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Medical Management - Capitation and/or Delegation Supplement, 2018 UnitedHealthcare Administrative Guide

The protocols outlined in this section are those that are unique to capitated and/or delegated medical management entities. The protocols outlined in Chapter 6: Medical Management may also apply if UnitedHealthcare is financially responsible for the service.

If we are financially responsible for the service, or responsible for processing the claim for such services, consult with us to determine if an authorization is required before you make any authorization decision.

Regulatory agencies and other entities hold us responsible for the performance of delegated activities. We hold our delegates to those same requirements. We perform clinical assessments of the delegated activities prior to delegation to ensure the potential delegate meets the requirements. We perform assessments after delegation to ensure continued compliance and rapid remediation of noncompliance. We help our delegates by providing them with the information they need to know and meet the regulatory and contractual requirements and accreditation standards.

Pre-contractual or Pre-delegation Assessments

When an entity – usually a medical group/IPA – expresses interest in contracting to perform delegated activities, we initiate an assessment process to confirm the entity’s ability to perform those activities. A clinical reviewer and medical management consultant request submission of documented processes (programs, policies and procedures, work flows or protocols) and supporting evidence prior to an onsite visit. Supporting evidence may include materials (letter templates, scripts, brochures, or website) and reports (or the demonstrated ability to produce required reports). The clinical reviewer and Medical Management consultant also arrange an onsite visit to further assess systems and processes, staffing and resources needed to take on delegation. Assessment results and delegation recommendations are reported to the Delegation Oversight Governance Committee, which makes the decision whether to proceed with delegation and determines any contingencies for delegation.


Post-contractual or Post-delegation Clinical Assessments

We conduct another assessment within 90 calendar days after the contract or delegation effective date. Assessments are based on documented processes, materials, reports and case records or files specific to the delegated activities. Subsequent assessments are performed on at least an annual basis, within 12 calendar months after the last annual assessment. The clinical reviewer informs the delegate of assessment results at an exit conference. We follow up with formal written notice of results and the delegation decision based on those results.

Clinical Delegation Improvement Action Plans

If a delegate does not meet the required score and pass all critical elements, we require improvement action and remediation within 30 calendar days of the written notice of deficiencies, which are detailed in an Improvement Action Summary report along with the delegation letter.

The delegate must submit a written improvement action plan (IAP) specifying how and when it will meet the requirements. The clinical reviewer follows up with the delegate on at least a weekly basis, working with the delegate to attain compliance. We expect the delegate to put quality controls into place to measure its compliance on an ongoing basis. A reassessment is performed within 30 calendar days of the written notice to document the delegate’s progress toward compliance. If the delegate does not demonstrate compliance by the IAP completion date, we escalate the IAP to engage leadership at the delegate and within UnitedHealthcare to facilitate remediation. Continued noncompliance may result in our beginning the de-delegation process while continuing to work with the delegate to achieve compliance.

UnitedHealthcare and medical group/IPAs delegated for utilization/medical management will review nationally recognized evidence-based criteria to determine medical necessity and appropriate level of care for services whenever possible. UnitedHealthcare and delegates will utilize multiple resources and guidelines to determine medical necessity and appropriate level of care.

Hierarchy of Criteria Use
When using criteria to make decisions about requests for services, the delegate must use the criteria hierarchy appropriate to the benefit plan:

  • Commercial
  1.  Eligibility and benefits (Evidence of Coverage)
  2. State-specific guidelines or mandates
  3. Guidelines or mandates referenced in UnitedHealthcare’s Coverage Determination Guidelines and Benefit Interpretation Policies
  4. Evidence-based criteria such as MCG and InterQual
  5. Other evidence-based criteria such as Hayes or evidence based literature
  • Medicare Advantage
  1. Plan eligibility and coverage (benefit plan package)
  2. CMS criteria
    • National Coverage Determination (NCD)
    • Local Coverage Determination (LCD) used only for the area specified in the LCD
    • Local Coverage Medical Policy Article
    • Medicare Benefit Policy Manual
  3. UnitedHealthcare or health plan criteria (e.g. Coverage Summary, Medical Policy)
  4. Evidence-based criteria such as MCG and InterQual
  5. Other evidence-based resources such as Hayes or evidence based literature
  • Community Plan (UnitedHealthcare Medicaid)
  1. Eligibility and benefits
  2. National or state-specific Medicaid guidelines
  3. UnitedHealthcare Community Plan Medical Coverage Guidelines
  4. Evidence-based criteria such as MCG or InterQual
  5. Other evidence-based criteria such as Hayes or evidence based literature

With limited exceptions, we do not reimburse for services that are not medically necessary, or when you have not followed correct procedures (e.g., notification requirements, prior authorization, or verification guarantee process). Delegates may institute the same policy.

Accreditation standards require that all health care organizations, health benefit plans, and medical group/IPAs delegated for utilization/medical management, distribute a statement to all members, physicians and health care providers and employees who make utilization management (UM) decisions affirming the following:

  • UM decision-making is based only on appropriateness of care and service, and existence of coverage
  • Practitioners or other individuals are not specifically rewarded for issuing denials of coverage or service
  • Financial incentives for UM decision-makers do not encourage decisions that result in under-utilization

Regardless of the Medical Management Program determination, the decision to render medical services lies with the member and the attending physician. If you and a member decide to go forward with the medical service once UnitedHealthcare or the delegate has denied prior authorization (and issued a denial notice to the member and physician as appropriate), neither UnitedHealthcare nor the delegate will reimburse for the denied services. Medical directors are available to discuss their decisions and our criteria with you. Medical policies and guidelines are also available on UHCprovider.com/policies or from the delegated medical group/IPA as applicable.

To track the specific level of care and services provided to its members, UnitedHealthcare requires care providers to utilize the most current service codes (i.e., ICD-10-CM, UB and CPT codes). We also require that the care provider make sure the documented bill type is appropriate for the type of service provided.

Care providers are required to participate, cooperate and comply with our Medical Management policies. All care providers must render covered services at the most appropriate level of care, based on nationally recognized criteria.

We may delegate medical management functions to a medical group/IPA or other entity that demonstrates compliance with our established standards. Care providers associated with these delegates must use the delegate’s medical management office and protocols. We may retain
responsibility for some medical management activities, such as inpatient admissions and outpatient surgeries. When a care provider is not associated with a delegate or when we retain responsibility for the specific medical management activity, the care provider must comply with
our Medical Management procedures.

For medical management functions retained by us, you have to confirm we have authorized a request for services before rendering services for a member. If a prior authorization has not been requested, you must submit the request for prior authorization within three business days before providing or ordering the covered service except in the case of emergent or urgent services.

To confirm prior authorization has been requested and approved, the Prior Authorization and Notification app on Link, or UHCprovider.com/priorauth. If the member is assigned to a delegated medical group/IPA, check with that medical group/IPA for confirmation.

For urgent or emergent cases, we will notify you within 24-hours of services rendered, or an admission.

If you don’t get prior authorization when required or tell us within the appropriate timeframe, we may deny payment.

The delegated medical group/IPA sets its own policies regarding the responsibilities of care providers.

If you do not get a prior authorization, neither UnitedHealthcare (or its delegate) nor our member, can be held responsible to reimburse care providers for medical services, admissions, inappropriate facility days, and/or not medically necessary services. Receiving an authorization does not affect the application of any payment policies or in determining reimbursement.

Continuity of care provides a short-term transition period so members may temporarily continue to receive services from a non-network care provider. The timeframes and conditions vary according to state regulations. In general, continuity of care is available to:

  • New members who are experiencing an acute episode of care while making the transition to UnitedHealthcare; and
  • Existing members who are experiencing an acute episode of care when:
    • A care provider participating with UnitedHealthcare terminates its agreement to provide services for UnitedHealthcare members; or
    • A care provider contracted with a participating medical group/IPA terminates its agreement to provide services for UnitedHealthcare members. This occurs when the medical group/IPA holds the contract with its care providers.

Typically, a condition that would warrant a request for continuity of care requires prompt medical attention and is of short duration. It is not enough that the member prefers receiving treatment from a former care provider or other non-network care provider, even for a chronic condition. A member should not continue care with a non-network care provider without formal approval by us or the delegate. Except for emergent or urgent out-of-area (OOA) care, if the member does not receive prior authorization from us or the delegate, payment for services performed by a non-network care provider is the member’s responsibility.

UnitedHealthcare (or the medical group/IPA delegated for continuity of care) shall review all requests for continuity of care on a case-by-case basis. Reasonable consideration must be given to the severity of the member’s condition and the potential clinical effect on the member’s treatment and outcome of the condition under treatment, which may result from a change of care provider.

A member may request to continue covered services with a care provider for continuity of care when the care provider:

  • Terminates from UnitedHealthcare, other than for cause or disciplinary action.
  • Agrees, in writing, to be subject to the same contractual terms and conditions as network care providers, including, but not limited to: credentialing, facility privileging, utilization review, peer review and quality assurance requirements.
  • Agrees, in writing, to compensation rates and methods of payment similar to those used by UnitedHealthcare and current network care providers providing similar services, who are not capitated and who are practicing in the same or a similar geographic area.

A member must be undergoing an active course of treatment to be considered for continuity of care.

For any service which requires a prior authorization from UnitedHealthcare, the admitting care provider initiates an authorization request by fax or online at least three business days prior to the scheduled date of service.

  • You must complete and submit the appropriate prior authorization request forms. Incomplete forms are not accepted. You may find the list of forms on UHCprovider.com/priorauth.
  • Our Medical Management team documents the information, responds to the authorization request, and provides a decision within the required regulatory timeframes. If approved, we issue an authorization number. If denied, we forward the reason for denial to you and the member.
  • In the case of a denial, you have an opportunity to speak with a medical director to discuss the case.
  • The authorized care provider delivers care to the member. They should share documentation of the recommended treatment with the member’s PCP.

The authorized care provider submits a claim with the authorization number in the usual manner to the appropriate address.

If you are a network provider for a delegated medical group/IPA, then you must follow the delegate’s protocols. Delegates may use their own systems and forms. They must meet the same regulatory and accreditation requirements as UnitedHealthcare.

The facility must tell us of an emergency admission of our member within 24 hours of admission, or as soon as the member’s condition has stabilized. The Medical Management Department can receive admission notifications 24 hours/day, seven days/week at:

Phone: 800-799-5252

Fax: 800-274-0569

The delegate sets its own policies regarding notification and authorization for these services.

The medical group/IPA/facility is financially responsible for providing all approved medical and facility services with a designated service area. Please refer to your participation agreement for your specific service area definition. Urgent or emergent services provided within the medical group/IPA/facility service area are the financial risk of the capitated entity regardless of whether services are rendered by the medical group/IPA/facility’s network of care providers, unless your participation agreement states otherwise.

Out-of-Area (OOA) Medical Services
OOA medical services are those emergent or urgently needed services to treat an unforeseen illness or injury that arises while a member is outside of the medical group/IPA’s contracted service area, typically 30 miles from medical group/IPA based on the shortest route using public streets and highways. These OOA services would have been the financial responsibility of the medical group/IPA had the services been provided within the medical group/IPA service area.

  • UnitedHealthcare retains the ultimate accountability for the management of OOA cases, unless otherwise contractually defined. Refer to the Division of Financial Responsibility (DOFR) section of your participation agreement to determine risk (financial accountability) for OOA medical services.
  • Medical services provided outside of the delegated medical group/IPA defined service area that are arranged and/or authorized or could be anticipated by the member’s medical group/IPA are the delegate’s responsibility, and are not considered OOA medical services. This includes those out-of-network (OON) care provider services referred by a care provider affiliated with the delegated medical group/IPA, whether or not that care provider received appropriate authorization. In such cases, it remains the responsibility of the delegated medical group/IPA to perform all delegated medical management activities, including issuing appropriate authorization and denials.
  • Members referred by the delegated medical groups/IPA for out of network outpatient consultation who are found at the time of the consult evaluation to require medically necessary inpatient care will be the responsibility of the referring medical group/IPA and will not meet the criteria of an OOA case.
  • The delegated medical group/IPA remains responsible to issue appropriate denials for member-initiated nonurgent, non-emergent medical services provided outside of the medical group/IPA’s defined service area.
  • The medical group/IPA shall notify UnitedHealthcare OOA department of all known OOA cases no later than the 1st business day after receiving member notification of an OOA admission, procedure and/or treatment.
  • Failure to notify us within this timeframe may result in UnitedHealthcare holding the medical group/IPA financially responsible for the OOA care and service.
  • Once a UnitedHealthcare member’s PCP or medical group/IPA identified specialist speaks with the out-of area attending care provider to determine the member’s stability for transport to an in-area facility member’s PCP or medical group/IPA identified specialist will:
    • Determine the appropriate mode of transportation and obtain any required authorization
    • Determine the appropriate level of care or facility for the member’s care and obtain any required authorization
    • Arrange for a bed at the accepting in-area facility
  • If the member is found stable for transfer to an in-area facility, the medical group/IPA must work actively and collaboratively with UnitedHealthcare to return the member to a network care provider and facility in a timely fashion.
  • The medical group/IPA shall facilitate the return of the member to network care provider by making sure that the following process occurs in a timely fashion:
    • If the medical group/IPA delays the transfer of a member considered medically stable for transfer, UnitedHealthcare may hold the medical group/IPA financially responsible for any additional out-of-area charges incurred in result of the delay.
    • If an accident or illness occurs within the medical group/IPA contracted service area, and emergency personnel transport the member to a facility outside the contracted service area for treatment, these services will not be considered as out-of-area services and will be handled by the medical group/IPA in the same manner as in-area services. The medical group/IPA must authorize and direct the member’s care in the same manner as if the member were receiving services at the affiliated facility or care provider facility.

Travel dialysis is not considered an out-of-area medical service unless otherwise contractually defined. It is the responsibility of the medical group/IPA.

In all cases, the delegated medical group/IPA is responsible for authorizing and arranging for medically necessary services. If the DOFR assigns risk for injectable medications to a medical group/IPA, the medical group/IPA is responsible for authorizing and paying for all injectable medications; whether self-injected or given with the aid of a health professional in the home.

Trauma services are defined as medically necessary, covered services rendered at a state-licensed, designated trauma facility or a facility designated to receive trauma cases. Trauma services must meet county or state trauma criteria.

The medical group/IPA shall review and authorize care and trauma services using the applicable provision review criteria.

For medical groups/IPAs that have risk for transplant services, notify the case management department when a member is referred for evaluation, authorized for transplant and admitted for transplant and/or may meet criteria for service denial. Medical groups/IPAs that do not have risk for transplant services, must refer members into UnitedHealthcare’s transplant case management program who have been identified as:

  • Requiring evaluation for a bone marrow/stem cell or solid organ transplant
  • Undergoing a transplant evaluation
  • Receiving a transplant
  • Receiving post-transplant care within the first year following the transplant Optum serves as UnitedHealthcare’s transplant network. The transplant case manager works in conjunction with the member’s transplant team, PCP, and other clinicians to complete an assessment of the member’s healthcare needs, develop, implement and monitor a care plan, coordinate services and re-evaluate the care plan for the member.
  • All care providers must get prior authorization for transplant evaluations and transplant surgery, regardless of financial risk.
  • Transplant evaluations and surgery must be performed at one of Optum Centers of Excellence, or a facility approved by UnitedHealthcare/Optum medical directors.
  • For medical groups/IPAs that do not have risk for transplant services, Optum is responsible for the authorization and management for all transplantrelated care and services. This includes the evaluation, transplant procedure, and through one year posttransplant, unless otherwise dictated by the member’s
    benefit or federal/state law.
  • Optum is responsible for the authorization and management of donor care and services directly related to transplant services from date of initiation of the stem cell/bone marrow collection, or 24 hours prior to solid organ donation surgery, until 60 calendar days post-transplant date, unless otherwise dictated by the member’s benefit or state law.
  • Optum is responsible for authorization and reimbursement of all travel expenses as covered under the member’s benefit plan.
  • Authorization and management of all non-transplant related (e.g., medically necessary, covered services for the member) remain the responsibility of the delegated medical group/IPA. Non-transplant related services include those services needed to treat the member’s underlying disease and maintain the member until transplant can be completed. (e.g., ventricular assist devices or mechanical circulatory support devices). Financial responsibility for non-transplant related, medically necessary covered services remain as described in the DOFR.
  • Medical groups/IPAs must comply with our transplant protocols, policies and procedures. We may at our sole discretion, modify these protocols, policies and procedures from time to time.
  • You may submit referrals to Optum via:
    • Phone: 866-300-7736
    • Fax: 888-361-0502

Notify the case management department when you refer a member for evaluation, authorized for:

  • VAD/MCSD and admitted for VAD/MCSD and/or may meet criteria for service denial.
  • VAD/MCSD evaluations and surgery must be performed at a facility in Optum’s VAD Network, or a facility approved by our medical directors, to align with heart transplant service centers.

Members have the right to second opinions. The delegate will provide a second opinion when either the member or a qualified health care professional requests it. Qualified health care professionals must provide the member with second opinions at no cost. We also allow a third opinion. When a member meets the following criteria, they may be authorized to receive a second opinion consultation from an appropriately qualified health care professional:

  • The member questions the reasonableness or necessity of a recommended surgical procedure;
  • The member questions a diagnosis or treatment plan for a condition that threatens loss of life, limb, bodily function, or substantial impairment (including, but not limited to, a serious chronic condition);
  • The clinical indications are not clear or are complex and confusing;
  • A diagnosis is in doubt due to conflicting test results;
  • The treating care provider is unable to diagnose the condition;
  • The member’s clinical condition is not responding to the prescribed treatment within a reasonable period of time given the condition, and the member is requesting a second opinion regarding the diagnosis or continuance of the treatment; or
  • The member has attempted to follow the treatment plan or has consulted with the initial care provider and still has serious concerns about the diagnosis or treatment plan.

PCP Second Opinions
When the PCP is affiliated with a delegated medical group/IPA, and the member requests a second opinion based on care received from that PCP, the medical group/IPA is responsible for authorization for a second opinion. The medical group/IPA is also responsible for claims payment if delegated for claims.

  • A second opinion regarding primary care is provided by an appropriately qualified health professional of the member’s choice from within the medical group/IPA group’s network of care providers.
    • California regulations allow E&I SignatureValue HMO members to obtain second and third opinions from out-of-network providers. The delegate sends to UnitedHealthcare all requests for second and third opinions from providers not participating in the delegate’s network.
  • If the request for a second medical opinion is denied, the medical group/IPA will notify the member in writing and provide the reasons for the denial. The member may appeal the denial. If the member gets a second medical opinion without prior authorization from the delegate and/or UnitedHealthcare, the member will be financially responsible for the cost of the opinion.

When the PCP is not affiliated with any participating medical group/IPA, but is instead independently contracted with us, the member may request a second opinion from a care provider or specialist listed in UnitedHealthcare’s care provider directory on UHCprovider.com/findprovider.

The approved care provider will document the second medical opinion in a consultation report, which they will make available to the member and the treating participating provider. The second opinion care provider will include in the report any recommended procedures or tests that he or she believes are appropriate. If this second medical opinion includes a recommendation for a particular treatment, diagnostic test or service covered by UnitedHealthcare, and the delegate or UnitedHealthcare (as appropriate) determines that the recommendation is medically necessary, then the delegate or UnitedHealthcare will arrange the treatment, diagnostic test or service.

Note: Although a second opinion may recommend a particular treatment, diagnostic test or service, this does not mean that the recommended action will be determined to be medically necessary or is a covered service. The member is responsible for paying any applicable costsharing amount to the care provider who gives the second medical opinion.

Specialist Care Second Opinions

  • The member has the right to request a second opinion consultation based on care received through an authorized referral to a specialist within the medical group/IPA network.
  •  The second opinion may be provided by any practitioner of the member’s choice from any medical group/IPA within the UnitedHealthcare network care provider of the same or equivalent specialty.
    • Medicare Advantage members: second and third opinions, whenever possible, should be provided innetwork.The delegate or we will consider authorizing providers outside of the delegate’s network if there isno available or appropriate network care provider.
    • California regulations allow Commercial HMO members to obtain second and third opinions fromout-of-network providers. The delegate sends to UnitedHealthcare all requests for second and third opinions from providers not participating in the delegate’s network.
  • If the healthcare professional is participating with the member’s assigned medical group/IPA, the medical group/IPA is responsible for authorization for the second opinion consultation. The medical group/IAP is also responsible to pay claims if it is delegated for claims.
  •  If approved, we are responsible for claims payment of the second opinion consultation by the nonparticipating health care professional.
  • A second opinion consists of one office visit for a consultation or evaluation only. The care provider’s opinion is included in a consultation report after completing the examination. The member must return to their assigned medical group/IPA for all follow-up care and authorizations.
  • If a second opinion consultation differs from the initial opinion, coverage for a third opinion must be provided if requested by the member or care provider, following the same process as for second opinions.
  • If the request for a second medical opinion is denied, the medical group/IPA will notify the member in writing and provide the reasons for the denial. The member may appeal the denial.If the member gets a second medical opinion without prior authorization from the participating medical group/IPA, or from us, the member will be financially responsible for the cost of the opinion.

Turnaround Time for Second or Third Opinions
We process requests for second opinions in a timely manner to support the clinical urgency of the member’s condition. We follow established utilization management procedures and regulatory requirements. When there is an imminent and serious threat to the member’s health, we (or the delegate) make the second opinion decision within 72 hours after receipt of the request. An imminent and serious threat includes the potential loss of life, limb, or other major bodily function. It can also exist when a lack of timeliness would be detrimental to the member’s ability to regain maximum function.

Experimental items and medications have limited coverage. We do not delegate coverage determinations related to experimental/investigational services or clinical trials.

For capitated providers, the member’s care provider is responsible for these tests, unless stated differently in your contract.

We only cover experimental/investigational services when they meet Medicare requirements. Do not authorize or deny services. Call us at 877-842-3210 for a clinical coverage review.

Looking for more information on Clinical Trials?

You can find additional information and requirements in Chapter 6: Medical Management > Clinical Trials, Experimental or Investigational Services, and on UHCprovider.com/policies > Commercial Policies > Medical and Drug Policies and Coverage Determination Guidelines > Clinical Trials - Commercial Coverage Determination Guidelines, or Medicare Advantage Policies > Coverage Summaries for Medicare Advantage Plans > Experimental Procedures and Items, Investigational Devices and Clinical Trials.

(Commercial, for Services Carved Out of Capitation)
This policy applies if UnitedHealthcare has financial responsibility (carved out of capitation) for IMRT currently covered under a commercial member’s medical benefit.

Prior Authorization Process for IMRT
Prior authorization is required for CPT codes 77385 and 77386 and HCPCS codes G6015 and G6016.

We review the request for IMRT services for compliance with the UnitedHealthcare Commercial IMRT Program Requirements. Noncompliant services will not be eligible for coverage. If the care provider medical groups (medical group/IPA) fails to obtain this review and receive prior authorization from us prior to the start of IMRT services we deny reimbursement for the IMRT services.

Prior Authorization Necessary for Payment to be Processed
The medical group/IPA must make the request for prior authorization for Commercial IMRT services by phone or fax utilizing a Prior Authorization form, or on UHCprovider.com/priorauth. You can also obtain forms by contacting your provider advocate.

Prior authorization staff will not process the request or make a decision until they receive all necessary information from the medical group/IPA. They will communicate with the medical group/IPA regarding the decision once they receive all the necessary and/or requested information. They make a decision within the applicable timeframe. We authorize IMRT services following the member’s benefit design, provided the member has not exceeded their benefit restrictions.

Looking for more information on IMRT?

Additional information and requirements can be found on:
1. UHCprovider.com/Oncology, or
2. UHCprovider.com/policies > Commercial Policies > Reimbursement Policies or Medical & Drug Policies and Coverage Determination Guidelines