The fastest way for us to talk is electronically. Electronic Data Interchange (EDI) is the preferred method for doing business transactions. Find more information on UHCprovider.com/edi.
The issues of confidentiality and objective medical observations are the key in the diagnosis and treatment of our members. Therefore, a care provider or other licensed independent health care professional who is also a UnitedHealthcare member shall not serve as PCP for themselves or their dependents.
You are responsible for checking member eligibility within 2 business days prior to the date of service. You may be eligible for reimbursement under the Authorization Guarantee program described in the Capitation and/or Delegation Supplement for authorized services if you have checked and confirmed the member’s eligibility within 2 business days before the date of service.
You must verify the member’s eligibility each time they receive services from you. We provide several ways to verify eligibility:
Get more details regarding a specific member’s benefit plan in the member’s Combined Evidence of Coverage and Disclosure Form, Evidence of Coverage, or Certificate of Coverage. Benefit plans may be addressed in procedures/protocols communicated by us. Details may include the following:
Each member receives a health plan ID card with information to help you submit claims accurately. Information may vary in appearance or location on the card due to payer or other unique requirements. You can view and download current member ID cards when you verify eligibility and benefits on Link.
For more detailed information on ID cards and to see a sample ID card, refer to the Health Care Identification (ID) Cards section of Chapter 2: Provider Responsibilities and Standards.
If we provide eligibility confirmation indicating that a member is eligible at the time the health care services are provided, and it is later determined that the patient was not eligible, we are not responsible for payment of services provided to the member,
except as otherwise required by state and/or federal law. In such event, you are entitled to collect the payment directly from the member (to the extent permitted by law) or from any other source of payment.
We reimburse Texas care providers who request a guarantee of payment through the verification process. The verification is based on the Agreement and the guidelines in Texas Senate Bill SB 418.
We will guarantee payment for proposed medical care or health care services if you provide the services to the member within the required time frame. We reduce the payment by any applicable copayments, coinsurance and/or deductibles.
You must include the unique UnitedHealthcare West verification number on the claim form (Field 23 of CMS 1500 or Field 63 of UB-04).
You must request eligibility prior to rendering a service. Otherwise, we are not responsible for payment of those services. You are entitled to collect the payment directly from the member to the extent permitted by law or from any other source of payment.
Submit service verification requests to:
P.O. Box 30975
Salt Lake City, UT 84130-0975
We monitor members’ access to medical and behavioral health care to make sure that we have an adequate care provider network to meet the members’ health care needs. We use member satisfaction surveys and other feedback to assess performance against standards.
Health plans in California must conduct an annual Provider Appointment and Availability Survey. The overall plan results are available at myuhc.com.
We have established access standards for appointments and after-hours care. Exceptions or additions to those standards are shown in the following table.
UnitedHealthcare Standard: 14 calendar days Exceptions:
California Commercial HMO: Members are offered appointments for non-urgent PCP within 10 business days of request, within 15 business days for non-urgent specialist request;
Texas: Within 3 weeks for medical conditions.
UnitedHealthcare Standard: Four weeks Exceptions:
California: Preventive care services and periodic follow-up care, including but not limited to, standing referrals to specialists for chronic conditions, periodic office visits to monitor and treat pregnancy, cardiac or mental health conditions, and laboratory and radiological monitoring for recurrence of disease may be scheduled in advance consistent with professionally recognized standards of practice as determined by the treating licensed health care provider acting within the scope of their practice.
Texas: Within 2 months for child and within 3 months for adult. Medicare Advantage within 30 days.
UnitedHealthcare Standard: Same day (24 hours) Exceptions:
California Commercial Members: Within 48 hours when no prior authorization required, within 96 hours when prior authorization required.
California: In-office wait time is less than 30 minutes.
Complete notification to the member in a timely manner, not to exceed 5 business days of a request for non-urgent care or 72 hours of a request for urgent care.
15 business days
For details on these access standards refer to Chapter 2: Provider Responsibilities, Timely Access to Non-Emergency Health Care Services (Applies to Commercial in California).
Report all demographic changes, open/closed status, product participation or termination to us.
For complete information, refer to the Demographic Changes section of Chapter 2: Provider Responsibilities and Standards.
Compliance with the Medical Management Program includes but is not limited to:
A complete library of Benefit Interpretation Policies (BIPs), and Medical Management Guidelines (MMGs) is available on UHCprovider.com/policies > Commercial Policies > UnitedHealthcare West Benefit Interpretation Policies or UnitedHealthcare West Medical Management Guidelines
We publish monthly editions of the BIP and MMG Update Bulletins. These online resources provide notice to our network care providers of changes to our BIPs and MMGs. The bulletins are posted on the first calendar day of every month on:
We post a supplemental link to the policy updates announced in the BIP and MMG Update Bulletins monthly on UHCprovider.com/networknews > Network Bulletin.
Continuity of care is a short-term transition period, allowing members to temporarily continue to receive services from a non- participating care provider.
Continuity of care does not apply when a member initiates a change of PCP or medical group/IPA. Authorizations granted by the previous medical group shall be invalid in such situations at the commencement of the member’s assignment to the new PCP or medical group/IPA; members shall not be entitled to continuing care unless the member’s new PCP or medical group/ IPA authorizes that care.
UnitedHealthcare of California added a new benefit for Virtual Visits to some member benefit plans. We define Virtual Visits as primary care services that include the diagnosis and treatment of low-acuity medical conditions for members through the use of interactive audio and video telecommunication and transmissions, and audio-visual communication technology.
Virtual Visit primary care services are typically delivered by the capitated care provider groups. Not all UnitedHealthcare West benefit plans will have the Virtual Visit benefit option.
To read more about Virtual Visits, refer to the Capitation and/or Delegation Supplement.