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Care Provider Responsibilities - UnitedHealthcare West Supplement, 2018 UnitedHealthcare Administrative Guide

Electronic Data Interchange

The fastest way for us to talk is electronically. Electronic Data Interchange (EDI) is the preferred method for doing business transactions. You can find more information in Chapter 2: Provider Responsibilities and Standards, or go online: UHCprovider.com/edi.

Panel Restriction

The issues of confidentiality and objective medical observations are the key in the diagnosis and treatment of our members. Therefore, the care provider or other licensed independent health care professional who is also a UnitedHealthcare member shall not serve as PCP for themselves or their dependents.

Monitor Eligibility

You are responsible for checking member eligibility within two business days prior to the date of service. You may be eligible for reimbursement under the Authorization Guarantee program described in the Capitation and/or Delegation Supplement for authorized services if you have checked and confirmed the member’s eligibility within two business days before the date of service.

Member Eligibility

You must verify the member’s eligibility each time they receive services from you. We provide several ways to verify eligibility:

You can get more details regarding a specific member’s benefit plan in the member’s Combined Evidence of Coverage and Disclosure Form, Evidence of Coverage, or Certificate of Coverage. Benefit plans may be addressed in procedures/protocols communicated by us. Details may include the following:

  • Selection of a PCP;
  • Effective date of coverage;
  • Changes in membership status while a member is in a hospital or skilled nursing facility (SNF);
  • Member transfer/disenrollment; or
  • Removal of member from receiving services by a PCP

Health Care Identification (ID) Cards

Each member receives a health care ID card with information to help you submit claims accurately. Information may vary in appearance or location on the card due to payer or other unique requirements. Check the member’s health care ID card at each visit, and keep a copy of both sides of the card for your records. Sample health care ID cards specific to the member are available when you verify eligibility online.

For more detailed information on ID cards and to see a sample health care ID card, please refer to the Health Care Identification (ID) Cards section of Chapter 2: Provider Responsibilities and Standards.

Services Provided to Ineligible Members (does not apply in CA)

If we provide eligibility confirmation indicating that a member is eligible at the time the health care services are provided, and it is later determined that the patient was not in fact eligible, we are not responsible for payment of services provided to the member, except as otherwise required by state and/or federal law. In such event, you are entitled to collect the payment directly from the member (to the extent permitted by law) or from any other source of payment.

California Prohibition Against Care Provider Rescission

California law requires that if:

  1. You contacted us immediately before or during the providing treatment, and
  2. You relied upon the member’s eligibility to treat, and
  3. The member is later retro-cancelled, you can submit an appeal showing proof that eligibility was obtained and relied upon at the time services were provided. If you do not verify eligibility immediately before each service date, the service is not subject to this provision. You can’t rely on another care provider’s eligibility verification, (as an example the facility’s verification). Each care provider must contact us to confirm eligibility.

Eligibility Verification Guarantee (TX Commercial)

We reimburse Texas care providers who request a guarantee of payment through the verification process. The verification is based on the participation agreement and the guidelines in Texas Senate Bill SB 418.

We will guarantee payment for proposed medical care or health care services if you provide the services to the member within the required timeframe. We reduce the payment by any applicable copayments, coinsurance and/or deductibles.

You must include the unique UnitedHealthcare West verification number on the claim form (Field 23 of CMS 1500 or Field 63 of UB-04).

You must request eligibility prior to rendering a service. Otherwise, we are not responsible for payment of those services. You are entitled to collect the payment directly from the member to the extent permitted by law or from any other source of payment.

Submit service verification requests to:

  • Phone: 877-847-2862
    or
  • Mail:
    Care Provider Correspondence
    P.O. Box 30975
    Salt Lake City, UT 84130-0975

Access & Availability: Exception Standards for Certain UnitedHealthcare West States

We monitor members’ access to medical and behavioral health care to make sure that we have an adequate care provider network to meet the members’ health care needs. We use member satisfaction surveys and other feedback to assess performance against standards.

We have established access standards for appointments and after-hours care. Exceptions or additions to those standards are shown in the following table.

Type of Care and Guideline:

Regular or routine

  • UnitedHealthcare Standard: 14 calendar days
  • Exceptions:
    • California Commercial HMO: Members are offered appointments for non-urgent PCP within 10 business days of request, within 15 business days for non-urgent specialist request;
    • Texas: Within three weeks for medical conditions.

Preventive care

  • UnitedHealthcare Standard: Four weeks
  • Exceptions:
    • California: Preventive care services and periodic follow-up care, including but not limited to standing referrals to specialists for chronic conditions, periodic office visits to monitor and treat pregnancy, cardiac or mental health conditions, and laboratory and radiological monitoring for recurrence of disease may be scheduled in advance consistent with professionally recognized standards of practice as determined by the treating licensed health care provider acting within the scope of their practice.
    • Texas: Within two months for child and within three months for adult.
    • Medicare Advantage within 30 days.

Urgent exam (PCP or Specialist)

  • UnitedHealthcare Standard: Same day (24 hours)
  • Exceptions: California Commercial Members: Within 48 hours when no prior authorization required, within 96 hours when prior authorization required.

In-office wait time

  • California Members: In-office wait time is less than 30 minutes.

Referral process

  • Notification to the member should be completed in a timely manner, not to exceed five business days of a request for non-urgent care or 72 hours of a request for urgent care.

Non-urgent ancillary (diagnostic)

  • 15 business days
  1. Our members must have access to all physicians and support staff who work for you and must not be limited to particular physicians. We recognize that some substitution between physicians who work out of the same office/building may occur due to urgent/emergent situations.
  2. Members must have access to appointments during all normal office hours and not be limited to appointments on certain days or during certain hours.
  3. Members must have access to the same time slots as all other patients who are not our members.
  4. You must work cooperatively with our Medical Management Department toward*:
    • Managing inpatient and outpatient utilization; and
    • Member care and member satisfaction;
  5. Use your best efforts to refer members to our network care providers. You must use only our network laboratory and radiology care providers unless specifically authorized by us.

*As an “authorization representative” of UnitedHealthcare, physicians are responsible to notify the member about the prior authorization determination, unless State regulation requires otherwise.

Timely Access to Non-Emergency Health Care Services (Applies to Commercial in California)

  • The timeliness standards require licensed health care providers to offer members appointments that meet the California time frames. The applicable waiting time for a particular appointment may be extended if the referring or treating licensed health care provider, or the health professional providing triage or screening services, as applicable, acting within the scope of their practice and consistent with professionally recognized standards of practice, has determined and noted in the relevant record that a longer waiting time will not have a detrimental impact on the health of the member.
  • Triage or screening services by phone must be provided by licensed staff 24 hours per day, seven days per week. Unlicensed staff persons shall not use the answers to those questions in an attempt to assess, evaluate, advise or make any decision regarding the condition of a member or determine when a member needs to be seen by a licensed medical professional.
  • UnitedHealthcare of California managed care members and covered persons of UnitedHealthcare Insurance Company benefit plans have access to free triage and screening services 24 hours a day, seven days a week through Optum’s NurseLine at 866-747-4325.

Notification of Practice or Demographic Changes

All demographic changes, open/closed status, product participation or termination should be reported to us.

For complete information please the Demographic Changes section of Chapter 2: Provider Responsibilities and Standards.

California Commercial Benefit Plans — As of July 1, 2016, California Senate Bill 137 requires us to perform ongoing updates to our care provider directories, both online and hardcopy. As a participating medical group, IPA or independent physician, you are required to update UnitedHealthcare within five business days if there are any changes to your ability to accept new patients.

As a participating medical group, IPA or independent physician, if a member or potential enrollee seeking to become a patient contacts you, and you are no longer accepting new patients, you must direct them to report any inaccuracy in our provider directory to both:

  • UnitedHealthcare for additional assistance in finding a care provider, and, as applicable,
  • Either the California Department of Managed Health Care or the California Department of Insurance.

You shall cooperate with and provide the necessary information to us so we may meet the requirements of Senate Bill 137.

We are required to contact all participating care providers, including but not limited to contracted medical groups or IPAs, on an annual basis, and independent physicians, every six months. This outreach includes a summary of the information that we have on record and requires you to respond by either confirming your information is accurate, or providing us with applicable changes.

If we do not receive a response from you within 30 business days, either confirming that the information on file is correct, or providing us with the necessary updates, we have an additional 15 business days to make attempts for you to verify the information. If these attempts are unsuccessful, we will notify you that, if you continue to be nonresponsive, we will remove you from our provider directory after 10 business days.

If the final 10-business day period lapses with no response from you, we may remove you from the directory. If we receive notification that the provider directory information is inaccurate, the provider group, IPA, or physician may be subject to corrective action.

In addition to outreach for annual or bi-annual attestations, we are required to make outreach if we receive a report of inaccuracy for any provider data in the directories. We are required to confirm your information is correct. If, after attempting to contact you for confirmation, a response is not received, we will provide you a 10 business-day notice that we will suppress your information from our provider directory.

To help ensure we have your most current provider directory information, medical groups, IPAs, or independent physicians can submit applicable changes to:

For Delegated providers: email changes to Pacific_ DelProv@uhc.com or delprov@uhc.com.

For Non-delegated providers: Visit UHCprovider.com/mypracticeprofile for the Provider Demographic Change Submission Form and further instructions.

Compliance with the Medical Management Program

Complying with the Medical Management Program includes but is not limited to:

  • Allowing our staff to have onsite access to members and their families while the member is an inpatient;
  • Allowing our staff to participate in individual case conferences;
  • Facilitating the availability and accessibility of key personnel for case reviews and discussions with the medical director or designee representing UnitedHealthcare West, upon request; and
  • Providing appropriate services in a timely manner.

Benefit Interpretation Policies & Medical Management Guidelines

A complete library of Benefit Interpretation Policies (BIPs), and Medical Management Guidelines (MMGs), is available on UHCprovider.com/policies > Commercial Policies > UnitedHealthcare SignatureValue/UnitedHealthcare Benefits Plan of California Benefit Interpretation Polices or UnitedHealthcare SignatureValue/UnitedHealthcare Benefits Plan of California Medical Management Guidelines.

The first calendar day of every month, we publish the BIP and MMG Update Bulletins. These are online resources that provide notice to our network care providers of changes to our BIPs and MMGs. The bulletins are posted on:

As a supplemental reminder to the detailed policy update summaries announced in the BIP and MMG Update Bulletins, a list of recently approved, revised and/or retired BIPs and MMGs is also included in the monthly Network Bulletin available on UHCprovider.com/news

Continuity of Care

Continuity of care is a short-term transition period, allowing members to temporarily continue to receive services from a non-participating care provider.

Examples of an Active Course of Treatment Considered for Continuity of Care

  • An Acute Condition is a medical condition that involves a sudden onset of symptoms due to an illness, injury or other medical problem that requires prompt medical attention and that has a limited duration. Completion of covered services provided for the duration of the acute condition.
  • A Serious Chronic Condition is a medical condition due to disease, illness, medical problem, mental health problem, or medical or mental health disorder that is serious in nature and that persists without full cure or worsens over an extended period, or requires ongoing treatment to maintain remission or prevent deterioration. Completion of covered services provided for the period necessary to complete the active course of treatment and to arrange for a clinically safe transfer to a network care provider. The active course of treatment is determined by a UnitedHealthcare West or medical group/IPA medical director in consultation with the member, the terminated care provider or the non-network care provider and as applicable, the receiving network care provider, consistent with good professional practice. Completion of covered services for this condition will not exceed 12 months from the participation agreement’s termination date, or 12 months after the effective date of coverage for a newly enrolled member.
  • A Terminal Illness is an incurable or irreversible condition that has a high probability of causing death within one year. Completion of covered services may be provided for the duration of the terminal illness, which could exceed 12 months, provided that the prognosis of death was made by the: (i) terminated care provider prior to the participation agreement termination date, or (ii) non-network care provider prior to the newly enrolled member’s effective date of coverage with UnitedHealthcare West.
  • A Pregnancy diagnosed and documented by the: (i) terminated care provider prior to termination of the participation agreement, or (ii) by the non-network care provider prior to the newly enrolled member’s effective date of coverage with UnitedHealthcare West. Completion of covered services provided for the duration of the pregnancy and immediate postpartum period.
  • The Care of a Newborn service provided to a child between birth and age 36 months. Completion of covered services will not exceed (i) 12 months from participation agreement, termination date, (ii) 12 months from the newly enrolled member’s effective date of coverage with UnitedHealthcare West, or (iii) the child’sthird birthday.
  • Surgery or Other Procedure: Performance of a surgery or other procedure that authorized by UnitedHealthcare West or the member’s assigned network care provider. Parts of a documented course of treatment have been recommended and documented by (i) the terminating care provider to occur within 180 calendar days of the participation agreement’s termination date, or (ii) the non-network care provider to occur within 180 calendar days of the newly enrolled member’s effective date of coverage with UnitedHealthcare West.

Continuity of care does not apply when a member initiates a change of PCP or medical group/IPA. Authorizations granted by the previous medical groups shall be invalid in such situations at the commencement of the member’s assignment to the new PCP or medical group/IPA; members shall not be entitled to continuing care unless the member’s new PCP or medical group/IPA authorizes that care.

Virtual Visits (Commercial HMO Plans CA only)

UnitedHealthcare of California added a new benefit for Virtual Visits to some member benefit plans in January 2017. We define Virtual Visits as primary care services that include the diagnosis and treatment of low-acuity medical conditions for members through the use of interactive audio and video telecommunication and transmissions, and audio-visual communication technology.

Virtual Visit primary care services are delivered by the care provider groups covered under professional capitation. Not all UnitedHealthcare West benefit plans will have the Virtual Visit benefit option.

To read more about Virtual Visits, refer to the Capitation and Delegation Provider Supplement.