Health care provider responsibilities, UnitedHealthcare West - 2022 UnitedHealthcare Administrative Guide
Electronic Data Interchange
The fastest way for us to talk is electronically. Electronic Data Interchange (EDI) is the preferred method for doing business transactions. Find more information on uhcprovider.com/edi.
The issues of confidentiality and objective medical observations are the key in the diagnosis and treatment of our members. Therefore, a care provider or other licensed independent health care professional who is also a UnitedHealthcare member shall not serve as PCP for themselves or their dependents.
You are responsible for checking member eligibility within 2 business days prior to the date of service. You may be eligible for reimbursement under the Authorization Guarantee program described in the Capitation and/or Delegation Supplement for authorized services if you have checked and confirmed the member’s eligibility within 2 business days before the date of service.
You must verify the member’s eligibility each time they receive services from you. We provide several ways to verify eligibility:
Get more details regarding a specific member’s benefit plan in the member’s Combined Evidence of Coverage and Disclosure Form, Evidence of Coverage, or Certificate of Coverage. Benefit plans may be addressed in procedures/protocols communicated by us. Details may include the following:
Selection of a PCP
Effective date of coverage
Changes in membership status while a member is in a hospital or skilled nursing facility (SNF)
Removal of member from receiving services by a PCP
Health Plan Identification (ID) Cards
Each member receives a health plan ID card with information to help you submit claims accurately. Information may vary in appearance or location on the card due to payer or other unique requirements. You can view and download current member ID cards when you verify eligibility and benefits in the UnitedHealthcare Provider Portal.
Services Provided to Ineligible Members (does not apply in CA)
If we provide eligibility confirmation indicating that a member is eligible at the time the health care services are provided, and it is later determined that the patient was not eligible, we are not responsible for payment of services provided to the member, except as otherwise required by state and/or federal law. In such event, you are entitled to collect the payment directly from the member (to the extent permitted by law) or from any other source of payment.
We reimburse Texas health care providers who request a guarantee of payment through the verification process. The verification is based on the Agreement and the guidelines in Texas Senate Bill SB 418.
We will guarantee payment for proposed medical care or health care services if you provide the services to the member within the required time frame. We reduce the payment by any applicable copayments, coinsurance and/or deductibles.
You must include the unique UnitedHealthcare West verification number on the claim form (Field 23 of CMS 1500 or Field 63 of UB-04).
You must request eligibility prior to rendering a service. Otherwise, we are not responsible for payment of those services. You are entitled to collect the payment directly from the member to the extent permitted by law or from any other source of payment.
Submit service verification requests to:
• Phone: 1-877-847-2862
• Mail: Care Provider Correspondence
P.O. Box 30975
Salt Lake City, UT 84130-0975
Access and availability: Standards and exceptions
We monitor members’ access to medical and behavioral health care to make sure that we have an adequate health care provider network to meet the members’ health care needs. We use member satisfaction surveys and other feedback to assess performance against standards.
Health plans in California must conduct an annual Provider Appointment and Availability Survey. The overall plan results are available at myuhc.com.
We have established access standards for appointments and after-hours care. Exceptions or additions to those standards are shown in the following table.
Exceptions: California Commercial HMO: Members are offered appointments for non-urgent PCP within 10 business days of request, within 15 business days for non-urgent specialist request;
Texas: Within 3 weeks for medical conditions.
Our members must have access to all physicians and support staff who work for you and must not be limited to particular physicians. We recognize that some substitution between physicians who work out of the same office/building may occur due to urgent/emergent situations.
Members must have access to appointments during all normal office hours and not be limited to appointments on certain days or during certain hours.
Members must have access to the same time slots as all other patients who are not our members.
You must work cooperatively with our Medical Management Department toward:
Managing inpatient and outpatient utilization.
Member care and member satisfaction.
Use your best efforts to refer members to our network care providers. You must use only our network laboratory and radiology care providers unless specifically authorized by us.
Timely Access to Non-Emergency Health Care Services (Applies to Commercial in California)
Compliance with the Medical Management Program includes:
Allowing our staff to have onsite access to members and their families while the member is an inpatient.
Allowing our staff to participate in individual case conferences.
Facilitating the availability and accessibility of key personnel for case reviews and discussions with the medical director or designee representing UnitedHealthcare West, upon request.
Providing appropriate services in a timely manner.
Benefit Interpretation Policies and Medical Management Guidelines
A complete library of Benefit Interpretation Policies (BIPs), and Medical Management Guidelines (MMGs) is available on uhcprovider.com/policies > Commercial Policies> UnitedHealthcare West Benefit Interpretation Policies or UnitedHealthcare West Medical Management Guidelines.
We publish monthly editions of the BIP and MMG Update Bulletins. These online resources provide notice to our network providers of changes to our BIPs and MMGs. The bulletins are posted on the first calendar day of every month on:
Examples of an active course of treatment or condition considered for continuity of care
An acute condition is a medical condition that involves a sudden onset of symptoms due to an illness, injury or other medical problem that requires prompt medical attention and that has a limited duration. Completion of covered services provided for the duration of the acute condition.
A serious chronic condition is a medical condition due to disease, illness, medical problem, mental health problem, or medical or mental health disorder that is serious in nature, persists without full cure, worsens over an extended period of time, or requires ongoing treatment to maintain remission or prevent deterioration. Completion of covered services provided for the period necessary to complete the active course of treatment and to arrange for a clinically safe transfer to a network provider. The active course of treatment is determined by a UnitedHealthcare West or medical group/IPA medical director in consultation with the member, the terminated health care provider or the non-network provider and as applicable, the receiving network provider, consistent with good professional practice. Completion of covered services for this condition will not exceed 12 months from the Agreement’s termination date, or 12 months after the effective date of coverage for a newly enrolled member.
A terminal illness is an incurable or irreversible condition that has a high probability of causing death within 1 year. Completion of covered services may be provided for the duration of the terminal illness, which could exceed 12 months, provided that the prognosis of death was made by the: (i) terminated health care provider prior to the Agreement termination date, or (ii) non-network provider prior to the newly enrolled member’s effective date of coverage with UnitedHealthcare West.
A pregnancy diagnosed and documented (i) by the terminated health care provider prior to termination of the Agreement, or (ii) by the non-network provider prior to the newly enrolled member’s effective date of coverage with UnitedHealthcare West. Completion of covered services provided for the duration of the pregnancy and immediate postpartum period.
The care of a newborn service provided to a child between birth and age 36 months. Completion of covered services will not exceed the earliest of: (i) 12 months from Agreement, termination date, (ii) 12 months from the newly enrolled member’s effective date of coverage with UnitedHealthcare West, or (iii) the child’s third birthday.
Surgery or other procedure Performance of a surgery or other procedure that was authorized by UnitedHealthcare West or the member’s PCP. Parts of a documented course of treatment have been recommended and documented by (i) the terminating health care provider to occur within 180 calendar days of the Agreement’s termination date, or (ii) the non-network provider to occur within 180 calendar days of the newly enrolled member’s effective date of coverage with UnitedHealthcare West.
Continuity of care does not apply when a member initiates a change of PCP or medical group/IPA. Authorizations granted by the previous medical group shall be invalid in such situations at the commencement of the member’s assignment to the new PCP or medical group/IPA; members shall not be entitled to continuing care unless the member’s new PCP or medical group/ IPA authorizes that care.
Virtual Visits (commercial HMO plans CA only)
UnitedHealthcare of California added a new benefit for Virtual Visits to some member benefit plans. We define Virtual Visits as primary care services that include the diagnosis and treatment of low-acuity medical conditions for members through the use of interactive audio and video telecommunication and transmissions, and audio-visual communication technology.
Virtual Visit primary care services are typically delivered by the capitated provider groups. Not all UnitedHealthcare West benefit plans will have the Virtual Visit benefit option.