2021 Care Provider Manual

1 Doc#: PCA-1-0 care Provider ManualPhysician, Health care Professional, Facility and Ancillary Tennessee2 | unitedhealthcare Community Plan of Tennessee v 2021 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 [ ]This Provider Manual supports TennCare, Tennessee s Medicaid program. It has been operating under a waiver from CMS since 1994 to offer coverage to the traditional Medicaid-eligible population as well as an expanded population (TennCare Standard).

2 All TennCare members are enrolled into a managed care organization (MCO) within their geographic entered into a Contractor Risk Agreement (CRA) for each Grand Region with the State of Tennessee for provision of the TennCare benefits. The TennCare program in each Grand Region is governed by its Contractor Risk Agreement, the TennCare Rules and Regulations as well as the TennCare Policies. The Division of TennCare website contains links to all governing documents. These include: Contractor Risk Agreement: [ ] TennCare Rules: [ ] TennCare Policies: [ ]We administer the TennCare program as an MCO in all three geographic regions doing business as unitedhealthcare Community Plan. We are a primary care practitioner (PCP)-driven HMO network focusing on PCPs providing appropriate care to covered persons based on established clinical guidelines.

3 We operate in an integrated model where all physical, behavioral and long-term services and supports health care needs are assessed, coordinated and monitored. We offer our covered individuals and providers programs in medical management, quality improvement, education and development, as well as quality customer TennCare enrollees are also eligible for enhanced services provided through CHOICES. CHOICES is the Long-Term Services and Supports (LTSS) program, which promotes quality and cost-effective care coordination for CHOICES enrollees with chronic, complex health care , social service and custodial needs. The CHOICES program includes both Nursing Facility and Home- and Community-Based (HCBS) care coordination. CHOICES care coordination operates based on our fully integrated model so the physical, behavioral and LTSS care health needs of the CHOICES enrollees are met.

4 You may find detailed information on the CHOICES program in Chapter 6: Long Term Services and Supports Program (LTSS), and Chapter 7: Employment and Community First (ECF) CHOICES of this the following links to access different manuals: Employment and Community First (ECF) CHOICES/Intellectual and Developmental Disabilities (DIDD) Benefits Supplemental Guide [ ] [ unitedhealthcare Administrative Guide] for Commercial and Medicare Advantage member information. Some states may also have Medicare Advantage information in their Community Plan Manual . A different state Community Plan Manual : go to [ ]. Click Menu on top left, select Administrative Guides and Manuals, then Community Plan care Provider Manuals, select state. unitedhealthcare Dual Complete: For information about unitedhealthcare Dual Complete in Tennessee, go to [ > Menu > Health Plans by State > Tennessee Medicare Advantage Health Plans > Tennessee Dual Complete Special Needs Plans].

5 March vision Routine care Provider reference guide: [ ]. Ophthalmologists rendering medical services to TennCare enrollees should refer to this | unitedhealthcare Community Plan of Tennessee v 2021 UnitedHealthcareEasily 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 covered persons. If you have questions about the information or material in this Manual , or about our policies, please call Provider 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.

6 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 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 .The Division of TennCare requires specific language in TennCare Provider Agreements. As noted in the Modification Section of your Provider Agreement, Division of TennCare required language and State of Tennessee mandates about the TennCare program can be updated by inclusion in the care Provider Manual .

7 For ease of your review, certain required language and TennCare program mandates are contained in a document titled TennCare Program Regulatory Appendix Requirements Appendix. The Appendix is at [ ] The appendix is routinely appended to our TennCare Provider Agreements. The latest version of this Appendix is also appended to this care Provider Manual . When we amend your Agreement to comply with federal and state regulatory requirements, most of these changes may be made within the body of this care Provider Manual . However, those regulatory requirements may require us to make changes to confidential portions of your Agreement, such as the payment provisions. When this type of change is required, we may provide you a separate confidential notice of the regulatory changes to your Agreement.

8 If the payment provisions are affected, we will send you a new fee schedule or payment appendix for your records. If we provide you notice of changes based on this paragraph, we will limit such changes to those required to comply with the change in regulatory | unitedhealthcare Community Plan of Tennessee v 2021 UnitedHealthcareTable of ContentsChapter 1: Introduction 5 Chapter 2: care Provider Standards and Policies 16 Chapter 3: care Provider Office Procedures and Individual Benefits 25 Chapter 4: Medical Management 36 Chapter 5: Early, Periodic Screening, Diagnostic and Treatment (EPSDT)/Prevention 52 Chapter 6: Long Term Services and Supports (LTSS) 55 Chapter 7: CoverKids 65 Chapter 8: Value-Added Services 69 Chapter 9: Mental Health and Substance Use 72 Chapter 10: Individual Rights and Responsibilities 79 Chapter 11: Medical Records 82 Chapter 12.

9 Quality Management (QM) Program and Compliance Information 88 Chapter 13: Billing and Submission 96 Chapter 14: Claim Reconsiderations, Appeals and Grievances 105 Chapter 15: care Provider Communications and Outreach 114 Chapter 16: Glossary 1165 | unitedhealthcare Community Plan of Tennessee v 2021 UnitedHealthcareChapter 1: IntroductionTennCare is the Tennessee State Medicaid program TennCare offers traditional Medicaid to eligible populations (TennCare Medicaid) as well as an expanded population (TennCare Standard). All TennCare individuals are enrolled into an Plan of the River Valley has entered into a contractor risk agreement (CRA) with the State of Tennessee to provide TennCare benefits to qualifying residents. unitedhealthcare Plan of the River Valley administers the TennCare program as unitedhealthcare Community Community Plan supports the Tennessee state goals of increased access, improved health outcomes and reduced costs by offering Medicaid benefits to eligible individuals: TennCare TennCare Kids TennCare Employment and Community First (ECF) CHOICES TennCare CHOICES Long-Term Services and Supports (LTSS) Program CoverKidsTennessee has three geographic regions.

10 All TennCare individuals are enrolled in an MCO within their geographic region. DHSS will determine enrollment you have questions about the information in this Manual or about our policies, go to [ ] or call Provider Services at 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 tools and other helpful contactsTopicLinkPhone NumberProvider , then sign in using your One Healthcare > Menu > Resource Library > Online Service Tools800-690-1606 Provider Portal TrainingCommunityCare Provider Portal User GuideOnline Service > Menu > Resource Library > Online Service Tools866-842-3278, option 1 Resource > Menu > Resource LibraryLooking for something else?