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 health care provider, use those who are in-network with the member’s benefit plan.
You must alert us if the covering health 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.
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|
|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 do one of the following:
When it is not an emergency, but the caller cannot wait until the next business day, advise them to do one of the following:
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.
You must have privileges at participating facilities or an arrangement with another participating health care provider to admit and offer facility services. This helps our members have access to appropriate care and lower their out-of-pocket costs.
Provide services in a culturally competent manner. This includes members with limited English proficiency, those with diverse backgrounds and/or disabilities.
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.