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Administrative Guides
Administrative Guides
2018 UnitedHealthcare Online Administrative Guide
2018 UnitedHealthcare Online Administrative Guide
Welcome to UnitedHealthcare 2018 Administrative Guide
Introduction - Chapter 1, 2018 UnitedHealthcare Administrative Guide
Introduction - Chapter 1, 2018 UnitedHealthcare Administrative Guide
Manuals and Benefit Plans Referenced in the Guide
Benefit Plans Subject to this Guide
Benefit Plans Not Subject to this Guide
Resources and How to Contact Us
Provider Responsibilities and Standards
Provider Responsibilities and Standards
Electronic Data Interchange (EDI)
Verifying Eligibility, Benefits and your Network Participation
Healthcare Identification (ID) Card
Access Standards
Primary Care Physicians (PCP) Responsibilities
Demographic Changes
Administrative Terminations for Inactivity
Continuity of Care Following Termination of Your Participation
Medicare Opt-Out
Additional Requirements
Filing a Lawsuit by a Member
Commercial Products
Commercial Products
Commercial Product Overview
Benefit Plan Types
Primary Care Physicians (PCP) Selection
HRAs and HSAs Consumer-Driven Health Benefit Plans
Medicare Products
Medicare Products
Medicare Product Overview
Coverage Summaries and Policy Guidelines for MA Members
Medicare Supplement Benefit Plans
Referrals
Referrals
Commercial Products Referrals
Non-Participating Care Provider Referrals (All Commercial Plans)
Medicare Advantage Referral Required Plans
Medical Management
Medical Management
Benefit Plans Not Subject to this Protocol
Advance Notification/Prior Authorization Requirements
Advance Notification/Prior Authorization List
Facilities: Standard Notification Requirements
Facility Denial Process
How to Submit Advance or Admission Notifications / Prior Authorizations
Updating Advance Notification or Prior Authorization Requests
Coverage and Utilization Management Decisions
Pre-Service Appeals
Clinical Trials, Experimental or Investigational Services
Medical Management Denials/Adverse Determinations
MA Part C Reopenings
Outpatient Cardiology Notification/Prior Authorization Protocol
Outpatient Radiology Notification/Prior Authorization Protocol
Trauma Services
Specialty Pharmacy and Medicare Advantage Pharmacy
Specialty Pharmacy and Medicare Advantage Pharmacy
Commercial Pharmacy
Specialty Pharmacy Requirements for Certain Commercial Specialty Medications
MA Pharmacy
Drug Utilization Review Program
Medication Therapy Management (MTM)
Transition Policy
Specific Protocols
Specific Protocols
Air Ambulance, Fixed-Wing Non-Emergency Transport
Laboratory Benefit Management Program Administered by BeaconLBSTM (Florida only)
Laboratory Services Protocol
Non-Participating Providers Consent Form
Nursing Home and Assisted Living Plans
Our Claims Process
Our Claims Process
Electronic Payments and Statements (EPS)
Claims and Encounter Data Submissions
Risk Adjustment Data – MA and Commercial
National Provider Identification (NPI)
Medicare Advantage Claim Processing Requirements
Hospital Responsibilities
Claim Submission Tips
Pass-through Billing/CLIA Requirements/Reimbursement Policy
Special Reporting Requirements for Certain Claim Types
Overpayments
Subrogation and Coordination of Benefits
Claim Correction and Resubmission
Claim Reconsideration, Appeals Process and Resolving Disputes
Resolving Disputes - Concern or Complaint
Member Appeals, Grievances or Complaints
Medical Claim Review
Compensation
Compensation
Reimbursement Policies
Charging Members
Member Financial Responsibility
Preventive Care
Provider Audits - Extrapolation
Hospital Audit Services
Notice of Medicare Non-Coverage (NOMNC)
Medical Records Standards and Requirements
Health and Disease Management
Health and Disease Management
Health Management Programs
Case Management
Wellness and Behavioral Health Programs
Consumer Transparency Tools: MyHealthcareCostEstimator (myHCE)
Behavior Health Information
Quality Management (QM) Program
Quality Management (QM) Program
UnitedHealth Premium Designation Program (Commercial Plans)
Star Ratings for MA and Prescription Drug Plans
Member Satisfaction
Imaging Accreditation Protocol
Credentialing and Re-Credentialing
Credentialing and Re-Credentialing
Credentialing/Profile Reporting Requirements
Care Provider Rights Related to the Credentialing Process
Initial Credentialing Process
Recredentialing Process
Credentialing Committee Decision Making Process (Non-Delegated)
Monitoring of All Network Care Providers
Member Rights and Responsibilities
Fraud, Waste and Abuse (FWA)
Fraud, Waste and Abuse (FWA)
Medicare Compliance Expectations and Training
Exclusion Checks
Prevention and Detection
Prevention and Detection
Corrective Action Plans
Beneficiary Inducement Law
Reporting Potential Fraud, Waste or Abuse to Unitedhealthcare
Provider Communication
Provider Communication
Network Bulletin and Provider News
Medical Policy Update Bulletin
Other Communications
All Savers Supplement
All Savers Supplement
How to Contact All Savers - All Savers Supplement
Capitated Providers
Capitated Providers
Capitated Providers, Capitation and/or Delegation Supplement
Delegated Providers and Accountable Care Organizations - Capitation and/or Delegation Supplement
How to Contact Us, Capitation and/or Delegation Supplement
Verifying Eligibility and Effective Dates, Capitation and/or Delegation Supplement
Commercial Eligibility, Enrollment, Transfers and Disenrollment - Capitation and/or Delegation Supplement
Medicare Advantage (MA) Enrollment, Eligibility and Transfers, and Disenrollment - Capitation and/or Delegation Supplement
Eligibility/Authorization Gaurantee
Provider Responsibilities
Delegated Credentialing Program
Virtual Visits (Commercial HMO Plans CA only)
Referrals & Referral Contracting
Medical Management
Pharmacy
Facilities
Claims Processes
Medicare Advantage (MA Delegated or Capitated)
Claims Disputes and Appeals
Contractual and Financial Responsibilities
Capitation Payments and Reporting
CMS Premiums and Adjustments
Appeals and Grievances
Leased Networks
Medica Healthcare Supplement
Medica Healthcare Supplement
How to Contact Us
Confidentiality of Protected Health Information (PHI)
Prior Authorizations and Referrals
Appeals and Reconsideration Processes
Member Rights and Responsibilities
Documentation and Confidentiality of Medical Records
Provider Reporting Responsibilities
Mid-Atlantic Regional Supplement
Mid-Atlantic Regional Supplement
Provider Responsibilities
Referrals
Prior Authorizations
Capitation
Claims Process
Neighborhood Health Partnership Supplement
Neighborhood Health Partnership Supplement
How to Contact NHP
Discharge of a Member from Participating Provider's Care
Laboratory Services
Referrals
Utilization Management (UM)
Claims Reconsiderations and Appeals
Capitated Health Care Provider
OneNet PPO Supplement
OneNet PPO Supplement
Discontinuation of the OneNet PPO Medical Network Product
How to Contact OneNet PPO
OneNet General Provider Administration Requirements
Referrals
Utilization Review Components for Workers' Compensation
Workers' Compensation Claims Process
Resolving Disputes
Medical Records Standards and Requirements
Quality Management and Health Management Programs
Participant Rights and Responsibilities
Oxford Commercial Supplement
Oxford Commercial Supplement
Oxford Commercial Product Overview
How to Contact Oxford Commercial
Care Provider Responsibilities and Standards
Referrals
Utilization Management
Using Non-Participating Health Care Providers or Facilities
Radiology and Cardiology Procedures
Emergencies and Urgent Care
Utilization Reviews
Claims Process
Member Billing
Claims Recovery, Appeals, Disputes and Grievances
Quality Assurance
Case Management and Disease Management Programs
Clinical Process Definitions
Member Rights and Responsibilities
Medical and Administrative Policy Updates
Preferred Care Partners Supplement
Preferred Care Partners Supplement
About Preferred Care Partners
How to Contact Us
Confidentiality of Protected Health Information (PHI)
Prior Authorizations and Referrals
Clinical Coverage Review
Appeal & Reconsideration Processes
Member Rights and Responsibilities
Documentation and Confidentiality of Medical Records
Case Management and Disease Management Program Information
Special Needs Plans
Care Provider Reporting Responsibilities
River Valley Entities Supplement
River Valley Entities Supplement
Eligibility
How to Contact River Valley
Reimbursement Policies
Referrals
Utilization Management
Claims Process
UnitedHealthcare West Supplement
UnitedHealthcare West Supplement
UnitedHealthcare West Information Regarding our Care Provider Website
How to Contact UnitedHealthcare West Resources - 2018 UnitedHealthcare Administrative Guide
Care Provider Responsibilities
Utilization and Medical Management
Hospital Notificiations
Pharmacy Network
Claims Process
CareProvider Claims Appeals and Disputes
California Language Assistance Program (California Commercial Plans)
Member Complaints & Grievances
California Quality Improvement Committee
UnitedHealthOne Individual Plans Supplement
UnitedHealthOne Individual Plans Supplement
How to Contact UnitedHealthOne Resources
Claims Process
Member Complaints & Grievances
Glossary
Community Plan Care Provider Manuals
Claims, Billing and Payments
Claims, Billing and Payments
claimsLink
Electronic Payments (EPS)
Eligibility and Benefits
Eligibility and Benefits
eligibilityLink
Demographics and Profiles
Demographics and Profiles
Attestation
My Practice Profile App
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Find a Care Provider
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Relative Cost of Network Providers Tool
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Health Plans by State
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Health Plans by State
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