEDIS focuses much of its attention on the major
health issues affecting Americans today. The health
plan analyzes and applies the results from HEDIS
measures when considering disease management
strategies in the areas of asthma, diabetes,
cardiovascular disease, women’s care, childhood
immunizations, and more.
Members and providers may use the health plan
annual HEDIS results to compare quality across
health plans and regions. HEDIS is a part of NCQA’s
accreditation program, accounting for 33 percent
of the accreditation ranking. Accredited plans are
required to submit audited HEDIS data annually.
NCQA reassesses a health plan’s accreditation
status with each year’s HEDIS, and may raise or
lower the standing accordingly.
Measures like Beta Blocker Treatment After a Heart
Attack, Comprehensive Diabetes Care, Use of
Appropriate Medications for People with Asthma,
and many others are important tools in care. The
focus of the health plan is to improve care to
our members, which is reflected by continuously
improved HEDIS scores.
To reflect the most accurate score HEDIS allows for
health plans to conduct “Hybrid Data Collection”.
Furthermore, NCQA is very interested in seeing
improvement in quality of care on an annual basis.
The health plan holds accreditation status from
NCQA. For more information about HEDIS, or for
a copy of the health plan’s latest HEDIS® report
card, contact your local provider service
representative. HEDIS® is a registered trademark
of the National Committee for Quality Assurance
(NCQA) www.ncqa.org.
Hybrid data collection is a combination of
administrative data and data found manually by
medical record review. A sample of members
for each measure is randomly selected from the
health plan’s population for chart review. HEDIS
data collectors review providers’ charts looking for
evidence of procedures related to specific care to
count in the HEDIS report.
64
Member Complaint and Appeal Process
member service and request the form. The form
must be signed by the member and the person
acting on the member’s behalf, then returned to
UnitedHealthcare.
UnitedHealthcare hawk-i members can voice a
complaint or submit a formal appeal about a service
or care their child received.
If the problem or concern is about their child’s
benefits, coverage or payments of services to a
provider, they can file an Appeal.
• The member also has the right to hire a lawyer
to act on their behalf.
If the complaint is about the quality of care they
received, waiting times or customer service at their
child’s doctor’s office, they can file a Complaint.
Complaint Process
The complaint process is used for problems related
to quality and/or service the member receives from
their child’s doctor. The following are types of
complaints:
Appeal Process
If UnitedHealthcare makes a decision and the
member is not satisfied with this decision, they can
“appeal” the decision. An appeal is a formal way of
asking UnitedHealthcare to review and change a
decision we made. This is called a Level 1 appeal.
• Quality of care
The appeal request must be within 180 calendar days
of the decision. When the member makes an appeal,
UnitedHealthcare reviews the decision made.
Once the review is complete, the decision
is communicated.
• Cleanliness
• Respecting Privacy
• Disrespect, poor customer service
• Waiting times
• Information you get from UnitedHealthcare
The member can call member services to make
a complaint. If the member does not wish to call
member service, they can put their complaint in
writing and send it to UnitedHealthcare at the
following address:
If the appeal is upheld, the member can request a
Level 2 Appeal. The Level 2 Appeal is conducted by
a UnitedHealthcare Reconsideration Committee. If
the member is not satisfied with the decision at the
Level 2 Appeal, the member may be able to continue
through more levels of appeal.
P.O. Box 31364
Salt Lake City, UT 84131
If the member needs help with the Appeal:
• The child’s doctor can request an appeal
on their behalf.
For full details about the complaint and
appeals process, refer to the member’s Evidence
of Coverage.
• The member may also ask someone to act
on their behalf. The person may be someone
who is already legally authorized to act on
the member’s behalf under State Law. If the
member wants a friend or relative to act on their
behalf, they must call UnitedHealthcare
65
Glossary of Terms
Adverse Action – Any action taken by the health
plan to deny, reduce, terminate, delay or suspend
a covered service as well as any other acts or
omissions of the health plan which impair the quality,
timeliness or availability of such benefits.
Iowa Department of Human Services (DHS) –
The Iowa governmental agency that administers
the State Medicaid and hawk-i programs. For the
purposes of this Agreement, Iowa DHS shall mean
the State of Iowa DHS and its representatives.
Appeal Procedure – The process to resolve a
member’s right to contest verbally or in writing,
any adverse action taken by the health plan to deny,
reduce, terminate, delay, or suspend a covered
service as well as any other acts or omissions of the
health plan which impair the quality, timeliness or
availability of such benefits. The appeal procedure
shall be governed by hawk-i rules and regulations
and any and all applicable court orders and
consent decrees.
Medical Emergency – A medical condition
manifesting itself by acute symptoms of sufficient
severity (including severe pain) such that a prudent
layperson, who possesses an average knowledge
of health and medicine, could reasonably expect the
absence of immediate medical attention to result in:
• placing the health of the individual (or with respect
to pregnant women, the health of the woman or her
unborn child) in serious jeopardy; or
• serious impairment of bodily functions; or
Behavioral Health Services – Mental health and
substance abuse services.
• serious dysfunction of any bodily organ or part.
Medically Necessary Services –
Covered services that are determined through
utilization management to be:
EPSDT – The Early and Periodic Screening,
Diagnostic, and Treatment (EPSDT) service is
Medicaid’s comprehensive and preventive child health
program for individuals under the age of 21. EPSDT
was defined by law as part of the Omnibus Budget
Reconciliation Act of 1989 (OBRA ‘89) legislation
and includes periodic screening, vision, dental, and
hearing services. In addition, Section 1905(r)(5) of
the Social Security Act (the Act) requires that any
medically necessary health care service listed at
Section 1905(a) of the Act be provided to an EPSDT
recipient even if the service is not available under
the State’s Medicaid plan to the rest of the Medicaid
population. The federal regulations for EPSDT are in
42 CFR Part 441, Subpart B.
1. Appropriate and necessary for the symptoms,
diagnosis, and treatment of the condition of
the member.
2. Provided for the diagnosis or direct care and
treatment of the condition of the member
enabling the member to make reasonable
progress in treatment.
3. Within standards of professional practice
and given at the appropriate time and in the
appropriate setting.
4. Not primarily for the convenience of the member,
the member’s physician or other provider, and
Exclusions – Specific conditions or circumstances
listed in the Standard Rules for which the hawk-i
plan will not provide coverage reimbursement.
5. The most appropriate level of covered services,
which can safely be provided.
66
Not Allowed Charges – Medical charges for
which the network provider is not permitted to
receive payment from the health plan and cannot bill
the member. Examples are:
1. the difference between billed charges and
contracted rates and
2. charges for services that are bundled or unbundled
as detected by Correct Coding Initiative edits.
Not Covered Services – Services for which the
benefits are not payable under a Member’s Evidence
of Coverage (EOC) and for which the Member is
financially responsible.
Post-stabilization Care Services – Covered
services, related to a medical emergency that are
provided after a member is stabilized in order to
maintain the stabilized condition to improve or resolve
the member’s condition.
Prior Authorization – Approval in advance of
services being rendered. Certain covered services
need prior authorization. Additional information can
be found in the Prior Authorization Guidelines section
of this manual.
67
Forms Appendix
The following forms can be found online at
UHCCommunityPlan.com. Click on “For Health
Professionals” and select the state of Iowa. Choose
“Provider Forms” from the navigation buttons on the
left side of the screen.
• Disclosure of Ownership
• Member Appeal Form
• Provider Claim Dispute Form
• Demographic Change
• Medical Prior Authorization
• Proscription Drug Prior Authorization
• Utilization Management Determination
68
Insurance coverage provided by or through UnitedHealthcare
Insurance Company, Inc., UnitedHealthcare Plan of the River
Valley, Inc., or their affiliates. Administrative services to
self-funded benefits provided by UnitedHealthcare Insurance
Company, Inc.
UHC1169b_20140305
© 2014 United HealthCare Services, Inc.
Community Plan
A proud partner in Iowa’s hawk-i program

Provider Manual hawk-i Community Plan

Transcription

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