Abuse: Actions that may, directly or indirectly, result in unnecessary costs to the health insurance plan, improper payment, payment for services that fail to meet professionally recognized standards of care, or medically unnecessary services. Abuse involves payment for items or services when there is no legal entitlement to that payment and the provider has not knowingly and/or intentionally misrepresented facts to obtain payment. Abuse cannot be differentiated categorically from fraud, because the distinction between “fraud” and “abuse” depends on specific facts and circumstances, intent and prior knowledge, and available evidence, among other factors.
Accreditation: A process that a care provider goes through to be recognized for meeting certain standards such as quality.
Acute Inpatient Care: Care provided to persons sufficiently ill or disabled requiring:
- Constant availability of medical supervision by attending provider or other medical staff
- Constant availability of licensed nursing personnel
- Availability of other diagnostic or therapeutic services and equipment available only in a hospital setting to help ensure proper medical management by the care provider
Adjudication: The process of determining the proper payment amount on a claim.
Ambulatory Care: Health services provided on an outpatient basis. While many inpatients may be ambulatory, the term “ambulatory care” usually implies that the patient has come to a location other than their home to receive services and has departed the same day. Examples include: chemotherapy and physical therapy.
Ambulatory Surgical Facility: A facility licensed by the state where it is located, equipped and operated mainly to provide for surgeries and obstetrical deliveries, and allows patients to leave the facility the same day surgery or delivery occurs.
Ancillary Provider Services: Health services ordered by a care provider, including, but not limited to, laboratory services, radiology services, and physical therapy.
Appeal: An oral or written request by a member or member’s personal representative received by UnitedHealthcare for review of an action.
Authorization: Approval obtained by care providers from UnitedHealthcare for a designated service before the service is rendered. Used interchangeably with preauthorization or prior authorization.
Authorized Care Provider: A care provider who meets UnitedHealthcare’s licensing and certification requirements and has been authorized by UnitedHealthcare to provide services.
Balanced Billing: When a care provider bills a member for the difference between billed charges and the UnitedHealthcare allowable charge after UnitedHealthcare pays a claim.
Benefit: The amount of money UnitedHealthcare pays for care and other services.
Capitation: Per person way of payment for medical services. UnitedHealthcare pays a participating capitated care provider a fixed amount for every member he or she cares for, regardless of the care provided.
Care Provider: A person who provides medical or other health care (doctor, nurse, therapist or social worker) or office support staff. A care provider can be a doctor practicing alone, in a hospital setting, or in a group practice. A care provider could work from a remote location, in a public space, or any combination of locations.
Claim: The documentation of the services that have occurred during the course of a visit to a health care provider.
Clinical Laboratory Improvement Amendments of 1988 (CLIA): United States federal regulatory standards that apply to all clinical laboratory testing performed on humans in the United States, except clinical trials and basic research.
Clean Claim: A claim that has no defect, impropriety (including lack of any required substantiating documentation), or particular circumstance requiring special treatment that prevents timely payment.
Centers for Medicare & Medicaid Services (CMS): A federal agency within the U.S. Department of Health and Human Services.
Coordination of Benefits (COB): Allows benefit plans that provide health and/or prescription coverage for a person with Medicare to determine their respective payment responsibilities (i.e., determine which insurance benefit plan has the primary payment responsibility and the extent to which the other benefit plans will contribute when an individual is covered by more than one benefit plan).
Coinsurance: The member’s share of the costs of a covered health care service, calculated as a percent (for example, 20%) of the allowed amount for the service. Members may pay co-insurance plus any deductibles owed.
Commercial: Refers to all UnitedHealthcare medical products that are not Medicare Advantage, Medicare Supplement, Medicaid, CHIP, workers’ compensation, TRICARE, or other governmental programs (except that “Commercial” also applies to benefit plans for the Health Insurance Marketplace, government employees or students at public universities).
Copayment: A fixed amount members may pay for a covered health care service, usually upon receiving the service.
Covered Services: Medically necessary services included in the member’s benefit plan. Covered services change periodically and may be mandated by federal or state legislation.
Credentialing: The verification of applicable licenses, certifications, and experience to assure that provider status is extended only to professional, competent providers who continually meet the qualifications, standards, and requirements established by UnitedHealthcare.
Current Procedural Terminology Codes (CPT): American Medical Association (AMA)-approved standard coding for billing of procedural services performed.
Deductible: The amount a member owes for health care services the health insurance or benefit plan covers before the health insurance or benefit plan begins to pay.
Delivery System: The mechanism by which health care is delivered to a patient. Examples include, but are not limited to, health care facilities, care provider offices, and home health care.
Dependent: A child, disabled adult or spouse covered by the health benefit plan.
Disallow Amount: Medical charges for which the network provider is not permitted to receive payment from the health benefit plan and cannot bill the member. Examples are:
- The difference between billed charges and contracted rates; and
- Charges for services, bundled or unbundled, as detected by Correct Coding Initiative edits.
Discharge Planning: Process of screening eligible candidates for continuing care following treatment in an acute care facility, and assisting in planning, scheduling and arranging for that care.
Disease Management: A prospective, disease-specific approach to improving health care outcomes by providing education to members through non-physician.
Disenrollment: The discontinuance of a member’s eligibility to receive covered services from a contractor.
Durable Medical Equipment (DME): Equipment used repeatedly or used primarily and customarily for medical purposes rather than convenience or comfort. It also is equipment that is appropriate for use in the home and prescribed by a physician.
Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS): In November 2006, the Centers for Medicare & Medicaid Services (CMS) approved 10 national accreditation organizations that will accredit suppliers of durable medical equipment, prosthetics, orthotics and supplies (DMEPOS) as meeting new quality standards under Medicare Part B.
Electronic Data Interchange (EDI): The electronic exchange of information between two or more organizations.
Electronic Funds Transfer (EFT): The electronic exchange of funds between two or more organizations.
Electronic Medical Record (EMR): The electronic version of a member’s health records.
Emergency Care: The provision of medically necessary services required for immediate attention to evaluate or stabilize a medical emergency (see definition below).
Employee Retirement Income Security Act of 1974 (ERISA): A federal law that sets minimum standards for most voluntarily established pension and health benefit plans in private industry to provide protection for individuals in these benefit plans.
Encounter: An interaction between a patient and health care providers, for the purpose of provider healthcare services or assessing the health status of a patient.
Expedited Appeal: An oral or written request by a member or member’s personal representative received by UnitedHealthcare requesting an expedited reconsideration of an action when taking the time for a standard resolution could seriously jeopardize the member’s life, health or ability to attain, maintain, or regain maximum function; or would subject the member to severe pain that cannot be adequately managed without the care or treatment that is the subject of the appeal.
Fee for Service: Care providers are paid for each service (like an office visit, test, or procedure).
Fraud: Health care fraud is a crime that involves misrepresenting information, concealing information, or deceiving a person or entity to receive benefits, or to make a financial profit. (18 U.S.C.§1347).
Grievance: An oral or written expression of dissatisfaction by a member, or representative on behalf of a member, about any matter other than an action received at UnitedHealthcare Community Plan.
Health Insurance Portability and Accountability Act (HIPAA) Act of 1996: A federal legislation that provides data privacy and security provisions for safeguarding medical information.
Health Plan Employer Data and Information Set (HEDIS): Set of standardized measures developed by NCQA. Originally HEDIS was designed to address private employers’ needs as purchasers of health care. It has since been adapted for use by public purchasers, regulators and consumers. HEDIS is used for quality improvement activities, health management systems, provider profiling efforts, an element of NCQA accreditation, and as a basis of consumer report cards for managed care organizations.
Home Health Care or Home Health Services: Medical care services provided in the home, often by a visiting nurse, usually for recovering patients, aged homebound patients, or patients with a chronic disease or disability.
Managed Care: A system designed to better manage the cost and quality of medical services. Managed care products not only offer less member liability but also less member control. Managed care aims to improve accessibility to health care, reduce cost, and improve quality of service. Many managed care health insurance programs work with Health Maintenance Organization (HMO) and Preferred Provider Organization (PPO) boards to promote use of specific health treatment procedures. Managed care health insurance benefit plans also educate and work with consumers to improve overall health by addressing disease prevention. The common types of managed care products are HMO, PPO, and Point of Service (POS) benefit plans.
Medical Emergency: A medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) that a prudent layperson, who possesses an average knowledge of health and medicine, could reasonably expect the absence of immediate medical attention to result in the following:
- Placing the health of the individual (or, with respect to a pregnant woman, the health of the woman or her unborn child) in serious jeopardy.
- Serious impairment to bodily functions.
- Serious dysfunction of any bodily organ or part.
Medically Necessary: To determine medical necessity, we use generally accepted standards of medical practice, based on credible scientific evidence published in peerreviewed medical literature and generally recognized by the relevant medical community. We may also use standards based on physician specially recommendations, professional standards of care, and other evidence based, industry recognized resources and guidelines, such as MCG®.
For Medicare Advantage and Medicaid members, we use Medicare guidelines, including National Coverage Determinations and Local Coverage Determinations to determine medical necessity of services requested.
If other nationally recognized criteria contradict MCG, UnitedHealthcare and delegated medical group/IPAs follow the Medicare guidelines for Medicare Advantage members. Individual criteria is provided to you upon request.
Member: Refers to an individual who has been determined UnitedHealthcare eligible and enrolled with UnitedHealthcare to receive services pursuant to the agreement. Other common industry terms: customer, patient, beneficiary, insured, enrollee, subscriber, dependent.
National Provider Identification (NPI): NPI is a unique 10-digit identification number issued to health care providers in the United States by CMS.
Network Care Provider: A professional or institutional care provider who has an agreement with UnitedHealthcare to provide care at a contracted rate. A network care provider agrees to file claims and handle other paperwork for UnitedHealthcare member. A network care provider accepts the negotiated rate as payment in full for services rendered.
Non-network Health Care Provider: A nonnetwork provider does not have an agreement with UnitedHealthcare, but is certified to provide care to UnitedHealthcare members. There are two types of nonnetwork care providers: participating and nonparticipating.
- Nonparticipating care provider: A nonparticipating care provider is a UnitedHealthcare-authorized hospital, institutional provider, physician, or other provider that furnishes medical services (or supplies) to UnitedHealthcare members but who does not have an agreement and does not accept the UnitedHealthcare allowable charge or file claims for UnitedHealthcare members. A nonparticipating care provider may only charge up to 15 percent above the UnitedHealthcare allowable charge.
- Participating care provider: A health care provider who has agreed to file claims for UnitedHealthcare members, accept payment directly from UnitedHealthcare, and accept the UnitedHealthcare allowable charge as payment in full for services received. Non-network care providers may participate on a claim-by-claim basis. Participating care providers may seek payment of applicable copayments, cost-shares and deductibles from the member. Under the UnitedHealthcare outpatient prospective payment system, all Medicare participating care providers and hospitals must, by law, also participate in UnitedHealthcare for inpatient and outpatient care.
Nurse Practitioner: A registered nurse who has graduated from a program which prepares registered nurses for advanced or extended practice and who is certified as a nurse practitioner by the American Nursing Association.
Optum: A UnitedHealth GroupTM health services and innovation company that designs and implements custom information technology systems, and offers management consulting, in the health care industry nationwide. Optum offers behavioral healthcare programs including integrated behavioral and medical programs, depression management, employee assistance, work/life management, disability support and pharmacy management programs.
Out-Of-Area Care: Care received by a UnitedHealthcare member when they are outside of their geographic territory.
Physician Assistant: A health care professional licensed to practice medicine with physician supervision. Physician assistants are trained in intensive education programs accredited by the Commission on Accreditation of Allied Health Education Programs.
Policy: A contract between the insurer and the insured, known as the policyholder, which determines the claims which the insurer is legally required to pay.
Primary Care Provider (PCP): A physician such as a family practitioner, pediatrician, internist, general practitioner, or obstetrician, who serves as a gatekeeper for their assigned members’ care. Other providers may be included as primary physicians such as nurse practitioners and physician assistants as allowed by state mandates.
Primary Care Team: a team comprised of a care manager, a PCP, and a Nurse Practitioner or Physician Assistant.
Prior Authorization and Notification: A unit under the direction of the UnitedHealthcare Clinical Services Department that is an essential component of any managed care organization. Prior authorization is the process where health care providers seek approval prior to rendering services as required by UnitedHealthcare policy.
Provider Group: A partnership, association, corporation, or other group of providers.
Provider Manual: This document is referred to as a care provider manual or guide. It may also be referred to as the provider administrative guide or handbook.
Quality Management (QM): A methodology used by professional health personnel to the degree of conformance to desired medical standards and practices; and activities designed to improve and maintain quality service and care, performed through a formal program with involvement of multiple organizational components and committees.
Reinsurance: The contract made between an insurance company and a third party to protect the insurance company from losses.
Secondary Payer: A source of coverage that pays after the primary insurance benefit has been applied.
Self-Funded Plan: Self-funded health care also known as Administrative Services Only (ASO) is a self insurance arrangement whereby an employer provides health or disability benefits to employees with its own funds.
Self- Insured: A self-insured group health benefit plan is one in which the employer assumes the financial risk for providing health care benefits to its employees.
Service Area: A geographic area serviced by a UnitedHealthcare contracted provider, as stated in the health care provider’s agreement with us.
Skilled Nursing Facility: A Medicare-certified nursing facility that (a) provides skilled nursing services and (b) is licensed and operated as required by applicable law.
Stop-loss: A product that provides protection against catastrophic or unpredictable losses. It is purchased by employers who have decided to self-fund their employee benefit health benefit plans, but do not want to assume 100% of the liability for losses arising from the benefit plans.
Subrogation: A health plan’s right, to the extent permitted under applicable state and federal law and the applicable benefit plan, to recover benefits paid for a member’s health care services when a third party causes the member’s injury or illness.
Subscriber: Person who owns an insurance policy.
Supplemental Benefits: Supplemental insurance includes health benefit plans specifically designed to supplement UnitedHealthcare standard benefits.
Third Party Administrator (TPA): An organization that provides or manages benefits, claims or other services, but it does not carry any insurance risk.
Transitional Care: A program that is designed for members to help ensure a coordinated approach takes place across the continuum of care.
UnitedHealthcare Assisted Living Plan: A Medicare Advantage Institutional-Equivalent Special Needs Plan that:
- Exclusively enrolls special needs individuals who living in a contracted Assisted Living Facility, have Medicare A and B, and meet the local state’s criteria for “institutional level of care”.
- Is issued by UnitedHealthcare Insurance Company or by one of UnitedHealthcare’s affiliates; and
- Is offered through our UnitedHealthcare Medicare Advantage business unit, as indicated by a reference to Assisted Living Plan name listed on the face of the valid health care ID card.
UnitedHealthcare Nursing Home Plan: A Medicare Advantage Institutional Special Needs Plan that:
- Exclusively enrolls special needs individuals who for 90 calendar days or longer, have had or are expected to need the level of service requiring an institutional level of care (as such term is defined in 42 CFR 422.2);
- Is issued by UnitedHealthcare Insurance Company or by one of UnitedHealthcare’s affiliates; and
- Is offered through our UnitedHealthcare Medicare Advantage business unit, as indicated by a reference to Nursing Home Plan or Erickson Advantage Guardian in the benefit plan name listed on the face of the valid health care ID card.
- Us: “Us,” “we” or “our” refers to UnitedHealthcare on behalf of itself and its other affiliates for those products and services subject to this Manual.
Utilization Management (UM): The process of evaluating and determining the coverage for and the appropriateness of medical care services, as well as providing assistance to a clinician or patient in cooperation with other parties, to help ensure appropriate use of resources. UM includes prior authorization, concurrent review, retrospective review, discharge planning and case management.
Waste: The overutilization of services, or other practices that, directly or indirectly, result in unnecessary costs to a health care benefit program. Waste is generally not considered to be caused by criminally negligent actions but rather misuse of resources.
Workers’ Compensation: Workers’ compensation is a form of insurance providing wage replacement and medical benefits to employees injured in the course of employment in exchange for mandatory relinquishment of the employee’s right to sue their employer for the tort of negligence.
You: “You,” “your” or “provider” refers to any health care provider subject to this guide, including physicians, health care professionals, facilities and ancillary providers; Except when indicated all items are applicable to all types of providers subject to this Guide.