Mid-Atlantic regional supplement- 2020 UnitedHealthcare Administrative Guide

Applicability of this Supplement

This Mid-Atlantic Regional Supplement applies to services provided to members enrolled in:

  • MD-Individual Practice Association, Inc. (“M.D. IPA”) and M.D. IPA Preferred, or
  • Optimum Choice, Inc. (“Optimum Choice”), and Optimum Choice Preferred, and Optimum Choice Small Business Health Options Program (SHOP).

It may apply to care providers in DE, DC, MD, PA, VA, WV; reference your Agreement for applicability.

Care providers are subject to both the main guide and this supplement. This supplement controls if it conflicts with information in the main guide. For protocols, policies and procedures not referenced in this supplement refer to appropriate chapter in the main guide.

The term “prior authorization” referenced in this supplement is also referred to as “preauthorization”. We use both terms in this supplement. They mean the same.

Mid-Atlantic Protocols

A complete list of Mid-Atlantic Health plan protocols pertaining to M.D. IPA, M.D. IPA Preferred, Optimum Choice, and Optimum Choice Preferred may be located on UHCprovider.com/plans > Choose Your State.

Product Summary

M.D. IPA and Optimum Choice

Members choose a PCP who arranges or coordinates their care, except emergency services, network OB/GYN, routine eye refraction care, behavioral health care services.

M.D. IPA Preferred and Optimum Choice Preferred

Network benefits: Members choose a PCP who arranges or coordinates care, with the exception of emergency services, network OB/GYN, routine eye refraction care, behavioral health care services.

Out-of-network benefits: Members are not required to have care arranged or coordinated by a PCP.

M.D. IPA and Optimum Choice

Yes; except for visits to a network OB/GYN, routine eye refraction care, emergency services, behavioral health care services.

M.D. IPA Preferred and Optimum Choice Preferred

Network benefits: Yes, except for visits to a network OB/ GYN, routine eye refraction care, emergency services, behavioral health care services. 

Out-of-network benefits: No referral needed.

M.D. IPA and Optimum Choice

Yes; view the section on Prior Authorizations process located within this supplement. Find a complete list of codes requiring prior authorization on UHCprovider.com/priorauth > Advance Notification and Plan Requirement Resources > UnitedHealthcare Mid-Atlantic Plan Notification/Prior Authorization Requirements.

M.D. IPA Preferred and Optimum Choice Preferred

Yes; view the section on Prior Authorizations process located within this supplement. Find a complete list of codes requiring prior authorization on UHCprovider.com/priorauth > Advance Notification and Plan Requirement Resources > UnitedHealthcare Mid-Atlantic Plan Notification/Prior Authorization Requirements.

 

UnitedHealthcare Optimum Choice Small Business Health Options Program (SHOP)

For information refer to Chapter 4: Health Insurance Marketplace (Exchanges).

Key Points

Optimum Choice, Inc.

For each covered family member, members choose a network PCP, or are assigned a PCP, to manage the member’s care and generate referrals to network specialists when required.

Yes, on selected procedures. See guidelines in the referral requirements section of Mid-Atlantic Supplement.

Yes, on selected procedures. See guidelines in the Prior Authorization List located on UHCprovider.com/priorauth.

UnitedHealthcare Optimum Choice Health Savings Account (HSA) Plan

The Optimum Choice and Optimum Choice Preferred HSA benefit plans are high-deductible medical benefit plans that combine our traditional gated HMO benefit plans with an HSA option. Expenses under this benefit plan are the member’s responsibility until their deductible is reached. HSA benefit plans require reimbursement for services provided to members are based on a fee-for-service reimbursement methodology.

Key Points

The Optimum Choice HSA product requires each UnitedHealthcare member to choose a PCP.

The member’s PCP generates referrals for specialty care and facility care.

Services for members enrolled in Optimum Choice HSA are excluded from your capitation payment and are paid on a fee-for-service (FFS) basis per the All Payer Payment Appendix included in the UnitedHealthcare physician Agreement.

The Optimum Choice HSA product name and member’s PCP are indicated on the member’s ID card. Specialist referral requirements are on the back of the ID card. Check Eligibility and Eligibility and Benefits (on Link).