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Administrative Guides and Manuals
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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
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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
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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
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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
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Specific Protocols
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Laboratory Services Protocol
Nursing Home and Assisted Living Plans
Our Claims Process
Our Claims Process
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Claims and Encounter Data Submissions
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National Provider Identification (NPI)
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Quality Management (QM) Program
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Member Satisfaction
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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
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Examples of Potentially Fraudulent, Wasteful, or Abusive Billing (not an inclusive list)
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Provider Communication
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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
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
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
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
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
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Reports and Quality Programs
CAHPS / HOS
Home Health and SNF High-Performing Provider Initiative Lists
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PATH
Peer Comparison Reports
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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
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