Laboratory Services Protocol - Chapter 8, 2018 UnitedHealthcare Adminstrative Guide

Clinical Information Submission

To comply with state and federal data collection and reporting requirements, we require clinical data from you. It helps us measure quality of care for our members. It helps us collaborate with you to address gaps in care. You must submit all clinical data including laboratory test results. 

Give us this data within 30 calendar days from the date of service or within the time specified by law.

Please follow state and federal laws when giving us the clinical data. We need to provide the source of the data to satisfy National Committee for Quality Assurance (NCQA) audits or other compliance requirements. You must confirm that the information given to us is accurate and complete. 

We verify that security measures, protocols, and practices are compliant with:

  • HIPAA regulations
  • UnitedHealthcare data usage, governance, and security policies

We use the clinical data to:

  • Perform treatment
  • Payment
  • Follow state and federal law 
  • Health care operations, as defined in HIPAA

Health care operations may include:

  1. Compliance with state and federal data collection and reporting requirements, including: 
    • Healthcare Effectiveness Data and Information Set (HEDIS)
    • Consumer Assessment of Healthcare Providers and Systems (CAHPS)
    • Health Outcomes Survey (HOS)
    • NCQA accreditation
    • CMS or Star Ratings
    • CMS Hierarchical Condition Category Risk Adjustment System
  2. Care coordination and other care management and quality improvement programs such as:
    • Physician performance
    • Pharmaceutical safety
    • Member health risks using predictive modeling and the subsequent development of disease management programs used by UnitedHealthcare
    • Other member and care provider health awareness programs
  3. Quality assessment and benchmarking data sets

We will work collaboratively with you to help ensure all clinical data values are being transmitted effectively. This allows for lawful identification and use of the clinical data.

We define the HIPAA minimum necessary data requirements defined in specific documents related to the method of clinical data acquisition. The companion guides that contain these requirements are on UHCprovider.com/edi.

Requirement to Use Participating Laboratories

The Laboratory Services Protocol applies to all participating physicians and health care professionals, and it applies to all lab services, clinical and anatomic, ordered by care providers, except this protocol does not apply:

  • When the physician bears financial risk of lab services.
  • When the physician provides laboratory services in their offices.

We maintain a large network of regional and local labs. These labs provide a fast, comprehensive range of services. They also provide clinical data and related information to support:

  • HEDIS reporting
  • Care management
  • UnitedHealth Premium Designation program
  • Other clinical quality improvement activities

Members will pay more for services if they use an out-of-network lab. You are required to refer lab services to a participating lab provider, except if we authorize otherwise. You can search for lab providers in our Physician Directory on UHCprovider.com. To confirm a lab’s participating and see if a test is covered, please contact us in advance. Some benefit plans are capitated for lab services; the member can only use the capitated lab provider.

Administrative Actions for Out-of-Network Laboratory Services Referrals

Our care providers use participating labs often. We expect that you can find participating labs that meet all of your needs.

If we see that a care provider is referring members to out-of-network labs, we remind them that they are required to refer our members to other participating providers. If the referrals to out-of-network labs continue, we will take administrative action. This includes:

  • Loss of eligibility for the Practice Rewards programs;
  • A decreased fee schedule;
  • Financial responsibility for any costs or expenses collected from a member by a non-participating laboratory, including non-covered services and balance bills, if there is no written member consent authorizing the referral to the non-participating laboratory; or
  • Termination of network participation, as provided in your agreement with us.

Self-Referral and Anti-Kickback

This protocol applies to all participating physicians and health care professionals, and it applies to all laboratory services, clinical and anatomic, ordered by physicians and health care professionals.

We do not allow our care providers to earn money from referring members to a lab. This includes profits from:

  • Investments in an entity where the referring care provider generates business 
  • Profits from collection, processing, and/or transporting of specimens

If you do not follow this rule, we may:

  • Decrease your fee schedule
  • Terminate your network participation

Structured Exchange of Clinical Data

In 2015, UnitedHealthcare implemented a new protocol requiring electronic submission of lab results within 30 days of a lab test. This initiative helped to increase HEDIS closure rates and significantly reduced the burden of manual chart requests on our providers.

As a result of this success, we have broadened the scope of our data sharing protocol – going forward, providers will be required to submit an expanded set of clinical data following a physician visit, as well as a discharge summary within seven days of an inpatient discharge. 

When you share this data with us electronically, we can:

  • Promote timely engagement between you and your patients.
  • Reduce the administrative burden of manual information sharing.
  • Drive quality outcomes for you and your patients by closing gaps and improving coordination of care. 

To begin sharing the required information, please contact our Data Acquisition Technical Support (DATS) team via email at dataacquisitiontechsupport@uhc.com. Care providers have different data transfer capabilities, and we will work with you to find the best method of data transmission.