Medical management- Capitation and/or delegation supplement - 2022 Administrative Guide

The protocols in this section are unique to capitated and/or delegated medical management entities. The protocols in Chapter 7: Medical management may also apply if we are financially responsible for the service.

If we are financially responsible for the service, or responsible for processing the claim, ask us if we require an authorization.

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We monitor the performance of delegated activities. We hold our delegates to the requirements outlined in the main guide and this supplement. We perform clinical assessments of those activities prior to the approval of delegation to make sure the potential delegate meets those requirements. Once we approve the delegate, and they are implemented, we make sure they remain compliant. We provide our delegates with information they need to meet regulatory and contractual requirements and accreditation standards.

Pre-contractual or pre-delegation assessments

When an entity – usually a medical group/IPA – expresses interest in contracting to perform delegated activities, we begin an assessment process to confirm the entity can perform those activities. Clinical reviewers request documented processes (e.g., programs, policies and procedures, work flows or protocols) and supporting evidence prior to an onsite visit. Supporting evidence may include materials (e.g., letter templates, scripts, brochures or website) and reports (or the demonstrated ability to produce required reports). Clinical reviewers arrange an onsite visit to further assess systems and processes, staffing and resources. We report assessment results and delegation recommendations to the Delegation Oversight Governance Committee, which decides whether to proceed with delegation and determines any contingencies for delegation.

Post-contractual or post-delegation clinical assessments

We conduct another assessment within 90 calendar days after the contract or delegation effective date. Assessments are based on documented processes, materials, reports and case records or files specific to the delegated activities. Further assessments are performed at least quarterly. The quarterly review process includes:

  • A review of all updated policies and/or procedures.
  • File review (3-month look back from previous review period).
  • Remediation plan, if appropriate.

Quarterly review process

The quarterly review process includes new scoring guidelines for any deficiencies found. Total assessment scores will no longer be provided. Any review items marked as not met will be placed into the following categories on your remediation plan:

  • Immediate Corrective Action Required (ICAR)
    • The issue requires immediate correction and may have impacted member’s health and safety or access to services.
    • You have 2 business days to respond with root cause.
    • You have 7 business days to remediate the issue.
  • Corrective Action Required (CAR)
    • The issue requires correction, but the member’s health and safety is not affected.
    • You have 5 business days to respond with root cause.
    • You have 14 business days to remediate the issue.
  • Observations
    • A non-systemic or one-off issue.
    • You have 5 business days to respond with root cause.
    • You have 21 business days to remediate the issue.

UnitedHealthcare and medical group/IPAs delegated for utilization/medical management review nationally recognized evidence-based criteria to determine medical necessity and appropriate level of care for services whenever possible. UnitedHealthcare and delegates use several resources and guidelines to determine medical necessity and appropriate level of care.

Hierarchy of criteria use

When using criteria to make decisions about service requests, the delegate must use the following criteria appropriate to the benefit plan:

Commercial

  • Eligibility and benefits
  • State/federal laws and regulations
  • Summary Plan Description/Certificate of Coverage
  • UnitedHealthcare clinical determination guidelines
  • UnitedHealthcare medical policies and review guidelines
  • For medical necessity only:
    • Evidence-based criteria, such as InterQual guidelines

UHC West

  • Eligibility
  • Evidence of Coverage (EOC)/Schedule of Benefits (SOB)
  • Benefit interpretation policies (BIP)
  • Medical management guidelines (MMG)
  • Medical/drug policies or review guidelines (when not addressed in MMG)
  • MCG Care Guidelines/InterQual criteria
  • Hayes

Medicare Advantage

  • Plan eligibility and coverage (benefit plan package or EOC)
  • CMS criteria
    • National Coverage Determination (NCD)
    • Local Coverage Determination (LCD) used only for the area specified in the LCD
    • Local Coverage Medical Policy Article (LCA)
    • Medicare Benefit Policy Manual (MBPM)
  • UnitedHealthcare Medicare Advantage coverage summaries and policy guidelines, and UnitedHealthcare medical/drug policies and review guidelines (including those labeled Commercial)
  • MCG Care Guidelines/InterQual criteria

With limited exceptions, we do not reimburse for services that are not medically necessary, or when you have not followed correct procedures (e.g., notification requirements, prior authorization, or verification guarantee process). Delegates may institute the same policy.

Accreditation standards require all health care organizations, health benefit plans, and medical group/IPAs delegated for utilization/medical management to distribute a statement to all members, physicians, health care providers and employees who make utilization management (UM) decisions stating:

  • UM decision-making is based only on appropriateness of care and service and existence of coverage.
  • Practitioners or other individuals are not rewarded for issuing denials of coverage or service.
  • Financial incentives for UM decision-makers do not encourage decisions that result in under-utilization.

Regardless of the medical management program determination, the decision to render medical services lies with the member and the attending physician.

If you and a member decide to go forward with the medical service once UnitedHealthcare or the delegate has denied prior authorization (and issued a denial notice to the member and physician as appropriate), neither UnitedHealthcare nor the delegate reimburse for the denied services. Medical directors are available to discuss their decisions and our criteria with you. Find medical policies and guidelines on uhcprovider.com/policies or from the delegated medical group/IPA as applicable.

To track the specific level of care and services provided to its members, UnitedHealthcare requires you to use the most current service codes (i.e., ICD-10-CM, UB and CPT codes). We also require you to make sure the documented bill type is appropriate for the type of service provided.

You must participate, cooperate and comply with our medical management policies. You must render covered services at the most appropriate level of care, based on nationally recognized criteria.

We may delegate medical management functions to a medical group/IPA or other entity that demonstrates compliance with our standards. Health care providers associated with these delegates must use the delegate’s medical management office and protocols. We may retain responsibility for some medical management activities, such as inpatient admissions and outpatient surgeries. When a health care provider is not associated with a delegate, or when we are responsible for the specific medical management activity, the health care provider must comply with our medical management procedures.

For medical management functions retained by us, you must receive authorization from us before rendering services for a member. If you have not requested a prior authorization, submit the request within 3 business days before providing or ordering the covered service. The exception is emergency or urgent services.

To confirm prior authorization has been approved by UnitedHealthcare, use the Prior Authorization and Notification tool in the UnitedHealthcare Provider Portal, or uhcprovider.com/paan. If the member is assigned to a delegated medical group/IPA, check with that medical group/IPA for confirmation.

For urgent or emergent cases, we notify you within 24 hours of services rendered, or an admission.

If you don’t get prior authorization when required or tell us within the appropriate time frame, we may deny payment.

The delegated medical group/IPA sets its own policies about health care provider responsibilities.

If you do not get a prior authorization, neither us (or our delegate) nor our member can be held responsible to reimburse health care providers for medical services, admissions, inappropriate facility days, and/or not medically necessary services. Receiving an authorization does not affect the payment policies or determining reimbursement.

Continuity of care provides a short-term transition period so members may temporarily continue to receive services from a non- network provider. See general information under the CAA requirements detailed in Chapter 2: Provider responsibilities and standards of this guide.

A condition that warrants a request for continuity of care requires prompt medical attention for a short time. It is not enough that the member prefers receiving treatment from a former health care provider or other non-network provider, even for a chronic condition. A member should not continue care with a non-network provider without formal approval by us or the delegate. Except for emergencies or urgent out-of-area (OOA) care, if the member does not receive prior authorization from us or the delegate, the member pays for services performed by a non-network provider.

We (or the medical group/IPA delegated for continuity of care) review and document all requests for continuity of care on a case-by-case basis. We consider the severity of the member’s condition and the potential clinical effect on the member’s treatment and outcome of the condition under treatment, which may result from a change of health care provider. Document member specifics for consideration in case reviews as relevant clinical information.

For any service that requires a prior authorization, the health care provider initiates an authorization request online at least 3 business days prior to the scheduled date of service.

  • You must complete and submit the appropriate prior authorization request forms as applicable to state and/or federal regulatory requirements. We do not accept incomplete or incorrect forms, or submissions with incomplete medical records. You may find the list of forms on uhcprovider.com/priorauth.
  • Our medical management team documents the information, responds to the authorization request, and provides a decision within required regulatory time frames. If approved, we issue an authorization number. If denied, we forward the reason for denial to you and the member.
  • In the case of a denial, you may speak with a medical director to discuss the case.
  • The authorized health care provider who delivers care to the member should share documentation of the recommended treatment with the member’s PCP.

The authorized health care provider submits a claim with the authorization number in the usual manner to the appropriate address.

If you are a network provider for a delegated medical group/IPA, follow the delegate’s protocols. Delegates may use their own systems and forms. They must meet the same regulatory and accreditation requirements as UnitedHealthcare.

Tell us of a member’s emergency admission within 24 hours of admission, or as soon as the member’s condition has stabilized. The medical management department receives admission notifications 24 hours a day, 7 days a week at:

EDI: Transaction 278N

Online: uhcprovider.com/paan

Phone: 1-800-799-5252

Document member specifics for consideration in case reviews as relevant clinical information.

The delegate sets its own policies regarding notification and authorization for these services.

The medical group/IPA/facility is financially responsible for providing all approved medical and facility services within a designated service area as well as approved services rendered while a member is outside of the medical group/IPA’s contracted service area. The contract service area is typically defined as being within 30 miles or less from medical group/IPA site based on the shortest route using public streets and highways but can be based on other contractual terms. Refer to your Agreement for your delegated entity service area. For MA members, refer to the CMS regulatory access requirements.

Urgent or emergency services provided within the medical group/IPA/facility service area are the financial risk of the capitated entity regardless of whether services are rendered by the medical group/IPA/facility’s network of health care providers unless your Agreement states otherwise.

OOA medical services

OOA medical services are emergency or urgently needed services that treat an unforeseen illness or injury while a member is outside of the medical group/IPA’s contracted service area. These would have been the medical group/IPA’s financial responsibility if they had been provided within the medical group/IPA service area.

  • UnitedHealthcare is accountable for managing OOA cases unless otherwise contractually defined. Refer to the Division of Financial Responsibility (DOFR) section of your Agreement to determine risk for OOA medical services.
  • Medical services provided outside of the delegated medical group/IPA defined service area that the member’s medical group/IPA arranges or authorizes are the delegate’s responsibility. They are not considered OOA medical services. This includes out-of-network provider services referred by a health care provider affiliated with the delegated medical group/IPA, whether or not that health care provider received appropriate authorization. In such cases, the delegated medical group/IPA performs all delegated medical management activities, including issuing appropriate authorization and denials.
  • Members referred by the delegated medical groups/IPA for out-of-network outpatient consultation, who are then found through their evaluation to require medically necessary inpatient care, are the referring medical group/IPA’s responsibility. They do not meet the OOA criteria.
  • The delegated medical group/IPA must issue appropriate denials for member-initiated non-urgent, non-emergency medical services provided outside the medical group/IPA’s defined service area.
  • The medical group/IPA notifies UnitedHealthcare OOA department of all known OOA cases no later than the first business day after receiving member notification of an OOA admission, procedure and/or treatment.
  • Failure to notify us within this time frame may result in UnitedHealthcare holding the medical group/IPA financially responsible for the OOA care and service.
  • Once a UnitedHealthcare member’s PCP or medical group/IPA identified specialist speaks with the OOA attending health care provider to determine the member’s stability for transport to an in-area facility, member’s PCP, or medical group/IPA identified specialist:
    • Determines the appropriate mode of transportation and obtains any required authorization.
    • Determines the appropriate level of care or facility for the member’s care and obtains any required authorization.
    • Arranges for a bed at the accepting in-area facility.
  • If the member is found stable for transfer to an in-area facility, the medical group/IPA must collaborate with the health plan to return the member to a network provider and facility in a timely fashion.
  • The medical group/IPA facilitates the return of the member to a network provider by making sure the following process occurs in a timely fashion:
    • The medical group is responsible for transfer and care coordination planning with the out-of-network provider to an in- network provider, as medically appropriate, as soon as the medical group is aware of the OOA admission.
    • If the medical group/IPA delays the transfer of a member considered medically stable for transfer to move, we may hold the medical group/IPA financially responsible for any OOA charges incurred as a result of the delay.
    • Ambulance transportation from OOA facility to in-area location.
    • If an accident or illness occurs within the medical group/IPA contracted service area, and emergency personnel transport the member to a facility outside the contracted service area for treatment, such services are not considered OOA and are handled by the medical group/IPA in the same manner as in-area services. The medical group/IPA must authorize and direct the member’s care as if the member were receiving services at the affiliated facility or health care provider facility.

Travel dialysis is not considered an OOA medical service unless contractually defined. Refer to your Division of Financial Responsibility (DOFR) to determine if the medical group/IPA is responsible for travel dialysis.

The delegated medical group/IPA is responsible for authorizing and arranging medically necessary services. If the DOFR assigns risk for injectable medications to a medical group/IPA, the medical group/IPA authorizes and pays for all injectable medications, whether self-injected or given with the aid of a health professional in the home.

Trauma services are medically necessary, covered services rendered at a state-licensed, designated trauma facility or a facility designated to receive trauma cases. Trauma services must meet county, state and/or federal regulatory requirements as applicable.

The medical group/IPA reviews and authorizes trauma services using the applicable provision review criteria.

Optum serves as our transplant network. For medical groups/IPAs that have risk for transplant services, notify the Optum case management department when a member is referred for evaluation, authorized for transplant and admitted for transplant and/or may meet criteria for service denial. Medical groups/IPAs that do not have risk for transplant services must refer members into Optum transplant case management program who have been identified as:

  • Requiring evaluation for a bone marrow/stem cell, including chimeric antigen receptor T-cell (CAR-T) therapy in certain hematologic malignancies or solid organ transplant.
  • Undergoing a transplant evaluation.
  • Receiving a transplant.
  • Receiving post-transplant care within the first year following the transplant.

You may submit referrals to Optum by:

  • Phone: 1-888-936-7246
  • Fax (Commercial): 1-855-250-8157
  • Fax (Medicare): 1-855-250-7278
  • Fax (Medicare Secure Horizon only): 1-888-361-0502

For UnitedHealthcare West members, you may submit referrals to Optum by:

  • Phone: 1-866-300-7736
  • Fax: 1-888-361-0502

The transplant case manager works with the member’s transplant team, PCP, and other clinicians to assess the member’s health care needs, develop, implement, and monitor a care plan. They also coordinate services and re-evaluate the member’s care plan.

  • Get prior authorization for transplant evaluations and transplant surgery, regardless of financial risk.
  • Transplant evaluations and surgery must be performed at one of Optum Centers of Excellence or a facility approved by UnitedHealthcare/Optum medical directors.
  • For medical groups/IPAs who do not have risk for transplant services, Optum handles the authorization and management for all transplant-related care and services. This includes the evaluation, transplant procedure, and 1 year post-transplant unless dictated by the member’s benefit or federal/state law.
  • Optum oversees the authorization and management of donor care and services related to transplants. This starts from the date of stem cell/bone marrow collection or 24 hours prior to organ donation surgery. It ends 60 calendar days after the transplant or as member’s benefit plan or state law dictates.
  • Optum manages authorization and reimbursement of all travel expenses per the member’s benefit plan. If the medical group/ IPA has financial risk for transplants, they need to authorize and reimburse all travel expenses per the member’s benefit plan in the same manner as Optum.
  • Authorization and management of all non-transplant related services (e.g., medically necessary, covered services for the member) is the delegated medical group/IPA’s responsibility. Non-transplant related services include those services needed to treat the member’s underlying disease and maintain the member until transplant can be completed (e.g., ventricular assist devices or mechanical circulatory support devices). Financial responsibility for non-transplant related, medically necessary covered services remain as described in the DOFR.
  • Medical groups/IPAs must comply with our transplant protocols, policies and procedures. We may modify these protocols, policies and procedures from time to time.

Notify the case management department when you refer a member for evaluation for VAD/MCSD and admit a member for VAD/ MCSD.

Perform VAD/MCSD evaluations and surgery at a facility in Optum VAD Network, or a facility approved by our medical directors, to align with heart transplant service centers.

 

Members have the right to second opinions. The delegate provides a second opinion when either the member or a qualified health care professional requests it. Qualified health care professionals must provide the member with second opinions at no cost. We also allow a third opinion.

When a member meets the following criteria, they may be authorized to receive a second opinion consultation from an appropriately qualified health care professional:

  • The member questions the reasonableness or necessity of a recommended surgical procedure.
  • The member questions a diagnosis or treatment plan for a condition that threatens loss of life, limb, bodily function, or substantial impairment (including a serious chronic condition).
  • The clinical indications are not clear or are complex and confusing.
  • A diagnosis is in doubt due to conflicting test results.
  • The treating health care provider cannot diagnose the condition.
  • The member’s clinical condition is not responding to the prescribed treatment within a reasonable period of time given the condition, and the member is requesting a second opinion.
  • The member attempted to follow the treatment plan or consulted with the initial health care provider and still has serious concerns about the diagnosis or treatment plan.

PCP second opinions

When the PCP is affiliated with a delegated medical group/IPA, and the member requests a second opinion based on care received from that PCP, the medical group/IPA is responsible for authorizing and paying for the second opinion. If delegated for claims, the medical group/IPA is responsible for claims payment.

A second opinion regarding primary care is provided by an appropriately qualified health professional of the member’s choice from within the medical group/IPA group’s network of health care providers.

  • California regulations allow SignatureValue HMO members to obtain second and third opinions from out-of-network providers. The delegate sends to UnitedHealthcare all requests for second and third opinions from health care providers not participating in the delegate’s network.

If the request for a second medical opinion is denied, the medical group/IPA tells the member in writing and provides the reasons for the denial. The member may appeal the denial. If the member gets a second medical opinion without prior authorization from the delegate and/or UnitedHealthcare, the member is financially responsible for the cost of the opinion.

When the PCP is not affiliated with any participating medical group/IPA but is independently contracted with us, the member may request a second opinion from a health care provider or specialist listed in our health care provider directory on uhcprovider.com/findprovider.

The approved health care provider documents the second medical opinion in a consultation report, which they will make available to the member and the treating participating health care provider. The second opinion health care provider reports any recommended procedures or tests they believe are appropriate. If this second medical opinion includes a recommendation for a particular treatment, diagnostic test or service covered by UnitedHealthcare, and the delegate or UnitedHealthcare (as appropriate) determines if the recommendation is medically necessary, then the delegate or UnitedHealthcare arranges the treatment, diagnostic test or service.

Note: Although a second opinion may recommend a particular treatment, diagnostic test or service, this does not mean the recommended action is medically necessary or covered. The member is responsible for paying any applicable cost- sharing amount to the health care provider who gives the second medical opinion.

Specialist care second opinions

The member has the right to request a second opinion consultation based on care received through an authorized referral to a specialist within the medical group/IPA network.

The second opinion may be provided by any practitioner of the member’s choice from any medical group/IPA within the UnitedHealthcare network provider of the same or equivalent specialty.

  • MA members: Second and third opinions, whenever possible, should be provided in-network. The delegate or we consider authorizing health care providers outside of the delegate’s network if there is no available or appropriate network provider.
  • California regulations allow commercial HMO members to obtain second and third opinions from out-of-network providers. The delegate sends to UnitedHealthcare all requests for second and third opinions from health care providers not participating in the delegate’s network.

If the health care professional is part of the member’s assigned medical group/IPA, the medical group/IPA authorizes the second opinion consultation. The medical group/IPA is also responsible to pay claims if it is delegated for claims.

If approved, we pay the claim for the non-participating health care professional’s second opinion consultation.

A second opinion consists of 1 office visit for a consultation or evaluation only. The health care provider’s opinion is included in a consultation report after completing the examination. The member must return to their assigned medical group/IPA for all follow-up care and authorizations.

If a second opinion consultation differs from the initial opinion, coverage for a third opinion must be provided if requested by the member or health care provider, following the same process as for second opinions.

If the request for a second medical opinion is denied, the medical group/IPA tells the member in writing and provides the reasons for the denial. The member may appeal the denial.

Turnaround time for second or third opinions

We process requests for second opinions in a timely manner to support the clinical urgency of the member’s condition. We follow established utilization management procedures and regulatory requirements. When a member’s health is seriously threatened, we (or the delegate) make the second opinion decision within 72 hours after receipt of the request. An imminent and serious threat includes the potential loss of life, limb, or other major bodily function. It can also exist when a delay would be detrimental to the member’s ability to regain maximum function.

Experimental items and medications have limited coverage. We do not delegate coverage determinations for experimental/ investigational services or clinical trials.

For capitated providers, the member’s health care provider is responsible for these tests, unless stated differently in your contract.

We only cover experimental/investigational services when they meet Medicare requirements. Do not authorize or deny services.

Contact:

Cancer Resource Services

Commercial:

  • Phone: 1-866-534-7209 x 38303
  • Fax: 1-855-250-2102

Medicare Advantage:

  • Phone: 1-877-842-3210

Transplant Resource Services (Commercial and Medicare Advantage):

  • Phone: 1-888-936-7246
  • Fax: 1-855-250-8157

For all other clinical trials, contact the prior authorization department at 1-877-842-3210 or visit uhcprovider.com/paan.

Delegates on the NICE platform may also visit uhcprovider.com to submit carve-out services in the UnitedHealthcare Provider Portal as a prior authorization submission, outlining commercial clinical trials request.

 

 

 

Looking for more information on clinical trials?

You can find additional information and requirements in the Clinical trials, experimental or investigational services section in Chapter 7: Medical Management, and on uhcprovider.com > Policies and Protocols > Medicare Advantage Policies > Coverage Summaries for Medicare Advantage Plans > Experimental Procedures and Items, Investigational Devices and Clinical Trials.

For certain radiation therapy services, such as intensity modulated radiation therapy (IMRT), proton beam therapy (PBT), stereotactic body radiation therapy (SBRT) and Yttrirum 90/Selective Internal Radiation Therapy (SIRT), prior authorization is required. For certain commercial plans, Image Guided Radiation Therapy (IGRT), Special Services and Fractionation also requires prior authorization. Use the Prior Authorization and Notification tool at uhcprovider.com/paan. You may also initiate your request by calling the number on the back of the member’s ID card.

Prior authorization staff will not process the request or make a decision until they receive all necessary information from the medical group/IPA. They make a decision and contact the medical group/IPA within the applicable time frame.


We authorize radiation therapy services following the member’s benefit design, provided the member has not exceeded their benefit restrictions.

Looking for more information on radiation therapy?

Go to:

1.  Go to the UnitedHealthcare Provider Portal by clicking the Sign In button in the top right corner of uhcprovider.com.

  • Go to Prior Authorization and Notification and select the Submission and Status link under the Radiology, Cardiology and Radiation Oncology section.
  • Select service type “Radiation Oncology.”

2.  uhcprovider.com/policies > Commercial Policies > Reimbursement Policies or Medical & Drug Policies and Coverage Determination Guidelines for UnitedHealthcare Commercial Plans.