Chapter 4: Medical Management (Including Benefit Information)

Air Ambulance

Air ambulance is covered only when the services are medically necessary and transportation by ground ambulance is not available. It is also only covered when:

• Great distances or other obstacles keep members from reaching the destination.
• Immediate admission is essential or
• The pickup point is inaccessible by land.

Emergency Ambulance Transportation

An emergency is a serious, sudden medical or behavioral condition that may include severe pain. Without immediate attention, the affected person could suffer major:

• Injury to their overall health.
• Impairment to bodily functions. 
• Dysfunction of a bodily organ or part.

Emergency transports (in- and out-of-network) are covered. They do not require an authorization.

Bill ambulance transport as a non-emergency transport when it doesn’t meet the definition of an emergency transport. This includes all scheduled runs and transports to nursing facilities or the member’s residence.

Non-Emergent Ambulance Transportation

UnitedHealthcare Community Plan members may get non-emergent transportation services through MTM for covered services. Covered transportation includes

sedan, taxi, wheelchair-equipped vehicle, public transit, mileage repayment and shared rides. Members may get transportation when:

• They are bed-confined before, during and after transport; and
• The services cannot be provided at their home (including a nursing facility or ICF/MR).

UnitedHealthcare Community Plan will provide members with 30 one-way or 15 round trips per year to and from their PCP, WIC, pharmacy, or other participating health care providers, such as vision or dental.

Members may also request help to get to their Medicaid redetermination visits. If a member must travel 30 miles or more from their home to receive covered health care services, UnitedHealthcare Community Plan will provide transportation to and from the provider’s office. These services must be medically necessary and not available in the member’s service area. Members must also have a scheduled appointment (except in the case of urgent/ emergent care). Please contact Member Services at least two business days in advance of the member’s appointment for assistance.

In addition to the transportation assistance that UnitedHealthcare Community Plan provides, members can still receive assistance with transportation for certain services through the local County Department of Job and Family Services Non-Emergency Transportation (NET) program. Call your County Department of Job and Family Services for questions or assistance with NET services.

Value-added non-emergent transportation services include substance abuse support groups, WIC appointments, parenting classes such as Lamaze, and pregnancy, health and wellness classes and meetings.

For non-urgent appointments, members must call Member Services for transportation at least three days before their appointment.

Ambulance services for a member receiving inpatient hospital services are not included in the payment to the hospital. They must be billed by the ambulance provider. This includes transporting the member to another facility for services (e.g., diagnostic testing) and returning them to the first hospital for more inpatient care.

Make urgent non-emergency trips, such as when a member is sent home from the hospital, through our Member Services after 7 p.m. Central Time (CT). Schedule rides up to 30 days in advance.

Bus transportation will also be available if the member:

• Lives less than half a mile from a bus stop.
• Has an appointment less than half a mile from the bus stop.

In addition to the transportation assistance that UnitedHealthcare Community Plan provides, members can get transportation assistance for certain services through the local County Department of Job and Family Services Non-Emergency Transportation (NET) program. Call your county office for questions or help with NET services.

UnitedHealthcare Connected helps manage the care of members with acute or chronic conditions. UnitedHealthcare Connected care management programs include:

• Special Needs Populations – These members have serious and chronic physical, developmental or behavioral conditions requiring health and related services of a type or amount beyond what most members need. We consider members to have special needs when the medical condition both:
  • Lasts or may last one year or longer.
  • Requires ongoing care a PCP generally does not provide.
    The following populations meet the criteria for the special needs designation. This includes members who:
  • Get services through the Ohio Department of Health Services Children’s Rehabilitative Services program.
  • Get services through the Ohio Department of Health Services/ Division of Behavioral Health- contracted Regional Behavioral Health Authorities.
  • Are diagnosed with HIV/AIDS.
  • Are diagnosed with end-stage renal disease receiving dialysis.
• Organ Transplantation – A Transplant Nurse Care Coordinator coordinates authorization requests for organ transplants. They work with the Medicaid Office of Medical Management, contracted providers and UnitedHealthcare Connected departments to coordinate service delivery included in the transplantation process.
• Emergency Department (ED) – Our Care Coordination Program helps members with multiple ED visits get appropriate medical and specialty care.
• HIV+/AIDS – This program is offered alongside the Medicaid guidelines for managing HIV/ AIDS members’ treatment regimens. The Medicaid guidelines require that any member receiving antiretroviral therapy be assigned to a UnitedHealthcare Connected HIV/AIDS Nurse Care Coordinator. Contact the department whenever a member is diagnosed with HIV or AIDS or if an HIV/AIDS- diagnosed member is noncompliant. The HIV/ AIDS Nurse Care Coordinator helps coordinate care for these members.
• Chronic Pain – The Specialty Care Coordination Department handles your requests for assistance with members with chronic pain and related drug- seeking behavior and/or ED abuse.

Call a UnitedHealthcare Personal Care Specialist at 888-303-6163 to refer candidates for care management.

Skilled Nursing Facility (SNF), Health Agency (HHA), And Comprehensive Outpatient Rehabilitation Facility (CORF) Notification Requirements

As a participating UnitedHealthcare SNF, HHA, or CORF provider, you give members the Notice of Medicare Non-Coverage (NOMNC). This notice tells members when their service coverage ends and what they should do if they want to appeal the decision or need more information.

CMS has developed a single, standardized NOMNC designed to make notice delivery easy. It has three variable fields (patient name, ID/Medicare number and last day of coverage) for you to fill in.

When to Deliver the NOMNC

Based on when services should end, the SNF, HHA,  or CORF delivers the NOMNC no later than two days before the end of coverage. If services are expected to end in fewer than two days, deliver the NOMNC upon admission. If there is more than a two-day span between services (e.g., home health setting), issue the NOMNC on the next to last time you furnish services. We encourage SNF, HHA, and CORF providers to work with us so these notices can be delivered as soon as the service termination date is known.

How to Deliver the NOMNC

SNF, HHA, and CORF providers must carry out “valid delivery” of the NOMNC. This means the member (or authorized representative) must sign and date the notice to acknowledge receipt. Authorized representatives may be notified by phone if personal delivery is not immediately available. In this case, notify the authorized representative of the notice contents. Document the call and mail the notice to the representative.

Expedited Review Process

If the member decides to appeal the end of coverage, they must contact the Quality Improvement Organization (QIO) by no later than noon the day before services are to end (as indicated in the NOMNC).

The QIO for Ohio is Livanta. A member may call Livanta at 888-524-9900.

The QIO tells us and you of the request for a review. We provide the QIO and member with a detailed explanation of why coverage is ending. Based on the expedited time frames, the QIO decision should take place by close of business of the day coverage is to end.

Exclusions From Nomnc Delivery Requirements

You do not have to deliver the NOMNC if coverage is ending for any of the following reasons:

1. Member’s benefit is exhausted.
2. Denial of an admission to an SNF, HHA or CORF.
3. Denial of non-Medicare covered services.
4. A reduction or termination of services that do not end the skilled stay.

We issue members a Detailed Explanation of Non- Coverage (DENC) explaining why services are no longer medically necessary. We notify the QIO no later than close of business (typically 4:30 p.m.) the day of the QIO’s notification that the member requested an appeal, or the day before coverage ends, whichever is later.

Find the form on CMS.gov > Medicare > Beneficiary Notices Initiative (BNI) > MA Expedited Determination Notices.

Durable Medical Equipment (DME) is equipment that provides therapeutic benefits to a member because of certain medical conditions and/or illnesses. DME consists of items which are:

• Primarily used to serve a medical purpose
• Not useful to a person in the absence of illness, disability, or injury
• Ordered or prescribed by a care provider
• Reusable
• Repeatedly used
• Appropriate for home use
• Determined to be medically necessary

See our Coverage Determination Guidelines at UHCprovider.com Policies and Protocols > Community Plan Policies > Medical & Drug Policies and Coverage Determination Guidelines for Community Plan.

Obtain authorization for DME rentals or any purchase with a billable charge greater than $500. A list of items requiring prior authorization is located at UHCprovider.com/priorauth. Call Provider Services to request prior authorization. You may also use the secure provider portal Link at UHCprovider.com.

Incontinence Supplies

Edgepark Medical Supply provides all incontinence supplies for UnitedHealthcare Community Plan. Call Edgepark at 844-564-1008 for more information.

Medical Advances

When UnitedHealthcare Community Plan receives requests to cover newly developed medical equipment or procedures, our national Technology Assessment Committee reviews them. This committee includes physicians and other health care professionals. The Committee uses national guidelines and scientific evidence from medical literature to help decide whether UnitedHealthcare Community Plan should approve the use of the equipment or procedures.

Emergency services do not require prior authorization.

While UnitedHealthcare Community Plan covers emergency services, we ask that you tell members about appropriate ER use. A PCP should treat non-emergency services such as sprains/strains, stomachaches, earaches, fever, cough and colds, and sore throats.

Covered services include:

• Hospital emergency department room, ancillary and care provider service by in and out-of-network care providers.
• Medical examination.
• Stabilization services.
• Access to designated Level I and Level II trauma centers or hospitals meeting the same levels of care for emergency services.
• Emergency ground, air and water transportation.
• Emergency dental services, limited to broken or dislocated jaw, severe teeth damage, and cyst removal.

We pay out-of-network care providers for emergency services at the current program rates at the time of service. We try to negotiate acceptable payment rates with out-of-network care providers for covered post-stabilization care services for which we must pay.

Emergency Room Care

For an emergency, the member should seek immediate care at the closest ER. If the member needs help getting to the ER, they may call 911. No referral is needed. Members have been told to call their PCP as soon as possible after receiving emergency care. They pay no out-of-pocket cost for ER or emergency ambulance services.

Before they are treated, UnitedHealthcare Community Plan members who visit an ER are screened to determine whether they have a medical emergency. Prior authorization is not required for the medical screening. UnitedHealthcare Community Plan covers these services regardless of the emergency care provider’s relationship with UnitedHealthcare Community Plan.

After the member has received emergency care, the hospital must seek approval within one hour for pre- approval for more care to make sure the member remains stable. If UnitedHealthcare Community Plan does not respond within one hour or cannot be reached, or if the health plan and attending care provider do not agree on the member’s care, UnitedHealthcare Community Plan lets the treating care provider talk with the health plan’s medical director. The treating care provider may continue with care until the health plan’s medical care provider is reached, or when one of these guidelines is met:

• A plan care provider with privileges at the treating hospital takes over the member’s care.
• A plan care provider takes over the member’s care by sending them to another place of service.
• An MCO representative and the treating care provider reach an agreement about the member’s care.
• The member is released.

Depending on the need, the member may be treated in the ER, in an inpatient hospital room, or in another setting. This is called Post Stabilization Services. Members do not pay for these services. This applies whether the member receives emergency services in or outside their service area.

Urgent Care (Non-Emergent)

Urgent care services are covered.

For a list of urgent care centers, contact Provider Services.

An emergency medical condition is defined as 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 a pregnant woman, the health of the woman and her unborn child) in serious jeopardy;
• Serious impairment to bodily functions; or,
• Serious dysfunction to any bodily organ or part.

Prior authorization is not required for emergency services.

Nurses in the Health Services Department review emergency admissions within one business day of notification.

Deliver emergency care without delay. Notify UnitedHealthcare Community Plan about admission within 48 hours. Call the Prior Authorization Department or fax your Prior Authorization Form within 24 hours, unless otherwise indicated. (The form is located at UHCprovider.com/priorauth.)

UnitedHealthcare Community Plan makes utilization management determinations based on appropriateness of care and benefit coverage existence using evidence- based, nationally recognized or internally-developed clinical criteria. UnitedHealthcare Community Plan does not reward you or reviewers for issuing coverage denials and does not financially incentivize Utilization Management staff to support service underutilization. Care determination criteria is available upon request by contacting the Prior Authorization Department (UM Department, etc.)

The criteria are available in writing upon request or by calling the Prior Authorization Department. Call Utilization Management at 800-366-7304 for authorization for hospital admissions. Call 866-261-7692 for approval for inpatient admissions for behavioral health.

If a member meets an acute inpatient level of stay, admission starts at the time you write the order.

Post-Stabilization Services

UnitedHealthcare Community Plan covers post- stabilization services as defined in federal Medicaid managed care regulation at 42 CFR 438.114(e) and 42 CFR 422.113(c) and OAC rule 5160-26-03(G) without requiring prior authorization. This is the case if any of the following situations exist:

• The post-stabilization services were pre-approved by UnitedHealthcare Community Plan.
• The post-stabilization services were not pre- approved by UnitedHealthcare Community Plan because UnitedHealthcare Community Plan did not respond to your request for the services within 1 hour of the request.
• The post-stabilization services were not pre- approved by UnitedHealthcare Community Plan because UnitedHealthcare Community Plan could not be reached to request pre-approval.
• The post-stabilization services are not pre-approved by a UnitedHealthcare Community Plan Utilization Management representative and a UnitedHealthcare Community Plan medical director was not available for consultation; the treating provider may continue with the proposed plan of care until a plan medical director can be reached.
• The attending or treating care provider shall determine when the member is stable for transfer or discharge. UnitedHealthcare Community Plan shall defer to the treating care provider regarding the point of stabilization.

Hospital Transfers

In the event of a transfer admission to or from the hospital, the sending and receiving hospital or the attending provider must contact the Utilization Management department. No party should assume the other has obtained prior authorization.

Outpatient Surgical Services

Prior authorization may be required for the procedure or surgery. The ordering Provider must make the request for such prior authorization.

The requesting Provider should make every attempt to request the above prior authorization at least 72 hours prior to admission unless contract guidelines stipulate otherwise.

In the event that a member’s condition requires an immediate admission, prior authorization must be obtained for the admission. The ordering Provider or the facility may make the request for such prior authorization. Please be sure that all claims include your appropriate Provider ID numbers and appropriate authorization information for each place of service.

Discharge Planning

Discharge planning begins at the time a member is admitted to the hospital and continues through the concurrent review process. The Utilization Management nurse will use approved medical criteria as discharge indicators. In addition to the member’s clinical status, the psychosocial situation and home environment are also taken into consideration when evaluating the member’s discharge status. Post-hospitalization services may include, but are not limited to, home health visits, DME, rehabilitation and pharmacy services. The Utilization Management nurse will refer pre-identified patients to a dedicated discharge team. This discharge team will assume responsibility for the finalization of the discharge plan and will serve as a resource to the attending provider, hospital team and the member. The discharge team will perform the following discharge planning tasks:

• Confirm benefit levels.
• Assist with the identification of participating care providers.
• Facilitate the certification process of post- hospitalization services.
• Refer members to Care Management for continuity of care.
• Identify high-risk patients for post-discharge follow- up contact to confirm the discharge plan was executed.
• Assist provider with identification and resolution of unanticipated issues identified immediately post- discharge.

The Utilization Management discharge team’s focus is to assist the hospital staff and attending provider with the coordination of the member’s discharge plan.

In addition, during the discharge planning process, the discharge team will identify those members who may be considered high-risk and will outreach to the member post-discharge to verify the discharge plan was executed as the treating provider intended.

Inpatient Rehabilitation Unit/Long Term Acute Care Facility

UnitedHealthcare Community Plan care providers may use an Inpatient Rehabilitation Unit only when prior authorized by the Utilization Management department. The ordering care provider of the facility may make the request for such prior authorization.

The requesting care provider should make every attempt to make the above prior authorization request at least 72 hours prior to admission, unless contract guidelines stipulate otherwise.

Family planning services are preventive health, medical, counseling and educational services that help members manage their fertility and achieve the best reproductive and general health. UnitedHealthcare Community Plan members may access these services without a referral.

They may also seek family planning services at the care provider of their choice. The following services are included:

• Annual gynecological examination
• Annual pap smear
• Contraceptive supplies, devices and medications for specific treatment
• Contraceptive counseling
• Laboratory services

Blood tests to determine paternity are covered only when the claim indicates tests were necessary for legal support in court.

Non-covered items include:

• Reversal of voluntary sterilization
• Hysterectomies for sterilization
• In-vitro fertilization, including:
  • GIFT (Gamete intrafallopian transfer)
  • ZIFT (zygote intrafallopian transfer)
  • Embryo transport
• Infertility services, if given to achieve pregnancy 
  Note: Diagnosis of infertility is covered. Treatment is not.
  • Morning-after pill. Contact ODM to verify state coverage.

Parenting/Child Birth Education Programs

• Child birth education is covered.
• Parenting education is not covered.

Voluntary Sterilization

In-network treatment with consent is covered. The member needs to give consent 30 days before surgery, be mentally competent and be at least 21 years old at the time of consent for:

• Tubal ligation
• Vasectomy

Out-of-network services require prior authorization.

View the ODM regulations for more information on sterilization.

Our care coordination program is led by our qualified, full- time care coordinators. You are encouraged to collaborate with us to ensure care coordination services are provided to members. This program is a proactive approach to help members manage specific conditions and support them as they take responsibility for their health.

The program goals are to:

• Provide members with information to manage their condition and live a healthy lifestyle
• Improve the quality of care, quality of life and health outcomes of members
• Help individuals understand and actively participate in the management of their condition, adherence to treatment plans, including medications and self-monitoring
• Reduce unnecessary hospital admissions and ER visits
• Promote care coordination by collaborating with providers to improve member outcomes
• Prevent disease progression and illnesses related to poorly managed disease processes
• Support member empowerment and informed decision making
• Effectively manage their condition and co-morbidities, including depression, cognitive deficits, physical limitations, health behaviors and psychosocial issues

Our program makes available population-based, condition-specific health education materials, websites, interactive mobile apps and newsletters that include recommended routine appointment frequency, necessary testing, monitoring and self-care. We send health education materials, based upon evidence-based guidelines or standards of care, directly to members that address topics that help members manage their condition. Our program provides personalized support to members in case management. The case manager collaborates with the member to identify educational opportunities, provides the appropriate health education and monitors the member’s progress toward management of the condition targeted by the care coordination program.

Programs are based upon the findings from our Health Education, Cultural and Linguistic Group Needs Assessment (GNA) and will identify the health education, cultural and linguistic needs.

You must obtain prior authorization for children younger than age 21. We do not require prior authorization for chiropractic care for members 21 years and older. Adult members may access care in 15 visits per year.

Health Home provides community-based intensive care coordination and comprehensive care management to improve health outcomes and reduce service costs for some of the state’s highest-need individuals. Health Home helps improve coordination of care, quality, and increase individual participation in their own care. The program reduces Medicaid inpatient hospital admissions, avoidable ER visits, inpatient psychiatric admissions, and the need for nursing home admissions. We work with area hospitals in providing transitional care services to members enrolled in Health Home. Hospitals and care providers may refer individuals to us for potential Health Home enrollment. Health Home eligibility is determined by Medicaid. The program provides services beyond those typically offered by care providers, including, but not limited to:

• Comprehensive care management
• Care coordination and health promotion,
• Individual and family support
• Referral to community services

Monaural and binaural hearing aids are covered, including fitting, follow-up care, batteries and repair. Bilateral cochlear implants, including implants, parts, accessories, batteries, charges and repairs are covered. Bone-anchored hearing aids (BAHA), including BAHA devices (both surgically implanted and soft band headbands), replacement parts and batteries are covered for members 20 years or younger.

Our Utilization Management oversees the authorization of home health care services. Home health care may include:

• Well-baby/post partum care
• Skilled nursing
• Physical therapy
• Respiratory therapy
• Occupational therapy
• Speech therapy
• IV therapy
• DME

Order home health care from any participating home health care provider. Obtain prior authorization for all home health care services.

UnitedHealthcare Community Plan provides in-home hospice and short-stay inpatient hospice. These services require prior authorization.

Home Hospice

UnitedHealthcare Community Plan covers benefits for routine home care every day the member is at home, under hospice and not receiving continuous home care. We cover care provider hospice at the member’s home during a medical crisis. A medical crisis is when a member requires continuous nursing care to manage symptoms.

Respite Hospice

Inpatient hospital or nursing facility respite care is covered for the hospice care provider each day the member is in an inpatient facility and receiving respite care. Hospice inpatient respite care is short-term inpatient care provided to the member when necessary to relieve the caregiver. Hospice inpatient respite care is restricted to five days per month. This includes the day of admission but not the day of discharge.

Inpatient Hospice

Inpatient care is covered during a sudden medical crisis. General inpatient care may be necessary for pain control or acute/chronic symptom management not provided in any other setting. Inpatient hospice care includes a hospital or an in-network hospice inpatient facility that meets the hospice standards for staffing and member care. Inpatient care is short-term and restricted to 10 days per month.

Members receiving inpatient hospice services through a residential facility are not covered under Managed Medicaid. ODM covers residential inpatient hospice services. ODM will cover hospice care provider benefits for both the hospice services provided and the facility residential services.

Advanced Outpatient Imaging Procedures

Advanced outpatient imaging procedures must be prior authorized by UnitedHealthcare Community Plan Clinical. Obtain prior authorization for any lab test not covered by the Ohio Medicaid program. 

To get prior authorization, go to UHCprovider.com/priorauth > click on the Radiology tab > Online Portal link, or call UnitedHealthcare Community Plan Radiology. Obtain prior authorization for any lab test not covered by the Ohio Medicaid program.

Reference the Medical Management chapter for more information on the Radiology Prior Authorization Program.

Lab Services

For more information on our in-network labs, go to UHCprovider.com > Find Dr. > Preferred Lab Network.

Use a UnitedHealthcare Community Plan in-network laboratory when referring members for lab services not covered in the office. Medically necessary laboratory services ordered by a PCP, other care providers or dentist in one of these laboratories do not require prior authorization except as noted on our prior authorization list.

When submitting claims, have a Clinical Laboratory Improvement Amendment number (CLIA #). Otherwise, claims will deny. CLIA standards are national and not Medicaid-exclusive. CLIA applies to all providers rendering clinical laboratory and certain other diagnostic services.

See the Billing and Submission chapter for more information.

UnitedHealthcare Connected members may get long- term services and supports (LTSS), also called Medicaid “waiver services.”

LTSS help members 18 years or older who are fully eligible for both Medicare and Medicaid and enrolled in MyCare Ohio stay in the community instead of going to a nursing home or hospital. If members are eligible for waiver services, their care manager helps meet their needs.

LTSS includes the following waiver services:

• Out-of-home respite.
• Adult day health.
• Home medical equipment and supplemental adaptive and assistive devices.
• Waiver transportation.
• Chore services.
  
• Social work counseling.
• Personal emergency response system.
• Home modification maintenance and repair.
• Personal care.
• Homemaker.
• Waiver nursing.
• Home-delivered meals.
• Alternative meals.
• Pest control.
• Assisted living.
• Home care attendant.
• Choices home care attendant.
• Enhanced community living.
• Nutritional consultation.
• Independent living assistance.
• Community transition.

Transition Period

A transition period applies to individuals who were enrolled on any of the Ohio Medicaid waivers (PASSPORT, Choices, Assisted Living, Ohio Home Care, or Transitions Carve-Out) before enrolling on the MyCare Ohio Waiver. Exact periods are shown in the Transition Requirements table.

During this period, we keep members’ existing service levels and care providers for a pre-determined amount of time, depending upon the service.

Exceptions:

We may change the member’s existing care provider during the transition period in the following cases:

• The member requests a change.
• The care provider gives appropriate notice of intent (typically 30 days) to stop a member’s services.
• We identify care provider performance issues that affect a member’s health.

When the transition period ends, the member’s services or care providers won’t necessarily change. UnitedHealthcare Connected only has the option to make changes to the member’s services after this period. Before the end of the transition period, the member’s Waiver Services Coordinator reviews their waiver service plan and discusses any needed changes with members. If a care provider change is required for any reason, the member is given information about other available care providers.

Email questions to UnitedHealthcare Connected at icdsprovider@uhc.com. Members may call Member Services at 800-396-1942 (TTY 800-947-6644).

Pregnancy/Maternity

Evaluate OB needs using the criteria indicated on the OB Needs Assessment Form. Send a copy of the form to Healthy First Steps. If you have questions, please call 877-353-6913 within 15 days from the initial assessment. You may also submit the form to the pregnancy care manager at any time during prenatal care if a member’s condition constitutes a change of risk status.

Bill the initial pregnancy visit as a separate office visit. You may bill global days if the mother has been a UnitedHealthcare Community Plan member for three or more consecutive months or had seven or more prenatal visits.

Medicaid does not consider ultrasounds medically necessary if they are done only to determine the fetal sex or provide parents with a photograph of the fetus. We allow the first three obstetrical ultrasounds per pregnancy. The fourth and subsequent obstetrical ultrasound procedures will only be allowed for identified high-risk members. High-risk member claims must include the corresponding diagnosis code.

For more information about global days, go to UHCprovider.com.

Pregnant UnitedHealthcare Community Plan members should receive care from UnitedHealthcare Community Plan care providers only. UnitedHealthcare Community Plan considers exceptions to this policy if:

1. The woman was in her second or third trimester of pregnancy when she became a UnitedHealthcare Community Plan member, and
2. If she has an established relationship with a non-participating obstetrician.

UnitedHealthcare Community Plan must approve all out-of-plan maternity care. Call 866-604-3267 to obtain prior approval for continuity of care.

Notify UnitedHealthcare Community Plan immediately of a member’s confirmed pregnancy to help ensure appropriate follow-up and coordination by the Healthy First Steps program.

To notify UnitedHealthcare Community Plan of pregnancies, care providers should call Healthy First Steps at 800-599-5985 or fax the notification to 877-353-6913.

A UnitedHealthcare Community Plan member does not need a referral from her PCP for OB/GYN care. Perinatal home care services are available for UnitedHealthcare Community Plan members when medically necessary.

In-Office Surgery

Any surgeries a gynecologic provider performs in the office do not require authorization prior to rendering services.

Maternity Admissions

All maternity admissions require notification. Days in excess of 48 hours for vaginal deliveries and 96 hours for C-section require clinical information and medical necessity review.

If the UnitedHealthcare Community Plan member is inpatient longer than the federal requirements, a prior notification is needed. Please go to UHCprovider.com/priorauth or call the Prior Authorization Department.

To notify UnitedHealthcare Community Plan of deliveries, call 866-604-3267 or fax to 800-897-8317. Provide the following information within one business day of the admission:

• Date of admission.
• Member’s name and Medicaid ID number.
• Obstetrician’s name, phone number, care provider ID.
• Facility name (care provider ID).
• Vaginal or cesarean delivery.

If available at time of notification, provide the following birth data:

• Date of delivery.
• Sex.
• Birth weight.
• Gestational age.
• Baby name.

Non-routine newborn care (e.g., unusual jaundice, prematurity, sepsis, respiratory distress) is covered but requires prior authorization. Infants remaining in the hospital after mother’s discharge require separate notification and will be subject to medical necessity review. The midwife (CNM) must be a licensed registered nurse recognized by the Board of Nurse Examiners as an advanced practice nurse (APN) in nurse-midwifery and certified by the American College of Nurse- Midwives.

A CNM must identify a licensed care provider or group of care providers with whom they have arranged for referral and consultation if complications arise.

Furnish obstetrical maternity services on an outpatient basis. This can be done under a physician’s supervision through a nurse practitioner, physician’s assistant or licensed professional nurse. If handled through supervision, the services must be within the staff’s scope of practice or licensure as defined by state law.

You do not have to be present when services are provided. However, you must assume professional responsibility for the medical services provided and help ensure approval of the care plan.

Post Maternity Care

UnitedHealthcare Community Plan covers post- discharge care to the mother and her newborn. Post- discharge care consists of a minimum of two visits, at least one in the home, according to accepted maternal and neonatal physical assessments. These visits must be conducted by a registered professional nurse with experience in maternal and child health nursing or a care provider. The first post-discharge visit should occur within 24 to 48 hours after the member’s discharge date. Prior authorization is required for home health care visits for post-partum follow-up. The attending care provider decides the location and post-discharge visit schedule.

Newborn Enrollment

The hospital is responsible to notify the county of all deliveries, including UnitedHealthcare Community Plan members (provided the mother was admitted using her ForwardHealth ID card).

If the mother delivers out of state, the member would need to contact the Enrollment Department to provide birth notification. The Enrollment Department would then add the baby to the health plan.

The hospital provides enrollment support by providing required birth data during admission.

Bright Futures Assessment

Bright Futures is a national health promotion and prevention initiative, led by the American Academy of Pediatrics and supported by the US Department of Health and Human Services, Health Resources and Services Administration (HRSA), Maternal and Child Health Bureau (MCHB).

The Bright Futures Guidelines provide guidance for all preventive care screenings and well-child visits. You may incorporate Bright Futures into health programs such as home visiting, child care, school-based health clinics, and many others. Materials developed for families are also available.

The primary goal of Bright Futures is to support primary care practices (medical homes) in providing well-child and adolescent care according to Bright Futures: Guidelines for Health Supervision of Infants,Children, and Adolescents. Settings for Bright Futures implementation include private practices, hospital-based or hospital-affiliated clinics, resident continuity clinics, school-based health centers, public health clinics, community health centers, Indian Health Service clinics, and other primary care facilities. A complementary goal is to provide home visitors, public health nurses, early child care and education professionals (including Head Start), school nurses, and nutritionists with an understanding of Bright Futures materials so that they can align their health promotion efforts with the recommendations in the Bright Futures Guidelines. This objective will ensure that patients receive information and support that is consistent from family and youth perspectives.

Home Care And All Prior Authorization Services

The discharge planner ordering home care should call the Prior Authorization Department to arrange for home care.

Hysterectomies

Hysterectomies cannot be reimbursed if performed for sterilization. Members who get hysterectomies for medical reasons must be told, orally and in writing, they will no longer be able to have children.

All hysterectomy claims (surgeon, assistant surgeon, anesthesiologist, hospital) must be accompanied by a consent form. The member should sign and date the form stating she was told before the surgery that the procedure will result in permanent sterility.

Find the form at the Ohio Department of Medicaid medicaid.ohio.gov).

Exception: ODM does not require informed consent if:

1. As the care provider performing the hysterectomy, you certify in writing the member was sterile before the procedure. You must also state the cause of the sterility.
2. You certify, in writing, the hysterectomy was performed under a life-threatening emergency situation in which prior acknowledgment was not possible. Include a description of the emergency.

UnitedHealthcare Community Plan requires, along with your claim, a copy of the signed medical assistance hysterectomy statement. Mail the claim and documentation to claims administration identified on the back of the member’s ID card. Reimbursement is made upon completion of documentation requirements and UnitedHealthcare Community Plan review. The member may not be billed if consent forms are not submitted.

Pregnancy Termination Services

Pregnancy termination services are not covered, except in cases to preserve the woman’s life. In this case, follow the Ohio consent procedures for abortion.

Allowable pregnancy termination services do not require a referral from the member’s primary care provider. Members must use the UnitedHealthcare Community Plan care provider network.

Sterilization and Hysterectomy Procedures

Reimbursement for sterilization procedures are based on the member’s documented request. This policy helps ensure UnitedHealthcare Community Plan members thinking about sterilization are fully aware of the details and alternatives. It also gives them time to consider their decision. In addition, the Ohio Medical Assistance Program must have documented evidence that all the sterilization requirements have been met before making a payment. The member must sign the Medical Assistance Consent Form at least 30 days, but not more than 180 days, before the procedure. The member must be at least 21 years old when they sign the form.

The member must not be mentally incompetent or live in a facility treating mental disorders. The member may agree to sterilization at the time of premature delivery or emergency abdominal surgery if at least 72 hours have passed since signing the consent form. However, in the case of premature delivery, they must have signed the form at least 30 days before the expected delivery date. If the requirements are not met for both sterilization procedures and hysterectomies, UnitedHealthcare Community Plan cannot pay the care provider, anesthetist or hospital.

Sterilization Informed Consent

A member has only given informed consent if the Ohio Department of Social Services Medical Assistance Consent Form for sterilization is properly filled out. Other consent forms do not replace the Medical Assistance Consent Form. Be sure the member fully understands the sterilization procedure and has been told of other family planning options. Informed consent may not be obtained while the member is in labor, seeking an abortion, or under the influence of alcohol or other substances that affect awareness.

Sterilization Consent Form

Use the consent form for sterilization:

• Complete all applicable sections of the form. Complete all applicable sections of the consent form before submitting it with the billing form. The Ohio Medical Assistance Program cannot pay for sterilization procedures until all applicable items on the consent form are completed, accurate and follow sterilization regulation requirements.
• Your statement section should be completed after the procedure, along with your signature and the date. This may be the same date of the sterilization or a date afterward. If you sign and date the consent form before performing the sterilization, the form is invalid.
• The state’s definition of “shortly before” is not more than 30 days before the procedure. Explain the procedure to the member within that time frame. However, do not sign and date the form until after you perform the procedure.

You may also find the form on the United States Department of Health and Human Services website at hhs.gov.

Have three copies of the consent form:

1. For the member.
2. To submit with the Request for Payment form.
3. For your records.

Our Neonatal Resource Services (NRS) program manages inpatient and post-discharge neonatal intensive care unit (NICU) cases to improve outcomes and lower costs. Our dedicated team of NICU nurse case managers, social workers and medical directors offer both clinical care and psychological services.

Neonatal Resource Services

The NRS program helps ensure NICU babies get quality of care and efficiency in treatment. Newborns placed in the NICU are eligible upon birth (including babies who are transferred from PICU) and/or any infants readmitted within their first 30 days of life and previously managed in the NICU. NRS follows all babies brought to the NICU.

NRS neonatologists and NICU nurses manage NICU members through evidence-based medicine and care plan use.

The NRS nurse case manager will:

• Work with the family, the care providers, and the facility discharge planner to help ensure timely discharge and service delivery.
• Develop care management strategies and interventions based on infant and family needs.
• Coordinate services prior to discharge and after discharge if the member is under NRS case management.

The NRS nurse case manager’s role includes:

• Planning and arranging the discharge.
• Coordinating care options and prior authorization, including home care, equipment and skilled nursing.
• Arranging post-discharge support for a minimum of 30 days and up to 15 months based on infant ongoing acuity
• Educating parents and families about available local resources and support services.
• Coordination with the Whole Person Care Team for additional case management needs and services.

Case managers provide benefit solutions to help families get the right services for the baby.

Inhaled Nitric Oxide

Use the NRS guideline for Inhaled Nitric Oxide (iNO) therapy at UHCprovider.com > Policies and Protocols > Clinical Guidelines.

Request prior authorization for UnitedHealthcare Community Plan members in Ohio for injectable outpatient chemotherapy drugs given for a cancer diagnosis.

We use the prior authorization process to help support compliance with evidence-based and professional society guidance for radiology procedures.

You must obtain prior authorization for the following advanced imaging procedures if you provide them in an office or outpatient setting:

• Computerized tomography (CT)
• Magnetic resonance imaging (MRI)
• Magnetic resonance angiography (MRA)
• Positron-rmission tomography (PET)
• Nuclear medicine
• Nuclear cardiology

Advanced imaging procedures do not require prior authorization if performed in the following places of service:

• ER
• Observation unit
• Urgent care
• Inpatient stay

If you do not complete the entire prior authorization process before performing the procedure, we will reduce or deny the claim. Do not bill the member for claims we deny for this reason.

Request prior authorization online or by phone at:

• Online: UHCprovider.com/radiology > Go to Prior Authorization and Notification Tool.
• Phone: 866-889-8054 from 8 a.m. - 5 p.m. Central Time, Monday through Friday. Make sure the medical record is available. An authorization number is required for each CPT code.

For a list of Advanced Outpatient Imaging Procedures that require prior authorization, a prior authorization crosswalk, and/or the evidence-based clinical guidelines, go to UHCprovider.com/radiology > Specific Radiology Programs.

SBIRT services are covered when:

• Provided by, or under the supervision of, a certified care provider or other certified licensed healthcare professional within the scope of their practice.
• Determining risk factors related to alcohol and other drug use disorders, providing interventions to enhance patient motivation to change, and making appropriate referrals as needed.
• SBIRT screening will occur during an Evaluation and Management (E/M) exam and is not billable with a separate code. You may provide a brief intervention on the same day as a full screen in addition to the E/M exam. You may also perform a brief intervention on subsequent days. Brief interventions are limited to four sessions per patient, per provider per calendar year.

What Is Included in SBIRT?

Screening: With just a few questions on a questionnaire or in an interview, you can identify members who have alcohol or other drug (substance) use problems and determine how severe those problems already are. Three of the most widely used screening tools are the Alcohol Use Disorders Identification Test (AUDIT), the Alcohol, Smoking, and Substance Involvement Screening Test (ASSIST) and the Drug Abuse Screening Test (DAST).

Brief intervention: If screening results indicate at risk behavior, individuals receive brief interventions. The intervention educates them about their substance use, alerts them to possible consequences and motivates them to change their behavior.

Referral to treatment: Refer members whose screening indicates a severe problem or dependence s to a licensed and certified behavioral health agency for assessment and treatment of a substance use disorder. This includes coordinating with the Alcohol and Drug Program in the county where the member resides for treatment.

SBIRT services will be covered when all of the following are met:

• The billing provider and servicing provider are SBIRT certified.
• The billing provider has an appropriate taxonomy to bill for SBIRT.
• The diagnosis code is V65.42.
• The treatment or brief intervention does not exceed the limit of four encounters per client, per provider, per year.

The SBIRT assessment, intervention, or treatment takes places in one of the following places of service:

• Office
• Urgent care facility
• Outpatient hospital
• ER – hospital
• Federally qualified health center (FQHC)
• Community mental health center
• Indian health service – freestanding facility
• Tribal 638 freestanding facility
• Homeless shelter

For more information about E/M services and outreach, see the Department of Health and Human Services Evaluation and Services online guide at cms.gov.

Medication-Assisted Treatment

Medication-assisted treatment (MAT) combines behavioral therapy and medications to treat Opioid Use Disorders (OUD). The Food and Drug Administration (FDA) approved medications for OUD include Buprenorphine, Methadone, and Naltrexone.

To prescribe Buprenorphine, you must complete the waiver through the Substance Abuse and Mental Health Services Administration (SAMHSA) and obtain a unique identification number from the United States Drug Enforcement Administration (DEA).

As a medical care provider, you may provide MAT services even if you don’t offer counseling or behavioral health therapy in-house. However, you must refer your patients to a qualified care provider for those services. If you need help finding a behavioral health provider, call the number on the back of the member’s health plan ID card or search for a behavioral health professional on liveandworkwell.com.

To find a medical MAT provider in Ohio:

1. Go to UHCprovider.com.
2. Select “Find a Provider” from the menu on the home page.
3. Select “Search for Care Providers in the General UnitedHealthcare Plan Directory.”
4. Click on “Medical Directory.”
5. Click on “Medicaid Plans.”
6. Click on applicable state.
7. Select applicable plan.
8. Refine the search by selecting “Medication Assisted Treatment.”

For more SAMHSA waiver information:

Physicians — samhsa.gov

Nurse Practitioners (NPs) and Physician Assistants (PAs) — samhsa.gov

If you have questions about MAT, please call Provider Services at 800-600-9007, enter your Tax Identification Number (TIN) then say “Representative,” and “Representative” a second time, then “Something Else” to speak to a representative.

Opioid Resources

• Interagency Guideline on Prescribing Opioids for Pain: agencymeddirectors.wa.gov > Interagency Guidelines > AMDG 2015 Interagency Guideline on Prescribing Opioids for Pain
• National Center for Biotechnology Information: ncbi.nlm.nih.gov > enter either “3218789” or “The Role of Psychological Interventions in the Management of Patients with Chronic Pain” in Search engine
• Opioid Use Disorder Diagnostic Criteria from the American Psychiatric Association in the Diagnostic and Statistical Manual of Mental Disorders, 5th edition, 2013.

Screening Tools

• Pain Assessment Scale: painedu.org > Pain Assessment Scales CAGE-AID (Adapted to Include Drugs): opioid risk > Type in “CAGE-AID” in the Search engine > Select CAGE - “Aid Screen Tool” Patient Substance Use.

Treatment Helpline

• Free, confidential service for UnitedHealthcare members. Specialized licensed clinicians provide treatment advocate services 24 hours a day, seven days a week.
• Phone: 855-780-5955
• Website: liveandworkwell.com

For other questions, call 888-362-3368.

With a few exceptions, UnitedHealthcare Connected members must use network pharmacies to get their outpatient prescription drugs covered. Generally, we only cover drugs filled at an out-of-network pharmacy when a network pharmacy is not available.

To find out what drugs are covered, go to UHCprovider.com.

For Medicaid, bill prescriptions filled through retail pharmacies to OptumRx. All written prescriptions must be tamper resistant.

BIN/Processor Control Number/Group Numbers Claims Processor (Medicaid)

• Name of Processor: OptumRx
• Bank Identification Number (BIN): 610494
• Processor Control Number (PCN): 9999
• Submitted Group (Group): ACUOH

For UnitedHealthcare Connected, bill prescriptions through retail pharmacies to OptumRx. All written prescriptions must be tamper-resistant.

BIN/Processor Control Number/Group Numbers Claims Processor (UnitedHealthcare Connected)

• Name of Processor: OptumRx
• Bank Identification Number (BIN): 610097
• Processor Control Number (PCN): 9999
• Submitted Group (Group): MPDOHCSP 

We cover the following:

• Drugs administered in a physician office, hospital, outpatient department, clinic, dialysis center, or infusion center. Previous prior authorization requirements still apply.
• Some medical supplies such as diabetic testing supplies, supplies for injection of insulin and other drugs, inhaler spacers and peak flow meters. Find more information on our Preferred Drug List (PDL).

Members may receive prescriptions at any network pharmacies. If a member is planning to travel out of state, work with the member to make sure they have enough of their medication.

Members may call Member Services (TTY Relay: 711).

UnitedHealthcare Community Plan determines and maintains its PDL of covered medications. This list applies to all UnitedHealthcare Community Plan members. Specialty drugs on the PDL are identified by a “SP” in the “Requirements and Limits” section of each page.

You must prescribe Medicaid members drugs listed on the PDL. We may not cover brand-name drugs not on the PDL if an equally effective generic drug is available and is less costly unless prior authorization is followed.

If a member requires a non-preferred medication, call the Pharmacy Prior Authorization department at 800-310- 6826. You may also fax a Pharmacy Prior Notification Request form to 866-940-7328.

We provide you PDL updates before the changes go into effect. Change summaries are posted on UHCprovider.com. Find the PDL and Pharmacy Prior Notification Request form at UHCprovider.com/priorauth.

Medications can be dispensed as an emergency 72- hour supply when drug therapy must start before prior authorization is secured and the prescriber cannot be reached. The rules apply to non-preferred PDL drugs and to those affected by a clinical prior authorization edit.

To request pharmacy prior authorization, call the OptumRx Pharmacy Help Desk at 800-310-6826. You may also fax your authorization request to 866-940- 7328. We provide notification for prior authorization requests within 24 hours of request receipt.

The Specialty Pharmacy Management Program provides high-quality, cost-effective care for our members.

A specialty pharmacy medication is a high-cost drug that generally has one or more of the following characteristics:

• Used by a small number of people
• Treats rare, chronic, and/or potentially life- threatening diseases
• Has special storage or handling requirements such as needing to be refrigerated
• May need close monitoring, ongoing clinical support and management, and complete patient education and engagement
• May not be available at retail pharmacies
• May be oral, injectable, or inhaled

Specialty pharmacy medications are available through our specialty pharmacy network.

Guidelines for tuberculosis (TB) screening and treatment should follow the recommendations of the American Thoracic Society (ATS) and the Centers for Disease Control and Prevention (CDC).

Responsibilities

The PCP determines the risk for developing TB as part of the initial health assessment. Testing is offered to all members at increased risk unless they have documentation of prior positive test results or currently have active TB under treatment. You will coordinate and collaborate with Local Health Departments (LHDs) for TB screening, diagnosis, treatment, compliance, and follow- up of members. PCPs must comply with all applicable state laws and regulations relating to the reporting of confirmed and suspected TB cases to the LHD. The PCP must report known or suspected cases of TB to the LHD TB Control Program within one day of identification.

All members receive an eye exam every 12 months. They also have a choice of glasses or $125 toward any type of contacts (must use at one time) every 12 months. UnitedHealthcare Community Plan also offers an additional frame selection beyond what Medicaid covers at no cost to the member. Refer to the Provider Directory for a list of optometrists in the UnitedHealthcare Community Plan network to set up eye appointments.

Human Immunodeficiency Virus (HIV)/ Acquired Immune Deficiency Syndrome (AIDS) Hcbs Waiver Program

The HIV/AIDS in-home waiver services program is available to members who would otherwise require long- term institutional services.

Identification – Members with symptomatic HIV or AIDS who require nursing home level of care services may be eligible for the waiver. The care coordinator or the PCP may identify members potentially eligible for the waiver program. They may also inform the member of the waiver program services.

Referral – If the member agrees to participation, provide the waiver agency with supportive documentation including history and physical, any relevant labs or other diagnostic study results and current treatment plan.

Continuity of Care – The HIV/AIDS waiver program will coordinate in-home HCBS services in collaboration with the PCP and care coordinator. If the member does not meet criteria for the waiver program, or declines participation, the health plan will continue care coordination as needed to support the member.

Other Federal Waiver Programs

Other waiver services, including the Nursing Facility Acute Hospital Waiver, may be appropriate for members who may benefit from HCBS services. These members are referred to the Long Term Care Division / HCBS Branch to determine eligibility and availability. If deemed eligible, the health plan will continue to cover all medically necessary covered services for the member unless/until member is disenrolled from the Medicaid Program.

Admission Authorization And Prior Authorization Guidelines

All prior authorizations must have the following:

• Patient name and ID number.
• Ordering care provider or health care professional name and TIN/NPI.
• Rendering care provider or health care professional and TIN/NPI.
• ICD CM.
• Anticipated dates of service.
• Type of service (primary and secondary) procedure codes and volume of service, when applicable.
• Service setting.
• Facility name and TIN/NPI, when applicable.

Call 800-366-7304 or use Link to obtain a medical prior authorization. For Behavioral Health Services, call 866-261-7692.

Some dental services require prior authorization. Submit requests to UnitedHealthcare Community Plan’s dental administrator DentaQuest by calling 855-398-8411.

DentaQuest will respond to prior authorization requests by phone or secure fax within 15 days.

Locate the Prior Authorization Fax Request Form at UHCprovider.com/priorauth. If you have questions, please call Prior Authorization Intake.

Additional requirements include:

• Ohio Medicaid managed care plans must respond to electronically submitted prior authorizations within 48 hours for urgent services and 10 calendar days for any non-urgent care services. This time period begins once the plan receives the request with all required information.
• Responses to prior authorization requests must indicate whether the request is approved, denied, or incomplete. When the response to a prior authorization is denied, the managed care plan must provide the specific reason.
• If the prior authorization request is incomplete, the department or its designee shall indicate the specific additional information that is required to process the request.

The Utilization Management (UM) department will respond to prior authorization requests by phone or secure fax within 10 days. If the member’s condition requires an expedited response, notify Intake/Prior Authorization to consider the request as urgent.

Prior authorization requests are generally reviewed and decided within 72 hours of the request; however, you may be granted an extension of up to 10 days from the date of the original request to provide additional information. For peer-to-peer discussions, call the UM prior authorization line at 800-366-7304.

See the following table for more information about requirements.

UnitedHealthcare Community Plan requires you to chart progress notes for each day of an inpatient stay. This includes acute and sub-acute medical, long-term acute care, acute rehabilitation, skilled nursing facilities, home health care and ambulatory facilities. We perform an on-site facility review or phone review for each day’s stay using MCG, CMS or other nationally recognized guidelines to help clinicians make informed decisions in many health care settings. You must work with UnitedHealthcare Community Plan for all information, documents or discussion requests. This includes gathering clinical information on a member’s status for concurrent review and discharge planning. When criteria are not met, the case is sent to a medical director.

UnitedHealthcare Community Plan denies payment for days that do not have a documented need for acute care services. Failure to document results in payment denial to the facility and you.

Concurrent Review Details

Concurrent Review is notification within 24 hours or one business day of admission. It finds medical necessity clinical information for a continued inpatient stay, including review for extending a previously approved admission. Concurrent review may be done by phone or on-site.

Your cooperation is required with all UnitedHealthcare Community Plan requests for information, documents or discussions related to concurrent review and discharge planning including: primary and secondary diagnosis, clinical information, care plan, admission order, member status, discharge planning needs, barriers to discharge and discharge date. When available, provide clinical information by access to Electronic Medical Records (EMR).

Your cooperation is required with all UnitedHealthcare Community Plan requests from our interdisciplinary care coordination team and/or medical director to support requirements to engage our members directly face-to- face or by phone. You must return/respond to inquiries from our interdisciplinary care coordination team and/or medical director.

UnitedHealthcare Community Plan uses MCG (formally Milliman Care Guidelines), CMS guidelines, or other nationally recognized guidelines to assist clinicians in making informed decisions in many health care settings. This includes acute and sub-acute medical, long-term acute care, acute rehabilitation, skilled nursing facilities, home health care and ambulatory facilities.

Medically necessary services or supplies are those necessary to:

• Prevent, diagnose, alleviate or cure a physical or mental illness or condition.
  
• Maintain health.
• Prevent the onset of an illness, condition or disability.
• Prevent or treat a condition that endangers life, causes suffering or pain or results in illness or infirmity.
• Prevent the deterioration of a condition.
• Promote daily activities; remember the member’s functional capacity and capabilities appropriate for individuals of the same age.
• Prevent or treat a condition that threatens to cause or worsen a handicap, physical deformity, or malfunction; there is no other equally effective, more conservative or substantially less costly treatment available to the member.

We do not cover experimental treatments.

Services which are necessary for the diagnosis or treatment of disease, illness or injury and without which the patient can be expected to suffer prolonged, increased or new morbidity, impairment of function, dysfunction of a body organ or part, or significant pain and discomfort. A medically necessary service must:

1. Meet generally accepted standards of medical practice;
2. Be appropriate to the illness or injury for which it is performed as to type of service and expected outcome;
3. Be appropriate to the intensity of service and level of setting;
4. Provide unique, essential, and appropriate information when used for diagnostic purposes;
5. Be the lowest cost alternative that effectively addresses and treats the medical problem; and
6. Meet the general principles regarding reimbursement for Medicaid-Covered Services set forth in Rule 5160-1-02 of the Ohio Administrative Code.

Benefit coverage for health services is determined by the member specific benefit plan document, such as a Certificate of Coverage, Schedule of Benefits, or Summary Plan Description, and applicable laws. You may freely communicate with members about their treatment, regardless of benefit coverage limitations.

UnitedHealthcare Community Plan uses evidence- based clinical guidelines to guide our quality and health management programs. For more information on our guidelines, go to UHCprovider.com.

Find medical policies and coverage determination guidelines at UHCProvider.com > Policies and Protocols > Community Plan Policies > Medical and Drug Policies and Coverage Determination Guidelines for Community Plan.

You must coordinate member referrals for medically necessary services beyond the scope of your practice. Monitor the referred member’s progress and help ensure they are returned to your care as soon as appropriate.

We require prior authorization of all out of-network referrals. The nurse reviews the request for medical necessity and/or service. If the case does not meet criteria, the nurse routes the case to the medical director for review and determination. Out-of-network referrals are approved for, but not limited to, the following:

• Continuity of care issues
• Necessary services are not available within network

UnitedHealthcare Community Plan monitors out-of- network referrals on an individual basis. Care provider or geographical location trends are reported to Network Management to assess root causes for action planning.

UnitedHealthcare Community Plan authorization helps ensure reimbursement for all covered services. You should:

• Determine if the member is eligible on the date of service by using Link on UHCprovider.com, calling Provider Services, or the Ohio Medicaid Eligibility System.
• Submit documentation needed to support the medical necessity of the requested procedure.
• Be aware the services provided may be outside the scope of what UnitedHealthcare Community Plan has authorized.
• Determine if the member has other insurance that should be billed first.

UnitedHealthcare Community Plan will not reimburse:

• Services UnitedHealthcare Community Plan decides are not medically necessary.
• Non-covered services.
• Services provided to members not enrolled on the dates of service.

If a UnitedHealthcare Community Plan member asks for a second opinion about a treatment or procedure, UnitedHealthcare Community Plan will cover that cost. Scheduling the appointment for the second opinion should follow the access standards established by the ODM. These access standards are defined in Chapter 2. The care provider giving the second opinion must not be affiliated with the attending care provider.

Criteria:

• The member’s PCP refers the member to an in- network care provider for a second opinion. You forward a copy of all relevant records to the second opinion care provider before the appointment. The care provider giving the second opinion will then forward his or her report to the member’s PCP and treating care provider, if different. The member may help the PCP select the care provider.
• If an in-network provider is not available, UnitedHealthcare Community Plan will arrange for a consultation with a non-participating provider. The participating provider should contact Provider Services.
• Once the second opinion has been given, the member and the PCP discuss information from both evaluations.
• If follow-up care is recommended, the member meets with the PCP before receiving treatment.

Medicaid helps with medical costs for certain people with limited incomes and resources. Ohio Medicaid pays for Medicare premiums for certain people, and may also pay for Medicare deductibles, co-insurance and co-payments except for prescriptions. Medicaid covers long-term care services such as home and community- based “waiver” services, which includes assisted living services and long-term nursing home care. It also covers dental and vision services.

Because a member chose or was assigned to only receive Medicaid-covered services from our plan, Medicare will be the primary payer for most services. Member can choose to receive both your Medicare and Medicaid benefits through UnitedHealthcare Connected so all of your services can be coordinated.

If a member must travel 30 miles or more from your home to receive covered health care services, UnitedHealthcare Connected will provide transportation to and from the provider’s office. These services must be medically necessary and not available in member’s service area. A member must also have a scheduled appointment (except in the case of urgent/ emergent care).

In addition to the transportation assistance that UnitedHealthcare Connected provides, members can still receive assistance with transportation for certain services through the local county department of job and family services Non-Emergency Transportation (NET) program.

If a member has been determined eligible and enrolled in a home and community-based waiver program, there are also waiver transportation benefits available to meet the member’s needs.

As a UnitedHealthcare Connected member, they will continue to receive all medically necessary Medicaid- covered services at no cost to the member. These services may or may not require an okay before the member receives the service. Please see the following charts to determine if the member’s benefits require an okay.

• Acupuncture (for the treatment of low back pain and migraines)
• Ambulance transportation
• Assisted living services
• Dental services
• Durable medical equipment and supplies
• Family planning services and supplies
• Free-standing birth center services at a free- standing birth center (please see the following charts for more information)
• Medicaid home health and private duty nursing services
• Hospice care in a nursing facility (care for terminally ill, e.g., cancer patients)
• Mental health and substance abuse services (please see the following charts for more information)
• Nursing facility and long-term care services and supports (please see the following charts for more information)
• Physical exam required for employment or for participation in job training programs if the exam is not provided free of charge by another source
• Prescription drugs (certain drugs not covered by Medicare Part D) (please see the following charts for more information)
• Services for children with medical handicaps (Title V)
• Hearing services, including hearing aids
• Vision (optical) services, including eyeglasses
• Waiver services
• Yearly well adult exams when Medicare does not cover these

The following services are not included in the UnitedHealthcare Community Plan program:

• Services considered not “reasonable and necessary,” based on Medicare and Medicaid standards, unless we list the services as covered under our plan
• Experimental medical and surgical treatments, items and drugs, unless covered by Medicare or under a Medicare-approved clinical research study or our plan
• Experimental treatment and items not generally accepted by the medical community
• Surgical treatment for morbid obesity, except when it is medically needed and Medicare covers it
• A private room in a hospital, except when medically needed
• Personal items in a member’s room at a hospital or a nursing facility, such as a phone or a television
• Inpatient hospital custodial care
• Full-time nursing care in the member’s home
• Elective or voluntary enhancement procedures or services (including weight loss, hair growth, sexual performance, athletic performance, cosmetic purposes, anti-aging and mental performance), except when medically needed
• Cosmetic surgery or other cosmetic work, unless it is needed because of an accidental injury or to correct a part of the body that is not shaped right. However, the plan will cover reconstruction of a breast after a mastectomy and for treating the other breast to match it.
• Chiropractic care other than diagnostic X-rays and manual spinal manipulation correct alignment consistent with Medicare and Medicaid coverage guidelines
• Routine foot care, except for the limited coverage provided based on Medicare and Medicaid guidelines
• Abortions, except in the case of a reported rape, incest, or when medically necessary to save the mother’s life
• Orthopedic shoes, unless the shoes are part of a leg brace and are included in the cost of the brace, or the shoes are for a person with diabetic foot disease
• Supportive devices for the feet, except for orthopedic or therapeutic shoes for people with diabetic foot disease
• Infertility services for males or females
• Voluntary sterilization if younger than age 21 or legally incapable of consenting to the procedure
• Reversal of sterilization procedures, sex change operations, and non-prescription contraceptive supplies
• Paternity testing
• Naturopath services (the use of natural or alternative treatments)
• Services provided to veterans in Veterans Affairs (VA) facilities
• Services to find cause of death (autopsy)
• Equipment or supplies that condition the air, wigs and their care, and other primarily non-medical equipment
• Paramedic intercept service (advanced life support provided by an emergency service entity, such as a paramedic services unit, which do not provide ambulance transport), unless Medicare criteria are met

Medicaid-Excluded Services

The following items and services are not covered by our plan:

• Services considered not “reasonable and necessary,” according to the standards of Medicare and Medicaid, unless these services are listed by our plan as covered services
• Experimental medical and surgical treatments, items, and drugs, unless covered by Medicare or under a Medicare-approved clinical research study or by our plan
• Experimental treatment and items are those that are not generally accepted by the medical community
• Surgical treatment for morbid obesity, except when it is medically needed and Medicare covers it
• A private room in a hospital, except when it is medically needed
• Inpatient hospital custodial care
• Full-time nursing care in the home
• Elective or voluntary enhancement procedures or services (including weight loss, hair growth, sexual performance, athletic performance, cosmetic purposes, anti-aging and mental performance), except when medically needed
• Cosmetic surgery or other cosmetic work, unless needed due to an accidental injury or to improve a part of the body that is not shaped right. However, the plan will cover reconstruction of a breast after a mastectomy and for treating the other breast to match it
• Chiropractic care, other than diagnostic X-rays and manual manipulation (adjustments) of the spine to correct alignment consistent with Medicare and Medicaid coverage guidelines
• Routine foot care, except for the limited coverage provided according to Medicare and Medicaid guidelines
• Abortions, except in the case of a reported rape, incest, or when medically necessary to save the life of the mother
• Orthopedic shoes, unless the shoes are part of a leg brace and are included in the cost of the brace, or the shoes are for a person with diabetic foot disease
• Supportive devices for the feet, except for orthopedic or therapeutic shoes for people with diabetic foot disease
• Infertility services for males or females
• Voluntary sterilization if younger than 21 years old or legally incapable of consenting to the procedure
• Reversal of sterilization procedures, sex change operations, and non-prescription contraceptive supplies
• Paternity testing
• Naturopath services (the use of natural or alternative treatments)
• Services provided to veterans in Veterans Affairs (VA) facilities
• Services to find cause of death (autopsy)
• Equipment or supplies that condition the air, wigs, and their care, and other primarily non-medical equipment
  
• Paramedic intercept service (advanced life support provided by an emergency service entity, such as a paramedic services unit, which do not provide ambulance transport), unless Medicare criteria are met
• Immunizations for foreign travel

For a list of services that require prior authorization, go to UHCprovider.com/priorauth.

Direct Access Services – Native Americans

Native Americans seeking tribal clinic or Indian Health hospital services do not require prior authorization.

Seek Prior Authorization Within The Following Time Frames

• Emergency or Urgent Facility Admission: one business day.
• Inpatient Admissions; After Ambulatory Surgery: one business day.
• Non-Emergency Admissions and/or Outpatient Services (except maternity): at least 14 business days beforehand; if the admission is scheduled fewer than five business days in advance, use the scheduled admission time.

Call 866-815-5334 to discuss the guidelines and utilization management.

Utilization Management (UM) is based on a member’s medical condition and is not influenced by monetary incentives. UnitedHealthcare Community Plan pays its in-network PCPs and specialists on a fee-for-service basis. We also pay in-network hospitals and other types of care providers in the UnitedHealthcare Community Plan network on a fee-for-service basis. The plan’s UM staff works with care providers to help ensure members receive the most appropriate care in the place best suited for the needed services. Our staff encourages appropriate use and discourages underuse. The UM staff does not receive incentives for UM decisions.

Utilization Management (UM) Appeals

These appeals contest UnitedHealthcare Community Plan’s UM decisions. They are appeals of UnitedHealthcare Community Plan’s admission, extension of stay, level of care, or other health care services determination. The appeal states it is not medically necessary or is considered experimental or investigational. It may also contest any admission, extension of stay, or other health care service due to late notification, or lack of complete or accurate information. Any member, their designee, or care provider who is dissatisfied with a UnitedHealthcare Community Plan UM decisions may file a UM appeal. Adverse determination decisions may include UnitedHealthcare Community Plan’s decision to deny a service authorization request or to authorize a service in an amount, duration, or scope less than requested. See Appeals in Chapter 12 for more details.