Using Non-Participating Health Care Providers or Facilities - Oxford Commercial Supplement, 2018 UnitedHealthcare Administrative Guide

As a participating care provider, you must utilize participating care providers and facilities within the member’s benefit plan network (i.e., Liberty Network). We have a compliance program to identify participating care providers who regularly use non-participating care providers and facilities. We take the appropriate measures to enforce compliance.

If a member asks you for a recommendation to a nonparticipating care provider, you must tell the member you may not refer to a non-participating care provider. The member must contact us to obtain the required prior authorization. They may obtain required prior authorizations by calling 800-444-6222.

If you contact us for authorization to perform a non-emergency procedure at a non-participating facility for a member who has out-of-network benefits, we may authorize the procedure as out-of-network.

This means the reimbursement to the non-participating facility is subject to the member’s out-of-network deductible and coinsurance obligations. The non-participating facility’s charges are only eligible for coverage up to the reimbursement levels available under the member’s benefit plan, using either a usual, customary and reasonable (UCR) fee schedule, or a Medicare reimbursement system (called the Out-of-Network Reimbursement Amount for our New York members).

Members are responsible for paying their out-of-pocket cost and the difference between the UCR fee or other out-of-network reimbursement and the non-participating facility’s billed charges. Remind the member their expenses may be significantly higher when using a nonparticipating care provider.

If you contact us for authorization to perform a non-emergency procedure at a non-participating facility on a member who does not have out-of-network benefits (HMO and EPO benefit plan members), we will deny the services.
If you ask for an exception we may consider it only when our medical director determines in advance that:

  1. Our network does not have an appropriate participating network care provider who can deliver the necessary care.
  2. Medically necessary services are not available through our network care providers.

In such cases, we must approve the referral, and it must include a treatment plan approved by our medical director, the PCP, and the non-participating care provider.

Participating Gastroenterologists Using Non-Participating Anesthesiologists: In-Office & Ambulatory Surgery Centers (New York)

Participating gastroenterologists located in New York performing non-emergent procedures with anesthesia in office (IO) or in an ambulatory surgery center (ASC), must use an Oxford participating anesthesiologist unless:

  1. The member explicitly agrees pre-service (no more than 90 days before the scheduled date of the procedure) to receive services from a non-participating anesthesiologist by signing the Non-Participating Provider Consent Form and understands that the use of this care provider is:

Out-of-Network: For members with out-of-network benefits, we pay non-participating anesthesiologist claims at the out-of-network benefit level. Out-of-network cost shares and deductibles apply.

Denied: For members without out-of-network benefits, we deny non-participating anesthesiologist claims as not covered because the member has no coverage for services provided by non-participating care providers.
Members are therefore responsible for the entire cost of the service;

or

2.  We have approved an in-network exception.

The following procedures and responsibilities apply in non-emergent situations when a participating gastroenterologist in New York (in office and ambulatory surgery center settings) provide the services:

  1. Verbally discuss options and financial impact with the member. You must explain participating and nonparticipating options, provide the member with an understanding of all the care providers involved in the member’s care (e.g.; anesthesiologist) and include a conversation explaining the financial impact of using a non-participating care provider.
  2.  Obtain a completed Non-Participating Provider Consent Form. The member needs to either agree or disagree to receive out-of-network services, by signing, dating and returning the Non-Participating Provider Consent Form no less than 14 days before the scheduled date of the procedure.
  3. Coordinate the member’s care as directed by the member in the Non-Participating Provider Consent Form (including, but not limited to, using a participating anesthesiologist, network exceptions and/or claim appeals).

You must keep a signed copy of the Non-Participating Provider Consent Form on file. Oxford may request a copy of the signed form at any time, including when responding to a member appeal. Care providers are not required to
submit this form with their initial claim.

If the participating gastroenterologist cannot provide the signed Non-Participating Provider Consent Form, within 15 days of the request, as proof they discussed the member’s options for selecting a participating or non-participating anesthesiologist in advance of the service, Oxford will administratively deny the participating gastroenterologist claim. Any payment previously made for the gastroenterology service will be subject to recovery.

The participating gastroenterologist cannot balance bill the member for claims denied for administrative reasons.

You can get more details and copies of the Non- Participating Provider Consent Form, on OxfordHealth.com > Providers > Tools & Resources > Medical Information > Medical and Administrative Policies > Medical & Administrative Policy Index > Participating Gastroenterologists Using Non-Participating Anesthesiologists: In-Office & Ambulatory Surgery Centers.

Participating Mastectomy Surgeon Using a Non-Participating Breast Reconstruction Surgeon (New York Products)

If a participating mastectomy surgeon is recommending the use of a non-participating breast reconstruction surgeon (including but not limited to plastic surgeons, assistant surgeons, etc.), for a reconstruction that is being performed within the same surgical or different operative session as the mastectomy, before making a recommendation or scheduling services the participating mastectomy surgeon is required to:

  1. Verbally discuss options and financial impact with the member. The discussion must happen no more than 90 days and no less than 14 days before the scheduled procedure date. You must explain participating and non-participating alternatives, and you must provide the member with an understanding of all the care providers involved in the member’s care (e.g.; plastic surgeon, assistant surgeon, etc.). You must explain the financial
    impact of using a non-participating care provider in this discussion.
  2. Obtain a completed Non-Participating Provider Consent Form. The member will need to either agree or disagree to receive out-of-network services, by signing, dating and returning the Non-Participating Provider Consent Form no less than 14 days before the scheduled procedure date.
  3. Coordinate the member’s care as directed by the member in the Non-Participating Provider Consent Form (including, but not limited to, using a participating breast reconstruction surgeon, plastic surgeons, assistant surgeons, etc., network exceptions and/or claim appeals).
  4. You must keep a signed copy of the Non- Participating Provider Consent Form on file to provide to us upon request. If you cannot provide the signed Non- Participating Provider Consent Form within 15 days of the request, we will administratively deny your mastectomy surgery claim for failure to comply with this protocol. Any payment previously made for the mastectomy surgery service will be subject to recovery.

You can get more details and copies of the Non- Participating Provider Consent Form, on OxfordHealth.com > Providers > Tools & Resources > Medical Information > Medical and Administrative Policies > Medical & Administrative Policy Index > In-Network Exceptions for Breast Reconstruction Surgery Following Mastectomy.

Hospital Services, Admissions and Inpatient and Outpatient Procedures

Facilities are responsible for providing admission notification and obtaining prior authorization as needed for all of the following types of inpatient admissions:

  • Planned/elective admissions for acute care
  • Unplanned admissions for acute care (admission notification only)
  • Skilled Nursing Facility (SNF) admissions
  • Admissions following outpatient surgery and observation
  • Newborns admitted to Neonatal Intensive Care Unit (NICU) and who remain hospitalized after the mother is discharged
  • The facility must request prior authorization even if the care provider supplied a prior authorization and a preservice approval is on file.

Care providers and ancillary providers are responsible for getting prior authorization for outpatient surgical and major diagnostic testing performed in an outpatient clinic or any ambulatory or freestanding surgical or diagnostic facility.

Inpatient Hospital Copayment

State regulations for commercial benefit plans determine when a member should be charged for subsequent inpatient hospital copayment(s) when readmitted into an inpatient setting. According to state laws, inpatient hospital copayments must be based on “per continuous confinement”.

Concurrent Review: Clinical Information

Upon admission, Clinical Services will accept concurrent review information provided by the admitting care provider or other health care professional and/or the hospital’s Utilization Review department. The hospital must also provide us with the discharge plan on the day of admission if one has not been submitted.

If a member requires an extended length of stay or more consultations, call our Clinical Services department at 800-666-1353 for prior authorization instructions.

  • For mental health/substance use, direct all calls related to inpatient prior authorization to 800-201-6991.
  • You must cooperate with all requests for information, documents or discussions for purposes of concurrent review and discharge. When available, provide clinical information using electronic medical records (EMR).
  • You must cooperate with all requests from the interdisciplinary care coordination team and/or medical director to engage our members directly face-to-face or by phone.
  • You must return/respond to inquiries from our interdisciplinary care coordination team and/or medical director. You must provide complete clinical information and/or documents as required within 4 hours if you receive our  request before 1 p.m. local time, or make best efforts to provide requested information within the same business day if you receive the request after 1 p.m. local time (but no later than 12 p.m. the next business day).
  • Oxford uses MCGTM Care Guidelines, which are nationally recognized clinical guidelines, to help clinicians make informed decisions in many health care settings.

Inpatient Maternity Stay and Subsequent Home Nursing

It is crucial the member, or their care provider, notify us of a pregnancy as early as possible to help ensure the proper application of benefits. Oxford follows state mandates regarding the length of an inpatient maternity stay and the coverage of subsequent home nursing visits. Regulations vary by state as outlined below.

Inpatient Maternity Length of Stay

Oxford will cover inpatient maternity stays for both mother and newborn as follows:

  • 48 hours following a vaginal delivery
  • 96 hours following a cesarean delivery

Post-Discharge Home Nursing Visits

  • Connecticut: Oxford will approve two (2) home nursing visits if both mother and newborn are discharged before the mandated length of stay described above.
  • New Jersey and New York Plans: Oxford will approve one (1) home nursing visit if both mother and newborn are discharged before the mandated length of stay described above.

Authorizations are required for non-emergency maternity admissions. Newborn coverage varies by benefit plan and state. For more details, refer to OxfordHealth.com > Providers or Facilities > Transactions > Check Eligibility & Benefits.

Neonatal Intensive Care Unit (NICU) Level of Care

We base NICU bed levels on the intensity of services and identifiable interventions received by the neonate. We link the NICU bed levels of care to a revenue code defined by the National Uniform Billing Committee. We will assign NICU levels for those facilities contracted with more than one level of NICU. We base claims reimbursement on the pay codes and bed types (levels of care per contract).

Hospital Responsibilities

The hospital is required to notify us of:

  • Newborns admitted to NICU and who remain hospitalized after the mother is discharged.
  • inpatient stays (notification prior to discharge).
  • Any member who changes level of care. The member must be enrolled and effective with us on the date the service(s) are rendered. But, if CMS or an employer or group retroactively disenrolls the member up to 90 days following the date of service, we may deny or reverse the claim.

The hospital must also:

  • Provide daily inpatient census log by 10 a.m. including all admits and discharges through midnight the day prior.
  • Provide notification of all admissions of our members at the time of, or before, admission. The hospital must notify us of all emergencies (upon admission or on the day of admission), and of “rollovers” (i.e., any member who is admitted immediately upon receiving a pre-authorized outpatient service).
  • Get prior authorization for any transfer admissions of members before the transfer unless the transfer is due to life-threatening medical emergency.
  • Communicate necessary clinical information daily, or as requested by our case manager, at a specified hour that gives us time to create our End of Day Report (EDR).
  • Verify the accuracy of the admission and discharge dates for our members listed on the EDR.

If the hospital does not provide the necessary clinical information, we deny the day. We give reconsideration only if we receive clinical information within 48 hours (72 hours for New Jersey facilities).

If we conduct onsite utilization review, the hospital will provide our onsite utilization management personnel reasonable workspace and access to the hospital, including access to members and their medical records. It is the responsibility of all care providers to deliver letters of non-coverage to the member before discharge. This includes hospitals, acute rehabilitation, skilled nursing facilities, and home care.

We will consider appeals if the hospital can show that the necessary clinical information was provided within 48 hours, but we failed to respond in a timely manner.

Retrospective Review of Inpatient Stays (Notification of Admission After Discharge)

If we request it, the hospital will provide the necessary clinical information to perform a medical necessity review within 45 days of discharge. If the hospital does not provide the necessary clinical information, we deny the day.

We will give reconsideration only if clinical information is received within 48 hours (72 hours for New Jersey members).

Our Responsibilities for Inpatient Notifications

  • We will maintain a system for verifying member eligibility/status and use reasonable efforts to transmit a decision regarding an emergency/urgent admission to the hospital.
  • We will request any necessary clinical information. If we do not ask for such information the day’s services will be our liability.
  • We also agree to provide concurrent and prospective certification for all services with a daily EDR when the hospital provides timely necessary clinical information.
  • We will assign a first day of review (FDOR) for all elective inpatient services, and certify all days up to and including the FDOR. We will provide coverage decisions for the next day on the EDR.
  • We will notify the hospital and attending care provider or other health care professional either verbally or in writing of all denied days.
  • We will perform clinical review of days that fall on the weekends and holidays for which we or the facility is closed, and days upon which there are unforeseen interruptions in business on the following business day. Such reviews will be considered concurrent.

We will not deny services retrospectively or reduce the level of payment for services that have been preauthorized or received concurrent review approval unless:

  • The member is retroactively disenrolled.
  • The certification or concurrent review approval was based on materially erroneous information.
  • The services are not provided in accordance with the proposed plan of care.
  • Hospital delays in providing an approved service to prolong the length of stay beyond what was approved.

Mental Health, Substance Use and Detoxification Treatment

Inpatient Care

All inpatient mental health/substance use treatment requires prior authorization.

Partial Hospitalization

Partial hospitalization always requires certification through the behavioral health department. If clinical criteria are met, the case manager will facilitate certification and management at a contracted facility with a partial hospitalization program. The case manager will continue to follow the member’s treatment while he or she is in the program.

Prior Authorization Outpatient Mental Health Services (New York)

Covered services are those received on an outpatient basis from duly licensed psychiatrists or practicing psychologists, certified social workers, or a facility issued operating certificate by the commissioner of mental health, a facility operated by the Office of Mental Health, a professional corporation or university faculty practice corporation including:

  • Diagnosis
  • Treatment planning
  • Referral services
  • Medication management
  • Crisis intervention

We will provide coverage to the maximum number of visits shown on the member’s Summary of Benefits.

Inpatient Mental Health Services (New York)

Members receive covered services on an inpatient or partial hospitalization basis in a facility as defined by subdivision 10 of section 1.03 of the Mental Hygiene Law, as well as by any other network care provider we deem appropriate to provide the medically necessary level of care.

We cover a required inpatient stay as a semi- private room. If we authorize partial hospitalization, two partial hospitalization visits may be substituted for one inpatient day. We provide coverage for active treatment to the maximum number of days shown on the member’s Summary of Benefits.

Visits for biologically based services will apply to this limit. Active treatment means treatment furnished together with inpatient confinement for mental, nervous or emotional disorders or ailments that meet standards prescribed within
the regulations of the commissioner of mental health.

Laboratory Policies and Procedures Ancillary Services

Our network of laboratory service providers consists of an extensive selection of walk-in patient service centers, many regional and local laboratories and a national provider of laboratory services, Laboratory Corporation of America (LabCorp).

Participating vs. Non-participating Laboratory Provider Referrals

It is important that you refer your patients to participating service centers and laboratories to help them avoid unnecessary costs. Referrals are not required (only a care provider’s prescription or lab order form is required).

We review laboratory ordering information periodically, if our data shows a pattern of out-of-network utilization for your practice, we will contact you to share this information and engage you to use the contracted network.

Participating Provider Laboratory & Pathology Protocol (New York)

You must follow specific guidelines when you are recommending the use of, making a referral to, or involving a non-participating laboratory or pathologist in a member’s care. This includes the following:

  • Specimens collected in your office for processing by a non-participating care provider (on and off-site).
  • Providing the member with a requisition form, prescription or other form to obtain laboratory or pathology services outside of your office.

Before you make the recommendation, involving, or referring a member to a non-participating laboratory or pathologist, you are required to:

  1. Verbally discuss options and financial impact with the member. The discussion must explain participating and non-participating alternatives and the reason for any referral to a non-participating laboratory or pathologist. The discussion must also include a conversation explaining the financial impact of using a nonparticipating care provider.
  2. Obtain a completed Laboratory & Pathology Services Consent Form. The member will need to either agree or disagree to the use of an out-of-network laboratory or pathologist by signing and dating the Laboratory & Pathology Services Consent Form.
  3. Coordinate the member’s care as directed by the member in the Laboratory & Pathology Services Consent Form.

You are required to keep a signed copy of the Laboratory & Pathology Services Consent Form on file to provide to us upon request. If you cannot provide the signed Laboratory & Pathology Services Consent Form within 15 days of the request, we will administratively deny and reverse the Evaluation & Management (E&M) code from the office visit which generated the non-participating laboratory or pathology referral for failure to comply with this protocol. Any payment previously made for the service will be subject to recovery. You cannot balance bill a member for claims denied for administrative reasons.


For additional details and/or to obtain a copy of the Non-Participating Provider Consent Form, refer to the complete policy at OxfordHealth.com > Providers > Tools & Resources > Medical Information > Medical and Administrative Policies > Medical & Administrative Policy Index > New York Participating Provider Laboratory & Pathology Protocol.

In-Office Laboratory Testing and Procedures List

The in-office laboratory testing and procedure list outlines the laboratory procedural/testing codes that we reimburse to network care providers when performed in the office setting.

For the most up-to-date list, refer to: OxfordHealth.com > Providers > Tools & Resources > Medical Information > Medical and Administrative Policies > In-Office Laboratory Testing and Procedures List.

One of our network laboratories must perform laboratory procedures/tests not appearing on this list. See the How to Contact Oxford Commercial section for contact information.

Specimen Handling and Venipuncture

A care provider’s prescription or lab order form is required when using participating laboratories to process specimen. If you bill specimen handling and venipuncture codes along with a lab code on the In-Office Laboratory Testing and Procedures List, we only reimburse the lab and venipuncture codes.

If you bill specimen handling and venipuncture codes without a lab code on our In-Office Laboratory Testing and Procedures List or with other non-laboratory services, we will reimburse the specimen handling and venipuncture codes per our fee schedule.