2018 UnitedHealthcare Care Provider …

1 2018 UnitedHealthcare care ProviderAdministrative Guidei | 2018 UnitedHealthcare care Provider administrative GuideWelcome to UnitedHealthcare 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 health care providers. This guide has useful contact information such as addresses, phone numbers and websites. More policies and electronic tools are available on If you are looking for a Community and State manual, go to > Health care Professionals, and select the correct state.

2 If you are looking for a UnitedHealthcare Dual Complete manual in Arizona, Massachusetts, New Jersey, New York or Tennessee, go to All other UnitedHealthcare Dual Complete plans follow this Provider administrative may easily find information in this guide using the following steps:1. Hold keys CTRL+ Type in the key Press Enter. Depending upon the version of PDF software you have, you may also use the binoculars icon to search for key 2018 UnitedHealthcare care Provider administrative guide (this guide ) applies to covered services you provide to our members or the members of our affiliates* through our benefit plans insured by or receiving administrative services from us, unless otherwise guide is effective April 1, 2018 for physicians, health care professionals, facilities and ancillary providers currently participating in our commercial and Medicare networks.

3 It is effective now for care providers who join our network on or after Jan. 1, 2018 . This guide is subject to change. We frequently update content in our effort to support our health care Provider 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 as defined or referenced in your agreement with us. Commercial refers to all UnitedHealthcare medical products that are not MA, Medicare Supplement, Medicaid, CHIP, workers compensation, or other governmental programs.

4 Commercial also applies to benefit plans for the Health Insurance Marketplace, government employees or students at public universities. You, your or Provider refers to any health care Provider subject to this guide , 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 . Us, we or our refers to UnitedHealthcare on behalf of itself and its other affiliates for those products and services subject to this 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 UnitedHealthcare Medicare Direct members and MA members enrolled in UnitedHealthcare Community Plan Medicare Advantage plans, and UnitedHealthcare Dual Complete members in Arizona, Massachusetts.

5 New Jersey, New York and Tennessee. If a particular section does not apply to such MA members, it is 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 there is an inconsistency between your agreement with us and this guide , your agreement controls (except where your agreement with us provides protocols for our affiliates). If those protocols are in a supplement to this guide , those protocols control for services you give to a member subject to that supplement.

6 * UnitedHealthcare affiliates offering commercial and Medicare Advantage benefit plans and other services, are outlined in Chapter 1: | 2018 UnitedHealthcare care Provider administrative Guideii | 2018 UnitedHealthcare care Provider administrative GuideContentsWelcome to UnitedHealthcare ..1 Chapter 1: Introduction 1 Manuals and Benefit Plans Referenced in This guide ..1 Online Resources and How to Contact Us ..3 Chapter 2: Provider Responsibilities and Standards 6 Electronic Data Interchange (EDI) ..6 Verifying Eligibility, Benefits and Your Network Participation Status.

7 6 Health care Identification (ID) Cards ..6 Access Standards ..8 Primary care Physicians (PCP) Responsibilities ..9 Demographic Changes ..9 administrative Terminations for Inactivity ..11 Continuity of care Following Termination of Your Participation ..11 Medicare Opt-Out ..11 Additional MA Requirements ..11 Filing of a Lawsuit by a Member ..13 Chapter 3: Commercial Products 14 Commercial Product Overview Table..14 Benefit Plan Types ..16 Primary care Providers (PCP) Selection ..16 HRAs and HSAs Consumer-Driven Health Benefit Plans ..16 Chapter 4: Medicare Products 17 Medicare Product Overview Tables.

8 17 Coverage Summaries and Policy Guidelines MA Members ..20 Medicare Supplement Benefit Plans ..20 Chapter 5: Referrals 22 Commercial Products Referrals ..22 Non-Participating care Provider Referrals (All Commercial Plans) ..23 Medicare Advantage (MA) Referral Required Plans ..24 Chapter 6: Medical Management 25 Benefit Plans Not Subject to this Protocol ..25 Advance Notification/Prior Authorization Requirements ..25 Advance Notification/Prior Authorization List ..26 Facilities: Standard Notification Requirements ..27 Facility Denial Process ..28 How to Submit Advance or Admission Notifications/ Prior Authorizations.

9 29 Updating Advance Notification or Prior Authorization Requests ..29 Coverage and Utilization Management Decisions ..29 Pre-Service Appeals ..31 Clinical Trials, Experimental or Investigational Services ..31 Medical Management Denials/Adverse Determinations ..31MA Part C Reopenings ..32 Outpatient Cardiology Notification/Prior Authorization Protocol ..33 Outpatient Radiology Notification/Prior Authorization Protocol ..37 Trauma Services ..40 Chapter 7: Specialty Pharmacy and Medicare Advantage Pharmacy 42 Commercial Pharmacy ..42 Specialty Pharmacy Requirements for Certain Specialty Medications (Commercial Plans not applicable to UnitedHealthcare West).

10 42MA Pharmacy ..43 Drug Utilization Review Program ..45 Medication Therapy Management (MTM) ..46 Transition Policy ..46 Chapter 8: Specific Protocols 47 Air Ambulance, Fixed-Wing Non-Emergency Transport ..47 Laboratory Benefit Management Program Administered by BeaconLBSTM (Florida Only) ..47 Laboratory Services Protocol ..47 Non-Participating Providers Consent Form ..48 Nursing Home and Assisted Living Plans ..49 Chapter 9: Our Claims Process 51 Electronic Payments and Statements (EPS) ..51 Claims and Encounter Data Submissions ..52 Risk Adjustment Data MA and Commercial.