UnitedHealthcare Member Handbook - Louisiana

UnitedHealthcare Member Handbook

MississippiCAN (Mississippi Coordinated Access Network)

MISSISSIPPI

Important Telephone Numbers

Member Services (8 a.m. to 6 p.m. Monday through Friday). . . . . . . . . . . . . 1-877-743-8731 Telecommunication Devices for the Deaf (TDD) . . . . . . 711

24/7 Nurse Line. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1-877-370-4009 (available 24 hours a day, 7 days a week) Healthy First Steps (for mothers-to-be). . . . . . . . . . . 1-800-599-5985 Poison Control Center . . . . . . . . . . . . . . . . . . . . . . . . . . 1-800-222-1222 Division of Medicaid. . . . . . . . . . . . . . . . . . . . . . . . . . . . 1-800-421-2408 Mental Health Crisis Line (English). . . . . . . . . . . . . . . 1-601-713-4357 Mental Health Crisis Line (Spanish). . . . . . . . . . . . . . 1-866-322-9832

Website

Your Health Providers

Name:_____________________________________ Phone:_ ___________________________________ Name:_____________________________________ Phone:_ ___________________________________ Name:_____________________________________ Phone:_ ___________________________________ Pharmacy:__________________________________ Phone:_ ___________________________________

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MississippiCAN Member Handbook

Table of Contents

Important Terms. . . . . . . . . . . . . . . . . . . . . . . . 2

Welcome. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4 Member Services. . . . . . . . . . . . . . . . . . . . . . . 4

Eligibility and Enrollment. . . . . . . . . . . . . . . . 4 Elligibility . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4 Enrollment. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5 If You Want To Leave. . . . . . . . . . . . . . . . . . . . 5 UnitedHealthcare Community Plan No?Discrimination . . . . . . . . . . . . . . . . . . . . . . 5

How to Use Your Health Plan. . . . . . . . . . . . 6 Member ID Card. . . . . . . . . . . . . . . . . . . . . . . . . 6 Language and Cultural Help. . . . . . . . . . . . . . . 6 Your Primary Care Provider (PCP). . . . . . . . . . 7 What Is A Medical Home?. . . . . . . . . . . . . . . . . 7 Why Would I Want A Medical Home?. . . . . . . 7 How Do I Find A PCP?. . . . . . . . . . . . . . . . . . . 7 Changing Your PCP. . . . . . . . . . . . . . . . . . . . . . 7

Getting Care . . . . . . . . . . . . . . . . . . . . . . . . . . . 8 Get To Know Your PCP. . . . . . . . . . . . . . . . . . . 8 Making An Appointment. . . . . . . . . . . . . . . . . . . 8 How Long Should It Take To Get A PCP Appointment?. . . . . . . . . . . . . . . . . . . 8 NurseLineSM Services. . . . . . . . . . . . . . . . . . . . . 9 Urgent Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9 Emergency Care .. . . . . . . . . . . . . . . . . . . . . . . . 9 Prior Authorization . . . . . . . . . . . . . . . . . . . . . . . 9 Utilization Review . . . . . . . . . . . . . . . . . . . . . . . 10 Hospital Care. . . . . . . . . . . . . . . . . . . . . . . . . . 10 In-Network Providers. . . . . . . . . . . . . . . . . . . . 10 Out-of-Network Providers. . . . . . . . . . . . . . . . 10 Second Opinions. . . . . . . . . . . . . . . . . . . . . . . 11 Medical Advances . . . . . . . . . . . . . . . . . . . . . . 11 Advance Directives (Living Wills) . . . . . . . . . . 11

Your MississippiCAN Benefits. . . . . . . . . . 12

Services Covered And Paid For By Medicaid. . . . . . . . . . . . . . . . . . . . . . . . . . . 14

Getting Prescriptions . . . . . . . . . . . . . . . . . . 15 How To Get A Prescription Drug . . . . . . . . . . 15 Prior Authorization . . . . . . . . . . . . . . . . . . . . . . 15 Step Therapy. . . . . . . . . . . . . . . . . . . . . . . . . . . 15 Brand Name Drugs Instead of Generic Equivalents. . . . . . . . . . . . . . . . . . . . . . . . . . . 15 Medications Not on UnitedHealthcare Community Plan's PDL. . . . . . . . . . . . . . . . . 16

UnitedHealthcare Community Plan Programs and Services. . . . . . . . . . . . . . . . . 17

Quality Improvement. . . . . . . . . . . . . . . . . . . . . 17 Disease and Care

Management Programs . . . . . . . . . . . . . . . . 17 If You Are Going To Have A Baby. . . . . . . . . . 18 Healthy First StepsTM Program. . . . . . . . . . . . . 18 (ESPDT) Well Child Program. . . . . . . . . . . . . 18 Dr. Health E. Hound? Program. . . . . . . . . . . . 18

Rights and Responsibilities. . . . . . . . . . . . 19

Complaints, Grievances, Appeals and State Fair Hearings. . . . . . . . 20

What Is A Complaint?. . . . . . . . . . . . . . . . . . . 20 What Is A Grievance? . . . . . . . . . . . . . . . . . . . 20 What Is An Appeal?. . . . . . . . . . . . . . . . . . . . . 21 How Do I File A State Fair

Hearing Request With DHH?. . . . . . . . . . . . 22 Continuation Of Benefits. . . . . . . . . . . . . . . . . 22 Fraud and Abuse Notice . . . . . . . . . . . . . . . . . 22

Privacy Policy . . . . . . . . . . . . . . . . . . . . . . . . 23 Medical Information . . . . . . . . . . . . . . . . . . . . . 23 Financial Information. . . . . . . . . . . . . . . . . . . . . 25

Grievance and Appeal Form. . . . . . . . . . . . 29

Mississippi

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Important Terms

Abuse

Term

Appeal

Complaint

Coordinated Care Organization Copay

Durable Medical Equipment (DME)

Emergency

Health Information Immunization In-Network Medical Home

Description

Harming someone on purpose. (Includes yelling, ignoring a person's need and inappropriate touching.)

A formal request for UnitedHealthcare to review a decision or an action.

When a member expresses dissatisfaction with his/her care. A complaint can be filed with UnitedHealthcare over the phone or in writing.

A company with healthcare providers and services.

A small fee members must pay when using certain services, like doctor or emergency room visits.

Things such as wheelchairs, walkers, glucose meter, IV poles. Also disposable supplies such as bandages, catheters and needles. DME must be requested by your doctor.

A sudden and unexpected change in physical or mental health which, if not treated right away, could result in 1)loss of life or limb, 2)impairment to a bodily function, or 3)permanent damage to a body part.

Facts about your health and care. This may come from UnitedHealthcare or a provider. It includes physical and mental health and payments for care.

A shot that protects from a disease. Children should get a variety at specific ages. Shots are often given during regular doctor visits.

Doctors, specialists, hospitals, pharmacies and other providers . who have an arrangement with UnitedHealthcare to offer services to members.

A doctor or medical practice that you go to all the time.

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MississippiCAN Member Handbook

Term Medically Necessary

Member Out-of-Network

Prescription Prior Authorization Provider or Practitioner Specialist

Description

1) a service that prevents, diagnoses or treats a physical or mental illness or injury; ensures age-appropriate growth and development; minimizes the worsening of a disability; or attains, maintains, or regains functional capacity per accepted standards of practice. (2) It cannot be omitted without affecting the member's condition or quality of care.(3) It is given in the best setting.

A person enrolled in UnitedHealthcare through MississippiCAN.

Doctors, specialists, hospitals, pharmacies and other providers who do not have an arrangement with UnitedHealthcare to offer services to members.

A doctor's written instructions for drugs or treatment.

Approval for services not normally covered by UnitedHealthcare.

A person or facility that provides health care. (Doctors, pharmacies, dentists, clinics, hospitals, etc.)

Any doctor who has special training for a specific condition or illness.

Mississippi

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