2019-UnitedHealthcare-Administrative-Guide.pdf - 2019 UnitedHealthcare Care Provider Administrative Guide Welcome to UnitedHealthcare Welcome to the

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Unformatted text preview: 2019 UnitedHealthcare Care Provider Administrative Guide Welcome to UnitedHealthcare Welcome to the UnitedHealthcare Care Provider Administrative Guide for Commercial and Medicare Advantage (MA) products. This guide has important information on topics such as claims and prior authorizations. It also has protocol information for health care providers. This guide has useful contact information such as addresses, phone numbers and websites. More policies and electronic tools are available on UHCprovider.com. • If you are looking for a Community and State manual, go to UHCprovider.com/guides > Community Plan Care Provider Manuals and select the state You may easily find information in this guide using these steps: 1. Hold keys CTRL+F. 2. Type in the key word. 3. Press Enter. Depending upon the version of PDF software you have, you may also use the binoculars icon to search for key words. This 2019 UnitedHealthcare Care Provider Administrative Guide (this “guide”) applies to covered services you provide to our members or the members of our affiliates* through our benefit plans insured by or receiving administrative services from us, unless otherwise noted. This guide is effective April 1, 2019 for physicians, health care professionals, facilities and ancillary providers currently participating in our Commercial and MA networks. It is effective now for care providers who join our network on or after Jan. 1, 2019. This guide is subject to change. We frequently update content in our effort to support our health care provider networks. Terms and definitions as used in this guide: • “Member” or “customer” refers to a person eligible and enrolled to receive coverage from a payer for covered services as defined or referenced in your Agreement. • “Commercial” refers to all UnitedHealthcare medical products that are not MA, Medicare Supplement, Medicaid, CHIP, workers’ compensation, or other governmental programs. “Commercial” also applies to benefit plans for the Health Insurance Marketplace, government employees or students at public universities. • “You,” “your” or “provider” refers to any health care provider subject to this guide, including physicians, health care professionals, facilities and ancillary providers; except when indicated and all items are applicable to all types of health care providers subject to this guide. • “Your Agreement,” “Provider Agreement” or “Agreement” refers to your Participation Agreement with us. • “Us,” “we” or “our” refers to UnitedHealthcare on behalf of itself and its other affiliates for those products and services subject to this guide. MA policies, protocols and information in this guide apply to covered services you provide to UnitedHealthcare MA members, including Erickson Advantage members and most UnitedHealthcare Dual Complete members, but excluding UnitedHealthcare Medicare Direct members. We indicate if a particular section does not apply to such MA members. If there is a conflict or inconsistency between a Regulatory Requirements Appendix attached to your Agreement and this guide, the provisions of the Regulatory Requirements Appendix controls for benefit plans within the scope of that appendix. If there is an inconsistency between your Agreement and this guide, your Agreement controls (except where your Agreement provides protocols for our affiliates). If those protocols are in a supplement to this guide, those protocols control for services you give to a member subject to that supplement. Per your Agreement, you must comply with protocol. Payment will be denied, in whole or in part, for failure to comply with a protocol. *UnitedHealthcare affiliates offering commercial and Medicare Advantage benefit plans and other services, are outlined in Chapter 1: Introduction. i | 2019 UnitedHealthcare Care Provider Administrative Guide Contents Contents Chapter 1: Introduction 1 Chapter 2: Provider Responsibilities and Standards 7 Manuals and Benefit Plans Referenced in This Guide. . . . . . . . . 1 Online Resources and How to Contact Us. . . . . . . . . . . . . . . . . . 3 Verifying Eligibility, Benefits and Your Network Participation Status. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7 Health Care Identification (ID) Cards. . . . . . . . . . . . . . . . . . . . . . . 7 Access Standards. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9 Primary Care Physicians (PCP) Responsibilities. . . . . . . . . . . . 10 Demographic Changes. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10 Notification of Practice or Demographic Changes (Applies to Commercial Benefit Plans in California). . . . . . . . . 12 Administrative Terminations for Inactivity . . . . . . . . . . . . . . . . . 12 Member Dismissals Initiated by a PCP (Medicare Advantage). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12 Medicare Opt-Out . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13 Additional MA Requirements. . . . . . . . . . . . . . . . . . . . . . . . . . . 13 Filing of a Lawsuit by a Member. . . . . . . . . . . . . . . . . . . . . . . . . 14 Chapter 3: Commercial Products 16 Commercial Product Overview Table. . . . . . . . . . . . . . . . . . . . . 16 Benefit Plan Types. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18 PCP Selection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18 Consumer-Driven Health Benefit Plans. . . . . . . . . . . . . . . . . . . 19 Chapter 4: Medicare Products 20 Medicare Product Overview Tables. . . . . . . . . . . . . . . . . . . . . . 20 PCP Selection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23 Coverage Summaries and Policy Guidelines for MA Members . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23 Dual Special Needs Plans Managed by Optum . . . . . . . . . . . . 23 Medicare Supplement Benefit Plans. . . . . . . . . . . . . . . . . . . . . 24 Free Medicare Education for Your Staff and Patients. . . . . . . . 25 Chapter 5: Referrals 26 Chapter 6: Medical Management 29 Commercial Products Referrals. . . . . . . . . . . . . . . . . . . . . . . . . 26 Non-Participating Care Provider Referrals (All Commercial Plans) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27 Medicare Advantage (MA) Referral Required Plans. . . . . . . . . 27 Benefit Plans Not Subject to this Protocol. . . . . . . . . . . . . . . . . 29 Advance Notification/Prior Authorization Requirements. . . . . 29 Advance Notification/Prior Authorization List. . . . . . . . . . . . . . 30 Facilities: Standard Notification Requirements. . . . . . . . . . . . . 31 How to Submit Advance or Admission Notifications/ Prior Authorizations* . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33 Updating Advance Notification or Prior Authorization Requests . . . . . . . . . . . . . . . . . . . . . . . . 33 Coverage and Utilization Management Decisions . . . . . . . . . . 34 Pre-Service Appeals. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35 Clinical Trials, Experimental or Investigational Services. . . . . . 35 Medical Management Denials/Adverse Determinations. . . . . 35 MA Part C Reopenings. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36 Outpatient Cardiology Notification/ Prior Authorization Protocol. . . . . . . . . . . . . . . . . . . . . . . . . . . . 37 Outpatient Radiology Notification/ Prior Authorization Protocol. . . . . . . . . . . . . . . . . . . . . . . . . . . . 41 Trauma Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45 Chapter 7: Specialty Pharmacy and Medicare Advantage Pharmacy 46 Commercial Pharmacy. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46 Specialty Pharmacy Requirements for Certain Specialty Medications (Commercial Plans – not applicable to UnitedHealthcare West) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46 MA Pharmacy (Includes UnitedHealthcare Dual Special Needs Plans [DSNP]) . . . . . . . . . . . . . . . . . . . . . . 47 Drug Utilization Review Program. . . . . . . . . . . . . . . . . . . . . . . . 49 Medication Therapy Management (MTM). . . . . . . . . . . . . . . . . 50 Transition Policy. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50 Chapter 8: Specific Protocols 51 Chapter 9: Our Claims Process 55 Air Ambulance, Fixed-Wing Non-Emergency Transport . . . . . 51 Laboratory Benefit Management Program Administered by BeaconLBSTM (Florida Only). . . . . . . . . . . . . . 51 Laboratory Services Protocol. . . . . . . . . . . . . . . . . . . . . . . . . . . 51 Non-Participating Providers Consent Form . . . . . . . . . . . . . . . 52 Nursing Home and Assisted Living Plans. . . . . . . . . . . . . . . . . 53 Electronic Payments and Statements (EPS). . . . . . . . . . . . . . . 55 Claims and Encounter Data Submissions. . . . . . . . . . . . . . . . . 56 Risk Adjustment Data – MA and Commercial. . . . . . . . . . . . . . 57 National Provider Identification (NPI). . . . . . . . . . . . . . . . . . . . . 58 Medicare Advantage Claim Processing Requirements. . . . . . 58 Claim Submission Tips. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59 Pass-through Billing/CLIA Requirements/ Reimbursement Policy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60 Special Reporting Requirements for Certain Claim Types . . . 60 Overpayments. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61 Subrogation and Coordination of Benefits . . . . . . . . . . . . . . . . 62 Claim Correction and Resubmission. . . . . . . . . . . . . . . . . . . . . 63 Claim Reconsideration, Appeals Process and Resolving Disputes. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63 Resolving Disputes – Concern or Complaint . . . . . . . . . . . . . . 65 Member Appeals, Grievances or Complaints. . . . . . . . . . . . . . 67 Medical Claim Review. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 67 ii | 2019 UnitedHealthcare Care Provider Administrative Guide Contents Chapter 10: Compensation 68 Reimbursement Policies. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 68 Charging Members. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 68 Member Financial Responsibility. . . . . . . . . . . . . . . . . . . . . . . . 70 Preventive Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 70 Provider Audits - Extrapolation. . . . . . . . . . . . . . . . . . . . . . . . . . 70 Hospital Audit Services. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 70 Audit Failure Denials . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 71 Notice of Medicare Non-Coverage (NOMNC). . . . . . . . . . . . . . 72 Chapter 11: Medical Records Standards and Requirements 73 Chapter 12: Health and Disease Management 75 Chapter 13: Quality Management (QM) Program 78 Chapter 14: Credentialing and Recredentialing 80 Health Management Programs. . . . . . . . . . . . . . . . . . . . . . . . . . 75 Special Needs Plans (SNP). . . . . . . . . . . . . . . . . . . . . . . . . . . . . 75 Case Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 75 Wellness and Behavioral Health Programs. . . . . . . . . . . . . . . . 76 Consumer Transparency Tools. . . . . . . . . . . . . . . . . . . . . . . . . . 76 Behavioral Health Information . . . . . . . . . . . . . . . . . . . . . . . . . . 76 UnitedHealth Premium® Program (Commercial Plans) . . . . . . 79 Star Ratings for MA and Prescription Drug Plans. . . . . . . . . . . 79 Member Satisfaction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 79 Imaging Accreditation Protocol . . . . . . . . . . . . . . . . . . . . . . . . . 79 Credentialing/Profile Reporting Requirements. . . . . . . . . . . . . 80 Care Provider Rights Related to the Credentialing Process . . 80 Credentialing Committee Decision Making Process (Non-Delegated). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 81 Monitoring of Network Care Providers and Health Care Professionals. . . . . . . . . . . . . . . . . . . . . . . . . . 81 Chapter 15: Member Rights and Responsibilities 82 Chapter 16: Fraud, Waste and Abuse (FWA) 83 Medicare Compliance Expectations and Training . . . . . . . . . . 83 Exclusion Checks . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 83 New Preclusion List Policy. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 84 Examples of Potentially Fraudulent, Wasteful, or Abusive Billing (not an inclusive list). . . . . . . . . . . . . . . . . . . 84 Prevention and Detection. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 84 Corrective Action Plans. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 85 Beneficiary Inducement Law . . . . . . . . . . . . . . . . . . . . . . . . . . . 85 Reporting Potential Fraud, Waste or Abuse to UnitedHealthcare. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 85 Chapter 17: Provider Communication 86 All Savers Supplement 87 Network Bulletin and Provider News . . . . . . . . . . . . . . . . . . . . 86 Medical Policy Update Bulletin. . . . . . . . . . . . . . . . . . . . . . . . . . 86 Other Communications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 86 How to Contact All Savers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 87 Capitation and/or Delegation Supplement 89 Capitated Providers. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 89 Delegated Providers and Accountable Care Organizations. . . 89 How to Contact Us. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 89 Verifying Eligibility and Effective Dates . . . . . . . . . . . . . . . . . . . 90 Commercial Eligibility, Enrollment, Transfers, and Disenrollment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 90 Medicare Advantage (MA) Enrollment, Eligibility and Transfers, and Disenrollment . . . . . . . . . . . . . . . . . . . . . . . 93 Eligibility/Authorization Guarantee. . . . . . . . . . . . . . . . . . . . . . . 95 Provider Responsibilities. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 95 Delegated Credentialing Program. . . . . . . . . . . . . . . . . . . . . . 100 Virtual Visits (Commercial HMO Plans CA only). . . . . . . . . . . 101 Medical Management. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 105 Pharmacy. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 111 Facilities. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 112 Claims Processes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 116 Claims Disputes and Appeals. . . . . . . . . . . . . . . . . . . . . . . . . . 120 Contractual and Financial Responsibilities. . . . . . . . . . . . . . . 122 CMS Premiums and Adjustments . . . . . . . . . . . . . . . . . . . . . . 129 Delegate Performance Management Program. . . . . . . . . . . . 131 Appeals and Grievances. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 131 Leased Networks 133 Medica HealthCare Supplement 134 Mid-Atlantic Regional Supplement 146 How to Contact Us. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 134 Confidentiality of Protected Health Information (PHI). . . . . . . 137 Referrals. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 137 Prior Authorizations. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 138 Appeal and Reconsideration Processes. . . . . . . . . . . . . . . . . 141 Member Rights and Responsibilities . . . . . . . . . . . . . . . . . . . 142 Documentation and Confidentiality of Medical Records. . . . 142 Provider Reporting Responsibilities. . . . . . . . . . . . . . . . . . . . . 144 Provider Responsibilities. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 147 Referrals. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 148 Prior Authorizations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 148 Claims Process . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 150 Capitation. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 150 iii | 2019 UnitedHealthcare Care Provider Administrative Guide Contents Neighborhood Health Partnership Supplement 152 How to Contact NHP. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 152 Discharge of a Member from Participating Provider’s Care . 155 Laboratory Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 155 Referrals. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 155 Utilization Management (UM). . . . . . . . . . . . . . . . . . . . . . . . . . 156 Claims Reconsiderations and Appeals. . . . . . . . . . . . . . . . . . 157 Capitated Health Care Providers . . . . . . . . . . . . . . . . . . . . . . . 157 OneNet PPO Supplement 158 Oxford Commercial Supplement 165 How to Contact OneNet PPO. . . . . . . . . . . . . . . . . . . . . . . . . . 159 OneNet General Provider Administrative Requirements . . . . 159 Referrals. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 160 Utilization Review Components for Workers’ Compensation. . 160 Workers’ Compensation Claims Process . . . . . . . . . . . . . . . . 160 Resolving Disputes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 163 Medical Records Standards and Requirements. . . . . . . . . . . 163 Quality Management and Health Management Programs. . . 163 Participant Rights and Responsibilities. . . . . . . . . . . . . . . . . . 164 Oxford Commercial Product Overview . . . . . . . . . . . . . . . . . . 165 How to Contact Oxford Commercial . . . . . . . . . . . . . . . . . . . . 165 Care Provider Responsibilities and Standards . . . . . . . . . . . . 170 Referrals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 174 Utilization Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 175 Using Non-Participating Health Care Providers or Facilities. . . 176 Radiology, Cardiology and Radiation Therapy Procedures. . . 180 Emergencies and Urgent Care. . . . . . . . . . . . . . . . . . . . . . . . . 184 Utilization Reviews . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 186 Claims Process . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 192 Member Billing. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 194 Claims Recovery, Appeals, Disputes and Grievances. . . . . . 195 Quality Assurance. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 199 Case Management and Disease Management Programs. . . 199 Clinical Process Definitions . . . . . . . . . . . . . . . . . . . . . . . . . . . 200 Member Rights and Responsibilities. . . . . . . . . . . . . . . . . . . . 202 Medical and Administrative Policy Updates . . . . . . . . . . . . . . 202 Preferred Care Partners Supplement River Valley Entities Supplement 214 UnitedHealthcare West Supplement 224 Eligibility. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 214 How to Contact River Valley . . . . . . . . . . . . . . . . . . . . . . . . . . . 214 Reimbursement Policies. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 216 Referrals. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 216 Utilization Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 217 Claims Process . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 220 UnitedHealthcare West Info...
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