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Claims and Payments
Payment Policy Notifications
Pharmacy Resources and Physician Administered Drugs
Policies and Clinical Guidelines
Policies and Clinical Guidelines
Community Plan Reimbursement Policies of Missouri
Prior Authorization and Notification
Provider Forms and References
Training and Education
UnitedHealthcare Dual Complete® Special Needs Plans
Montana Health Plans
Montana Health Plans
Montana Commercial Health Plans
MT Medicare Advantage Health Plans
MT Medicare Advantage Health Plans
MT AARP® Medicare Advantage Plans
Montana UnitedHealthcare® MedicareDirect (PFFS)
Nebraska Health Plans
Nebraska Health Plans
Nebraska Commercial Health Plans
NE Medicare Advantage Health Plans
NE Medicare Advantage Health Plans
Nebraska AARP® Medicare Advantage Plans
NE Dual Complete® SNP
Nebraska Group Medicare Advantage Plans
Nebraska UnitedHealthcare® MedicareDirect (PFFS)
NE UnitedHealthcare Medicare Advantage Plans
UnitedHealthcare Community Plan of Nebraska Homepage
UnitedHealthcare Community Plan of Nebraska Homepage
Behavioral Health
Bulletins and Newsletters
Bulletins and Newsletters
Practice Matters
Practice Matters
New Transportation Benefit Provider
Heritage Health Adult Expansion Program
Care Provider Manuals
Claims and Payments
Payment Policy Notifications
Pharmacy Resources and Physician Administered Drugs
Policies and Clinical Guidelines
Policies and Clinical Guidelines
Community Plan Reimbursement Policies of Nebraska
Prior Authorization and Notification
Provider Forms and References
Training and Education
Transportation Services
UnitedHealthcare Dual Complete® Special Needs Plans
Nevada Health Plans
Nevada Health Plans
Nevada Commercial Health Plans
NV Medicare Advantage Health Plans
NV Medicare Advantage Health Plans
Nevada AARP® Medicare Advantage Plans
Nevada Group Medicare Advantage Plans
Nevada Medicare Advantage Plans
Nevada UnitedHealthcare Dual Complete® Special Needs Plans
Nevada UnitedHealthcare Medicare Advantage Assist
New Hampshire Health Plans
New Hampshire Health Plans
New Hampshire Commercial Health Plans
NH Medicare Advantage Health Plans
NH Medicare Advantage Health Plans
New Hampshire AARP® Medicare Advantage Plans
New Hampshire Group Medicare Advantage Plans
New Hampshire Nursing Home Plan
New Hampshire UnitedHealthcare Medicare Advantage Plans
New Hampshire Assisted Living Plan
New Jersey Health Plans
New Jersey Health Plans
New Jersey Commercial Health Plans
NJ Medicare Advantage Health Plans
NJ Medicare Advantage Health Plans
New Jersey AARP® Medicare Advantage Plans
New Jersey Dual Complete® SNP
New Jersey Erickson Advantage® Freedom/Signature Plans
New Jersey Erickson Advantage® SNP Plans
New Jersey Group Medicare Advantage Plans
New Jersey Nursing Home Plan
UnitedHealthcare Community Plan of New Jersey Homepage
UnitedHealthcare Community Plan of New Jersey Homepage
Bulletins and Newsletters
Bulletins and Newsletters
Practice Matters
Practice Matters
A Member’s Right to Culturally Competent Care
Benefit enhancements for New Jersey dual special needs plan (DSNP)
Case Managers Help Members With Complex Needs
Early Elective Delivery Reimbursement Changes
UnitedHealthcare Dual Complete®: New Jersey Members Matched With a Navigator
Perinatal Risk Assessment Form Requirements
Providers Must Obtain Hospital Privileges
New Disease Management Program in New Jersey for End-Stage Renal Disease
Referral Reminder: Out-of-Network Labs
Measures for Respiratory Conditions
Managing Medication for People With Asthma
Office-Based Addictions Treatment
Access and Availability Standards
Understanding Early and Periodic Screening, Diagnostic and Treatment Requirements
Updated (PCM) Medical Care Coordination: Private Duty Nursing Policy
Care Provider Manuals
Claims and Payments
Managed Long-Term Care Services and Supports (MLTSS)
Payment Policy Notifications
Pharmacy Resources and Physician Administered Drugs
Policies and Clinical Guidelines
Policies and Clinical Guidelines
Community Plan Reimbursement Policies of New Jersey
Prior Authorization and Notification
Provider Forms and References
Training and Education
UnitedHealthcare Dual Complete® Special Needs Plans
New Mexico Health Plans
New Mexico Health Plans
New Mexico Commercial Health Plans
NM Medicare Advantage Health Plans
NM Medicare Advantage Health Plans
New Mexico AARP® Medicare Advantage Plans
New Mexico Dual Complete® SNP
New Mexico Group Medicare Advantage Plans
New Mexico UnitedHealthcare Medicare Advantage Plans
New York Health Plans
New York Health Plans
New York Commercial Health Plans
NY Medicare Advantage Health Plans
NY Medicare Advantage Health Plans
NY AARP® Medicare Advantage Plans
New York Group Medicare Advantage Plans
New York UnitedHealthcare Medicare Advantage Plans
New York Nursing Home Plan
New York UnitedHealthcare Dual Complete® Special Needs Plans
New York Assisted Living Plan
UnitedHealthcare Community Plan of New York Homepage
UnitedHealthcare Community Plan of New York Homepage
Bulletins and Newsletters
Care Provider Manuals
Claims and Payments
Payment Policy Notifications
Pharmacy Resources and Physician Administered Drugs
Policies and Clinical Guidelines
Policies and Clinical Guidelines
Community Plan Reimbursement Policies of New York
Prior Authorization and Notification
Provider Forms and References
Training and Education
UnitedHealthcare Connected
UnitedHealthcare Dual Complete® Special Needs Plans
North Carolina Health Plans
North Carolina Health Plans
North Carolina Commercial Health Plans
NC Medicare Advantage Health Plans
NC Medicare Advantage Health Plans
North Carolina AARP® Medicare Advantage Plans
North Carolina Assisted Living Plan
North Carolina Dual Complete® SNP
North Carolina Erickson Advantage® Freedom/Signature Plans
North Carolina Erickson Advantage® SNP Plans
North Carolina Group Medicare Advantage Plans
North Carolina Nursing Home Plan
UnitedHealthcare Community Plan of North Carolina Homepage
UnitedHealthcare Community Plan of North Carolina Homepage
Bulletins and Newsletters
Care Provider Manuals
Claims and Payments
Payment Policy Notifications
Pharmacy Resources and Physician Administered Drugs
Policies and Clinical Guidelines
Policies and Clinical Guidelines
Community Plan Medical & Drug Policies for North Carolina
Prior Authorization and Notification
Provider Forms, Resources and References
Education and Training
Transportation Services
UnitedHealthcare Dual Complete® Special Needs Plans
North Dakota Health Plans
North Dakota Health Plans
North Dakota Commercial Health Plans
ND Medicare Advantage Health Plans
ND Medicare Advantage Health Plans
North Dakota Group Medicare Advantage Plans
North Dakota AARP® Medicare Advantage Plans
North Dakota UnitedHealthcare Medicare Advantage Plans
Ohio Health Plans
Ohio Health Plans
Ohio Commercial Health Plans
OH Medicare Advantage Health Plans
OH Medicare Advantage Health Plans
Ohio AARP® Medicare Advantage Plans
Ohio Assisted Living Plan
Ohio Dual Complete® SNP
Ohio Group Medicare Advantage Plans
Ohio Nursing Home Plan
UnitedHealthcare Community Plan of Ohio Homepage
UnitedHealthcare Community Plan of Ohio Homepage
Bulletins and Newsletters
Bulletins and Newsletters
Practice Matters
Practice Matters
Benefit enhancements for Ohio dual special needs plan (DSNP)
Change in Transportation Vendor Network
Electronic Visit Verification - Phase 3
ODM is Requiring Providers to Register NPIs for Payments
Ohio Suicide Prevention Initiative
UnitedHealthcare Dual Complete: Ohio Members Matched with a Navigator
Diabetic Self-Management Education
Transportation to Food Resources for UHC Community Plan of Ohio Members
Claims and Payments
Forms, Billing and Reference Guides
Ohio Care Provider Manual
Ohio Care Provider Manual
Care Provider Manual: Chapter 1
Care Provider Manual: Chapter 2
Care Provider Manual: Chapter 3
Care Provider Manual: Chapter 4
Care Provider Manual: Chapter 4
Long-Term Services and Supports (MyCare)
Care Provider Manual: Chapter 5
Care Provider Manual: Chapter 6
Care Provider Manual: Chapter 7
Care Provider Manual: Chapter 8
Care Provider Manual: Chapter 9
Care Provider Manual: Chapter 10
Care Provider Manual: Chapter 11
Care Provider Manual: Chapter 12
Care Provider Manual: Chapter 13
Care Provider Manual: Chapter 14
Payment Policy Notifications
Pharmacy Resources and Physician Administered Drugs
Policies and Clinical Guidelines
Policies and Clinical Guidelines
Community Plan Reimbursement Policies of Ohio
Prior Authorization and Notification
Training and Education
UnitedHealthcare Connected
UnitedHealthcare Dual Complete® Special Needs Plans
Oklahoma Health Plans
Oklahoma Health Plans
Oklahoma Commercial Health Plans
OK Medicare Advantage Health Plans
OK Medicare Advantage Health Plans
Oklahoma AARP® Medicare Advantage Plans
OK Dual Complete® SNP
Oklahoma Group Medicare Advantage Plans
Oklahoma UnitedHealthcare® MedicareDirect (PFFS)
UnitedHealthcare Community Plan of Oklahoma Homepage
UnitedHealthcare Community Plan of Oklahoma Homepage
Bulletins and Newsletters
Care Provider Manuals
Claims and Payments
Policies and Clinical Guidelines
Prior Authorization and Notification
Training and Education
UnitedHealthcare Dual Complete® Special Needs Plans
Oregon Health Plans
Oregon Health Plans
Oregon Commercial Health Plans
OR Medicare Advantage Health Plans
OR Medicare Advantage Health Plans
Oregon AARP® Medicare Advantage Plans
Oregon Assisted Living Plan
Oregon Group Medicare Advantage Plans
Oregon Nursing Home Plan
OR UnitedHealthcare Medicare Advantage Plans
Pennsylvania Health Plans
Pennsylvania Health Plans
Pennsylvania Commercial Health Plans
PA Medicare Advantage Health Plans
PA Medicare Advantage Health Plans
Pennsylvania AARP® Medicare Advantage Plans
Pennsylvania Dual Complete® SNP
Pennsylvania Erickson Advantage® SNP Plans
Pennsylvania Erickson Advantage® Freedom/Signature Plans
Pennsylvania Group Medicare Advantage Plans
Pennsylvania Nursing Home Plan
UnitedHealthcare Community Plan of Pennsylvania Homepage
UnitedHealthcare Community Plan of Pennsylvania Homepage
Bulletins and Newsletters
Bulletins and Newsletters
Practice Matters
Practice Matters
Additional Incentive Program
Benefit enhancements for Pennsylvania dual special needs plan (DSNP)
Covid-19 Resources Reminder
Family Visiting Program
Key to Know… Changes to Well-Child Measures in 2020
Low Acuity Non-Emergent Follow Up Appointments
Special Needs Unit Reminder
UnitedHealthcare Dual Complete: Pennsylvania Members Matched with a Navigator.
Spotlight for Home Health Providers
We’re Your Partner to Connect with Members benefits and services
HEDIS® Measure: Appropriate Testing for Children with Pharyngitis
Long-Acting Reversible Contraceptives
Care Provider Manuals
Claims and Payments
Early and Periodic Screening, Diagnosis and Treatment (EPSDT)
Payment Policy Notifications
Pharmacy Resources and Physician Administered Drugs
Policies and Clinical Guidelines
Policies and Clinical Guidelines
Community Plan Reimbursement Policies of Pennsylvania
Prior Authorization and Notification
Quality Rewards Program
Training and Education
UnitedHealthcare Dual Complete® Special Needs Plans
Rhode Island Health Plans
Rhode Island Health Plans
Rhode Island Commercial Health Plans
RI Medicare Advantage Health Plans
RI Medicare Advantage Health Plans
Rhode Island AARP® Medicare Advantage Plans
Rhode Island Assisted Living Plan
Rhode Island Dual Complete® SNP
Rhode Island Group Medicare Advantage Plans
Rhode Island Nursing Home Plan
UnitedHealthcare Community Plan of Rhode Island Homepage
UnitedHealthcare Community Plan of Rhode Island Homepage
Bulletins and Newsletters
Bulletins and Newsletters
Practice Matters
Practice Matters
Increased Member Satisfaction Revealed by CAHPS Survey
Benefit enhancements for Rhode Island dual special needs plan (DSNP)
Care Provider Manuals
Claims and Payments
Payment Policy Notifications
Pharmacy Resources and Physician Administered Drugs
Policies and Clinical Guidelines
Policies and Clinical Guidelines
Community Plan Reimbursement Policies of Rhode Island
Prior Authorization and Notification
Provider Forms and References
Training and Education
UnitedHealthcare Dual Complete® Special Needs Plans
SC Health Plans
SC Health Plans
SC Commercial Health Plans
SC Medicare Advantage Health Plans
SC Medicare Advantage Health Plans
SC AARP® Medicare Advantage Plans
South Carolina Dual Complete® SNP
SC Group Medicare Advantage Plans
South Carolina UnitedHealthcare Medicare Advantage Plans
SC UnitedHealthcare Medicare Gold/Silver
SD Health Plans
SD Health Plans
SD Commercial Health Plans
SD Medicare Advantage Health Plans
SD Medicare Advantage Health Plans
South Dakota Group Medicare Advantage Plans
South Dakota AARP® Medicare Advantage Plans
TN Health Plans
TN Health Plans
Exchange Plans
TN Commercial Health Plans
TN Medicare Advantage Health Plans
TN Medicare Advantage Health Plans
TN AARP® Medicare Advantage Plans
TN Dual Complete® SNP
TN Group Medicare Advantage Plans
TN Nursing Home Plan
TN UnitedHealthcare Medicare Advantage Plans
UnitedHealthcare Community Plan of Tennessee Homepage
UnitedHealthcare Community Plan of Tennessee Homepage
Behavioral Health
Bulletins and Newsletters
Care Provider Manuals
Claims and Payments
Payment Policy Notifications
Pharmacy Resources and Physician Administered Drugs
Policies and Clinical Guidelines
Policies and Clinical Guidelines
Community Plan Reimbursement Policies of Tennessee
Prior Authorization and Notification
Provider Forms, Resources and References
Tennessee Episodes of Care / Patient Centered Medical Home / TN Health Link / Medication Therapy Management
Training and Education
UnitedHealthcare Dual Complete® Special Needs Plans
TX Health Plans
TX Health Plans
TX Commercial Health Plans
TX Medicare Advantage Health Plans
TX Medicare Advantage Health Plans
TX AARP® Medicare Advantage Plans
TX UnitedHealthcare® Chronic Complete Special Needs Plan
TX Dual Complete® SNP
TX Erickson Advantage® Freedom/Signature Plans
TX Erickson Advantage® SNP Plans
TX Group Medicare Advantage Plans
Texas UnitedHealthcare Medicare Advantage Plans
TX UnitedHealthcare® MedicareDirect (PFFS)
TX Medicare Gold/Silver
TX Nursing Home Plan
UnitedHealthcare Community Plan of Texas Homepage
UnitedHealthcare Community Plan of Texas Homepage
Bulletins and Newsletters
Bulletins and Newsletters
Practice Matters
Practice Matters
Dental Prevention - More than Mouth Care
Help When and Where It’s Needed
Making the Most of Life While Living With Complex Care Needs
Texas Community Plan Quality Newsletter
Care Provider Manuals
Claims and Payments
Contact Us
Electronic Visit Verification
Messages from the Texas Credentialing Alliance
Messages from the Texas Health and Human Services Commission
Payment Policy Notifications
Pharmacy Resources and Physician Administered Drugs
Policies and Clinical Guidelines
Policies and Clinical Guidelines
Community Plan Reimbursement Policies of Texas
Prior Authorization and Notification
Prior Authorization and Notification
Prior Authorization Requirements
Prior Authorization Timelines
Prior Authorization Forms
Specialty Programs Prior Authorizations
Reference Guides and Value-Added Services
Training and Education
UnitedHealthcare Dual Complete® Special Needs Plans
UT Health Plans
UT Health Plans
UT Commercial Health Plans
UT Medicare Advantage Health Plans
UT Medicare Advantage Health Plans
UT AARP® Medicare Advantage Plans
UT Group Medicare Advantage Plans
Utah UnitedHealthcare Medicare Advantage Plans
Utah UnitedHealthcare Medicare Advantage Assist plans
UT Nursing Home Plan
VT Health Plans
VT Health Plans
VT Commercial Health Plans
VT Medicare Advantage Health Plans
VT Medicare Advantage Health Plans
VT AARP® Medicare Advantage Plans
VT Group Medicare Advantage Plans
VT UnitedHealthcare® MedicareDirect (PFFS)
Vermont UnitedHealthcare Medicare Advantage Plans
VA Health Plans
VA Health Plans
Virginia Commercial Health Plans
VA Medicare Advantage Health Plans
VA Medicare Advantage Health Plans
Virginia AARP® Medicare Advantage Plans
v
VA Dual Complete® SNP
Virginia Erickson Advantage® Freedom/Signature Plans
Virginia Erickson Advantage® SNP Plans
Virginia Group Medicare Advantage Plans
Virginia UnitedHealthcare® MedicareDirect (PFFS)
Virginia Nursing Home Plan
Virginia Piedmont Plans
UnitedHealthcare Community Plan of Virginia Homepage
UnitedHealthcare Community Plan of Virginia Homepage
Bulletins and Newsletters
Bulletins and Newsletters
Practice Matters
Practice Matters
Social Determinants of Health Protocol
Resources to Help You Prepare for a Challenging Influenza Season
How to Manage and Close the Measure
Community & State Plan: 2020 Transportation Benefit Information
Annual Wellness Visit Through Telehealth
Initiation and Engagement of Alcohol and Other Drug Dependence Treatment
Medication Reconciliation Post-Discharge (MRP)
UnitedHealthcare Dual Complete: Virginia Members Matched with a Navigator
Virginia Medicaid Appointment Standards
Virginia Medicaid Appointment Standards
Virginia Medicaid Appointment Standards
Virginia Medicaid Appointment Standards
Care Provider Manuals
Claims and Payments
Payment Policy Notifications
Pharmacy Resources and Physician Administered Drugs
Policies and Clinical Guidelines
Policies and Clinical Guidelines
Community Plan Reimbursement Policies of Virginia
Prior Authorization and Notification
Provider Forms and References
Training and Education
UnitedHealthcare Dual Complete® Special Needs Plans
WA Health Plans
WA Health Plans
Exchange Plans
Washington Commercial Health Plans
WA Medicare Advantage Health Plans
WA Medicare Advantage Health Plans
Washington AARP® Medicare Advantage Plans
Washington Assisted Living Plan
Washington Dual Complete® SNP
Washington Group Medicare Advantage Plans
Washington Nursing Home Plan
UnitedHealthcare Community Plan of Washington Homepage
UnitedHealthcare Community Plan of Washington Homepage
Behavioral Health
Bulletins and Newsletters
Bulletins and Newsletters
Practice Matters
Practice Matters
Behavioral Health Services
Benefit enhancements for Washington dual special needs plan (DSNP)
Care Coordination
Care Management
Early Learning Programs
Health Home Program
Long-Term Services and Support
Quality Improvement Program
Ongoing Educational Opportunities
Online Care Provider Directory
Pregnancy Intention Screening: Family Planning for Social Change
UnitedHealthcare Dual Complete: Washington Members Matched With a Navigator
Care Provider Manuals
Claims and Payments
Payment Policy Notifications
Pharmacy Resources and Physician Administered Drugs
Policies and Clinical Guidelines
Policies and Clinical Guidelines
Community Plan Reimbursement Policies of Washington
Prior Authorization and Notification
Training and Education
UnitedHealthcare Dual Complete® Special Needs Plans
WV Health Plans
WV Health Plans
West Virginia Commercial Health Plans
WV Medicare Advantage Health Plans
WV Medicare Advantage Health Plans
West Virginia AARP® Medicare Advantage Plans
WV Dual Complete® SNP
West Virginia Group Medicare Advantage Plans
UnitedHealthcare Community Plan of West Virginia Homepage
UnitedHealthcare Community Plan of West Virginia Homepage
Care Provider Manuals
Claims and Payments
Policies and Clinical Guidelines
Prior Authorization and Notification
UnitedHealthcare Dual Complete® Special Needs Plans
WI Health Plans
WI Health Plans
Wisconsin Commercial Health Plans
WI Medicare Advantage Health Plans
WI Medicare Advantage Health Plans
Wisconsin AARP® Medicare Advantage Plans
Wisconsin Assisted Living Plan
Wisconsin Dual Complete® SNP
Wisconsin UnitedHealthcare Medicare Advantage Plans
Wisconsin Group Medicare Advantage Plans
Wisconsin Nursing Home Plan
Wisconsin UnitedHealthcare Medicare Advantage Assist plans
UnitedHealthcare Community Plan of Wisconsin Homepage
UnitedHealthcare Community Plan of Wisconsin Homepage
Behavioral Health
Bulletins and Newsletters
Bulletins and Newsletters
Practice Matters
Practice Matters
Benefit enhancements for Wisconsin dual special needs plan (DSNP)
Care Provider Manuals
Claims and Payments
Payment Policy Notifications
Pharmacy Resources and Physician Administered Drugs
Policies and Clinical Guidelines
Policies and Clinical Guidelines
Community Plan Reimbursement Policies of Wisconsin
Prior Authorization and Notification
Provider Forms and References
Training and Education
UnitedHealthcare Dual Complete® Special Needs Plans
WY Health Plans
WY Health Plans
WY Commercial Health Plans
WY Medicare Advantage Health Plans
WY Medicare Advantage Health Plans
WY Group Medicare Advantage Plans
Wyoming UnitedHealthcare® MedicareDirect (PFFS)
USVI Health Plans
USVI Health Plans
U.S. Virgin Islands Commercial Health Plans
Policies and Protocols
Policies and Protocols
Protocols
Clinical Guidelines
Commercial Policies
Commercial Policies
Clinical Guidelines
Dental Policies
UnitedHealthcare Commercial Medical & Drug Policies and Coverage Determination Guidelines
UnitedHealthcare Commercial Reimbursement Policies
Oxford Policies
UnitedHealthcare West Benefit Interpretation Policies
UnitedHealthcare West Medical Management Guidelines
Dental Policies
Exchange Plans Policies
Exchange Plans Policies
Clinical Guidelines
UnitedHealthcare Value & Balance Exchange Medical & Drug Policies and Coverage Determination Guidelines
Reimbursement Policies for UnitedHealthcare Value & Balance Exchange Plans
Medicare Advantage Policies
Medicare Advantage Policies
Clinical Guidelines
Medicare Advantage Coverage Summaries
Dental Policies
Medicare Advantage Policy Guidelines
Medicare Advantage Reimbursement Policies
Medicare Advantage Terms and Conditions
Community Plan Policies
Community Plan Policies
Clinical Guidelines
Dental Policies
Community Plan Medical & Drug Policies
Community Plan Reimbursement Policies
Community Plan Drug Lists for Limited Supplier Protocol
Laboratory Test Registry Protocol
sec_mcg-index
InterQual Clinical Criteria
Demographics and Profiles
Demographics and Profiles
Link Self-Service Tools
My Practice Profile
Area of Expertise
Attestation
Get Credentialed
Administrative Guides and Manuals
Administrative Guides and Manuals
Community Plan Care Provider Manuals for Medicaid Plans By State
Administrative Guide for Commercial, Medicare Advantage and DSNP
Administrative Guide for Commercial, Medicare Advantage and DSNP
Welcome to UnitedHealthcare 2021 Administrative Guide
Quick reference guide 2021 Administrative Guide
Introduction
Introduction
Manuals and benefit plans referenced in the guide
Online/interoperability resources and how to contact us
Provider responsibilities and standards
Provider responsibilities and standards
Verifying eligibility, benefits and your network participation status
Healthcare plan identification (ID) cards
Access standards
Network participating care provider responsibilities
Civil rights
Cooperation with quality improvement and patient safety activities
Demographic changes
Notification of practice or demographic changes (Applies to Commercial Benefit Plans in California)
Administrative terminations for inactivity
Member dismissals initiated by a PCP (Medicare Advantage)
Medicare opt-out
Additional MA requirements
Filing a lawsuit by a member
Commercial products
Commercial products
Commercial product overview table
Benefit plan types
PCP selection
Consumer-driven health benefit plans
Health Insurance Marketplace (Exchanges)
Health Insurance Marketplace (Exchanges)
Individual marketplace vs. small business health options program marketplace
UnitedHealthcare’s participation in Exchanges
What is the health insurance marketplace?
Plan coverage and metal levels
UnitedHealthcare benefit plans for exchanges
Understanding your network participation
Verifying eligibility and benefits
Plan requirements/features
Patient care coordination and case management
Telehealth visits
Pharmacy
Specialty services
Claims process
Policies and protocols
Pharmacy
Medicare products
Medicare products
Medicare product overview tables
PCP selection
Coverage summaries and policy guidelines for MA members
Dual special needs plans managed by Optum
Medicare supplement benefit plans
Free Medicare education for your staff and patients
Referrals
Referrals
Commercial products referrals
Non-Participating Care Provider Referrals (All Commercial Plans)
Medicare Advantage Referral Required Plans
Individual 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
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
Medication-assisted treatment (MAT)
Trauma services
Air Ambulance Licensure
Specialty pharmacy and Medicare Advantage pharmacy
Specialty pharmacy and Medicare Advantage pharmacy
Commercial pharmacy
Optum specialty medication guidance program (commercial plans – not applicable to UnitedHealthcare West)
Coverage of self-infused/injectable medications under the pharmacy benefit
MA pharmacy
Drug utilization review program
Drug management program (DMP)
Medication Therapy Management (MTM)
Transition policy
Specific protocols
Specific protocols
Non-Emergent ambulance ground transportation
Interoperability protocol
Laboratory services protocol
Nursing home and assisted living plans
Social determinants of health protocol
Telehealth services protocol
Our claims process
Our claims process
Optum Pay
Virtual card payments
Enroll and learn more about Optum Pay
Claims and encounter data submissions
Risk adjustment data – MA and commercial
National Provider Identification (NPI)
Medicare Advantage claim processing requirements
Claim submission tips
Pass-through billing
Special reporting requirements for certain claim types
Overpayments
Subrogation and coordination of benefits
Claim correction and resubmission
Claim reconsideration, appeals process
Resolving concerns or complaints
Member appeals, grievances or complaints
Medical claim review
Compensation
Compensation
Reimbursement policies
Charging members
Member financial responsibility
Preventive care
Extrapolation
Audit services
Audit failure denials
Notice of Medicare Non-Coverage (NOMNC)
Medical records standards and requirements
Health and disease management
Health and disease management
Health management programs
Case management
Commercial health services, wellness and behavioral health programs
Commercial consumer transparency tools
Medicare Advantage (MA)
Commercial and Medicare Advantage behavioral health information
Quality Management (QM) program
Quality Management (QM) program
UnitedHealth Premium® program (commercial plans)
Star ratings for MA and prescription drug plans
Member satisfaction
Imaging accreditation protocol
Credentialing and recredentialing
Credentialing and recredentialing
Credentialing/profile reporting requirements
Care provider rights related to the credentialing process
Credentialing committee decision-making process (non-delegated)
Monitoring of network care providers and health care professionals
Member rights and responsibilities
Fraud, Waste and Abuse (FWA)
Fraud, Waste and Abuse (FWA)
Medicare compliance expectations and training
Exclusion checks
Preclusion list policy
Examples of potentially fraudulent, wasteful, or abusive billing (not an inclusive list)
Prevention and detection
Corrective action plans
Beneficiary inducement law
Reporting potential fraud, waste or abuse to UnitedHealthcare
Provider communication
Provider communication
Network News: Provider news and updates
Network Bulletin: Policy and protocol updates
Medical Policy Update Bulletin
Other communications
All Savers supplement
All Savers supplement
How to contact All Savers
Capitation and/or delegation supplement
Capitation and/or delegation supplement
What is capitation?
What is delegation?
How to contact us, Capitation and/or delegation
Verifying eligibility and effective dates, Capitation and/or Delegation
Commercial eligibility, enrollment, transfers, and disenrollment, Capitation and/or delegation
Medicare Advantage (MA) enrollment, eligibility and transfers, and disenrollment Capitation and/or delegation
Authorization guarantee (CA Commercial only), Capitation and/or delegation
Care provider responsibilities
Delegated credentialing program, Capitation and/or delegation
Virtual Visits (Commercial HMO plans – CA only)
Virtual Visits (Medicare Advantage)
Referrals and referral contracting
Medical management, Capitation and/or delegation
Pharmacy, Capitation and/or Delegation Supplement
Facilities, Capitation and/or Delegation Supplement
Claims processes, Capitation and/or delegation supplement
Claims disputes and appeals, Capitation and/or delegation supplement
Contractual and financial responsibilities, Capitation and/or delegation supplement
Capitation reports and payments, Capitation and/or delegation supplement
CMS premiums and adjustments, Capitation and/or delegation supplement
Delegate performance management program, Capitation and/or delegation supplement
Appeals and grievances, Capitation and/or delegation supplement
Empire Plan supplement
Empire Plan supplement
Applicability of this supplement
Referrals
ID cards
Prior authorization and notification requirements
Online resources and how to contact us
Capitation and/or Delegation Supplement
Leased Networks
Medica HealthCare supplement
Medica HealthCare supplement
How to contact us, Medica
Confidentiality of Protected Health Information (PHI)
Referrals
Prior authorizations
Appeal and reconsideration processes
Member rights and responsibilities, Medica
Documentation and confidentiality of medical records
Provider reporting responsibilities, Medica
Mid-Atlantic regional supplement
Mid-Atlantic regional supplement
Provider responsibilities
Referrals
Prior authorizations
Claims process
Capitation
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 providers
OneNet PPO supplement
OneNet PPO supplement
Who to contact
Bills process
Referrals
Provider responsibilities and workflows
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, Oxford
Referrals, Oxford
Utilization management, Oxford
Using non-participating health care providers or facilities, Oxford
Radiology, cardiology and radiation therapy procedures
Emergencies and urgent care
Utilization reviews, Oxford
Claims process, Oxford
Member billing
Claims recovery, appeals, disputes and grievances
Quality assurance, Oxford
Case management and disease management programs
Clinical process definitions
Member rights and responsibilities
Medical and administrative policy updates, Oxford
Oxford Level-Funded plans (NJ and CT)
Oxford Level-Funded plans (NJ and CT)
How to contact us - Oxford Level-Funded plans (NJ and CT) - 2021 UnitedHealthcare Administrative Guide
Our claims process - Oxford Level-Funded plans (NJ and CT) - 2021 UnitedHealthcare Administrative Guide
How to submit your reconsideration or appeal- Oxford Level-Funded plans (NJ and CT) - 2021 UnitedHealthcare Administrative Guide
Preferred Care Partners Supplement
Preferred Care Partners Supplement
About Preferred Care Partners
How to contact Preferred Care Partners
Confidentiality of Protected Health Information (PHI), Preferred Care Partners
Prior authorizations and referrals, Preferred Care Partners
Clinical coverage review, Preferred Care Partners
Appeal and reconsideration processes, Preferred Care Partners
Member rights and responsibilities
Documentation and confidentiality of medical records, Preferred Care Partners
Case management and disease management program information, Preferred Care Partners
Special needs plans, Preferred Care Partners
Care provider reporting responsibilities, Preferred Care Partners
River Valley Entities Supplement
River Valley Entities Supplement
Information regarding the use of this supplement
Eligibility, River Valley
How to contact River Valley
Reimbursement policies, River Valley
Referrals, River Valley
Utilization Management, River Valley
Claims process, River Valley
UMR supplement
UMR supplement
How to contact UMR
Health plan identification (ID) cards
Prior authorization and notification requirements
Clinical trials, experimental or investigational services
Pharmacy and specialty pharmacy benefits
Medication therapy management
Specific protocols
Our claims process
Health and disease management
Frequently asked questions (FAQs)
UnitedHealthcare Level Funded supplement
UnitedHealthcare West supplement
UnitedHealthcare West supplement
UnitedHealthcare West information regarding our care provider website
How to contact UnitedHealthcare West resources
Care provider responsibilities, UnitedHealthcare West
Utilization and medical management, UnitedHealthcare West
Hospital notifications, UnitedHealthcare West
Pharmacy network, UnitedHealthcare West
Claims process, UnitedHealthcare West
Care provider claims appeals and disputes, UnitedHealthcare West
California language assistance program (California commercial plans), UnitedHealthcare West
Member complaints and grievances, UnitedHealthcare West
California Quality Improvement Committee, UnitedHealthcare West
UnitedHealthOne individual plans supplement
UnitedHealthOne individual plans supplement
How to contact UnitedHealthOne resources
Claims process, UnitedHealthOne
Member complaints and grievances, UnitedHealthOne
Glossary
Reports and Quality Programs
Reports and Quality Programs
CAHPS / HOS
Designated Diagnostic Provider
Home Health and SNF High-Performing Provider Initiative Lists
Hospital Performance
PATH
Peer Comparison Reports
Physician Performance
Quality-Based Physician Incentive Program (QPIP)
Quality-Based Shared Savings Program (QSSP)
Star Ratings Program
UnitedHealthcare Capitation, Claim, Quality, Roster and Profile Reports
UnitedHealthcare West Capitation, Settlement, Shared Risk Claims, Eligibility, and Patient Management Reports
UnitedHealth Premium® Program
New User Registration
New User Registration
Link Self-Service Tools
Health Plans by State
Connecticut Health Plans
UnitedHealthcare Community Plan of Connecticut Homepage
Policies and Clinical Guidelines
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Policies and Clinical Guidelines
For the Dual Complete (HMO-SNP) Program, please follow the Medicare Advantage policies.
View Medicare Advantage Policies