Care Provider Resources For UnitedHealthcare Community Plan of Texas

Proud Texas Medicaid partner for 25 years

Welcome

For UnitedHealthcare Community Plan of Texas Proud Texas Medicaid partner for 25 years

Care Provider Resources For UnitedHealthcare Community Plan of Texas

Proud Texas Medicaid partner for 25 years

Welcome

For UnitedHealthcare Community Plan of Texas Proud Texas Medicaid partner for 25 years

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UnitedHealthcare Community Plan of Texas Homepage

We know you don't have time to spare, so we put all the UnitedHealthcare Community Plan resources you need in one place. Use the navigation on the left to quickly find what you're looking for. Be sure to check back frequently for updates.

Information about the End of Continuous Medicaid Coverage

Maternal & Child Health (MCH) Information

For important information from the Texas Department of State Health Services on Maternal & Child Health and the formula shortage, visit dshs.state.tx.us/mch.

For updates in pharmacological considerations in oral health care during pregnancy, visit DSHS's Oral Health Care During Pregnancy: Guidance for Texas Prenatal and Dental Providers.

Prior Authorization and Notification Resources

Learn More

Current Policies and Clinical Guidelines

Learn More

Provider Administrative Manual and Guides

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For Credentialing and Attestation updates, please contact the National Credentialing Center at 1-877-842-3210.

To Providers: Please update your enrollment and demographic information with TMHP (Texas Medicaid Healthcare Partnership). TMHP is HHSC’s provider enrollment administrator and serves as the authoritative source for HHSC Providers’ enrollment and demographic information. Once you update your enrollment and demographic information with TMHP, your data will be reconciled with the demographic information on file with the MCOs.

To make updates to your current enrollment (e.g. new practice locations or change of ownership updates), please access the web page titled “Provider Enrollment” and click on “Enroll Today” at the following URL: Provider Enrollment | TMHP.

For instructions on how to make demographic changes to your current enrollment, please access the web page titled “Provider Enrollment and Management System (PEMS): A Step-by-Step Guide” at the following URL: Provider Enrollment and Management System (PEMS) | TMHP.

Otherwise, you can contact TMHP directly at 800-925-9126 for assistance. 

Behavioral Health Providers

Learn how to join the Behavioral Health Network, review Community Plan Behavioral Health information, or submit demographic changes at Community Plan Behavioral Health.

Facility/Hospital-Based Providers, Group/Practice Providers and Individually-Contracted Clinicians

The state-specific requirements and process on how to join the UnitedHealthcare Community Plan network is found in the UnitedHealthcare Community Plan Care Provider Manuals.  

Learn about requirements for joining our network. 

The Centers for Medicare & Medicaid Services (CMS) established the Medicaid Managed Care Rule to:

  • Promote quality of care
  • Strengthen efforts to reform the delivery of care to individuals covered under Medicaid and Children’s Health Insurance Plans (CHIP)
  • Strengthen program integrity by improving accountability and transparency

Enhance policies related to program integrity With the Medicaid Managed Care Rule, CMS updated the type of information managed care organizations are required to include in their care provider directories.

Visit UHCCommunityPlan.com/TX for current member plan information including sample member ID cards, provider directories, dental plans, vision plans and more.

Plan information is available for:

  • Care Improvement Plus Dual Advantage (Regional PPO SNP)
  • Texas STAR
  • Texas STAR Kids
  • Texas STAR+PLUS
  • UnitedHealthcare Community Plan - Children's Health Insurance Program (CHIP)
  • UnitedHealthcare Connected (Medicare-Medicaid Plan)
  • UnitedHealthcare Dual Complete® (HMO SNP) and UnitedHealthcare Dual Complete® (HMO SNP)
  • UnitedHealthcare Dual Complete® (PPO SNP) 

Information available includes:

  • Current plan names
  • Plan details
  • Overvew of eligibility information
  • Member contact information
  • Member Handbook, which includes great information, including:
    • Member rights and responsibilities
    • Member complaints process
    • Member appeals process 

Member plan and benefit information can also be found at UHCCommunityPlan.com/TX and myuhc.com/communityplan.

The best way for primary care providers (PCPs) to view and export the full member roster is using the CommunityCare tool, which allows you to:  

  • Identify Medicaid recipients who need to have their Medicaid recertification completed and approved by the State Agency in order to remain eligible to receive Medicaid benefits
  • See a complete list of all members, or just members added in the last 30 days
  • Export the roster to Excel
  • View most Medicaid and Medicare SNP members’ plans of care and health assessments
  • Enter plan notes and view notes history (for some plans)
  • Obtain HEDIS information for your member population
  • Access information about members admitted to or discharged from an inpatient facility
  • Access information about members seen in an Emergency Department

For help using CommunityCare, please see our Quick Reference Guide. If you’re not familiar with our portal, go to UHCprovider.com/portal.

Check out Care Conductor in the UnitedHealthcare Provider Portal under Clinical & Pharmacy.

Complaint

The following complaint form can be sent to:

UnitedHealthcare Community Plan
PO Box 31364
Salt Lake City, UT 84131-0364

Claims Reconsiderations and Appeals

A Claims Reconsideration can be completed online faxed.  For more information, see UHCProvider.com > Claims & Payments > Submit a Corrected Claim, Claim Reconsideration/Begin Appeals Process.

An appeal can be sent to:

UnitedHealthcare Community Plan

 Attn:  Complaint and Appeals Dept.

 PO Box 31364

 Salt Lake City, UT 84131-0364

Appeals can be written in a letter format

The way you submit a referral request depends on the member’s plan. You can use Eligibility and Benefits to determine the right tool to use for your submission.

Visit the Referral Section for More Information

Reporting Fraud, Waste or Abuse to Us

When you report a situation that could be considered fraud, you’re doing your part to help save money for the health care system and prevent personal loss for others. If you suspect another provider or member has committed fraud, waste or abuse, you have a responsibility and a right to report it. 

Taking action and making a report is an important first step. After your report is made, we will work to detect, correct and prevent fraud, waste, and abuse in the health care system.

Call us at 1-844-359-7736 or visit uhc.com/fraud to report any issues or concerns.  

Reporting Fraud, Waste or Abuse to the State of Texas

You can report suspected fraud, waste, or abuse by recipients or providers in Texas health and human services programs online or by calling their toll-free fraud hotline. The Texas health and human services system includes:

  • Medicaid
  • The Supplemental Nutrition Assistance Program (SNAP, formerly known as Food Stamps)
  • Temporary Assistance for Needy Families (TANF)
  • Women, Infants, and Children (WIC) program
  • The Children's Health Insurance Program (CHIP)

Learn more about how to make a report to Texas Health Human Services.

UnitedHealthcare Dual Complete® Special Needs Plan

UnitedHealthcare Dual Complete Special Needs Plans (SNP) offer benefits for people with both Medicare and Medicaid. These SNP plans provide benefits beyond Original Medicare, and may include transportation to medical appointments and vision exams. Members must have Medicaid to enroll.

Learn more about the Dual Special Needs Program

Health Insurance Portability and Accountability Act (HIPAA) Information

HIPAA standardized both medical and non-medical codes across the health care industry and under this federal regulation, local medical service codes must now be replaced with the appropriate Healthcare Common Procedure Coding System (HCPCS) and CPT-4 codes.

Integrity of Claims, Reports, and Representations to the Government

UnitedHealth Group requires compliance with the requirements of federal and state laws that prohibit the submission of false claims in connection with federal health care programs, including Medicare and Medicaid. View our policy.

Disclaimer

If UHG policies conflict with provisions of a state contract or with state or federal law, the contractual / statutory / regulatory provisions shall prevail. To see updated policy changes, select the Bulletin section at left.