Care Provider Responsibilities and Standards
Compliance with Quality Assurance and Utilization Review
Physicians and other health care professionals agree to fully comply with and abide by the rules, policies and procedures that we have or will establish. We provide written notice of any changes 30 days in advance, including, but not limited to:
- Quality assurance, such as onsite case management of members, incentivist programs and notification compliance measures.
- Utilization management, including prior authorization procedures, referral processes or protocols and reporting of clinical accounting data.
- Member, physician and other health care professional grievances.
- Timely provision of medical records when we or our contracted business associates request them.
- Cooperation with quality of care investigations, including timely response to queries and/or completion of improvement action plans.
- Care provider credentialing.
- Any similar programs developed by us.
Advising Members of Their Rights
Our members have the right to obtain complete, current information concerning diagnosis, treatment and prognosis in terms they may understand. When it is not advisable to give such information to the member, make the information available to an appropriate person acting on the member’s behalf.
Our members also have the right to receive information as necessary to give informed consent before the start of any procedure or treatment. They may refuse treatment to the extent permitted by law. You must inform them of the medical consequences of that action.
Office and Access Standards
Your office must adhere to policies regarding:
- Confidentiality of member medical records and related member information.
- Patient-centered education.
- Informed consent, including telling a member before initiating services when a particular service is not covered and disclosing to them the amount they must pay for the service.
- Maintenance of advance directives.
- Handling of medical emergencies.
- Compliance with all federal, state and local requirements.
- Minimum standards for appointment and after-hours accessibility.
- Safety of the office environment.
- Use of physician extenders, such as physician assistants (PA), nurse practitioners (NP) and other allied health professionals, together with the relevant collaborative agreements.
As a participating care provider, you agree to certain access standards. You agree to arrange coverage for medical services, 24 hours a day, seven days a week, including:
- Telephone coverage after hours: You must have either a constantly operating answering service or a telephone recording directing members to call a special number to reach a covering medical professional. Your message must tell the caller to go to the emergency room (ER) or call 911 if there is an emergency. The message should be in English and any other relevant languages if your panel consists of members with special language needs.
- Covering care providers: You must provide coverage of your practice 24 hours a day, seven days a week. Your covering care provider must be a participating care provider unless there isn’t one in your area. UnitedHealthcare must certify any non-participating health care professionals you use to provide coverage for your practice.
Americans with Disabilities Act (ADA) Guidelines
You must have practice policies showing you accept for treatment any patient in need of the health care you provide. Your organization and care providers must make public declarations (i.e., through posters or mission statements) of their commitment to non-discriminatory behavior in conducting business with all members. These documents should explain that this expectation applies to all personnel, clinical and non-clinical, in their dealings with each member.
In this regard, you are required to undertake new construction and renovations, as well as barrier reductions required to achieve program accessibility, following the established accessibility standards of the ADA guidelines. For complete details go to ADA.gov > Featured Topics > (scroll to) A Guide to Disability Rights Laws.
We May Request From a Care Provider’s Office We may request any of the following ADA-related descriptions of:
- Accessibility to your office or facility.
- The methods you or your staff uses to communicate with members who have visual or hearing impairments.
- The training your staff receives to learn and implement these guidelines.
Care for Members Who Are Hearing-Impaired
Refusing to provide either care or the help of an interpreter while caring for a person with a qualifying disability is an ADA violation. Members who are hearing-impaired have the right to use sign-language interpreters to help them at their doctor visits.
We will bear the reasonable cost of providing an interpreter. You must not bill the member for interpreter fees (28 CFR* Sect. 36.301(c)**). The care provider/ facility pays the interpreters for their services, then bills us for these services by submitting a claim form with Current Procedural Terminology (CPT) code 99199 with a description of the interpreter service.
Confirming Eligibility and Benefits
Checking the member’s eligibility and benefits before rendering services helps ensure you submit the claim to the correct payer, collect correct copayments, determine if a referral is required and reduce denials for non-coverage. To check eligibility and benefits, use any of the following methods:
- EDI: 270/271 Eligibility and Benefit Inquiry and Response transactions are available through your vendor or clearinghouse.
- Online: OxfordHealth.com > Providers or Facilities > Transactions > Check > Eligibility and Benefits
- Phone: 800-666-1353, and say “benefits and eligibility” when prompted (Monday through Friday, 8 a.m. - 6 p.m. ET).
For additional help with web, Oxford Voice Portal and EDI solutions, please refer to OxfordHealth.com > Providers or Facilities > Tools & Resources > Administrative Tools & Information. You will find quick reference guides and instructions to assist you.
Member Health Care Identification (ID) Cards
We give each member a health care ID card for identification only. The member should present their card when requesting a covered health care service. We suggest that each time you check a member’s health care ID card you also request photo identification to reduce the risk of an unauthorized use of the member’s card.
Possession of a health care ID card is not proof of eligibility. You must verify eligibility and benefits before or at the point of service for each office visit.
You may see more detailed information on ID cards and a sample health care ID card, in the section titled Commercial Health Care ID Card Legend in Chapter 2:
Provider Responsibilities and Standards. You may see a sample ID card image specific to the member when you verify eligibility using our eligibilityLink application.
Participating Hospitals, Ancillary Providers and Care Providers Agree to:
- Verify a member’s status. We will not pay for services rendered to persons who are not our members.
- Obtain prior authorization from us or a delegated vendor for all hospital services requiring prior authorization before rendering services. Generally, all hospital services require our prior authorization.
- Notify us of all emergency/urgent admissions of members upon admission or on the day of admission. If the facility is unable to determine on the day of admission that the patient is our member, the facility must notify us as soon as possible after discovering that the patient has coverage with us.
- Notify us of an ambulatory surgery performed due to an ER or urgent care visit within 24-48 hours.
- Admit and treat our members the same way you treat all other facility patients (i.e., according to the severity of the medical need and the availability of covered services).
- Render services to members in a timely manner. The services provided must be consistent with the treatment protocols and practices used for any other facility patient.
- Work with the responsible PCP to help ensure continuity of care for our members.
- Maintain appropriate standards for your facility.
- Cooperate with our utilization review program and audit activities.
- Receive compensation only from us and adhere to our balance billing policies.
- Complete appeals process in a timely manner, before proceeding to arbitration.
- Standards of Practice
Services you perform for members must be consistent with the proper practice of medicine and be performed following the customary rules of ethics and conduct of the American Medical Association and other bodies, formal or informal, governmental or otherwise, from which you seek advice and guidance or to which they are subject to licensing and control.
All HMO products require members to select a PCP to provide primary care services and coordinate their overall care. Female members may also select an obstetrician/ gynecologist (OB/GYN) which they may see without a referral from their PCP. Members may only select a PCP within their network (e.g., a Liberty Plan member must select a Liberty Network participating PCP).
Role of the PCP
As a PCP, you must deliver medically necessary primary care services. You are the coordinator of our members’ total health care needs. Your role is to provide all routine and preventive medical services and coordinate all other covered services, specialist care, and care at our participating facilities or at any other participating medical facility where our members might seek care (e.g., emergency care). You are responsible for seeing all members on your panel who need care, even if the member has never been in for an office visit. You may not discriminate on the basis of race, ethnicity, national origin, religion, sex, age, mental or physical disability, sexual orientation, genetic information, place of residence, health status, or source of payment. Some PCPs are also qualified to perform services ordinarily handled by a specialist. We will only pay claims submitted for specialist services by such a PCP if they are listed as a participating specialist in the particular specialty.
Per New York regulations, all care providers must develop and implement policies and procedures to maintain the confidentiality of HIV-related information. You must have the following procedures in place to comply with regulations specific to the confidentiality, maintenance and appropriate disclosure of HIV patient information.
Office staff will:
- Receive initial and annual in-service education regarding the legal prohibition of unauthorized disclosure.
- Maintain a list containing job titles and specified functions for employees authorized to access such information.
- Maintain and secure records, including records which are stored electronically, and ensure records are used for the purpose intended.
- Maintain procedures for handling requests by other parties for confidential HIV-related information.
- Maintain protocols prohibiting employees, agents and contractors from discriminating against persons having or suspected of having HIV infection.
- Perform an annual review of the following policies and procedures:
› Perform HIV testing on all newborns.
› Prenatal care providers should counsel expectant mothers regarding the required testing of newborns and the importance of the mother getting tested.
› Advise expectant mothers of the counseling and services offered when results are positive. This includes psychosocial support, and case management for medical, social, and addictive services.
Only employees, contractors and medical nursing or health- related students who have received such education on HIV confidentiality shall have access to confidential HIV-related information while performing the authorized functions.
As a participating specialist, you agree to:
- Provide referrals for specialty services.
- Provide results of medical evaluations, tests and treatments to the member’s PCP.
- Pre-certify inpatient admission.
- Receive compensation only from us and adhere to our balance billing policies.
- Provide access to your records relating to services rendered to our members. If you believe consent is required from the specific member, you must obtain their consent.
- Follow our authorization guidelines for those services requiring prior authorization.
We only reimburse you for services if:
- We have a referral on file or the member has a non- gatekeeper benefit plan and the service is covered and medically necessary.
- A referral is not on file, and the member has an out- of-network benefit (i.e., a POS benefit plan), and if the service is covered and medically necessary, you are entitled to the contracted rate. However, the member is required to pay any deductible and/or coinsurance based on their out-of-network benefits.
- If the member is enrolled in a benefit plan without an out- of-network benefit (i.e., an HMO benefit plan), we are not responsible for payment (except in cases of emergency), nor may the member be balance billed.
Specialists as PCPs
We allow a member who has a life-threatening condition or a degenerative and disabling condition (i.e., complex medical condition) or disease, either of which requires specialized medical care over a prolonged period of time, to elect a network specialist as their PCP. We may grant a standing referral and the specialist PCP becomes responsible
for providing and coordinating all of the member’s primary care and specialty care. The PCP, specialist, and UnitedHealthcare must all be in agreement with the established treatment plan.
We may authorize a standing referral (See Standing Referrals and Specialty Care Centers) when the care provider is requesting more than 30 visits within a six-month period or covered services beyond a six-month period but within 12 months. Under a standing referral, a member may seek treatment with a designated specialist or facility without a separate PCP referral for each service.
If such an election appears to be appropriate, our Clinical Services department faxes the specialist a form to complete and return.
We cover such services without a referral only after you complete the form and we accept it. Otherwise, a referral is required for members with a gatekeeper benefit plan.
Continuity and coordination of care helps ensure ongoing communication, monitoring and overview by the PCP across each member’s health care continuum. Documentation of services provided by specialists such as podiatrists, ophthalmologists and mental health practitioners, as well as ancillary care providers including home care and rehabilitation facilities, help the PCP maintain a medical record supporting whole person care.
The NCQA and state departments in the tri-state area (New York, New Jersey and Connecticut) require elements of the chart to indicate continuity and coordination of care among care providers. We monitor the continuity and coordination of care that members receive through the following mechanisms:
- Medical record reviews
- Adverse outcomes that may develop as the result of disruptions in continuity or coordination of care
- Care provider termination
Newly Enrolled Members Who Need Transitional Care or Continuity of Care
When a new member enrolls with us, they may qualify for coverage of transitional care services rendered by their non-participating care providers. If the member has a life- threatening disease or condition, or a degenerative and disabling disease or condition, the transitional care period is 60 days.
For more information about transitional care, members may call UnitedHealthcare at 800-444-6222.
Reassignment of Members Who Are in an Ongoing Course of Care or Who Are Being Treated for Pregnancy We adhere to the following guidelines when notifying members affected by a care provider termination:
- We notify all members who are patients of any terminated PCP’s panel - internal medicine, family practice, pediatrics, OB/GYN - about our policy and what steps to follow, should the member require transitional care. We follow the same policy for members who regularly see a specialist who is terminated.
- We instruct members of a terminated PCP’s panel to call Member Service if they choose to select a new PCP, or to request transitional care from their current care provider. We encourage them to request our Roster of Participating Physicians and Other Health Care Professionals to make their new selection.
- We instruct members of a terminated specialist to call Member Service if they need to request transitional care from their current specialist. We also direct members to call their current PCP for an alternate specialist referral.
Transitional Care When a Care Provider Leaves Our Network
We use the following rules when notifying members affected by a care provider termination:
- UnitedHealthcare members in New York qualify for transitional services on a network basis for up to 90 days from the date a care provider ceases to be in the UnitedHealthcare network.
- We tell all members who are patients of any terminated PCP, such as internal medicine, family practice, pediatrics and OB/GYN, about our policy and what steps to follow should they need transitional care. We follow the same policy for members being seen regularly by a specialist who is terminated.
- We instruct members with terminated PCPs to call Member Service whether they choose to select a new PCP, or to ask for transitional care from their current care provider. We encourage them to visit OxfordHealth.com to make their new selection.
- We tell our members who are patients of a terminated specialist to call Member Service if they need to request transitional care from their current specialist. Additionally, we tell them to call their current PCP to ask for a referral to a different network specialist.
If the member has entered the second trimester of pregnancy at the effective date of enrollment, the transitional period includes the provision of postpartum care directly related to the delivery. Our medical director must find the treatment by the non-participating care provider medically necessary. Transitional care is available only if the care provider agrees to:
- Accept as payment our negotiated fees for such services before transitional care.
- Adhere to our Quality Management procedures and provide medical information related to the member’s care.
- Adhere to our policies and procedures regarding the delivery of covered services, including referrals and preauthorization policies, and a treatment plan approved by us.