Abuse: Actions that may, directly or indirectly, result in unnecessary costs to the health insurance plan, improper payment, payment for services that fail to meet professionally recognized standards of care, or medically unnecessary services. Abuse involves payment for items or services when there is no legal entitlement to that payment and the provider has not knowingly and/or intentionally misrepresented facts to obtain payment. Abuse cannot be differentiated categorically from fraud because the distinction between “fraud” and “abuse” depends on specific facts and circumstances, intent and prior knowledge, and available evidence, among other factors.
Accreditation: A process that a health care provider goes through to be recognized for meeting certain standards such as quality.
Acute Inpatient Care: Care provided to persons sufficiently ill or disabled requiring:
Constant availability of medical supervision by attending provider or other medical staff.
Constant availability of licensed nursing personnel.
Availability of other diagnostic or therapeutic services and equipment available only in a hospital setting to help ensure proper medical management by the health care provider.
Adjudication: The process of determining the proper payment amount on a claim.
Ambulatory Care: Health services provided on an outpatient basis. While many inpatients may be ambulatory, the term “ambulatory care” usually implies that the patient has come to a location other than their home to receive services and has departed the same day. Examples include chemotherapy and physical therapy.
Appeal: An oral or written request by a member or member’s personal representative received by UnitedHealthcare for review of an adverse action.
Authorization: Approval obtained by health care providers from UnitedHealthcare for a designated service before the service is rendered. Used interchangeably with preauthorization or prior authorization.
Authorized Health Care Provider: A health care provider who meets UnitedHealthcare’s licensing and certification requirements and has been authorized by UnitedHealthcare to provide services.
Benefit: The amount of money UnitedHealthcare pays for care and other services.
Capitation: Per-person way of payment for medical services. UnitedHealthcare pays a participating capitated provider a fixed amount for every member they care for, regardless of the care provided.
Claim: The documentation of the services that have occurred during the course of a visit to a health care provider.
Clinical Laboratory Improvement Amendments of 1988 (CLIA): United States federal regulatory standards that apply to all clinical laboratory testing performed on humans in the United States, except clinical trials and basic research.
Clean Claim: A claim that has no defect, impropriety (including lack of any required substantiating documentation) or particular circumstance requiring special treatment that prevents timely payment.
Centers for Medicare & Medicaid Services (CMS): A federal agency within the U.S. Department of Health and Human Services.
Coordination of Benefits (COB): Allows benefit plans that provide health and/or prescription coverage for a person with Medicare to determine their respective payment responsibilities (i.e., determine which insurance benefit plan has the primary payment responsibility and the extent to which the other benefit plans will contribute when an individual is covered by more than 1 benefit plan).
Coinsurance: The member’s share of the costs of a covered health care service, calculated as a percent (for example, 20%) of the allowed amount for the service. Members may pay coinsurance plus any deductibles owed.
Commercial: Refers to all UnitedHealthcare medical products that are not Medicare Advantage, Medicare Supplement, Medicaid, CHIP, workers’ compensation, TRICARE, or other governmental programs (except that “Commercial” also applies to benefit plans for the Health Insurance Marketplace, government employees or students at public universities).
Copayment: A fixed amount members may pay for a covered health care service, usually upon receiving the service.
Covered Services: Medically necessary services included in the member’s benefit plan. Covered services change periodically and may be mandated by federal or state legislation.
Credentialing: The verification of applicable licenses, certifications and experience to assure that provider status is extended only to professional, competent providers who continually meet the qualifications, standards and requirements established by UnitedHealthcare.
Current Procedural Terminology (CPT) Codes: American Medical Association (AMA)-approved standard coding for billing of procedural services performed.
Deductible: The amount a member owes for health care services the health insurance or benefit plan covers before the health insurance or benefit plan begins to pay.
Delivery System: The mechanism by which health care is delivered to a patient. Examples include, but are not limited to, health care facilities, health care provider offices and home health care.
Dependent: A child, disabled adult or spouse covered by the health benefit plan.
Discharge Planning: Process of screening eligible candidates for continuing care following treatment in an acute care facility, and assisting in planning, scheduling and arranging for that care.
Disease Management: A prospective, disease-specific approach to improving health care outcomes by providing education to members through non-physician.
Disenrollment: The discontinuance of a member’s eligibility to receive covered services from a contractor.
Dual-Eligibles: Members who qualify for both Medicare and Medicaid.
Durable Medical Equipment (DME): Medical equipment that is all of the following:
Ordered or provided by a physician for outpatient use primarily in a home setting
Used for medical purposes
Not consumable or disposable except as needed for the effective use of covered DME
Not of use to a person in the absence of a disease or disability
Serves a medical purpose for the treatment of a sickness or injury
Primarily used within the home
Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS): In November 2006, the Centers for Medicare & Medicaid Services (CMS) approved 10 national accreditation organizations that will accredit suppliers of DMEPOS as meeting new quality standards under Medicare Part B.
Electronic Data Interchange (EDI): The electronic exchange of information between 2 or more organizations.
Electronic Funds Transfer (EFT): The electronic exchange of funds between 2 or more organizations.
Electronic Medical Record (EMR): The electronic version of a member’s health records.
Emergency Care: The provision of medically necessary services required for immediate attention to evaluate or stabilize a medical emergency (see definition to follow).
Employee Retirement Income Security Act of 1974 (ERISA): A federal law that sets minimum standards for most voluntarily established pension and health benefit plans in private industry to provide protection for individuals in these benefit plans.
Encounter: An interaction between a patient and health care providers, for the purpose of provider health care services or assessing the health status of a patient.
Expedited Appeal: An oral or written request by a member or member’s personal representative received by UnitedHealthcare requesting an expedited reconsideration of an action when taking the time for a standard resolution could seriously jeopardize the member’s life, health or ability to attain, maintain or regain maximum function; or would subject the member to severe pain that cannot be adequately managed without the care or treatment that is the subject of the appeal.
Fee for Service: Health care providers are paid for each service (like an office visit, test or procedure).
Fraud: Health care fraud is a crime that involves misrepresenting information, concealing information or deceiving a person or entity to receive benefits, or to make a financial profit (18 U.S.C.§1347).
Grievance: An oral or written expression of dissatisfaction by a member, or representative on behalf of a member, about any matter other than an adverse action.
Health Care Provider: A person who provides medical or other health care (doctor, nurse, therapist or social worker) or office support staff. A health care provider may be a doctor practicing alone, in a hospital setting or in a group practice. A health care provider could work from a remote location, in a public space or any combination of locations.
Health Insurance Portability and Accountability Act (HIPAA) Act of 1996: A federal legislation that provides data privacy and security provisions for safeguarding medical information.
Health Plan Employer Data and Information Set (HEDIS): Set of standardized measures developed by National Committee for Quality Assurance (NCQA). Originally HEDIS was designed to address private employers’ needs as purchasers of health care. It has since been adapted for use by public purchasers, regulators and consumers. HEDIS is used for quality improvement activities, health management systems, provider profiling efforts, an element of NCQA accreditation and as a basis of consumer report cards for managed care organizations.
Home Health Care or Home Health Services: Medical care services provided in the home, often by a visiting nurse, usually for recovering patients, aged homebound patients or patients with a chronic disease or disability.
Managed Care: A system designed to better manage the cost and quality of medical services. Managed care products not only offer less member liability but also less member control. Managed care aims to improve accessibility to health care, reduce cost and improve quality of service. Many managed care health insurance programs work with Health Maintenance Organization (HMO) and Preferred Provider Organization (PPO) boards to promote use of specific health treatment procedures. Managed care health insurance benefit plans also educate and work with consumers to improve overall health by addressing disease prevention. The common types of managed care products are HMO, PPO and Point of Service (POS) benefit plans.
Medical Emergency: A medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) that a prudent layperson, who possesses an average knowledge of health and medicine, could reasonably expect the absence of immediate medical attention to result in the following:
Placing the health of the individual (or, with respect to a pregnant woman, the health of the woman or her unborn child) in serious jeopardy.
Serious impairment to bodily functions.
Serious dysfunction of any bodily organ or part.
Medically Necessary: To determine medical necessity, we use generally accepted standards of medical practice, based on credible scientific evidence published in peer-reviewed medical literature and generally recognized by the relevant medical community. We may also use standards based on physician specialty recommendations, professional standards of care and other evidence-based, industry-recognized resources and guidelines, such as InterQual® Care Guidelines.
For Medicare Advantage and Medicaid members, we use Medicare guidelines, including National Coverage Determinations and Local Coverage Determinations, to determine medical necessity of services requested.
If other nationally recognized criteria contradict InterQual, UnitedHealthcare and delegated medical group/IPAs follow the Medicare guidelines for Medicare Advantage members. Individual criteria is provided to you upon request.
Member: Refers to an individual who has been determined UnitedHealthcare-eligible and is enrolled with UnitedHealthcare to receive services pursuant to the Agreement. Other common industry terms: customer, patient, beneficiary, insured, enrollee, subscriber, dependent.
National Provider Identification (NPI): NPI is a unique 10-digit identification number issued to health care providers in the United States by CMS.
Network provider: A professional or institutional health care provider who has an Agreement with UnitedHealthcare member’s plan to provide care at a contracted rate. A network provider agrees to file claims and handle other paperwork for UnitedHealthcare member. A network provider accepts the negotiated rate as payment in full for services rendered.
Non-Network Provider: A non-network provider does not have an Agreement with UnitedHealthcare but is certified to provide care to UnitedHealthcare members. There are 2 types of non-network providers: non-participating and participating.
Non-participating health care provider: A non- participating health care provider is a UnitedHealthcare- authorized hospital, institutional provider, physician or other provider that furnishes medical services (or supplies) to UnitedHealthcare members but who does not have an Agreement and does not accept the UnitedHealthcare allowable charge or file claims for UnitedHealthcare members. A non-participating health care provider may only charge up to 15% above the UnitedHealthcare allowable charge.
Participating health care provider: A health care provider who has agreed to file claims for UnitedHealthcare members, accept payment directly from UnitedHealthcare, and accept the UnitedHealthcare allowable charge as payment in full for services received. Non-network providers may participate on a claim-by-claim basis. Participating health care providers may seek payment of applicable copayments, cost-shares and deductibles from the member. Under the UnitedHealthcare outpatient prospective payment system, all Medicare participating health care providers and hospitals must, by law, also participate in UnitedHealthcare for inpatient and outpatient care.
Nurse Practitioner: A registered nurse who has graduated from a program which prepares registered nurses for advanced or extended practice and who is certified as a nurse practitioner by the American Nursing Association.
Optum: A UnitedHealth GroupTM health services and innovation company that designs and implements custom information technology systems, and offers management consulting, in the health care industry nationwide. Optum offers behavioral health care programs including integrated behavioral and medical programs, depression management, employee assistance, work/life management, disability support and pharmacy management programs.
Out-of-Area Care: Care received by a UnitedHealthcare member when they are outside of their geographic territory.
Password Owners: Individuals at a health care provider’s organization who set up and maintain co-workers’ access to our health care provider websites, the UnitedHealthcare Provider Portal and uhcprovider.com.
Physician Assistant: A health care professional licensed to practice medicine with physician supervision. Physician assistants are trained in intensive education programs accredited by the Commission on Accreditation of Allied Health Education Programs.
Policy: A contract between the insurer and the insured, known as the policyholder, which determines the claims the insurer is legally required to pay.
Primary Care Provider (PCP): A physician such as a family practitioner, pediatrician, internist, general practitioner or obstetrician, who serves as a gatekeeper for their assigned members’ care. Other providers may be included as primary physicians such as nurse practitioners and physician assistants as allowed by state mandates.
Pre-Service Appeals: A pre-service appeal is a request to change a denial of coverage for a planned health care service. The member’s rights in the member’s benefit plan govern this process.
Primary Care Team: A team comprised of a care manager, a PCP, and a Nurse Practitioner or Physician Assistant.
Prior Authorization and Notification: A unit under the direction of the UnitedHealthcare Clinical Services Department that is an essential component of any managed care organization. Prior authorization is the process where health care providers seek approval prior to rendering services as required by UnitedHealthcare policy.
Provider Group: A partnership, association, corporation or other group of providers.
Provider Manual: This document is referred to as a health care provider manual or guide. It may also be referred to as the provider administrative guide or handbook.
Qualified Medicare Beneficiary (QMB): A Medicaid program for beneficiaries who need help paying for Medicare services.
Quality Management (QM): A methodology used by professional health personnel to the degree of conformance to desired medical standards and practices; and activities designed to improve and maintain quality service and care, performed through a formal program with involvement of multiple organizational components and committees.
Reinsurance: The contract made between an insurance company and a third party to protect the insurance company from losses.
Secondary Payer: A source of coverage that pays after the primary insurance benefit has been applied.
Self-Funded Plan: Self-funded health care, also known as Administrative Services Only (ASO), is a self-insurance arrangement whereby an employer provides health or disability benefits to employees with its own funds.
Self-Insured: A self-insured group health benefit plan is one in which the employer assumes the financial risk for providing health care benefits to its employees.
Service Area: A geographic area serviced by a UnitedHealthcare contracted provider, as stated in the health care provider’s Agreement with us.
Skilled Nursing Facility: A Medicare-certified nursing facility that (a) provides skilled nursing services and (b) is licensed and operated as required by applicable law.
Subrogation: A health plan’s right, to the extent permitted under applicable state and federal law and the applicable benefit plan, to recover benefits paid for a member’s health care services when a third party causes the member’s injury or illness.
Subscriber: Person who owns an insurance policy.
Supplemental Benefits: Supplemental insurance includes health benefit plans specifically designed to supplement UnitedHealthcare standard benefits.
Third-Party Administrator (TPA): An organization that provides or manages benefits, claims or other services, but it does not carry any insurance risk.
Transitional Care: A program that is designed for members to help ensure a coordinated approach takes place across the continuum of care.
UnitedHealthcare Assisted Living Plan: A Medicare Advantage Institutional-Equivalent Special Needs Plan that:
Exclusively enrolls special needs individuals who are living in a contracted assisted living facility, have Medicare A and B and meet the local state’s criteria for “institutional level of care.”
Is issued by UnitedHealthcare Insurance Company or by one of UnitedHealthcare’s affiliates.
Is offered through our UnitedHealthcare Medicare Advantage business unit, as indicated by a reference to assisted living plan name listed on the face of the valid member ID card.
UnitedHealthcare Nursing Home Plan: A Medicare Advantage Institutional Special Needs Plan that:
Exclusively enrolls special needs individuals who, for 90 calendar days or longer, have had or are expected to need the level of service requiring an institutional level of care (as defined in 42 CFR 422.2).
Is issued by UnitedHealthcare Insurance Company or by one of UnitedHealthcare’s affiliates.
Is offered through our UnitedHealthcare Medicare Advantage business unit, as indicated by a reference to Nursing Home Plan or Erickson Advantage Guardian in the benefit plan name listed on the face of the valid member ID card.
Us: “Us,” “we” or “our” refers to UnitedHealthcare on behalf of itself and its other affiliates for those products and services subject to this guide.
Utilization Management (UM): The process of evaluating and determining the coverage for and the appropriateness of medical care services, as well as providing assistance to a clinician or patient in cooperation with other parties, to help ensure appropriate use of resources. UM includes prior authorization, concurrent review, retrospective review, discharge planning and case management.
Waste: The overutilization of services, or other practices that, directly or indirectly, result in unnecessary costs to a health care benefit program. Waste is generally not considered to be caused by criminally negligent actions but rather misuse of resources.
Workers’ Compensation: Workers’ compensation is a form of insurance providing wage replacement and medical benefits to employees injured in the course of employment in exchange for mandatory relinquishment of the employee’s right to sue their employer for the tort of negligence.
You: “You,” “your” or “provider” refers to any health care provider subject to this guide, including physicians, health care professionals, facilities and ancillary providers; except when indicated all items are applicable to all types of providers subject to this guide.