2021 Administrative Guide/ Care Provider Manual

1 Doc#: PMG care Provider ManualPhysician, Health care Professional, Facility and Ancillary care Provider Manual ( Administrative Guide)Tex a sChildren s Health insurance Program (CHIP), State of Texas Access Reform (STAR), STAR+ plus , STAR KidsServing the following service areas: Jefferson, Harris, Hidalgo, Nueces and Travis, as well as Medicaid Rural Service Area (MRSA) Central and MRSA NortheastCustomer Service: 888-887-9003 April 15, and unitedhealthcare Provider Portal2 | unitedhealthcare Community Plan Texas v 2022 UnitedHealthcareWelcomeWelcome to the unitedhealthcare Community Plan Provider Manual . This up-to-date reference PDF Manual allows you and your staff to find important information such as how to process a claim and submit prior authorization requests. This Manual also includes important phone numbers and websites on the How to Contact Us page. Find operational policy changes and other electronic transactions on our website at the following links to access different manuals: unitedhealthcare Administrative Guide for Commercial and Medicare Advantage member information.

2 Some states may also have Medicare Advantage information in their Community Plan Manual . A different unitedhealthcare Community Plan of Texas Manual : go to > Community Plan care Provider Manuals > find information in this Manual using the following steps:1. Select CTRL+ Type in the key Press Enter. If available, use the binoculars icon on the top right hand side of the PDF to search for information and topics. We greatly appreciate your participation in our program and the care you offer our members. If you have questions about the information in this Manual , or about our policies, please call Customer information about the use of this manualIf there is a conflict between your Agreement and this care Provider Manual , use this Manual unless your Agreement states you should use it, instead. If there is a conflict between your Agreement, this Manual and applicable federal and state statutes and regulations and/or state contracts, applicable federal and state statutes and regulations and/or state contracts will control.

3 unitedhealthcare Community Plan reserves the right to supplement this Manual to help ensure its terms and conditions remain in compliance with relevant federal and state statutes and Manual will be amended as policies agreementIn this Manual , we refer to your Participation Agreement as Agreement .Terms and definitions as used in this Manual : 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. You, your or Provider refers to any health care Provider subject to this Manual , 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. Community Plan refers to unitedhealthcare s Medicaid plan Your Agreement, Provider Agreement or Agreement refers to your Participation Agreement with us.

4 Us, we or our refers to unitedhealthcare Community Plan on behalf of itself and its other affiliates for those products and services subject to this guide. Any reference to ID card includes both a physical or digital | unitedhealthcare Community Plan Texas v 2022 UnitedHealthcareTable of ContentsChapter 1: Introduction 4 Chapter 2: care Provider Standards & Policies 17 Chapter 3: care Provider Office Procedures and Member Benefits 30 Chapter 4: Medical Management 37 Chapter 5: Long-Term Services and Supports (STAR Kids, STAR+ plus ) 70 Chapter 6: Early, Periodic Screening, Diagnosis and Treatment (EPSDT)/Prevention 80 Chapter 7: Value-Added Services 85 Chapter 8: Mental Health and Substance Use 86 Chapter 9: Member Rights and Responsibilities 94 Chapter 10: Medical Records 96 Chapter 11: Quality Management (QM) Program and Compliance Information 100 Chapter 12: Billing and Submission 107 Chapter 13: Claim Reconsiderations, Appeals and Grievances 119 Chapter 14: care Provider Communications & Outreach 133 Glossary 135 Appendices.

5 Table of Contents 1424 | unitedhealthcare Community Plan Texas v 2022 UnitedHealthcareChapter 1: IntroductionUnitedHealthcare Community Plan of Texas supports increased access, improved health outcomes and reduced costs by offering Medicaid benefits to the following members: Children and youth, from birth through 18 years of age, eligible for Medicaid. Pregnant women. Children eligible for the Children s Health insurance Program (CHIP). Adults who qualify for Texas Medicaid due to chronic conditions and financial eligibility. Children and young adults through age 20 with disabilities, including those in the Medically Dependent Children Program (MDCP).Program objectivesThe principle objectives of Texas Medicaid managed care are to: Emphasize early intervention Promote improved access to quality care , thereby significantly improving health outcomes for the target population, with a special focus on pre-natal and well-child care Promote member responsibility for their personal health care by helping them choose a health plan and PCP and by encouraging them to use of preventive primary care services Reduce the higher use of medical services which occurs when members obtain non-urgent or emergent acute care through emergency rooms or access duplicate services for the same medical condition Encourage eligible members to choose a dental plan and a main dentistThis collaborative approach to health care delivery helps reduce costs by eliminating duplicate services and unnecessary emergency and inpatient care .

6 Key contactsTopicLinkPhone NumberProvider , then Sign In using your One Healthcare ID or go to Provider Portal Self Service: users: > New User and User Access888-887-9003 Provider Portal Supportemail: Provider Portal TrainingCommunityCare Provider Portal User GuideResource > Resources > Resource LibraryLooking for something else? In PDF view, click CTRL+F, then type the keyword. In web view, type your keyword in the what can we help you find? search 1: Introduction5 | unitedhealthcare Community Plan Texas v 2022 UnitedHealthcareFor STAR+ plus : Improve access to care , provides care in the least restrictive setting Provide more accountability and control on costs through service coordination Integrate acute care and long-term services and supports (LTSS)Our programsChildren s Health insurance Program (CHIP) CHIP is health insurance designed for families who earn too much money to qualify for Medicaid, yet cannot afford to buy private health insurance .

7 To qualify for CHIP, a child must be younger than age 19, a Texas resident, and a citizen or legal permanent CHIP Perinate services must meet the definition of medically necessary covered services. There is no lifetime maximum on benefits; however, 12-month enrollment period or lifetime limitations do apply to certain services. CHIP Perinate newborns are eligible for 12 months of continuous coverage, beginning with the month of enrollment as a CHIP Perinate. The CHIP Perinate mother is eligible for limited coverage during prenatal and postnatal of Texas Access Reform (STAR)The STAR Program emphasizes early intervention and promotes improved access to quality care , significantly improving health outcomes for the target populations. The special focus of the STAR Program is on pre-natal and well-child +PLUSThe STAR+ plus program improves access to care , provides care in the least restrictive setting, and provides more accountability and control on costs.

8 STAR+ plus integrates acute care and long-term care services. Service coordination is fundamental to managing the complex needs of these KidsThe STAR Kids program provides Medicaid benefits to children and young adults with disabilities, including those in the Medically Dependent Children Program (MDCP). STAR Kids improves access to care , provides care in the least restrictive setting, and provides more accountability and control on costs. Service coordination is fundamental to managing the complex needs of these Texas Health and Human Services Commission (HHSC) determines enrollment eligibility of our you have questions about the information in this Manual or about our policies, go to or call Customer Service at AreaChildren s Health insurance Program (CHIP) and CHIP Perinate Harris, Jefferson, NuecesState of Texas Access Reform (STAR)Harris, Hidalgo, JeffersonSTAR KidsHarris, Hidalgo, Jefferson, Medicaid Rural Service Area (MRSA) Central, MRSA NortheastSTAR+PLUSH arris, Jefferson, MRSA Central, MRSA Northeast, Nueces and TravisHow to join our networkFor instructions on joining the unitedhealthcare Community Plan Provider network, go to There you will find guidance on our credentialing process, how to sign up for self-service and other helpful information.

9 For information about joining supporting networks such as dental, vision and behavioral health, please call Customer Service at 888-887-9003 for 1: Introduction6 | unitedhealthcare Community Plan Texas v 2022 UnitedHealthcareAlready in network and need to make a change?To change an address, phone number, add or remove physicians from your TIN, or other changes, go to My Practice Profile at > Our Network > Demographics and approach to health careCare ModelThe care Model program seeks to empower unitedhealthcare Community Plan members enrolled in Medicaid, care providers and our community to improve care coordination and elevate outcomes. Targeting unitedhealthcare Community Plan members with chronic complex conditions who often use health care , the program helps address their needs holistically. care Model examines medical, behavioral and social/environmental concerns to help members get the right care from the right care Provider in the right place and at the right program provides interventions to members with complex medical, behavioral, social, pharmacy and specialty needs, resulting in better quality of life, improved access to health care and reduced expenses.

10 care Model provides a care management/coordination team that helps increase member engagement, offers resources to fill gaps in care and develops personalized health goals using evidence-based clinical guidelines. This approach is essential to improving the health and well-being of the individuals, families and communities unitedhealthcare Community Plan serves. care Model provides: Market-specific care management encompassing medical, behavioral and social care . Extended care team including primary care Provider (PCP), pharmacist, medical and behavioral director, and peer specialist. Engage members, connecting them to needed resources, care and services. Individualized and multidisciplinary care plan. Assistance with appointments with PCP and coordinating appointments. The Clinical care Team refers members to a specialist as required for complex needs. Education and support with complex conditions. Tools for helping members engage with providers, such as appointment reminders and help with transportation.