Commercial eligibility, enrollment, transfers, and disenrollment, Capitation and/or delegation - 2021 UnitedHealthcare Administrative Guide

Members must meet all eligibility requirements established by the employer group and us. We may request proof of eligibility requirements.

To enroll, an applicant must complete a UnitedHealthcare enrollment form or an employer enrollment form approved by us. Some larger member accounts may provide open enrollment through electronic means rather than enrollment forms.

Newly eligible members may present a copy of the enrollment form as proof of eligibility. Completing an enrollment form does not ensure enrollment in a Medicare Advantage (MA) prescription drug plan. Enrollment may be denied if eligibility requirements are not met. See Chapter 2, section 20 of the CMS Medicare Managed Care Manual for eligibility information. Make a copy of the enrollment form. If unable to verify member eligibility online or through our voice response systems, follow up with member service the next business day. The capitated medical group/IPA is responsible for making sure the contracted network of care providers accepts the enrollment form as temporary proof of eligibility.

Each employer group typically has an annual open enrollment period where current employees elect their health insurance choices for the following benefit year. Jan. 1 is a commonly used benefit start date. However, many employers select different dates throughout the year. Benefit plan codes change throughout the year on your eligibility reports.

Coverage begins at 12:01 a.m. on the effective date.

Members enrolled in some commercial benefit plans, such as HMO or Managed Care Organization (MCO) plans, must choose a primary care provider (PCP). This process is outlined in the PCP Selection section in Chapter 3: Commercial Products.

Coverage of the subscriber’s newborn children begins at birth. The subscriber must submit an enrollment application to the employer group or UnitedHealthcare, as applicable, within 30 calendar days from the date of birth to continue coverage, unless the subscriber’s benefit plan says otherwise.

If the mother is the subscriber’s dependent, but not their spouse, domestic partner or common law spouse, we will not cover any services provided to the newborn grandchild beginning upon delivery unless coverage is stated in the subscriber’s benefit plan.

We do not cover medical or facility services for surrogate mothers who are not our members.

California Commercial: Eligible newborns have coverage for the first 30 days, beginning on their date of birth. If the newborn is not enrolled as a dependent on the subscriber’s plan, the newborn has 30 days eligibility with the subscriber’s medical group/ IPA following birth. However, coordination of benefits may be applied as determined by the birthday rule.

Unless the subscriber’s benefit plan dictates otherwise:

If the mother (subscriber, spouse or domestic partner) is our member, the newborn remains with the mother’s medical group/ IPA until another PCP or medical group/IPA is selected following the 15/30 rules.

When the father is primary for the newborn per the birthday rule, his plan covers the newborn for the first 30 days, even if the newborn is not enrolled on his plan.

If both the mother’s and the father’s insurance plans provide coverage for the newborn, coordination of benefit rules apply once the mother is discharged. The medical group/IPA must make sure they handle care coordination appropriately.

If both the mother and father of a dependent newborn are eligible under separate UnitedHealthcare benefit plans, we add the dependent newborn to both plans as determined by the subscribers.

Any subsequent PCP or medical group/IPA transfer of a dependent newborn will follow the 15/30 rules.

Coverage begins on the first day of physical custody if the subscriber submits an enrollment application to the employer group within 30 calendar days of physical custody of the child, unless the subscriber’s benefit plan dictates otherwise.

We may provide coverage for a surrogate when the surrogate is the subscriber or eligible dependent. Refer to the UnitedHealthcare benefit plan. However, the newborn dependent(s) may not have coverage at birth. Surrogate cases need individual review. We make decisions on a case-by-case basis. We may issue newborn coverage denials to the facility before the newborn’s birth. Contact your Provider Relations representative if a surrogate case comes to your attention.

California: Under California rescission rules, if UnitedHealthcare or the member’s care provider or medical group/IPA authorizes surrogate newborn care (beyond 30 days from birth), and the facility relies upon such authorization to render treatment, those claims must be paid.

We may seek recovery of our actual costs from a member receiving reimbursement for medical expenses for maternity services while acting as a surrogate.

A member may select a new medical group/IPA or PCP by calling Member Service or accessing myuhc.com.

Members may change their PCP within the same medical group/IPA. The change is effective the first day of the following month after the member calls requesting the change, unless the benefit plan says otherwise.

If a member requests a transfer out of the member’s medical group/IPA entirely, and the change request is received prior to or on the 15th of the month, we will change the member’s medical group/IPA effective the first day of the following month. If the request to transfer to another medical group/IPA is received after the 15th of the month, the change is effective the first day of the second month following receipt of the request.

If the member expresses dissatisfaction with the proposed effective date, we, in our discretion, may process the member’s request as a ‘Forward Primary Care Provider Change Request’, (if our contract with requested network care provider allows for a “retroactive” transfer). Based on the contract, the network care provider may have the right to refuse to accept the member until the first day of the second month following the request receipt. Some care provider groups may only accept new members during an open enrollment period. If the member meets all eligibility requirements, the change becomes effective the first day of the following month, even though the change request was received after the 15th of the month. If the 15th of the month falls on a weekend or holiday, we will allow transfer requests received on the first business day after the 15th to become effective the first day of the following month.

Transfers from one participating medical group/IPA to another, or PCP transfers initiated outside a member’s open enrollment period, will not be effective until the first day of the month following the member’s discharge from care, if at the time of the request for transfer or on the effective date of transfer, the member is currently:

  • Receiving inpatient care at an acute care facility.
  • Receiving inpatient care at a skilled nursing facility (SNF), at a skilled level.
  • Receiving other acute institutional care.
  • In the third trimester of her pregnancy (defined as when the member reaches the 27th week of pregnancy).
  • Experiencing a high-risk pregnancy (not applicable to California members).

Members may retroactively change their medical group/IPA or PCP within the same month if the member calls to request a change within 30 calendar days:

  • Of their effective date and has not received services with the originally assigned care provider; or
  • Due to a household move over 30 miles, and the member has not received services with the originally assigned care provider. If the member received services during the current month from you, other than the month requested, a current month change is not permitted.

If the member’s medical group/IPA, PCP, or facility is terminated, we give prior written notice to members as applicable or when required by state or federal law. In such event, the member may qualify for continuation of care as outlined in the Continuity of care section of this supplement. For individual physician terminations, the medical group/IPA is responsible for providing the notice to commercial members in the following circumstances:

  • PCP terminations in medical group/IPAs where medical group/IPA assigns members to the PCPs; and
  • All specialist terminations.

Each commercial member has at least 30 calendar days (exception: 60 calendar days in California) to select another medical group, IPA, PCP or facility.

When a member needs care, and their PCP terminated without proper notice, we transfer the member to another PCP. The new PCP will be in the same medical group/IPA with an effective date retroactive to the first of the current month.

The medical group/IPA agrees we may move a medically stable member to another medical group/IPA or care provider due to a strained relationship between the medical group/IPA and member.

When commercial members refuse treatment or prevent you from delivering care, the medical group/IPA may consider the care provider-member relationship as unworkable. In these cases, the medical group/IPA may believe they need to dismiss the member from their panel.

The medical group/IPA may request a member change medical groups/IPAs in these cases. We evaluate requests based on the interest of the member and accessibility of another medical group/IPA. If we approve the transfer request, we ask the member to choose another medical group/IPA within 30 calendar days. The primary medical group/IPA is responsible for directing and managing all care until the change or transfer is effective.

If the member fails to select another medical group/IPA, we choose another medical group/IPA for them.

If no professionally acceptable alternatives exist, neither UnitedHealthcare nor the medical group/IPA are responsible to provide or arrange for the medical care or pay for the condition under treatment.

Areas of concern for requesting removal of a commercial member from the medical group/IPA include:

  • Repeated disruptive behavior or dangerous behavior exhibited in the course of seeking/receiving care.
  • Failure to pay required copayments (minimum dollar amount of $200 outstanding).
  • Fraudulently applying for any UnitedHealthcare benefits.

After we receive a completed Incident Report for Removal of Members and related documentation, we respond to the member. We copy the PCP or medical group/IPA on all correspondence.

If you receive notification of a member’s intent to sue, tell your provider advocate.

Send copies of all notification letters, request for removal and supporting documentation to your provider advocate.

Level I

Criteria

Demanding a payment from medical group/IPA for non-authorized services.

Minor disruptive behavior*

Failure to pay required copayments**

3 or more missed appointments within 6 consecutive months without 24-hour prior notice.

1st Occurrence:

Medical group/IPA must counsel with and send the member a certified letter saying such behavior is unacceptable.

Discussions need documentation. Send copies to UnitedHealthcare, which sends a warning letter outlining behavior and possible consequences

2nd Occurrence:

Medical group/IPA must counsel with and send second letter to member expressing concern regarding their unacceptable behavior.

Send copies to UnitedHealthcare, which sends warning letter outlining continued behavior and possible consequences.

3rd Occurrence:

Send us a request to immediately remove a subscriber/member from the medical group/IPA. We review the medical group/IPA documentation, which outlines continued unacceptable behavior.

Level II

Criteria

Refusal to follow recommended treatment or procedures by care provider resulting in deterioration of member’s medical condition.

Disruptive behavior, verbal threats of bodily harm toward medical group/ IPA personnel and/or other members, provided the conduct is not a direct result of the member’s medical condition or prescribed medication.+

1st Occurrence:

Medical group/IPA must counsel with and send the member a certified letter saying such behavior is unacceptable.

Discussions need documentation. Send copies to UnitedHealthcare, which will send warning letter outlining behavior and possible consequences.

2nd Occurrence:

Send UnitedHealthcare a request to immediately remove subscriber/member from the medical group/IPA. UnitedHealthcare reviews the medical group/IPA documentation outlining continued unacceptable behavior.

Level III

Criteria

Member fraudulently applies for any UnitedHealthcare benefits.

Dangerous behaviors exhibited in the course of seeking or receiving care provided the conduct is not a direct result of the member’s medical condition or prescribed medication.

Need an eyewitness willing to formally document the incident in writing.

1st Occurrence:

Medical group/IPA requests immediate removal of subscriber/member from medical group/IPA. Incident must be, formally documented by medical group/IPA.

Send written notification to member in a certified letter. Mail copies of documentation and member letter to UnitedHealthcare for review.

2nd Occurrence:

Send UnitedHealthcare a request to immediately remove subscriber/member from the medical group/IPA. UnitedHealthcare reviews the medical group/IPA documentation outlining continued unacceptable behavior.


* Minor disruptive behavior: Unruly behavior, use of abusive and/or profane language directed toward medical group/IPA and/or other members.
** UnitedHealthcare West will not consider the removal of a member unless the unpaid copayment balance exceeds $200.00.
+ Disruptive behavior: Physical or verbal threat of bodily harm toward medical group/IPA personnel and/or other members or property, and/or use of unacceptable behavior relative to drug and/or alcohol misuse. # Dangerous behavior such as attempted physical abuse, display of weapon or damage to property, use of unacceptable behavior relative to drug and/or alcohol misuse, and/or chronic demands for unreasonable services.

A delegated entity agrees to provide at least 120 days advance written notice to UnitedHealthcare and its contract administrator or provider advocate of its intent to:

  1. Change administrative platforms for impacted delegated functions or upgrade current platform, including migrations or versions.
  2. Make material changes in existing administrative platforms impacting delegated functions.

If you are unsure of what a material change is, contact your delegation oversight representative. Some changes may require pre- cutover evaluation by UnitedHealthcare delegation oversight team(s).