UnitedHealthcare Community Plan’s comprehensive Quality Improvement program falls under the leadership of the CEO and the chief medical officer. A copy of our Quality Improvement program is available upon request.
The program consists of:
As a participating care provider, you may offer input through representation on our Quality Improvement Committees and your provider services representative/ provider advocate.
You must comply with all quality-improvement activities. These include:
Every year, UnitedHealthcare Community Plan conducts care provider satisfaction assessments as part of our quality improvement efforts. We assess and promote your satisfaction through:
Our main concern with the survey is objectivity. That’s why UnitedHealthcare Community Plan engages independent market research firm Center for the Study of Services (CSS) to analyze and report findings.
Survey results are reported to our Quality Management Committee. It compares the results year over year as well as to other UnitedHealthcare Community Plan plans across the country. The survey results include key strengths and improvement areas. Additionally, we carry out improvement plans as needed.
UnitedHealthcare Community Plan credentials and re- credentials you according to applicable Ohio statutes and the National Committee of Quality Assurance (NCQA). The following items are required to begin the credentialing process:
We verify information from primary sources regarding licensure, education and training. We also verify board certification and malpractice claims history.
UnitedHealthcare Community Plan’s credentialing and recredentialing process determines whether you are a good fit for the UnitedHealthcare Community Plan care provider network. You must go through the credentialing and recredentialing process before you may treat our members.
UnitedHealthcare Community Plan evaluates the following practitioners:
Excluded from this process are practitioners who:
Facility providers such as hospitals, home health agencies, skilled nursing facilities and ambulatory surgery centers are also subject to applicable credentialing and licensure requirements. Facilities must meet the following requirements or verification:
UnitedHealthcare Community Plan does not make credentialing and recredentialing decisions based on race, ethnic/national identity, gender, age, sexual orientation or the type of procedure or patient in which the practitioner specializes.
The National Credentialing Center (NCC) completes these reviews. Find applications on the Council for Affordable Quality Healthcare (CAQH) website.
First-time applicants must call the National Credentialing Center (VETTS line) to get a CAQH number and complete the application online.
Submit the following supporting documents to CAQH after completing the application:
A peer review committee reviews all credentialing applications and makes a final decision. The decisions may not be appealed if they relate to mandatory criteria at the time of credentialing. We will notify you of the decision in writing within 60 calendar days of the review.
UnitedHealthcare Community Plan recredentials practitioners every three years. This process helps assure you update time-limited documentation and identify legal and health status changes. We also verify that you follow UnitedHealthcare Community Plan’s guidelines, processes and care provider performance standards. You are notified before your next credentialing cycle to complete your application on the CAQH website. Not responding to our request for recredentialing information results in administrative termination of privileges as a UnitedHealthcare Community Plan care provider. You have three chances to answer the request before your participation privileges are terminated.
As part of the recredentialing process, UnitedHealthcare Community Plan looks in its Quality Management database for information about your performance. This includes member complaints and quality of care issues.
When evaluating your performance, UnitedHealthcare Connected (MyCare Ohio) reviews at a minimum the following areas:
You have the right to review information you submitted to support your credentialing/recredentialing application. This excludes personal or professional references or peer review protected information. You have the right to correct erroneous information you find. You may call the NCC to correct your information at any time. If the NCC finds erroneous information, a representative will contact you by fax or in writing. You must submit corrections within 30 days of notification by phone, fax or in writing to the number or address the NCC representative provided. You also have the right to receive the status of your credentialing or recredentialing application by calling the NCC (VETTS) number listed in How to Contact Us.
All credentialing information collected during the review process is kept confidential. It is only shared with your approval or as required by law with those involved in the credentialing process.
The Health Insurance Portability and Accountability Act (HIPAA) of 1996 aims to improve the efficiency and effectiveness of the United States health care system. While the Act’s core goals were to maintain insurance coverage for workers and fight health care fraud and abuse, its Administrative Simplification provisions have had the greatest impact on how the health care industry works. UnitedHealthcare Community Plan is a “covered entity” under these regulations. So are all health care providers who conduct business electronically.
If you conduct business electronically, submit claims using the standard formats adopted under HIPAA. Otherwise, submit claims using a Clearinghouse.
HIPAA also requires unique identifiers for employers, health care providers, health plans and individuals for use in standard transactions.
The NPI is your standard unique identifier. It is a 10-digit number with no embedded intelligence that covered entities must accept and use in standard transactions. While HIPAA only requires you to use the NPI in electronic transactions, many state agencies require it on fee-for-service claims and on encounter submissions. For this reason, UnitedHealthcare Community Plan requires the NPI on paper transactions.
The NPI number is issued by the National Plan and Provider Enumeration System (NPPES). Share it with all affected trading partners, such as care providers to whom you refer patients, billing companies and UnitedHealthcare Community Plan. If you don’t have one, go to nppes.cms.hhs.gov.
The privacy regulations limit how health plans, pharmacies, hospitals and other covered entities can use members’ medical information. The regulations protect medical records and other identifiable health information. This includes electronic, paper or spoken data.
They enhance consumers’ rights by giving them access to their health information and controlling its inappropriate use. They also improve health care delivery by extending the privacy efforts of states and health systems to a national level.
Covered entities must meet basic security measures:
UnitedHealthcare Community Plan expects you to comply with all HIPAA regulations.
Find additional information on HIPAA regulations at cms.hhs.gov.
UnitedHealthcare Community Plan is dedicated to conducting business honestly and ethically with you, members, suppliers and government officials and agencies. Making sound decisions as we interact with you, other health care providers, regulators and others is necessary for our continued success and that of our business associates. It’s also the right thing to do.
As a segment of UnitedHealth Group, UnitedHealthcare Community Plan is governed by the UnitedHealth Group Ethics and Integrity program. The UnitedHealthcare Community Plan Compliance program incorporates the required seven elements of a compliance program as outlined by the U.S. Sentencing Guidelines:
UnitedHealthcare Community Plan has compliance officers for each health plan. In addition, each health plan has a compliance committee consisting of senior managers from key organizational areas. The committee provides program direction and oversight.
Report any unethical, unlawful or inappropriate activity by a UnitedHealthcare Community Plan employee to a UnitedHealthcare Community Plan senior manager or directly to the Compliance Office.
UnitedHealthcare Community Plan’s Special Investigations Unit (SIU) is an important part of the Compliance program. The SIU focuses on prevention, detection and investigation of potentially fraudulent and abusive acts committed by care providers and members. This department oversees coordination of anti-fraud activities.
To facilitate the reporting process of questionable incidents involving members or care providers, call our Fraud and Abuse line.
Please refer to the Fraud, Waste and Abuse section of this manual for additional details about the UnitedHealthcare Community Plan Fraud, Waste and Abuse program.
An important aspect of the Compliance program is assessing high-risk areas of UnitedHealthcare Community Plan operations and implementing reviews to help ensure compliance with law, regulations and policies/contracts. When informed of potentially inappropriate or fraudulent practices within the plan or by you, UnitedHealthcare Community Plan will conduct an investigation. You must cooperate with the company and government authorities. This means giving access to pertinent records (as required by your applicable Provider Agreement and this manual) as well as access to office staff. If we establish activity in violation of law or regulation, we will advise appropriate governmental authorities.
If you become the subject of a government inquiry or investigation, or a government agency requests documents relating to your operations (other than a routine request for documentation), you must provide UnitedHealthcare Community Plan with the details. You must also reveal what triggered the inquiry.
UnitedHealthcare Connected must provide to CMS information necessary for CMS to administer and evaluate the UnitedHealthcare Connected program and to establish and facilitate a process for current and prospective members to exercise choice in obtaining Medicare and Medicaid services. Such information includes plan quality and performance indicators such as disenrollment rates; information on member satisfaction; and information on health outcomes. You must cooperate with UnitedHealthcare Connected in its data reporting obligations by providing to UnitedHealthcare Connected any information that it needs to meet its obligations.
UnitedHealthcare Connected is specifically required to submit to CMS data necessary to characterize the context and purposes of each encounter between a member and a provider, supplier, physician, or other practitioner (encounter data). Participating care providers that furnish diagnostic data to assist UnitedHealthcare Connected in meeting its reporting obligations to CMS must certify (based on best knowledge, information, and belief) the accuracy, completeness, and truthfulness of the data.
You are encouraged to comprehensively code all members’ diagnoses to the highest level of specificity possible. All members’ medical encounters must be submitted to UnitedHealthcare Connected.
UnitedHealthcare Community Plan will work with the State of Ohio to perform “individual and corporate extrapolation audits.” This may affect all programs supported by dual funds (state and federal funding) as well as state-funded programs, as requested by the Ohio DHHS.
You must maintain an adequate record-keeping system for recording services, charges, dates and all other commonly accepted information for services rendered to our members. Records must be kept for at least 10 years from the close of the Ohio program agreement between the state and UnitedHealthcare Community Plan or another period as required by law. Retain records based on Ohio Administrative Code. If records are under review, they must be retained until the audit is complete. UnitedHealthcare Community Plan and its affiliated entities (including OptumHealth) will request and obtain prior approval from you for the records under review or inspection. You agree to refund the state any overpayment disclosed by any such audit.
If any litigation, claim, negotiation, audit or other action involving the records has been started before the 10-year period ends, you agree to keep the records until one year after the resolution of all issues that come from it. The state may also perform financial, performance and other special audits on such records during business hours throughout your Provider Agreement.
To help ensure members receive quality services, you must also comply with requests for on-site reviews conducted by the state. During these reviews, the state will address your capability to meet Ohio program standards.
You must cooperate with the state or any of its authorized representatives, the Ohio DHHS, CMS, the Office of Inspector General, or any other agency prior- approved by the state, at any time during your Provider Agreement.
These entities may, at all reasonable times, enter your premises. You agree to allow access to and the right to audit, monitor and examine any relevant books, documents, papers and records to otherwise evaluate (including periodic information systems testing) your performance and charges.
We will perform reviews and audits without delaying your work. If you refuse to allow access, this will constitute a breach of your Provider Agreement.
If you delegate or subcontract any function, the delegate or subcontractor must include all requirements of your applicable Provider Agreement and this manual.
We may assign medical management to a medical group/ Independent Practice Association (IPA) with established medical management standards. We refer to the medical group/ IPA as a “delegate”. Care providers associated with these delegates may use the delegate’s office and protocols for authorizations. The delegate’s medical management protocols and procedures must comply with UnitedHealthcare Community Plan as well as all applicable state and federal regulatory requirements.
Before assigning medical management functions, we assess the delegate. Within 90 calendar days of the contract effective date, we assess it again to measure compliance with UnitedHealthcare Community Plan standards. We assess the delegate annually thereafter. We may also conduct an off-cycle assessment if needed.
Based on the assessment findings, we may have the delegate develop and implement a corrective action plan to bring the medical group/IPA back into compliance.
Delegates who do not achieve compliance within the established timeframes may undergo further corrective action. If the action is not successful, the medical management function will be withdrawn.
When we review a member or care provider’s adverse determination appeal from a delegate, we use MCG (formerly Milliman Care Guidelines) as the externally licensed medical management guidelines. This happens even if the delegate used different externally licensed medical management guidelines to make the determination.
The delegate provides UnitedHealthcare Community Plan with semi-annual reports as outlined in the delegation agreement. Reports must meet applicable requirements and accreditation standards.
The Medical Management Program helps determine if medical services are:
Delegates review nationally recognized criteria to determine medical necessity and appropriate level of care for services. This includes Medicaid coverage guidelines. For services not addressed in Medicaid coverage guidelines, delegates use UnitedHealthcare Community Plan’s medical policies. If other nationally recognized criteria disagree with Medicaid coverage guidelines, delegates follow Medicaid coverage guidelines.
Members may call the delegate’s general number (or the number listed in the denial letters) to request individual eligibility and benefit criteria. They may also call our Member Services department.
NCQA Accreditation standards require all health care organizations, health plans and delegates distribute a statement to members, care providers and employees who make UM decisions. The statement must note the following:
Render covered services at the most appropriate level of care based on nationally recognized criteria. With few exceptions, we do not reimburse for non-covered services and those not medically necessary. We do not reimburse for the wrong procedures (e.g., notification requirements, preauthorization, verification guarantee process). Authorization receipts do not affect how payment policies determine reimbursement.
We nor the member are responsible for reimbursing medical services, admissions, inappropriate facility days, and/or medically necessary services if you did not obtain required prior authorization. Regardless of the Medical Management Program determination, the decision to render medical services lies with the member and you, as the attending care provider. If you and the member decide to go forward with the medical services after UnitedHealthcare Community Plan or the delegate deny preauthorization, no care provider, facility or ancillary services will be reimbursed. The delegate’s medical director can discuss the decisions and criteria with the member. The delegate also makes the medical policy decisions available upon request.
UnitedHealthcare Community Plan or a delegate may issue a denial when a non-covered benefit is requested but deemed not medically necessary. This may also happen when we receive insufficient information.
UnitedHealthcare Community Plan or the delegate must make and communicate timely approvals, modifications or denials.
We or the delegate must also state the decision to delay a service based on medical necessity or benefit coverage appropriate to the member’s medical condition,based on applicable state and federal law.
We base all authorization decisions on sound clinical evidence, including medical record review, consultation with the treating care providers, and review of nationally recognized criteria. You must clearly document the medical appropriateness with your authorization request. State and federal law applies to criteria disclosure.
The medical director, Utilization Management Committee (UMC) or you must review referral requests not meeting the authorization criteria. Otherwise, you must present the information to UMC or the subcommittee for discussion and a determination. Only a care provider (or pharmacist, psychiatrist, doctoral level clinical psychologist or certified addiction medicine specialist, as appropriate) may delay, modify or deny services for medical necessity reasons. Board- certified, licensed care providers from appropriate specialties must help make medical necessity decisions, as appropriate.
Determination rules include:
Possible request for authorization determinations include:
Reasons for denials of requests for services include:
The written denial is an important part of the member’s chart and the delegate’s records. Regardless of the form used, the denial letter documents member and care provider notification of:
CMS requires the use of the CMS Integrated Denial Notice/ Notice of Denial of Medical Coverage (IDN/NDMC) for Medicaid plan members. Do not alter this template except to add text to the requested areas.
Most states require approved standardized templates for member notices, such as denial of services. UnitedHealthcare Community Plan will provide appropriate and approved templates to the delegates.
Written or electronic notices to deny, delay or modify a health care services authorization request must include the following:
Occasionally, a member may contact the delegate instead of the plan. In such cases, delegates must:
The delegate may initiate a member referral. (Refer to the delegated group’s pre-authorization list, as applicable). The following capitated medical services are examples of when a referral authorization may be needed:
The delegate, PCP and/or other referring care provider must verify the care provider participates in UnitedHealthcare Community Plan.
You must also comply with the following procedures:
If the request is not approved, the delegate must issue the member a denial letter.
The delegate may design its own authorization form, without approval from UnitedHealthcare Community Plan. The form should include all the following:
The delegate provides this form to the following:
The delegate does so within 36 hours of receipt of information necessary to make a decision. This includes one working day and does not exceed 14 calendar days.
If UnitedHealthcare Community Plan is financially responsible for the services, the delegate submits the authorization information to the plan.
Continuity of care lets members temporarily continue receiving services from a non-participating care provider. It is intended to last a short period.
The delegate facilitates continuity of care for medically necessary covered services. If a member entering thehealth plan is receiving medically necessary services (in addition to or other than prenatal services) the day before enrollment, the health plan covers the continued costs of such services without prior approval. This is regardless of whether in-network or out- of-network care providers grant these services.
Members in their third trimester of pregnancy may receive services from their prenatal care provider (whether in-network or out-of-network) without any form of prior authorization through the postpartum period (defined as 60 calendar days from date of birth).
A member should not continue care with a non- participating care provider without formal approval by UnitedHealthcare Community Plan or the delegate. Except for emergent or urgent out-of-area (OOA) care, payment for services performed by a non-participating medical group/IPA become the member’s responsibility.
UnitedHealthcare Community Plan (or the delegate) reviews all requests for continuity of care. We consider the member’s condition and the potential effect on the member’s treatment.
We also consider how changing the care provider can affect the health outcome.
A member may request to continue covered services with a care provider who has terminated from UnitedHealthcare Community Plan for reasons other than cause or disciplinary action. As the care provider, you must agree in writing:
Contracted facilities are accountable to provide timely notification to both the delegate and UnitedHealthcare Community Plan within 24 hours of admission for all inpatient cases. This information is needed to verify eligibility, authorize care, and initiate concurrent review and discharge planning. In maternity cases, notify vaginal delivery or C-section delivery on or before the end of the mandated period 48 hours or 96 hours, respectively. We require notification if the baby stays longer than the mother. In all cases, separate notification is required immediately when a baby is admitted to the neonatal intensive care unit.
For emergency admissions, notification occurs once the member has been stabilized in the emergency department.
Authorization logs for all inpatient acute, observation status and skilled nursing facility cases must be accurately submitted at least twice a week to the Authorization Log Unit at firstname.lastname@example.org. When no inpatient acute, observation statuses or skilled nursing facility cases are active, the delegate must submit its weekly authorization log indicating either “no activity” or “no admissions” for each designated admission service type specified in this section and for the applicable reporting time.
Authorization logs covering facility and skilled nursing facility daily information includes the following:
The delegate must clearly define medical necessity and authorizing outpatient services paid as either shared risk or plan risk per the medical group/IPA contract. It must submit authorization or denials for services the group authorized or denied care on behalf of UnitedHealthcare Community Plan.
For more information, please contact your provider advocate.
UnitedHealthcare Community Plan and affiliates monitor complaints for quality of services (QOS) concerning participating care providers and facilities. Complaints about you or your site are recorded and investigated. We conduct appropriate follow-up to assure that members receive care in a safe, clean and accessible environment. For this reason, UnitedHealthcare Community Plan has set Clinical Site Standards for all primary care provider office sites to help ensure facility quality.
UnitedHealthcare Community Plan requires you and your facilities meet the following site standards:
The following table outlines the criteria used to require a site visit. When the threshold is met, we conduct a site visit according to UnitedHealthcare Community Plan policy.
Issue may pose a substantive threat to patient’s safety
Issues with physical appearance, physical accessibility and adequacy of waiting and examination room space
Two complaints in six months
All other complaints concerning the office facilities
Three complaints in six months