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Chapter 1: Introduction

UnitedHealthcare Community Plan supports the Ohio state goals of increased access, improved health outcomes and reduced costs by offering benefits to the following Medicaid members in every Ohio county.

Ohio Medicaid covers members in the Covered Families and Children (CFC) program. This includes Healthy Start and Healthy Families, Foster Care, or the Aged, Blind, or Disabled (ABD) programs. CFC Medicaid consumers include families, children younger than age 19, and pregnant women. ABD Medicaid consumers include adults age 65 and older and people who are blind or disabled at any age.

UnitedHealthcare Connected for MyCare Ohio serves members who are dually eligible for Medicare and Medicaid within the UnitedHealthcare Connected service area. UnitedHealthcare Connected members must be eligible and enrolled in Medicare Part A, Medicare Part B, and Ohio Medicaid.

UnitedHealthcare Connected is available in Columbiana, Cuyahoga, Geauga, Lake, Lorain, Mahoning, Medina, Portage, Stark, Summit, Trumbull and Wayne Counties.

The Ohio Department of Medicaid (ODM) will determine enrollment eligibility.

For More Information:

If you have questions about the information in this manual or about our policies, go to UHCprovider.com or call Provider Services at 800-600-9007.

For instructions on joining the UnitedHealthcare Community Plan provider network, go to UHCprovider.com/join. There you will find guidance on our credentialing process, how to sign up for self-service tools and other helpful information.

Whole Person Care Model

The Whole Person Care (WPC) program seeks to empower UnitedHealthcare Community Plan members enrolled in Medicaid, care providers and our community partners to improve care coordination and elevate outcomes. Targeting UnitedHealthcare Community Plan members with chronic complex conditions who often use health care, the program helps address their needs holistically. WPC examines medical, behavioral and social/environmental concerns to help members get the right care from the right care provider in the right place and at the right time.

The program provides interventions to members with complex medical, behavioral, social, pharmacy and specialty needs, resulting in better quality of life, improved access to health care and reduced expenses. WPC provides a care management/coordination team that helps increase member engagement, offers resources to fill gaps in care and develops personalized health goals using evidence-based clinical guidelines. This approach is essential to improving the health and well-being of the individuals, families and communities UnitedHealthcare Community Plan serves. WPC provides:

  • Market-specific care management encompassing medical, behavioral and social care.
  • Extended care team including primary care provider (PCP), pharmacist, medical and behavioral director, and peer specialist.
  • Options that engage members, connecting them to needed resources, care and services.
  • Individualized and multidisciplinary care plan.
  • Assistance with appointments with PCP and coordinating appointments. The Clinical Health Advocate (CHA) refers members to an RN, Behavioral Health Advocate (BHA) or other specialists as required for complex needs.
  • Education and support with complex conditions.
  • Tools for helping members engage with providers, such as appointment reminders and help with transportation.
  • Foundation to build trust and relationships with hard- to-engage members.

The goals of the WPC program are to:

  • Lower avoidable admissions and unnecessary emergency room (ER) visits, measured outcomes by inpatient (IP) admission and ER rates.
  • Improve access to PCP and other needed services, measured by number of PCP visit rates within identified time frames.
  • Identify and discuss behavioral health needs, measured by number of behavioral health care provider visits within identified time frames.
  • Improve access to pharmacy.
  • Identify and remove social and environmental barriers to care.
  • Improve health outcomes, measured by improved Health Plan Employer Data and Information Set (HEDIS) and Centers for Medicare & Medicaid Services (CMS) Star Ratings metrics.
  • Empower the member to manage their complex/ chronic illness or problem and care transitions.
  • Improve coordination of care through dedicated staff resources and to meet unique needs.
  • Engage community care and care provider networks to help ensure access to affordable care and the appropriate use of services.

Referring Your Patient

To refer your patient who is a UnitedHealthcare Community Plan member to WPC, call Member Services. You may also call Provider Services at 800-600-9007.

HIPAA mandates National Provider Identifier (NPI) usage in all standard transactions (claims, eligibility, remittance advice, claims status request/response, and authorization request/response) for all health care providers who handle business electronically.

 

Cultural Competency

To help you meet membership needs, UnitedHealthcare Community Plan has developed a Cultural Competency Program. Linguistic and cultural barriers can negatively affect access to health care participation. You must help UnitedHealthcare Community Plan meet this obligation for our members.

UnitedHealthcare Community Plan offers the following support services:

•  Language Interpretation Line: We provide oral interpreter services 24 hours a day, seven days a week to our members free of charge. More than 240 non-English languages and hearing impaired services are available. If a UnitedHealthcare Community Plan member needs Interpreter Services, we prefer care providers use a professional interpreter. To access a professional interpreter during regular business hours, call Member Services.

•  Cultural member materials: We provide simplified materials for members with limited English proficiency and who speak languages other than English or Spanish. We also provide materials for visually impaired members.

UnitedHealthcare Community Plan uses Interqual Care Guidelines (formally MCG Care Guidelines) for medical care determinations.

UHCprovider.com is your home for care provider information with access to Electronic Data Interchange (EDI), Provider Portal self-service tools, medical policies, news bulletins, and great resources to support administrative tasks including eligibility, claims, claims status and prior authorizations and notifications.

Electronic Data Interchange (EDI)

EDI is a self-service resource using your internal practice management or hospital information system to exchange transactions with us through a clearinghouse.

The benefit of using EDI is it permits care providers to send batch transactions for multiple members and multiple payers in lieu of logging into different payer websites to manually request information. This is why EDI is usually care providers’ first choice for electronic transactions.

  • Send and receive information faster
  • Identify submission errors immediately and avoid processing delays 
  • Exchange information with multiple payers
  • Reduce paper, postal costs and mail time
  • Cut administrative expenses
  • EDI transactions available to care providers are:
    • Claims (837), 
    • Eligibility and benefits (270/271),
    • Claims status (276/277),
    • Referrals and authorizations (278),
    • Hospital admission notifications (278N), and
    • Electronic remittance advice (ERA/835).

Visit UHCprovider.com/EDI for more information. Learn how to optimize your use of EDI at UHCprovider.com/optimizeEDI.

Getting Started
  • If you have a practice management or hospital information system, contact your software vendor for instructions on how to use EDI in your system.
  • Contact clearinghouses to review which electronictransactions can interact with your software system.

Read our Clearinghouse Options page for more information.

Provider Portal - Secure Care Provider Website

UnitedHealthcare Provider Portal provides a secure online portal to support your administrative tasks including eligibility, claims and prior authorization and notifications. To sign in to the Provider Portal, go to UHCprovider.com and click on the Sign in button in the upper right corner. For more information about all Provider Portal tools, go to UHCprovider.com, thien click Sign in.

To access the Provider Portal, the secure care provider website, go to UHCprovider.com and either sign in or create a user ID. You will receive your user ID and password within 48 hours.

The secure care provider website lets you:

  • Verify member eligibility including secondary coverage.
  • Review benefits and coverage limit.
  • Check prior authorization status.
  • Access remittance advice and review recoveries.
  • Review your preventive health measure report.
  • Access the Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) toolset.
  • Search for CPT codes. Type the CPT code in the header search box on UHCprovider.com, and the search results will display all documents and/or web pages containing that code.
  • Find certain web pages more quickly using vanity URLs. You’ll see changes in the way we direct you to specific web pages on our UHCprovider.com provider portal. You can now use certain vanity URLs, which helps you find and remember specific web pages easily and quickly. You can access our most used and popular web pages on UHCprovider.com by typing in that page’s vanity URL identified by a forward slash in the web address, e.g. UHCprovider.com/claims. When you see that forward slash in our web links, you can copy the vanity URL into your web page address bar to quickly access that page.

Here are most frequently used tools:

  • Eligibility and Benefits — View patient eligibility and benefits information for most benefit plans. For more information, go to UHCprovider.com/. 
  • Claims — Get claims information for many UnitedHealthcare plans, including access letters, remittance advice documents and reimbursement policies. For more information, go to UHCprovider.com/Claims.
  • Prior Authorization and Notification — Submit notification and prior authorization requests. For more information, go to UHCprovider.com/paan. 
  • Specialty Pharmacy Transactions — Submit notification and prior authorization requests for certain medical injectable specialty drugs using the Specialty Pharmacy Transaction tile on your Link dashboard. 
  • My Practice Profile — View and update* your provider demographic data that UnitedHealthcare members see for your practice. For more information, go to UHCprovider.com/mypracticeprofile.
  • Document Vault — Access reports and claim letters for viewing, printing, or download. For more information, go to UHCprovider.com/documentvault. 
  • Paperless Delivery Options — When you use Document Vault to access claim letters, your Provider Portal OneHealthcare ID Password Owner may turn off delivery of paper copies by mail. The Paperless Delivery Options tool can send daily or weekly email notifications to alert you to new letters when we add them to your Document Vault. With our delivery options, you decide when and where the emails are sent for each type of letter. This is available to Provider Porfal OneHealthcar ID password owners only. 

* For more instructions, visit UHCprovider.com/Training. 

Watch for the most current information on our selfservice resources by email, in the Network Bulletin, or online at UHCprovider.com/EDI or UHCprovider.com then click Sign In.. For more instructions, visit UHCprovider.com/Training.

To help our members access appropriate care and minimize out-of-pocket costs, you must have privileges at applicable in-network facilities or arrangements with an in-network provider to admit and provide facility services. This includes full admitting hospital privileges, ambulatory surgery center privileges and/or dialysis center privileges.

Provider Services is the primary contact for care providers who require assistance. It is staffed with representatives trained specifically for UnitedHealthcare Community Plan.

Provider Services can assist you with questions on Medicaid benefits, eligibility, claim decision, forms required to report specific services, billing questions and more.

Provider Services works closely with all departments in UnitedHealthcare Community Plan.

A full list of contact details can be found on the Ohio Care Provider Manual.