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January 1, 2022 at 12:00 AM CT

Applicable to all states except NC.

Mid-Atlantic regional supplement- 2022 UnitedHealthcare Administrative Guide

Applicability of this supplement

This Mid-Atlantic Regional supplement applies to services provided to members enrolled in:

  • MD-Individual Practice Association, Inc. (“M.D.IPA”) and M.D.IPA Preferred.
  • Optimum Choice, Inc. (“Optimum Choice”), and Optimum Choice Preferred, and Optimum Choice Small Business Health Options Program (SHOP).

It may apply to health care providers in Delaware, Washington, D.C., Maryland, Pennsylvania, Virginia and West Virginia; reference your Agreement for applicability.

Health care providers are subject to both the main guide and this supplement. This supplement controls if it conflicts with information in the main guide. For protocols, policies and procedures not referenced in this supplement refer to appropriate chapter in the main guide.

Mid-Atlantic Protocols

A complete list of Mid-Atlantic Health plan protocols pertaining to M.D.IPA, M.D.IPA Preferred, Optimum Choice, and Optimum Choice Preferred may be located on uhcprovider.com/plans > Choose Your State.

The term “prior authorization” referenced in this supplement is also referred to as “preauthorization.” We use both terms in this supplement. They mean the same.

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This table provides information about M.D.IPA and Optimum Choice products for the Mid-Atlantic Region.

Attributes M.D.IPA and Optimum Choice M.D.IPA Preferred and Optimum Choice Preferred

How do members access physician and health care professionals?

Members choose a PCP who arranges or coordinates their care, except emergency services, network OB/GYN, routine eye refraction care, and behavioral health care services.

Network benefits: Members choose a PCP who arranges or coordinates care, with the exception of emergency services, network OB/GYN, routine eye refraction care, and behavioral health care services.

Out-of-network benefits: Members are not required to have care arranged or coordinated by a PCP.

Does a PCP have to write a referral to a specialist? Yes; except for visits to a network OB/GYN, routine eye refraction care, emergency services, and behavioral health care services.

Network benefits: Yes, except for visits to a network OB/GYN, routine eye refraction care, emergency services, and behavioral health care services.

Out-of-network benefits: No referral needed.

Is the treating physician required to obtain prior authorization for procedures or services? Yes; view the section on Prior Authorizations process located within this supplement. Find a complete list of codes requiring prior authorization on uhcprovider.com/priorauth > Advance Notification and Plan Requirement Resources > UnitedHealthcare Mid-Atlantic Plan Notification/Prior Authorization Requirements. Yes; view the section on  Prior Authorizations process located within this supplement. Find a complete list of codes requiring prior authorization on uhcprovider.com/priorauth > Advance Notification and Plan Requirement Resources > UnitedHealthcare Mid-Atlantic Plan Notification/Prior Authorization Requirements.

For more information, refer to Chapter 4: Individual Exchange Plans.

Key Points Optimum Choice SHOP Exchange
Product Name Optimum Choice, Inc.
How do members access physicians and health care professionals? For each covered family member, members choose a network PCP, or are assigned a PCP, to manage the member’s care and generate referrals to network specialists when required.
Is a special referral required? Yes, on selected procedures. See guidelines in the referral requirements section of Mid-Atlantic Supplement.
Are treating physicians and/or facilities required to request prior authorization when providing certain services? Yes, on selected procedures. See guidelines in the Prior Authorization List located on uhcprovider.com/priorauth.

The Optimum Choice and Optimum Choice Preferred HSA benefit plans are high-deductible medical benefit plans that combine our traditional gated HMO benefit plans with an HSA option. Expenses under this benefit plan are the member’s responsibility until their deductible is reached. HSA benefit plans require reimbursement for services provided to members are based on a fee-for-service reimbursement methodology.

Key Points Optimum Choice, Inc. Health Savings Account
PCP requirement The Optimum Choice HSA product requires each UnitedHealthcare member to choose a PCP.
PCP referrals to network specialists The member’s PCP generates referrals for specialty care and facility care.
Reimbursement Services for members enrolled in Optimum Choice HSA are excluded from your capitation payment and are paid on a fee-for-service (FFS) basis per the All Payer Payment Appendix included in the UnitedHealthcare physician Agreement..
Optimum Choice HSA member health plan ID card? The Optimum Choice HSA product name and member’s PCP are indicated on the member’s ID card. Specialist referral requirements are on the back of the ID card. Check Eligibility and Benefits in the UnitedHealthcare Provider Portal.