Coverage Summaries and Policy Guidelines for MA Members - Chapter 4, 2018 UnitedHealthcare Administrative Guide

Hierarchy of References/Resources

We develop our MA coverage summaries and policy guidelines with the help of: 

  1. National Coverage Determination (NCD) or other Medicare guidance, e.g., Medicare Policy Benefit Guide, Medicare Managed Care Guide, Medicare Claims Processing Guide, Medicare Learning Network (MLN) Matters Articles 
  2. Local Coverage Determination (LCD) and Local Policy Articles (A/B MAC & DME MAC) 
  3. UnitedHealthcare Commercial Medical Policies/Coverage Determination Guidelines 

Primary Care Physicians (PCP) Selection

Members are required to select a network PCP. If not, we assign one automatically.

Changing PCP

Members may change their PCP at any time. Changes are generally effective on the first day of the following month. The change does not affect referrals previously submitted by their PCP.

Coverage Summaries and Policy Guidelines

Our MA plan Evidence of Coverage (EOC) and Summary of Benefits (SB) list the member’s covered benefits, limitations and exclusions. We use our MA Coverage Summaries and Policy Guidelines to interpret benefits for our members. The policies are subject to change based on Medicare’s coverage requirements, clinical evidence, technology and evolving practice patterns.

You are responsible for reviewing the CMS Medicare coverage guidance documents. If there is a conflict between our policies and the guidance documents, the CMS information controls. Our MA Coverage Summaries and Policy Guidelines are available on: UHCprovider.com/policies > Medicare Advantage Policies

Coverage Summary and Policy Guideline Updates

We publish monthly editions of the Medicare Advantage Coverage Summary Update Bulletin. This online resource provides notice to our network care providers of changes to MA Coverage Summaries. The bulletin is posted on the first calendar day of every month on UHCprovider.com/policies > Medicare Advantage Policies > Coverage Summaries for Medicare Advantage Plans > Medicare Advantage Coverage Summary Update Bulletins.

As a supplemental reminder to the detailed policy update summaries announced in the Medicare Advantage Coverage Summary Update Bulletins, a list of recently approved, revised and/or retired Coverage Summaries, as well as Policy Guidelines, is also included in the monthly Network Bulletin available on UHCprovider.com/News.