2019 UnitedHealthcare Care Provider Administrative Guide

Transcription

2019UnitedHealthcare Care ProviderAdministrative Guide

Welcome to UnitedHealthcareWelcome to the UnitedHealthcare Care Provider Administrative Guide for Commercial and Medicare Advantage (MA) products.This guide has important information on topics such as claims and prior authorizations. It also has protocol information forhealth care providers. This guide has useful contact information such as addresses, phone numbers and websites. Morepolicies and electronic tools are available on UHCprovider.com. If you are looking for a Community and State manual, go to UHCprovider.com/guides Community Plan Care ProviderManuals and select the stateYou may easily find information in this guide using these steps:1. Hold keys CTRL F.2. Type in the key word.3. Press Enter.Depending upon the version of PDF software you have, you may also use the binoculars icon to search for key words.This 2019 UnitedHealthcare Care Provider Administrative Guide (this “guide”) applies to covered services you provide to ourmembers or the members of our affiliates* through our benefit plans insured by or receiving administrative services from us,unless otherwise noted.This guide is effective April 1, 2019 for physicians, health care professionals, facilities and ancillary providers currentlyparticipating in our Commercial and MA networks. It is effective now for care providers who join our network on or after Jan. 1,2019. This guide is subject to change. We frequently update content in our effort to support our health care provider networks.Terms and definitions as used in this guide: “Member” or “customer” refers to a person eligible and enrolled to receive coverage from a payer for covered services asdefined or referenced in your Agreement. “Commercial” refers to all UnitedHealthcare medical products that are not MA, Medicare Supplement, Medicaid, CHIP,workers’ compensation, or other governmental programs. “Commercial” also applies to benefit plans for the Health InsuranceMarketplace, government employees or students at public universities. “You,” “your” or “provider” refers to any health care provider subject to this guide, including physicians, health careprofessionals, facilities and ancillary providers; except when indicated and all items are applicable to all types of health careproviders subject to this guide. “Your Agreement,” “Provider Agreement” or “Agreement” refers to your Participation Agreement with us. “Us,” “we” or “our” refers to UnitedHealthcare on behalf of itself and its other affiliates for those products and servicessubject to this guide.MA policies, protocols and information in this guide apply to covered services you provide to UnitedHealthcare MA members,including Erickson Advantage members and most UnitedHealthcare Dual Complete members, but excluding UnitedHealthcareMedicare Direct members. We indicate if a particular section does not apply to such MA members.If there is a conflict or inconsistency between a Regulatory Requirements Appendix attached to your Agreement and this guide,the provisions of the Regulatory Requirements Appendix controls for benefit plans within the scope of that appendix.If there is an inconsistency between your Agreement and this guide, your Agreement controls (except where your Agreementprovides protocols for our affiliates). If those protocols are in a supplement to this guide, those protocols control for servicesyou give to a member subject to that supplement.Per your Agreement, you must comply with protocol. Payment will be denied, in whole or in part, for failure to comply with aprotocol.*UnitedHealthcare affiliates offering commercial and Medicare Advantage benefit plans and other services, are outlined in Chapter 1: Introduction.i 2019 UnitedHealthcare Care Provider Administrative Guide

ContentsContentsChapter 1: Introduction1Chapter 2:Provider Responsibilities and Standards7Manuals and Benefit Plans Referenced in This Guide. . . . . . . . . 1Online Resources and How to Contact Us. . . . . . . . . . . . . . . . . . 3Verifying Eligibility, Benefits and Your NetworkParticipation Status. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7Health Care Identification (ID) Cards. . . . . . . . . . . . . . . . . . . . . . . 7Access Standards. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9Primary Care Physicians (PCP) Responsibilities. . . . . . . . . . . . 10Demographic Changes. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10Notification of Practice or Demographic Changes(Applies to Commercial Benefit Plans in California). . . . . . . . . 12Administrative Terminations for Inactivity . . . . . . . . . . . . . . . . . 12Member Dismissals Initiated by a PCP(Medicare Advantage). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12Medicare Opt-Out . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13Additional MA Requirements. . . . . . . . . . . . . . . . . . . . . . . . . . . 13Filing of a Lawsuit by a Member. . . . . . . . . . . . . . . . . . . . . . . . . 14Chapter 3: Commercial Products16Commercial Product Overview Table. . . . . . . . . . . . . . . . . . . . . 16Benefit Plan Types. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18PCP Selection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18Consumer-Driven Health Benefit Plans. . . . . . . . . . . . . . . . . . . 19Chapter 4: Medicare Products20Medicare Product Overview Tables. . . . . . . . . . . . . . . . . . . . . . 20PCP Selection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23Coverage Summaries and Policy Guidelinesfor MA Members . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23Dual Special Needs Plans Managed by Optum . . . . . . . . . . . . 23Medicare Supplement Benefit Plans. . . . . . . . . . . . . . . . . . . . . 24Free Medicare Education for Your Staff and Patients. . . . . . . . 25Chapter 5: Referrals26Chapter 6: Medical Management29Commercial Products Referrals. . . . . . . . . . . . . . . . . . . . . . . . . 26Non-Participating Care Provider Referrals(All Commercial Plans) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27Medicare Advantage (MA) Referral Required Plans. . . . . . . . . 27Benefit Plans Not Subject to this Protocol. . . . . . . . . . . . . . . . . 29Advance Notification/Prior Authorization Requirements. . . . . 29Advance Notification/Prior Authorization List. . . . . . . . . . . . . . 30Facilities: Standard Notification Requirements. . . . . . . . . . . . . 31How to Submit Advance or Admission Notifications/Prior Authorizations* . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33Updating Advance Notificationor Prior Authorization Requests . . . . . . . . . . . . . . . . . . . . . . . . 33Coverage and Utilization Management Decisions . . . . . . . . . . 34Pre-Service Appeals. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35Clinical Trials, Experimental or Investigational Services. . . . . . 35Medical Management Denials/Adverse Determinations. . . . . 35MA Part C Reopenings. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36Outpatient Cardiology Notification/Prior Authorization Protocol. . . . . . . . . . . . . . . . . . . . . . . . . . . . 37Outpatient Radiology Notification/Prior Authorization Protocol. . . . . . . . . . . . . . . . . . . . . . . . . . . . 41Trauma Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45Chapter 7: Specialty Pharmacy and MedicareAdvantage Pharmacy46Commercial Pharmacy. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46Specialty Pharmacy Requirements for Certain SpecialtyMedications (Commercial Plans – not applicable toUnitedHealthcare West) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46MA Pharmacy (Includes UnitedHealthcareDual Special Needs Plans [DSNP]) . . . . . . . . . . . . . . . . . . . . . . 47Drug Utilization Review Program. . . . . . . . . . . . . . . . . . . . . . . . 49Medication Therapy Management (MTM). . . . . . . . . . . . . . . . . 50Transition Policy. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50Chapter 8: Specific Protocols51Chapter 9: Our Claims Process55Air Ambulance, Fixed-Wing Non-Emergency Transport . . . . . 51Laboratory Benefit Management ProgramAdministered by BeaconLBSTM (Florida Only). . . . . . . . . . . . . . 51Laboratory Services Protocol. . . . . . . . . . . . . . . . . . . . . . . . . . . 51Non-Participating Providers Consent Form . . . . . . . . . . . . . . . 52Nursing Home and Assisted Living Plans. . . . . . . . . . . . . . . . . 53Electronic Payments and Statements (EPS). . . . . . . . . . . . . . . 55Claims and Encounter Data Submissions. . . . . . . . . . . . . . . . . 56Risk Adjustment Data – MA and Commercial. . . . . . . . . . . . . . 57National Provider Identification (NPI). . . . . . . . . . . . . . . . . . . . . 58Medicare Advantage Claim Processing Requirements. . . . . . 58Claim Submission Tips. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59Pass-through Billing/CLIA Requirements/Reimbursement Policy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60Special Reporting Requirements for Certain Claim Types . . . 60Overpayments. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61Subrogation and Coordination of Benefits . . . . . . . . . . . . . . . . 62Claim Correction and Resubmission. . . . . . . . . . . . . . . . . . . . . 63Claim Reconsideration, Appeals Processand Resolving Disputes. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63Resolving Disputes – Concern or Complaint . . . . . . . . . . . . . . 65Member Appeals, Grievances or Complaints. . . . . . . . . . . . . . 67Medical Claim Review. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 67ii 2019 UnitedHealthcare Care Provider Administrative Guide

ContentsChapter 10: Compensation68Reimbursement Policies. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 68Charging Members. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 68Member Financial Responsibility. . . . . . . . . . . . . . . . . . . . . . . . 70Preventive Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 70Provider Audits - Extrapolation. . . . . . . . . . . . . . . . . . . . . . . . . . 70Hospital Audit Services. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 70Audit Failure Denials . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 71Notice of Medicare Non-Coverage (NOMNC). . . . . . . . . . . . . . 72Chapter 11: Medical Records Standardsand Requirements73Chapter 12:Health and Disease Management75Chapter 13:Quality Management (QM) Program78Chapter 14:Credentialing and Recredentialing80Health Management Programs. . . . . . . . . . . . . . . . . . . . . . . . . . 75Special Needs Plans (SNP). . . . . . . . . . . . . . . . . . . . . . . . . . . . . 75Case Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 75Wellness and Behavioral Health Programs. . . . . . . . . . . . . . . . 76Consumer Transparency Tools. . . . . . . . . . . . . . . . . . . . . . . . . . 76Behavioral Health Information . . . . . . . . . . . . . . . . . . . . . . . . . . 76UnitedHealth Premium Program (Commercial Plans) . . . . . . 79Star Ratings for MA and Prescription Drug Plans. . . . . . . . . . . 79Member Satisfaction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 79Imaging Accreditation Protocol . . . . . . . . . . . . . . . . . . . . . . . . . 79Credentialing/Profile Reporting Requirements. . . . . . . . . . . . . 80Care Provider Rights Related to the Credentialing Process . . 80Credentialing Committee Decision Making Process(Non-Delegated). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 81Monitoring of Network Care Providersand Health Care Professionals. . . . . . . . . . . . . . . . . . . . . . . . . . 81Chapter 15:Member Rights and Responsibilities82Chapter 16:Fraud, Waste and Abuse (FWA)83Medicare Compliance Expectations and Training . . . . . . . . . . 83Exclusion Checks . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 83New Preclusion List Policy. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 84Examples of Potentially Fraudulent, Wasteful,or Abusive Billing(not an inclusive list) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 84Prevention and Detection. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 84Corrective Action Plans. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 85Beneficiary Inducement Law . . . . . . . . . . . . . . . . . . . . . . . . . . . 85Reporting Potential Fraud, Waste or Abuseto UnitedHealthcare. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 85Chapter 17: Provider Communication86All Savers Supplement87Capitation and/or Delegation Supplement89Network Bulletin and Provider News . . . . . . . . . . . . . . . . . . . . 86Medical Policy Update Bulletin. . . . . . . . . . . . . . . . . . . . . . . . . . 86Other Communications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 86How to Contact All Savers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 87Capitated Providers. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 89Delegated Providers and Accountable Care Organizations. . . 89How to Contact Us. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 89Verifying Eligibility and Effective Dates . . . . . . . . . . . . . . . . . . . 90Commercial Eligibility, Enrollment, Transfers,and Disenrollment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 90Medicare Advantage (MA) Enrollment, Eligibilityand Transfers, and Disenrollment . . . . . . . . . . . . . . . . . . . . . . . 93Eligibility/Authorization Guarantee. . . . . . . . . . . . . . . . . . . . . . . 95Provider Responsibilities. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 95Delegated Credentialing Program. . . . . . . . . . . . . . . . . . . . . . 100Virtual Visits (Commercial HMO Plans CA only). . . . . . . . . . . 101Medical Management. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 105Pharmacy. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 111Facilities. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 112Claims Processes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 116Claims Disputes and Appeals. . . . . . . . . . . . . . . . . . . . . . . . . . 120Contractual and Financial Responsibilities. . . . . . . . . . . . . . . 122CMS Premiums and Adjustments . . . . . . . . . . . . . . . . . . . . . . 129Delegate Performance Management Program. . . . . . . . . . . . 131Appeals and Grievances. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 131Leased Networks133Medica HealthCare Supplement134Mid-Atlantic Regional Supplement146How to Contact Us. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 134Confidentiality of Protected Health Information (PHI). . . . . . . 137Referrals. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 137Prior Authorizations. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 138Appeal and Reconsideration Processes. . . . . . . . . . . . . . . . . 141Member Rights and Responsibilities . . . . . . . . . . . . . . . . . . . 142Documentation and Confidentiality of Medical Records. . . . 142Provider Reporting Responsibilities. . . . . . . . . . . . . . . . . . . . . 144Provider Responsibilities. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 147Referrals. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 148Prior Authorizations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 148Claims Process . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 150Capitation. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 150iii 2019 UnitedHealthcare Care Provider Administrative Guide

ContentsNeighborhood Health PartnershipSupplement152How to Contact NHP. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 152Discharge of a Member from Participating Provider’s Care . 155Laboratory Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 155Referrals. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 155Utilization Management (UM). . . . . . . . . . . . . . . . . . . . . . . . . . 156Claims Reconsiderations and Appeals. . . . . . . . . . . . . . . . . . 157Capitated Health Care Providers . . . . . . . . . . . . . . . . . . . . . . . 157OneNet PPO Supplement158Oxford Commercial Supplement165How to Contact OneNet PPO. . . . . . . . . . . . . . . . . . . . . . . . . . 159OneNet General Provider Administrative Requirements . . . . 159Referrals. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 160Utilization Review Components for Workers’ Compensation. . 160Workers’ Compensation Claims Process . . . . . . . . . . . . . . . . 160Resolving Disputes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 163Medical Records Standards and Requirements. . . . . . . . . . . 163Quality Management and Health Management Programs. . . 163Participant Rights and Responsibilities. . . . . . . . . . . . . . . . . . 164Oxford Commercial Product Overview . . . . . . . . . . . . . . . . . . 165How to Contact Oxford Commercial . . . . . . . . . . . . . . . . . . . . 165Care Provider Responsibilities and Standards . . . . . . . . . . . . 170Referrals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 174Utilization Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 175Using Non-Participating Health Care Providers or Facilities. . . 176Radiology, Cardiology and Radiation Therapy Procedures. . . 180Emergencies and Urgent Care. . . . . . . . . . . . . . . . . . . . . . . . . 184Utilization Reviews . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 186Claims Process . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 192Member Billing. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 194Claims Recovery, Appeals, Disputes and Grievances. . . . . . 195Quality Assurance. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 199Case Management and Disease Management Programs. . . 199Clinical Process Definitions . . . . . . . . . . . . . . . . . . . . . . . . . . . 200Member Rights and Responsibilities. . . . . . . . . . . . . . . . . . . . 202Medical and Administrative Policy Updates . . . . . . . . . . . . . . 202Preferred Care Partners SupplementRiver Valley Entities Supplement214UnitedHealthcare West Supplement224UnitedHealthOne Individual PlansSupplement245Glossary252Eligibility. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 214How to Contact River Valley . . . . . . . . . . . . . . . . . . . . . . . . . . . 214Reimbursement Policies. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 216Referrals. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 216Utilization Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 217Claims Process . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 220UnitedHealthcare West Information Regardingour Care Provider

Welcome to the UnitedHealthcare Care Provider Administrative Guide for Commercial and Medicare Advantage (MA) products. This guide has important information on topics such as claims and prior authorizations. It also has protocol information for . Virtual Visits (Commercial HMO Plans CA