Virtual Care Services (Commercial HMO plans – CA only)- Capitation and/or delegation supplement - 2022 Administrative Guide

Commercial HMO members can use Virtual Visits for 24/7 Virtual Visits (urgent care), Virtual Primary Care or through their selected PCP or medical group/IPA. Virtual Visits provide communication of medical information in real time between the member and a health care provider or health specialist, through use of interactive audio and video communications equipment outside of a medical facility (e.g., home or work). When covered by a member’s benefit plan, the Virtual Visit benefit has a separate defined copayment.

24/7 Virtual Visits: Commercial members can connect to a doctor by video through myuhc.com or the UnitedHealthcare app. Doctors treat a wide range of health conditions (e.g., flu, pinkeye and migraines) and can even prescribe medication as needed. 24/7 Virtual Visits treats many of the same conditions as in-person urgent care and utilizes the Designated Virtual Network Provider benefit. The network provider groups offering Virtual Visit services must comply with the service standards. 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 their Virtual Visit.

Virtual Primary Care: Virtual Primary Care delivers many of the same services as traditional primary care, including preventive and regular exams, management of chronic conditions and acute non-emergency needs. It combines convenience with the potential advantages of seeing a doctor regularly who knows your employees’ health history. Virtual Primary Care uses the Physician Office Benefit.

We prefer members to access Virtual Visits through their selected PCP or medical group/IPA (local care), if available. Commercial HMO members may access Virtual Visits from a Designated Virtual Network Care Provider. If the member’s medical group/IPA or PCP does not offer Virtual Visit services, we make a nationally contracted Virtual Visit health care provider available. The Designated Virtual Network Care Provider groups offering Virtual Visit services must comply with the service standards.

Service standards

Access — When the health care provider group develops Virtual Visit technology, it may offer services to assigned members who have the coverage as a part of their benefit plan. We pay for Virtual Visit primary care services delivered by health care providers covered under professional capitation. Not all benefit plans have the Virtual Visit benefit option. The health care provider group must confirm member eligibility and cost-share for Virtual Visit service. This applies only if medical group/IPA develops its own virtual visit technology.

24 Hour/7 day availability — Virtual Visit technology services are available 24 hours a day, 7 days a week.

Staffing credentials — All professional staff are certified or licensed in their specialty or have a level of certification, licensure, education and/or experience based on state and federal laws.

Staff orientation and ongoing training — The health care provider group must take part in a written orientation plan with documented skill demonstrations. It must also have initial and ongoing training programs, including policies and procedures. The health care provider group will pursue accreditation of its Virtual Visit program with the American Telemedicine Association.

Service response time — Within 30 minutes after a member requests a visit, the health care provider group contacts the member to either schedule or hold a Virtual Visit.

Technology security — The health care provider group conducts all member Virtual Visits using interactive audio and/or video telecommunications systems on a secure technology platform that meets state and federal law requirements for security and confidentiality of electronic member information. It maintains member records in a secure medium that meets state and federal law requirements for encryption and security of electronic member information.

Professional accreditation — The health care provider group pursues applicable accreditation by the American Telemedicine Association (or other mutually agreed upon accreditation body) to become accredited within 1 year after the accreditation program release date.

Continuous quality improvement (CQI) — The health care provider group must have a documented CQI program for identifying data opportunities for time-measured improvement in areas of core competencies. There must be demonstrated ties between CQI findings and staff orientation, training, and policies and procedures.

Member complaints — The health care provider group logs, by category and type, member complaints with specific improvement action plans for any patterns. There should be complaints registered on less than 2% of member cases.

Regulatory assessment results — If we ask, the health care provider will allow access to any applicable regulatory audit results.

Utilization — The health care provider group submits Virtual Visit encounters with proper coding as part of its existing encounter submission process.

Electronic billing/encounter coding — The health care provider group will submit Virtual Visit encounters or claims with proper coding as part of its existing encounter submission process.

Eligibility verification — The health care provider group uses existing eligibility validation methods to confirm Virtual Visit benefits.

Case communication — The health care provider group will support member records management for Virtual Visits using existing EMR systems and standard forms. Keep required medical information in EMR records, including referrals and authorizations.

Joint operating committee — The health care provider meets with us up to quarterly at our request to review data reports and quality issues. We also address any administration issues.

Professional environment — The health care provider group helps ensure that, when conducting Virtual Visits with members, the rendering health care provider is in a professional and private location. The health care provider group (rendering health care providers) may not conduct member Virtual Visits in vehicles or public locations.

Medical director — The health care provider employs or engages a licensed health care provider as medical director. The medical director is responsible for clinical direction.