01/2020: UnitedHealthcare Care Provider Administrative Guide for Commercial and Medicare Advantage Plans

Updated UnitedHealthcare Care Provider Administrative Guide available Jan. 1, 2020*

We post this essential resource for physicians, hospitals, facilities and other care providers on UHCprovider.com/guides annually on Jan. 1. In addition to the PDF version of the Guide, you can view the 2020 Guide in HTML. Both versions are available at UHCprovider.com/guides. We developed this resource based on care provider feedback. It contains information you’re likely to need early and often in your relationship with UnitedHealthcare.

Here are just some of the changes you’ll find in this year’s Guide. For more information, go online to the 2020 UnitedHealthcare Care Provider Administrative Guide.

What’s New in the 2020 Guide:

  • ID Cards: New 2020 ID card samples for commercial and Medicare Advantage plans.  Any reference to “ID card” includes a physical and digital card. Chapter 2: Provider Responsibilities and Standards.
  • New York Domestic and Sexual Violence Hotline (only applicable to New York care providers who see commercial and Oxford Health Plan members): New York state law requires that all New York care providers post the Domestic and Sexual Violence Hotline information in their office. Chapter 2: Provider Responsibilities and Standards.
  • Non-Participating Care Providers (All Commercial Plans): In non-emergency situations, UnitedHealthcare contractually requires participating care providers to refer members to care providers in UnitedHealthcare’s network, unless an exception applies. In the past, exceptions to the requirement varied by service type. Going forward, the exceptions to the requirement will be uniform across all service types. You are required to refer UnitedHealthcare members to care providers that are in UnitedHealthcare’s network unless (1) you have prior approval from us, or (2) you obtained the member’s consent on the Member Consent for Referring to an Out-of-Network Provider form. This form aims to better help our members understand what may happen when you refer them to an out-of-network care provider. If our members aren’t aware that they’re referred to, or are receiving the services of, an out-of-network care provider, they can’t make informed health care decisions and effectively control their out-of-pocket health care costs. For more information on the exceptions and the Member Consent for Referring to an Out-of-Network Provider form, see Chapter 5: Referrals.
  • New Prior Authorization Process for Certain Outpatient Medical Benefit Specialty Medications: Optum manages prior authorization requests for certain medical benefit injectable medications for UnitedHealthcare commercial plan members. Click on the Specialty Pharmacy Transactions tile on your Link dashboard. Chapter 7: Specialty Pharmacy and Medicare Advantage Pharmacy.
  •  Substance Use Disorder Helpline: Details on 24/7 helpline for care providers and patients is provided through Optum. Chapter 12: Health and Disease Management.
  • Notification of Platform Transitions or Migrations: A delegated entity agrees to provide at least 120 days advance written notice to UnitedHealthcare and its contract administrator or provider advocate of its intent to either change administrative platforms, or upgrade current platform, for impacted delegated functions or make material changes in existing administrative platforms. Capitation and/or Delegation Supplement.
  • OneNet PPO Supplement: We further defined Property and Casualty benefit plans, which includes Workers Compensation plans, federal programs and auto liability plans. OneNet PPO Supplement.
  • Maternal Mental Health Screening (California Commercial Plans): The California Department of Managed Health Care (AB 2193) requires licensed health care practitioners who provide prenatal or postpartum care for a patient to offer maternal mental health screening during the second and/or third trimester and/or at the postpartum visit. UnitedHealthcare West Supplement.

*Except as otherwise noted, the new guide will become effective on April 1, 2020, for currently contracted care providers and effective Jan. 1, 2020, for care providers newly contracted on or after Jan. 1, 2020. This guide applies to commercial and Medicare Advantage plans only.