Ohio Care Provider Manual
Physician, Health Care Professional, Facility and Ancillary Care
Ohio: Medicaid and UnitedHealthcare Connected
Welcome
Welcome to the UnitedHealthcare Community Plan provider manual. This up-to-date reference manual allows you and your staff to find important information such as how to process a claim and submit prior authorization requests. This manual also includes important phone numbers and websites on the How to Contact Us page.
Find operational policy changes and other electronic tools on our website at UHCprovider.com.
Click the following links to access different manuals:
- UnitedHealthcare Administrative Guide for Commercial and Medicare Advantage member information. Some states may also have Medicare Advantage information in their Community Plan manual.
- A different Community Plan manual: go to UHCprovider.com. Click Menu on top left, select Administrative Guides and Manuals, then Community Plan Care Provider Manuals, select state.
If there is a conflict between your Agreement and this care provider manual, use this manual unless your Agreement states you should use it, instead. If there is a conflict between your Agreement, this manual and applicable federal and state statutes and regulations and/ or state contracts, applicable federal and state statutes and regulations and/or state contracts will control.
UnitedHealthcare Community Plan reserves the right to supplement this manual to help ensure its terms and conditions remain in compliance with relevant federal and state statutes and regulations.
This manual will be amended as policies change.
Terms and definitions as used in this manual:
- “Member” or “customer” refers to a person eligible and enrolled to receive coverage from a payer for covered services as defined or referenced in your Agreement.
- “You,” “your” or “provider” refers to any health care provider subject to this manual, including physicians, health care professionals, facilities and ancillary providers; except when indicated and all items are applicable to all types of health care providers subject to this guide.
- Community Plan refers to UnitedHealthcare’s Medicaid plan
- “Your Agreement,” “Provider Agreement” or “Agreement” refers to your Participation Agreement with us.
- “Us,” “we” or “our” refers to UnitedHealthcare Community Plan on behalf of itself and its other affiliates for those products and services subject to this guianualde.
- Any reference to “ID card” includes both a physical or digital card.
Questions About Material?
If you have questions about this manual or about our policies, please call Provider Services. See How to Contact Us at bottom of page.
Chapters
- Chapter 1: Introduction
- Chapter 2: Care Provider Standards & Policies
- Chapter 3: Care Provider Office Procedures and Member Benefits
- Chapter 4: Medical Management
- Chapter 5: Early, Periodic Screening, Diagnosis and Treatment (EPSDT) / Prevention
- Chapter 6: Value-Added Services
- Chapter 7: Mental Health and Substance Use
- Chapter 8: Member Rights and Responsibilities
- Chapter 9: Medical Records
- Chapter 10: Quality Management (QM) Program and Compliance Information
- Chapter 11: Billing and Submission
- Chapter 12: Claim Reconsiderations, Appeals and Grievances
- Chapter 13: Care Provider Communications & Outreach
- Chapter 14: Glossary
How to Contact Us
Optum providerexpress.com
866-209-9320 (toll-free)
Eligibility, claims, benefits, authorization and appeals.
Refer members for behavioral health services. A PCP referral is not required.
Medical Care Management Services: 800- 508-2581
Call Monday through Friday, 8 a.m. to 5 p.m., Central Time.
Behavioral Health Care Management: 866-261-7692
Call 24 hours a day, 7 days a week for help with with referrals, prior authorizations, admissions, discharges and coordination of members’ care.
myoptumhealthphysicalhealth.com
We provide members older than 21 with up to six visits per calendar year with an in-network chiropractor. This benefit does not need prior authorization.
Use the UnitedHealthcare Provider Portal at UHCprovider.com/claims
Mailing address:
UnitedHealthcare Community Plan
P.O. Box 8207 Kingston, NY 12402
Verify a claim status or get information about proper completion or submission of claims.
See the Overpayment section for requirements before sending your request.
Sign in to UHCprovider.com/claims to access the Provider Portal, then select the UnitedHealthcare Online app
Mailing address:
UnitedHealthcare Community Plan
ATTN: Recovery Services
P.O. Box 740804 Atlanta, GA 30374-0800
Ask about claim overpayments.
DentaQuest: 800-341-8478
Call DentaQuest to find a network provider.
Fax 866-839-8058
Fax requests for medically necessary durable medical equipment.
Information is also available at UHCprovider.com/edi.
To access eligibility information, go to UHCprovider.com then Sign In to the Provider Portal or go to UHCprovider.com/eligibility
Interactive Voice Response 888-586-4766
Confirm member eligibility online or call our toll- free Interactive Voice Response (IVR) system 24 hours a day, 7 days a week.
The Enterprise Voice Portal provides self-service functionality or call steering prior to speaking with a contact center agent.
Notify us of suspected fraud or abuse by a care provider or member.
Refer high-risk OB members. Fax initial prenatal visit form.
UHCprovider.com > Find Dr > Preferred Lab Network
LabCorp: 800-833-3984
Quest Diagnostics: questdiagnostics.com
LabCorp and Quest Diagnostics are network laboratories.
Sign in to the Provider Portal at UHCprovider.com or go to UHCprovider.com/claims for more information.
Reconsiderations mailing address:
UnitedHealthcare Community Plan
P.O. Box 8207
Kingston, NY 12402-5240
Appeals mailing address:
UnitedHealthcare Community Plan Grievances and Appeals
P.O. Box 31364
Salt Lake City, UT 84131-0364
Claim issues include overpayment, underpayment, payment denial, or an original or corrected claim determination you don’t agree with.
Medicaid: 800-895-2017 Relay 711 (TTY)
7 a.m. – 7 p.m. Central Time, Monday through Friday.
MyCare: 877-542-9236 (TTY 711)
8 a.m. – 8 p.m. Central Time, Monday through Friday. Voicemail available 24 hours a day, seven days a week.
Assist members with issues or concerns.
Refer members for behavioral health services. (A PCP referral is not required.)
*See Behavioral Health row for more information.
Member Services
Medicaid: 800-895-2017 Relay 711 (TTY)
7 a.m. – 7 p.m. Central Time, Monday through Friday.
MyCare: 877-542-9236 (TTY 711)
8 a.m. – 8 p.m. Central Time, Monday through Friday. Voicemail available 24 hours a day, seven days a week.
Self-service functionality to update or check credentialing information.
Ask about contracting and care provider services.
888-980-8728 or TTY 711 for hearing impaired
Available 24 hours a day, seven days a week.
Healthy First Steps 800-599-5985
Pregnancy Notification Form at UHCprovider.com
800-599-5985
Fax: 877-353-6913
Links for pregnant moms and newborn babies.
Contact if you have issues with your ID. Available 7 a.m. – 9 p.m. Central Time, Monday through Friday; 6 a.m. – 6 p.m. Central Time, Saturday; and 9 a.m. – 6 p.m. Central Time, Sunday.
877-305-8952 (OptumRx)
Technical Help Desk (pharmacies call): 877-305-8952
OptumRx oversees and manages our network pharmacies.
UHCprovider.com > Prior Authorization and Notification > Clinical Pharmacy and Specialty Drugs
Medicaid: 800-310-6826
Fax: 866-940-7328
MyCare: 800-711-4555
Provider Pharmacy Prior Authorization Help Desk: 800-310-6826
Help Desk Fax: 866-940-7328
Request authorization for medications as required.
Use UnitedHealthcare Provider Portal to access the PreCheck MyScript tool. Request prior authorization and receive results, and see which prescriptions require prior authorization or are not covered or preferred Check coverage and price, including lower-cost alternatives.
UHCprovider.com > Prior Authorization and Notification
Medicaid: 866-604-3267
Fax: 866-622-1428
MyCare: 800-366-7304
Request authorization/notify of the procedures and services outline in the prior authorization/ notification requirements section of this manual.
Complete and current list of prior authorizations.
UHCprovider.com/priorauth > Prior Authorization Notification Tool
The process for completing the notification/ prior authorization request and time frames remains the same. Learn how to use the prior authorization advanced notification (PAAN) tool, complete the notification/prior authorization process or confirm a coverage decision.
Call 7 a.m. to 7 p.m. local time, Monday through Friday.
UHCprovider.com/OHcommunityplan
UnitedHealthcare Community Plan
9200 Worthington Road, 3rd Floor
Worthington, OH 43082
Available 8 a.m. – 5 p.m. Central Time, Monday through Friday.
UHCprovider.com > Prior Authorization and Notification > Radiology
Request prior authorization of the procedures and services outlined in this manual’s prior authorization requirements.
Complete and current list of prior authorizations.
UHCprovider.com > Click Menu on top left, then select Referrals or use Provider Services
Submit new referral requests and check the status of referral submissions.
UHCprovider.com/OHcommunityplan > Bulletins and Newsletters
Reimbursement policies that apply to UnitedHealthcare Community Plan members. Visit this site often to view reimbursement policy updates.
Ask about services for quitting tobacco / smoking.
MTM 800-269-4190
Call Member Services to schedule transportation or for transportation assistance through MTM. To arrange non-urgent transportation, please call three days in advance.
UM helps avoid overuse and under-use of medical services by making clinical coverage decisions based on available evidence-based guidelines.
Request a copy of our UM guidelines or information about the program.
Care providers must participate in the VFC Program administered by the Department of Health and Senior Services (DHSS) and must use the free vaccine when administering vaccine to qualified eligible children. Providers must enroll as VFC providers with DHSS to bill for the administration of the vaccine.
March Vision marchvisioncare.com
Prior authorization is required for all routine eye exams and hardware. Authorizations must be obtained from March Vision.
UHCprovider.com/OHcommunityplan
Access your state-specific Community Plan information on this website.
Refer high-risk members (e.g., asthma, diabetes, obesity) and members who need private-duty nursing.