As a participating care provider, you must use 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 appropriate measures to enforce compliance.
If a member asks you for a recommendation to a non- participating 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 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 non- participating 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 may deny the services based on the benefit plan.
If you ask for an exception, we may consider it only when our medical director determines in advance that:
In such cases, we will approve the requested authorization. It must include a treatment plan approved by our medical director, the PCP and the non-participating care provider.
For participating care providers, the use of participating care providers is required unless:
a. Out-of-Network: For members with out-of-network benefits, we pay non-care provider claims at the out- of-network benefit level. Out-of-network cost-shares and deductibles apply.
b. Denied: For members without out-of-network benefits, we deny non-participating care provider 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.
You can get more details and copies of the Non- Participating Provider Consent Form, at OxfordHealth.com > Providers > Tools & Resources > Medical Information > Medical and Administrative Policies > Medical & Administrative Policy Index or UHCprovider.com/ policies > Commercial Policies > UnitedHealthcare Oxford Clinical, Administrative and Reimbursement Policies.
Refer to the back of the member’s health care ID card for the applicable website. Specific policies include but are not limited to:
Facilities are responsible for providing admission notification for all of the following types of inpatient admissions, even if advance notification was provided by the physician and coverage approval is on file:
Care providers and ancillary providers are responsible for obtaining prior authorization for outpatient surgical and major diagnostic testing performed in an outpatient clinic or any ambulatory or freestanding surgical or diagnostic facility.
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 or before the discharge date. 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.
Oxford follows federal mandates regarding the length of an inpatient maternity stay and the coverage of subsequent home nursing visits. Home nursing visit regulations vary by state as outlined below.
Oxford will cover inpatient maternity stays for both mother and newborn as follows:
We base NICU bed levels on the intensity of services and identifiable interventions received by the neonate. NICU bed levels are linked to revenue codes defined by the National Uniform Billing Committee. Based on our medical necessity review, we assign a bed day level for those facilities contracted with more than one level of NICU. Claims are reimbursed based on what has been authorized per a medical necessity review of the NICU bed day per the facility contract.
The hospital is required to notify us of:
The hospital must also:
If the hospital does not provide the necessary clinical information, we may deny the day for medical necessity. 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. All care providers must deliver letters of non-coverage to the member before discharge. This includes hospitals, acute rehabilitation, SNFs, and home care.
We 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.
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 may deny the day for medical necessity. We give reconsideration only if clinical information is received within 48 hours (72 hours for New Jersey members).
All inpatient mental health/substance use treatment requires prior authorization.
Partial hospitalization always requires certification through the behavioral health department. If clinical criteria are met, the case manager facilitates certification and management at a contracted facility with a partial hospitalization program. The case manager continues
to follow the member’s treatment while they are in the program.
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. This includes:
We 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 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.
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).
Refer our members 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 contact you to share this information and engage you to use the contracted network.
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.
For additional details and/or to obtain a copy of the Non-Participating Provider Consent Form, refer to the Participating Provider Laboratory and Pathology Protocol policy at OxfordHealth.com > Providers > Tools & Resources > Medical Information > Medical and Administrative Policies > Medical & Administrative Policy Index or UHCprovider.com/policies > Commercial Policies > UnitedHealthcare Oxford Clinical, Administrative and Reimbursement Policies. Refer to the back of the member’s health care ID card for the applicable website.
The in-office laboratory testing and procedure list outlines the laboratory procedural/testing codes we reimburse to network care providers when performed in the office setting. For the most up-to-date list, refer to the In-Office Laboratory Testing and Procedures List at OxfordHealth. com > Providers > Tools & Resources > Medical Information > Medical and Administrative Policies or UHCprovider.com/policies > Commercial Policies > UnitedHealthcare Oxford Clinical, Administrative and Reimbursement Policies. Refer to the back of the member’s health care ID card for the applicable website. 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.
Your 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 reimburse the specimen handling and venipuncture codes per our fee schedule.