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A Member’s Right to Culturally Competent Care
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UnitedHealthcare Community Plan of Ohio Homepage
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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
Claims and Payments
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Ohio Care Provider Manual
Ohio Care Provider Manual
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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
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UnitedHealthcare Community Plan of Pennsylvania Homepage
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Practice Matters
Additional Incentive Program
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
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Training and Education
UnitedHealthcare Dual Complete® Special Needs Plans
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Rhode Island Health Plans
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RI Medicare Advantage Health Plans
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Rhode Island Nursing Home Plan
UnitedHealthcare Community Plan of Rhode Island Homepage
UnitedHealthcare Community Plan of Rhode Island Homepage
Bulletins and Newsletters
Care Provider Manuals
Claims and Payments
Payment Policy Notifications
Pharmacy Resources and Physician Administered Drugs
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Policies and Clinical Guidelines
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Prior Authorization and Notification
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Training and Education
UnitedHealthcare Dual Complete® Special Needs Plans
SC Health Plans
SC Health Plans
SC Commercial Health Plans
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SC Medicare Advantage Health Plans
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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
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SD Medicare Advantage Health Plans
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TN Health Plans
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UnitedHealthcare Community Plan of Tennessee Homepage
UnitedHealthcare Community Plan of Tennessee Homepage
Behavioral Health
Bulletins and Newsletters
Bulletins and Newsletters
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Practice Matters
Adult Checkup Reminder
EPSDT Campaign 2020 Thank you
EPSDT Coding Guide
Fraud, Waste, and Abuse Update – Foot Baths and Prescription Anti-Infective Agents
Flu Season Reminder
Healthcare Professional Community Engagement Partnership
Importance of EPSDT Screenings
Pneumococcal Screening Reminder
UnitedHealthcare Dual Complete – Medicare Advantage Special Needs Plan (DSNP) and UnitedHealthcare Community Plan – TennCare
Care Provider Manuals
Claims and Payments
Payment Policy Notifications
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Community Plan Reimbursement Policies of Tennessee
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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
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TX Medicare Advantage Health Plans
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TX UnitedHealthcare® Chronic Complete Special Needs Plan
TX Dual Complete® SNP
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TX Group Medicare Advantage Plans
Texas UnitedHealthcare Medicare Advantage Plans
TX UnitedHealthcare® MedicareDirect (PFFS)
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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
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Utah UnitedHealthcare Medicare Advantage Plans
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UT Nursing Home Plan
VT Health Plans
VT Health Plans
VT Commercial Health Plans
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VT UnitedHealthcare® MedicareDirect (PFFS)
Vermont UnitedHealthcare Medicare Advantage Plans
VA Health Plans
VA Health Plans
Virginia Commercial Health Plans
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VA Medicare Advantage Health Plans
Virginia AARP® Medicare Advantage Plans
VA Dual Complete® SNP
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Virginia Group Medicare Advantage Plans
Virginia UnitedHealthcare® MedicareDirect (PFFS)
Virginia Nursing Home Plan
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VA UnitedHealthcare Medicare Advantage 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
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UnitedHealthcare Dual Complete® Special Needs Plans
WA Health Plans
WA Health Plans
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UnitedHealthcare Community Plan of Washington Homepage
Behavioral Health
Bulletins and Newsletters
Bulletins and Newsletters
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Practice Matters
Behavioral Health Services
Care Coordination
Care Management
UnitedHealthcare Dual Complete: Washington Members Matched With a Navigator
Pregnancy Intention Screening: Family Planning for Social Change
Health Home Program
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Long-Term Services and Support
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Online Care Provider Directory
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Pharmacy Resources and Physician Administered Drugs
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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
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WV Medicare Advantage Health Plans
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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
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Prior Authorization and Notification
UnitedHealthcare Dual Complete® Special Needs Plans
WI Health Plans
WI Health Plans
Wisconsin Commercial Health Plans
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Wisconsin UnitedHealthcare Medicare Advantage Plans
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Wisconsin Nursing Home Plan
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UnitedHealthcare Community Plan of Wisconsin Homepage
Behavioral Health
Bulletins and Newsletters
Care Provider Manuals
Claims and Payments
Payment Policy Notifications
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Policies and Clinical Guidelines
Policies and Clinical Guidelines
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Prior Authorization and Notification
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Training and Education
UnitedHealthcare Dual Complete® Special Needs Plans
WY Health Plans
WY Health Plans
WY Commercial Health Plans
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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
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 2020 UnitedHealthcare Administrative Guide
Introduction
Introduction
Manuals and Benefit Plans Referenced in the Guide
Benefit Plans Subject to this Guide
Benefit Plans Not Subject to this Guide
Online Resources and How to Contact Us
Provider Responsibilities and Standards
Provider Responsibilities and Standards
Verifying Eligibility, Benefits and Your Network Participation
Healthcare Identification (ID) Card
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 Opt-Out
Additional MA Requirements
Filing a Lawsuit by a Member
Commercial Products
Commercial Products
Commercial Product Overview Table
Benefit Plan Types
PCP Selection Selection
Consumer-Driven Health Benefit Plans
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
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
Trauma Services
Medication-Assisted Treatment (MAT)
Specialty Pharmacy and Medicare Advantage Pharmacy
Specialty Pharmacy and Medicare Advantage Pharmacy
Commercial Pharmacy
Specialty Pharmacy Requirements for Certain Specialty Medications (Commercial Plans - Not Applicable to UnitedHealthcare West) - Chapter 7, 2020 UnitedHealthcare Administrative Guide
MA Pharmacy
Drug Utilization Review Program
Medication Therapy Management (MTM)
Transition Policy
Specific Protocols
Specific Protocols
Laboratory Services Protocol
Nursing Home and Assisted Living Plans
Non-Emergent Ambulance Ground Transportation
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
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 Concerns or Complaints
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
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 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
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
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 Bulletin and Provider News
Medical Policy Update Bulletin
Other Communications
All Savers Supplement
All Savers Supplement
How to Contact All Savers, All Savers Supplement
Capitation and/or Delegation Supplement
Capitation and/or Delegation Supplement
What is Capitation?
What Is a Delegated ACO?
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, Capitation and/or Delegation
Care Provider Responsibilities, Capitation and/or Delegation
Delegated Credentialing Program, Capitation and/or Delegation
Service Standards
Virtual Visits
Referrals & 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
Capitation Reports and Payments, Capitation and/or Delegation Supplement
Contractual and Financial Responsibilities, 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
Leased Networks
Medica Healthcare Supplement
Medica Healthcare Supplement
How to Contact Us, Medica
Confidentiality of Protected Health Information (PHI)
Referrals
Prior Authorizations
Appeals 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 Provider
OneNet PPO Supplement
OneNet PPO Supplement
Who to Contact
Referrals
Medical Records Standards and Requirements
Quality Management and Health Management Programs
Participant Rights and Responsibilities
Bills Process
Provider Responsibilities and Workflows
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
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 & 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
Eligibility, River Valley
How to Contact River Valley
Reimbursement Policies, River Valley
Referrals, River Valley
Utilization Management, River Valley
Claims Process, River Valley
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 & 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 & Grievances, UnitedHealthOne
Glossary
Reports and Quality Programs
Reports and Quality Programs
CAHPS / HOS
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
New Jersey Health Plans
UnitedHealthcare Community Plan of New Jersey Homepage
Bulletins and Newsletters
Practice Matters - New Jersey
Print
Practice Matters
