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Access Standards - Chapter 2, 2019 UnitedHealthcare Administrative Guide

Covering Physician

As a Primary Care Provider (PCP), you must arrange for 24 hours a day, seven days per week coverage for our members. If you are arranging a substitute care provider, use those who are in-network with the member’s benefit plan.

You must alert us if the covering care provider is not in your medical group practice to prevent claim payment issues.. Use modifiers for substitute physician (Q5), covering physician (CP) and locum tenens (Q6) when billing services as a covering physician. Collect the copay at the time of service.

To find the most current directory of our network physicians and health care professionals, go to UHCprovider.com/FindProvider.

Appointment Standards

We have standards for appointment access and after-hours care to help ensure timely access to care for members. We use these standards to measure performance annually. Our standards are shown by service below.

  • Preventive Care: Within four weeks
  • Regular/Routine Care Appointment: Within 14 days
  • Urgent Care Appointment: Same day
  • Emergency Care: Immediate
  • After-Hours Care: 24 hours/seven days a week for PCPs

These are general UnitedHealthcare guidelines. State or federal regulations may require standards that are more stringent. Contact your Network Management representative for help determining your state or federal-specific regulations.

After-Hours Phone Message Instructions

If a member calls your office after hours, we ask that you provide emergency instructions, whether a person or a recording answers. Tell callers with an emergency to:

  • Hang up and dial 911, or its local equivalent, or
  • Go to the nearest emergency room.

When it is not an emergency, but the caller cannot wait until the next business day, advise them to:

  • Go to a network urgent care center,
  • Stay on the line to connect to the physician on call,
  • Leave a name and number with your answering service (if applicable) for a physician or qualified health care professional to call back within specified time frames, or
  • Call an alternative phone or pager number to contact you or the physician on call.

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, is:
    • Acting within the scope of their practice and consistent with professionally recognized standards of practice, and
    • Has determined and noted in the relevant record that a longer waiting time will not have a detrimental impact on the member’s health.
  • Triage or screening services by phone must be provided by licensed staff 24 hours a day, seven days a week. Unlicensed staff 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 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. If a member or covered person is unable to obtain a timely referral to an appropriate provider, refer to the Non-Participating Care Provider Referrals or Referrals & Referral Contracting, Out-of-Network Provider Referrals (Commercial HMO and Medicare Advantage) section for further details. If still unable to obtain a timely referral to a care provider after following these steps, contact:
  • For members with Department of Managed Healthcare regulated plans: 888-466-2219
  • For members with California Department of Insurance regulated plans: 800-927-4357

Provider Privileges

You must have privileges at participating facilities or an  arrangement with another participating care provider to admit and offer facility services. This helps our members have access to appropriate care and lower their out-of-pocket costs.

Cultural Competency

Provide services in a culturally competent manner. This includes handling members with limited English proficiency or reading skills, diverse backgrounds and physical or mental disabilities.