2022 Care Provider Manual

1 2022. Care Provider Manual Physician, Health Care Professional, Facility and Ancillary New York Medicaid Doc#: PMG 20220523_161033. Welcome Welcome to the UnitedHealthcare Community Plan Provider Manual . This up-to-date reference PDF Manual Important Information allows you and your staff to find important information about the Use of this Manual such as how to process a claim and submit prior authorization requests. This Manual also includes If there is a conflict between your Agreement and this important phone numbers and websites on the How care Provider Manual , use this Manual unless your to contact Us page. Find operational policy changes Agreement states you should use it instead. If there is and other electronic transactions on our website at 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 Click the following links to access different control.

2 UnitedHealthcare Community Plan reserves manuals: the right to supplement this Manual to help ensure its terms and conditions remain in compliance with relevant > Administrative Guide federal and state statutes and regulations. for Commercial and Medicare Advantage. This Manual will be amended as policies change. Some states may also have Medicare Advantage information in their Community Plan Manual . A different Community Plan Manual : UHCprovider. Participation Agreement com/guides > Community Plan Care Provider Manuals for Medicaid Plans by State > Find your In this Manual , we refer to your Participation Agreement State. as Agreement.. Terms and definitions as used in this Manual : Easily find information in this Manual using Member or customer refers to a person eligible the following steps: and enrolled to receive coverage from a payer for covered services as defined or referenced in your 1.

3 Select CTRL+F. Agreement. 2. Type in the key word. You, your or Provider refers to any health 3. Press Enter. care Provider subject to this Manual , including physicians, health care professionals, facilities and If available, use the binoculars icon on the top right hand ancillary providers; except when indicated and side of the PDF to search for information and topics. We all items are applicable to all types of health care greatly appreciate your participation in our program and providers subject to this guide. the care you offer our members. Community Plan or The Plan refers to lines of business that fall under UnitedHealthcare If you have questions about the information Community Plan. or material in this Manual , or about our Your Agreement, Provider Agreement or policies, please call 866-362-3368. Agreement refers to your Participation Agreement with us. 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.

4 Any reference to ID card includes a physical or digital card. 2 | UnitedHealthcare Community Plan New York 2022 UnitedHealthcare Table of Contents Chapter 1: Introduction 4. Chapter 2: Care Provider Standards and Policies 16. Chapter 3: Care Provider Office Procedures and Member Benefits 27. Chapter 4: Medical Management 32. Chapter 5: Early, Periodic Screening, Diagnosis and Treatment (EPSDT)/Prevention 51. Chapter 6: Value-Added Services 53. Chapter 7: Mental Health and Substance Use 55. Chapter 8: Foster Care 70. Chapter 9: Member Rights and Responsibilities 83. Chapter 10: Medical Records 86. Chapter 11: Quality Management (QM) Program and Compliance Information 90. Chapter 12: Billing and Submission 97. Chapter 13: claim Reconsiderations, Appeals and Grievances 106. Chapter 14: Care Provider Communications and Outreach 116. Chapter 15: Products 118. Chapter 16: Dual Complete One (HMO D-SNP), a Medicaid Advantage Plus Plan 119.

5 Glossary 127. Appendices 132. 3 | UnitedHealthcare Community Plan New York 2022 UnitedHealthcare Chapter 1: Introduction Key contacts Topic Link Phone Number Provider Services 866-362-3368. Training 866-362-3368. Provider Portal , then Sign In using your One 866-362-3368. Healthcare ID or go to Provider Portal Self Service: New users: > New User and User Access CommunityCare Provider CommunityCare Provider Portal User Guide Portal Training Provider Portal Support email: 855-819-5909. Resource Library > Resources > Resource Library Looking 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 bar. UnitedHealthcare Community Plan supports the New CHIP Plans York state goals of increased access, improved health Child Health Plus outcomes and reduced costs by offering Medicaid Marketplace Plan benefits to the following members: Essential Plan Children, from birth through 18 years of age, eligible for Medicaid under expanded pediatric coverage Dual Eligible Plans (Medicare-Medicaid).

6 Provisions of the Social Security Act. UnitedHealthcare Dual Complete; Dual Eligible Pregnant women eligible for Medicaid under Special Needs (D-SNP). expanded maternity coverage provisions of the UnitedHealthcare Dual Complete ONE (HMO. Social Security Act. D-SNP), a Medicaid Advantage Plus Plan Children eligible for the Children's Health Insurance Program (CHIP). If you have questions about the information Blind and disabled children and adults who are not in this Manual or about our policies, go to eligible for Medicare. or call Provider 19 64 years old who are not eligible for another type Services at 866-362-3368. of Medicaid and who have an income of less than 138% of the federal poverty level. Medicaid-eligible families. We offer the following Medicaid plans: UnitedHealthcare Community Plan UnitedHealthcare Dual Advantage UnitedHealthcare Wellness4Me (HARP). 4 | UnitedHealthcare Community Plan New York 2022 UnitedHealthcare Chapter 1: Introduction How to join our network using evidence-based clinical guidelines.

7 This approach is essential to improving the health and well-being of the individuals, families and communities UnitedHealthcare For instructions on joining the Community Plan serves. Care Model provides: UnitedHealthcare Community Plan Market-specific care management encompassing Provider network, go to UHCprovider. medical, behavioral and social care. com/join. There you will find guidance on An extended care team including primary care our credentialing process, how to sign up Provider (PCP), pharmacist, medical and behavioral for self-service and other helpful director, and peer specialist. information. If you are interested in joining Options that engage members, connecting them to the Long-Term Support Services network, needed resources, care and services. contact Individualized and multidisciplinary care plans. Assistance with appointments with PCP and coordinating appointments.

8 The Clinical Health Already in network and need to make a Advocate (CHA) refers members to an RN, change? Behavioral Health Advocate (BHA) or other specialists as required for complex needs. Education and support with complex conditions. To change an address, phone number, add Tools for helping members engage with providers, or remove physicians from your TIN, or such as appointment reminders and help with other changes, go to My Practice Profile at transportation. > Our Network > Foundation to build trust and relationships with hard- Demographics and Profiles. to-engage members. To refer your patient who is a Approach to health care UnitedHealthcare Community Plan member to the Care Model program, call Provider Services at 866-362-3368. Care Model The goals of the Care Model program are to: The Care Model program seeks to empower Lower avoidable admissions and unnecessary UnitedHealthcare Community Plan members enrolled emergency room (ER) visits, measured outcomes by in Medicaid, care providers and our community to inpatient (IP) admission and ER rates.

9 Improve care coordination and elevate outcomes. Improve access to PCP and other needed services, Targeting UnitedHealthcare Community Plan members measured by number of PCP visit rates within with chronic complex conditions who often use health identified time frames. care, the program helps address their needs holistically. Identify and discuss behavioral health (BH) needs, Care Model examines medical, behavioral and social/ measured by number of BH care Provider visits environmental concerns to help members get the right within identified time frames. care from the right care Provider in the right place and at Identify and remove social and environmental the right time. barriers to care. The program provides interventions to members with Improve health outcomes, measured by improved complex medical, behavioral, social and specialty needs, Healthcare Effectiveness Data and Information Set resulting in better quality of life, improved access to (HEDIS ) and Centers for Medicare & Medicaid health care and reduced expenses.

10 Care Model provides Services (CMS) Star Ratings metrics. a care management/coordination team that helps Empower the member to manage their complex/. increase member engagement, offers resources to fill chronic illness or problem and care transitions. gaps in care and develops personalized health goals 5 | UnitedHealthcare Community Plan New York 2022 UnitedHealthcare Chapter 1: Introduction Improve coordination of care through dedicated staff Article 28, resources and to meet unique needs. 31, 32 and Engage community care and care Provider networks 16 facilities to help ensure access to affordable care and the HCPCS Procedure Office-Based that bill with appropriate use of services. Code T1013 Practitioners Ambulatory Patient Groups (APG). Compliance One Unit: Includes $ $ a minimum of eight HIPAA mandates National Provider Identifier (NPI) and up to 22 minutes usage in all standard transactions (claims, eligibility, of medical language remittance advice, claims status request/response, interpreter services and authorization request/response) for all health care Two Units: Includes $ $ providers who handle business electronically.