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:
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.
Your office must adhere to policies regarding:
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:
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:
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.
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:
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.
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 Eligibility and Benefits (on Link) application.
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).
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:
› 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:
We only reimburse you for services if:
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:
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 use the following rules when notifying members affected by a care provider termination:
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: