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Access Standards - Chapter 2, 2018 UnitedHealthcare Administrative Guide

Covering Physician

As a Primary Care Provider (PCP), you must arrange for 24 hours a day, seven days per week coverage of your patients who are our members. If you are arranging a substitute care provider, please use those who participate with the member’s benefit plan so that services may be covered under the member’s network benefit.

You must alert us if the covering care provider is not in your group practice to prevent claim payment issues. Use modifiers for substitute physician (Q5), covering physician (CP) and locum tenens (Q6) when billing services as a covering physician. Collect the copay at the time of service.

To find the most current directory of our network physicians and health care professionals, go to UHCprovider.com/FindProvider.

Appointment Standards

We have standards for appointment access and after-hours care to help ensure timely access to care for members. We use these standards to measure performance annually. Our standards are shown by service below.

  • Preventive Care: Within four weeks
  • Regular/Routine Care Appointment: Within 14 days
  • Urgent Care Appointment: Same day
  • Emergency Care: Immediate
  • After-Hours Care: 24 hours/seven days a week for PCPs

The guidelines listed above are general UnitedHealthcare guidelines. State or federal regulations may require standards that are more stringent. Contact your Network Management representative for help determining your state or federal-specific regulations.

After-Hours Phone Message Instructions

If a member calls your office after hours, we ask that you provide emergency instructions, whether a person or a recording answers. Tell callers with an emergency to:

  • Hang up and dial 911, or its local equivalent, or
  • Go to the nearest emergency room.

When it is not an emergency, but the caller cannot wait until the next business day, advise them to:

  • Go to a network urgent care center,
  • Stay on the line to connect to the physician on call,
  • Leave a name and number with your answering service (if applicable) for a physician or qualified health care professional to call back within specified time frames, or
  • Call an alternative phone or pager number to contact you or the physician on call.

Provider Privileges

You must have privileges at participating facilities or an  arrangement with another participating care provider to admit and offer facility services. This helps our members have access to appropriate care and lower their out-ofpocket costs.

Cultural Competency

Services provided in a culturally competent manner to all members, including those with limited English proficiency or reading skills, diverse cultural and ethnic backgrounds,and physical or mental disabilities, as required by state and federal regulations.