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Laboratory services protocol - Chapter 9, 2022 UnitedHealthcare Administrative Guide

Clinical information submission

To comply with state and federal data collection and reporting requirements, we require clinical data from you. It helps us measure quality of care for our members. It helps us collaborate with you to address gaps in care. You must submit all clinical data including laboratory test results. Give us this data within 30 calendar days from the date of service or within the time specified by law.

When giving us clinical data, you must follow state and federal laws, and obtain prior consent to give us the clinical data when state or federal law requires it. We need to provide the source of the data to satisfy National Committee for Quality Assurance (NCQA) audits or other compliance requirements. You must confirm that the information given to us is accurate and complete.

We verify that security measures, protocols and practices are compliant with:

  • HIPAA regulations.
  • UnitedHealthcare data usage, governance and security policies.

We use the clinical data to:

  • Perform treatment.
  • Payment.
  • Follow state and federal law.
  • Health care operations, as defined in HIPAA. 

Health care operations may include:

  1. Compliance with state and federal data collection and reporting requirements, such as:
    • Healthcare Effectiveness Data and Information Set (HEDIS).
    • Consumer Assessment of Healthcare Providers and Systems (CAHPS).
    • Health Outcomes Survey (HOS).
    • NCQA accreditation.
    • Centers for Medicare and Medicaid Services (CMS) or Star Ratings.
    • CMS Hierarchical Condition Category Risk Adjustment System.
  2. Care coordination and other care management and quality improvement programs such as:
    • Physician performance.
    • Pharmaceutical safety.
    • Member health risks using predictive modeling and the subsequent development of disease management programs used by UnitedHealthcare.
    • Other member and health care provider health awareness programs.
  3. Quality assessment and benchmarking data sets.

We will work with you to help ensure all clinical data values are being transmitted effectively. This allows for lawful identification and use of the clinical data.

We define the HIPAA minimum necessary data requirements defined in specific documents related to the method of clinical data acquisition. The companion guides that contain these requirements are on uhcprovider.com/edi.

Self-referral and anti-kickback

This protocol applies to all participating physicians and health care professionals. It also applies to all laboratory services, clinical and anatomic, ordered by physicians and health care professionals.

We do not allow our health care providers to earn money from referring members to a lab. This includes profits from:

  • Investments in an entity where the referring health care provider generates business.
  • Profits from collection, processing and/or transporting of specimens.
  • Cost reductions such as:
    • Free Wi-Fi.
    • Free urine cups.

If you do not follow this rule, we may:

  • Decrease your fee schedule.
  • Terminate your network participation.
  • Prosecute.

Structured exchange of clinical data

Our protocols require electronic submission of lab results within 30 days of a lab test. This supports HEDIS closure rates and significantly reduces the burden of manual chart requests for our health care providers.

Health care providers are required to submit an expanded set of clinical data following a physician visit, as well as a discharge summary within 7 days of an inpatient discharge. Failure to comply with this clinical data exchange may result in penalties to your practice.

When you share this data with us electronically, we can:

  • Promote timely engagement between you and our members.
  • Reduce the administrative burden of manual information sharing.
  • Drive quality outcomes for you and our members by closing gaps and improving coordination of care.

To begin sharing the required information, visit uhcprovider.com/ediconnect to find the best solution for your practice. Health care providers have different data transfer capabilities, and we will work with you to find the best method of data transmission.