Welcome to the UnitedHealthcare Care Provider Administrative Guide for Commercial and Medicare Advantage (MA) products.
This guide has important information on topics such as claims and prior authorizations. It also has protocol information for health care providers. This guide has useful contact information such as addresses, phone numbers and websites. More policies and electronic tools are available on UHCprovider.com.
- If you are looking for a Community and State manual, go to UHCCommunityPlan.com > Health Care Professionals, and select the correct state.
- If you are looking for a UnitedHealthcare Dual Complete manual in Arizona, Massachusetts, New Jersey, New York or Tennessee, go to UHCCommunityPlan.com. All other UnitedHealthcare Dual Complete plans follow this Provider Administrative Guide.
This 2018 UnitedHealthcare Care Provider Administrative Guide (this “guide”) applies to covered services you provide to our members or the members of our affiliates* through our benefit plans insured by or receiving administrative services from us, unless otherwise noted.
This guide is effective April 1, 2018 for physicians, health care professionals, facilities and ancillary providers currently participating in our commercial and Medicare networks. It is effective now for care providers who join our network on or after Jan. 1, 2018.
This guide is subject to change. We frequently update content in our effort to support our health care provider networks.
Terms and definitions as used in this guide:
- “Member” or “customer” refers to a person eligible and enrolled to receive coverage from a payer for covered services as defined or referenced in your agreement with us.
- “Commercial” refers to all UnitedHealthcare medical products that are not MA, Medicare Supplement, Medicaid, CHIP, workers’ compensation, or other governmental programs. “Commercial” also applies to benefit plans for the Health Insurance Marketplace, government employees or students at public universities.
- “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 and all items are applicable to all types of health care providers subject to this guide.
- “Us,” “we” or “our” refers to UnitedHealthcare on behalf of itself and its other affiliates for those products and services subject to this guide.
Medicare policies, protocols and information in this guide apply to covered services you provide to UnitedHealthcare MA members, including Erickson Advantage members and most UnitedHealthcare Dual Complete members, but excluding UnitedHealthcare Medicare Direct members and MA members enrolled in UnitedHealthcare Community Plan Medicare Advantage plans, and UnitedHealthcare Dual Complete members in Arizona, Massachusetts, New Jersey, New York and Tennessee. If a particular section does not apply to such MA members, it is indicated.
If there is a conflict or inconsistency between a Regulatory Requirements Appendix attached to your agreement and this guide, the provisions of the Regulatory Requirements Appendix controls for benefit plans within the scope of that appendix.
If there is an inconsistency between your agreement with us and this guide, your agreement controls (except where your agreement with us provides protocols for our affiliates). If those protocols are in a supplement to this guide, those protocols control for services you give to a member subject to that supplement.
* UnitedHealthcare affiliates offering commercial and Medicare Advantage benefit plans and other services, are outlined in Chapter 1: Introduction.