Transcription
University of Utah Health PlansProvider ManualUniversity of Utah Health PlansProvider ManualUniversity Health Care PlusHealthy UHealthy AdvantageHealthy Advantage PlusHealthy PreferredHealthy PremierGrand Valley Preferred-1–Provider Manual 03212017.docVersion 03.21.17
University of Utah Health PlansProvider ManualTable Of ContentsRevision Date: 01/01/2017General Information . 5University of Utah Health Plans – An Introduction. 6UUHP Contact Information . 7Provider Responsibilities . 8Provision of Covered Services . 8Service Delivery / Non-Discrimination . 8Physical Facilities . 8Medical Records . 8Patient Confidentiality & HIPAA . 9Medical Necessity . 9Compliance with UUHP Policies and Procedures . 9Compliance with State & Federal Regulations (Medicaid & Medicare Advantage) . 10Licensure & Insurance . 10Notification of Changes . 10Complaint Resolution . 10Appointment Wait times . 11Appointment Scheduling . 11Office Wait Times. 11After Hours Care . 11Access Standards . 11Credentialing & Recredentialing . 12Practitioners . 12Monitoring of Provider Sanctions and Disciplinary Actions . 12Institutional & Supply Providers . 12Site Audits & Ensuring Appropriate Physical Facilities. 13Billing & Claims Payment . 14Claims Submission Requirements . 14Claims Review and Audit . 14Remittance Advice . 14Timely Filing Requirement . 15Overpayments . 15Coordination of Benefits . 16Electronic Data Interchange (EDI) . 16Corrected Claims . 16Claims Appeal Process . 17Claims Editing . 18Mid-Level Provider Reimbursement . 18Member Rights & Responsibilities . 19Member Rights. 19-2–Provider Manual 03212017.docVersion 03.21.17
University of Utah Health PlansProvider ManualMember Responsibilities . 19Provider Complaints . 21On behalf of a Member . 21Regarding Health Plan Policies . 21Utilization and Case Management . 22Key Program Components . 22Program Purpose . 22General Structure . 23Rules and Regulations. 26Advanced Directives . 26Domestic Abuse, Neglect and/or Exploitation. 26Medicaid Fraud Abuse Prevention and Detection . 27Fraud Detection & Prevention: . 27Newborn and Mothers’ Health Protection Act . 28University Health Care Plus. 29Eligibility Verification . 29Prescriptions . 29Case Management . 29UHCP Utilization Review Guidelines . 29Medical Appeals Process . 30Healthy U (Medicaid Managed Care) . 31Service Area . 31Use of Primary Care Providers . 31Receiving Care . 31Care Management . 31General Policies Regarding Covered Services . 32Non-Covered Services . 32Verification of Eligibility. 33‘Lock-in’ or Medicaid Restriction Program . 34Direct Billing of Services. 34Medically Necessary . 35Emergency Services . 35Out-of-network . 35Translation Services . 36Women’s Services . 36Family Planning Services . 36Foster Children. 37Child Health Evaluation and Care (CHEC) . 37Utilization Management. 43Medical Appeals Process . 45State Fair Hearing Process . 46Healthy Advantage (Medicare Advantage Special Needs) . 47Advantages of Participating with Healthy Advantage & Healthy U . 48Service Area . 48General Plan Information . 48Eligibility & Enrollment . 48-3–Provider Manual 03212017.docVersion 03.21.17
University of Utah Health PlansProvider ManualEligibility Card. 51Member Rights & Responsibilities . 51Billing of Members . 51Benefits Summary. 52Healthy Advantage Medical Pre-Authorization / Utilization Management . 52Medical Appeals Process . 53Pharmacy Benefits . 53Mental Health Benefits . 57Healthy Advantage Provider Responsibilities . 62Healthy Advantage Payments . 64Healthy Advantage Plus (HMO) . 65Service Area . 66General Plan Information . 66Eligibility & Enrollment . 66Eligibility Card. 68Member Rights & Responsibilities . 68Billing of Members. 69Benefits Summary . 69Healthy Advantage Plus Medical Pre-Authorization / Utilization Management. 69Medical Appeals Process . 70Pharmacy Benefits . 70Mental Health Benefits . 74Healthy Advantage Plus Provider Responsibilities . 79Healthy Advantage Plus Payments . 81Healthy Premier Individual and Family Plans . 82Service Area . 82Plan Categories and Benefits . 82Individual Plan Provider Appeals . 82Coverage and Eligibility . 83Coverage for Dependent Child Due to Court or Administrative Order . 83Premiums. 86Utilization Review Guidelines . 87Utilization Review Guidelines and limitations can be found on our website at: . dual.pdf. 87Healthy Premier, Healthy Preferred and Grand Valley Preferred Group Plans . 88Healthy Premier Group Plans . 88Healthy Preferred Group Plans . 88Grand Valley Preferred Group Plans . 88Healthy Premier, Healthy Preferred and Grand Valley Preferred Group Appeals . 88-4–Provider Manual 03212017.docVersion 03.21.17
University of Utah Health PlansProvider ManualGeneral InformationThe provider manual is broken into six main sections: A general section containing policies andprocedures that apply to all UUHP products, and five additional sections, one for each of the fiveproducts offered by UUHP. Where policies and procedures (p&p) contained within one of thethree product sections overlaps with the same p&p in the General Section, the p&p in theProduct Section supersedes that part of the p&p in the General Section.This provider manual is considered an attachment to and thereby part of all executedUniversity of Utah Health Plans Provider Services agreements as referenced thereto andincorporated therein.-5–Provider Manual 03212017.docVersion 03.21.17
University of Utah Health PlansProvider ManualUniversity of Utah Health Plans – An IntroductionWelcome to the University of Utah HeathPlans (UUHP). We value and honor thedistinctive connection that you share withour members.UUHP was organized in 1998 with theformation of Healthy U (a MedicaidManaged Care Plan) as a managed careentity to handle the administrative functionsof Healthy U. Our initial enrollment wasapproximately 3,000 members. Since ourinception, we have grown to over 48,000Healthy U members, and have addedseveral lines of business.In 1999, the University of Utah Health Plan(now known as University Health Care Plus)was added. University Health Care Plus(UHCP) is a self-funded health plan for theemployees of the University of Utah andtheir dependents.Effective July 1, 2016, University HealthCare Plus will be administered by RegenceBlueCross BlueShield of Utah in a new jointventure between Cambia and the Universityof Utah.In subsequent years we became the claimsadministrator for the other University andState projects – UNI HOME, as well theUniversity’s behavioral health benefits.We partner with Molina Health to administerHealthy Advantage and Healthy AdvantagePlus. Healthy Advantage is a Special NeedsMedicare Advantage plan. As a specialneeds plan, Healthy Advantage serves theneeds of members who are enrolled inMedicare Parts A&B, as well as in one ofthe State’s Medicaid plans. Healthy-6–Provider Manual 03212017.docVersion 03.21.17Advantage Plus HMO is a Medicare Part Cplan that offers exceptional healthcarefor Utah seniors. UUHP oversees alloperational managed care plan functions;including provider relations, credentialing,quality improvement programs, memberservices, claims processing as well asutilization and case management services.Molina Healthcare oversees the priorauthorizations and provider directories forHealthy Advantage and Healthy AdvantagePlus.Healthy Premier is a commercial plan thatwe offer to employer groups and individualsthroughout the state of Utah andsurrounding areas. Healthy Preferred is acommercial plan that we offer to employergroups, primarily along the Wasatch Front,for their employees.Grand Valley Preferred is a commercial planthat we offer to employer groups in the stateof Colorado.As a member of the University Health Careteam, we ho
Trading Partner Number: HT000179-002 Paper Claims University of Utah Health Plans PO Box 45180 Salt Lake City, UT 84145-0180 UUHP Telephone and Fax Numbers University Healthcare Plus, Healthy Premier and Healthy Preferred Healthy U Healthy Advantage and Healthy Advantage Plus Claim Inquiries / Customer Service 801 -587 -6480 Opt 4 .File Size: 1MB
