2021 Care Provider Manual

2021 Care ProviderManual

Physician, Health Care Professional,

Facility and Ancillary Louisiana

Doc#: PCA-1-016623030920210

v 56.02.2020

Welcome 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 prior authorization. This manual also includes important phone numbers and websites on the How to Contact Us page. Find operational policy changes and other electronic

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? 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 Community Plan manual: go to . Click Menu on top left, select Administrative Guides and Manuals, then Community Plan Care Provider Manuals, select state.

Easily find information in this manual using the following steps:

1. Select CTRL+F. 2. Type in the key word. 3. 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 or material in this manual, or about our policies, please call Provider Services.

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Important information about the use of this manual

If 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. 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 regulations.

This manual will be amended as policies change.

Participation Agreement

In 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 ? "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.

? 2021 UnitedHealthcare

? Any reference to "ID card" includes both a physical or digital card.

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Table of Contents

Chapter 1:Introduction

How to Join Our Network Our Approach to Health Care Compliance Cultural Competency Resources Evidence-Based Clinical Review Criteria and Guidelines Online Resources Privileges Provider Services How to Contact Us

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10 10 10 10 11 11 13 13 14

Chapter 2:Care Provider Standards & Policies

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General Care Provider Responsibilities

21

Care Provider Bill of Rights

23

Appointment Standards (LDH Access and Availability Standards)

23

Care Provider Directory

24

My Practice Profile

24

Advance Notification Requirements

25

Prior Authorization Request

25

Timeliness Standards for Notifying Members of Test Results

25

Reportable Disease Surveillance

25

Requirements for PCP and Specialists Serving in PCP Role

26

Responsibilities of PCPs and Specialists Serving in PCP Role

26

Assistance with Locating Specialists for UnitedHealthcare Community Plan

Members

28

Rural Health Clinic, Federally Qualified Health Center or Primary Care Clinic

as PCP

28

Primary Care Provider Checklist

28

Specialist Care Providers Responsibilities

29

Ancillary Care Provider Responsibilities

29

Ancillary Care Provider Checklist

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Table of Contents

Chapter 3:Care Provider Office Procedures and Member Benefits

Benefit Information Assignment to PCP Panel Roster Choosing a PCP Deductibles/Copayments Medically Necessary Service Member Assignment Verifying and Validating PCP Assignments Re-evaluating Member Removals Member Eligibility Member ID Card Member Missed Appointments Non-Compliant Members Sample Health Member ID Card Verifying Member Enrollment UnitedHealthcare Community Plan Welcome Packet UnitedHealthcare Dual Complete (HMO SNP)

Chapter 4:Medical Management

Ambulance Services Cardiology Durable Medical Equipment Emergency/Urgent Care Services Emergency Care Resulting in Admissions Family Planning Care Coordination/Health Education Health Home Program Hearing Services Hospice Laboratory Maternity/Pregnancy/Well-Child Care Neonatal Resource Services (NICU Case Management) Patient-Centered Medical Home Pharmacy Radiology

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