Access standards - Chapter 2, 2021 UnitedHealthcare Administrative Guide

Covering physician

As a PCP, you must arrange for 24 hours a day, 7 days per week coverage of 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 appointment standards for access and after-hours care to help ensure timely access to care for members. We use these to measure performance annually. Our standards are shown in the following table.

Type of Service: Standard

• Preventive care: Within 30 calendar days 
• Regular/routine care appointment: Within 14 calendar days 
• Urgent care appointment : Same day
• Emergency Care: Immediate
• After-hours care: 24 hours/7 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 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, 7 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 under UnitedHealthcare benefit plans have access to free triage and screening services 24 hours a day, 7 days a week through the Optum NurseLine at 1-866-747-4325. If a member or covered person is unable to obtain a timely referral to an appropriate care provider, refer to the 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: 1-888-466-2219
• For members with California Department of Insurance regulated plans: 1-800-927-4357

Telehealth services

Under certain benefit plans, we provide coverage for telehealth services regardless of whether the member is located at a CMS-designated originating site. For more information on telehealth services, see the Telehealth services protocol in Chapter 9: Specific Protocols.

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 members with limited English proficiency, those with diverse backgrounds and/or disabilities.

Translation/interpretation/auxiliary aide services

You must provide language services and auxiliary aides, including, but not limited to, sign language interpreters to members as required, to provide members with an equal opportunity to access and participate in all health care services.

If the member requests translation/interpretation/auxiliary aide services, you must promptly arrange these services at no cost to the member.

Members have the right to a certified medical interpreter or sign language interpreter to accurately translate health information. Friends and family of members with limited English proficiency, or members who are deaf or hard of hearing, may arrange interpretation services only after you have explained our standard methods offered, and the member refuses. Document the refusal of professional interpretation services in the member’s medical record.

Any materials you have a member sign, and any alternative check-in procedures (like a kiosk), must be accessible to an individual with a disability.

If you provide Virtual Visits, these services must be accessible to individuals with disabilities. Post your Virtual Visits procedures for members who are deaf or hard of hearing, so they receive them prior to the Virtual Visit.