PDF 2018 UnitedHealthcare Care Provider Administrative Guide

[Pages:270]2018 UnitedHealthcare Care Provider

Administrative Guide

Welcome to UnitedHealthcare

Welcome to the UnitedHealthcare Care Provider Administrative Guide for Commercial and Medicare Advantage (MA) products. This guide has important information on topics such as claims and prior authorizations. It also has protocol information for health care providers. This guide has useful contact information such as addresses, phone numbers and websites. More policies and electronic tools are available on . ? If you are looking for a Community and State manual, go to > Health Care Professionals, and

select the correct state. ? If you are looking for a UnitedHealthcare Dual Complete manual in Arizona, Massachusetts, New Jersey, New York

or Tennessee, go to . All other UnitedHealthcare Dual Complete plans follow this Provider Administrative Guide. You may easily find information in this guide using the following steps: 1. Hold keys CTRL+F. 2. Type in the key word. 3. Press Enter. Depending upon the version of PDF software you have, you may also use the binoculars icon to search for key words. This 2018 UnitedHealthcare Care Provider Administrative Guide (this "guide") applies to covered services you provide to our members or the members of our affiliates* through our benefit plans insured by or receiving administrative services from us, unless otherwise noted. This guide is effective April 1, 2018 for physicians, health care professionals, facilities and ancillary providers currently participating in our commercial and Medicare networks. It is effective now for care providers who join our network on or after Jan. 1, 2018. This guide is subject to change. We frequently update content in our effort to support our health care provider networks. Terms and definitions as used in this guide: ? "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 with us. ? "Commercial" refers to all UnitedHealthcare medical products that are not MA, Medicare Supplement, Medicaid, CHIP, workers' compensation, or other governmental programs. "Commercial" also applies to benefit plans for the Health Insurance Marketplace, government employees or students at public universities. ? "You," "your" or "provider" refers to any health care provider subject to this guide, 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. ? "Us," "we" or "our" refers to UnitedHealthcare on behalf of itself and its other affiliates for those products and services subject to this guide. Medicare policies, protocols and information in this guide apply to covered services you provide to UnitedHealthcare MA members, including Erickson Advantage members and most UnitedHealthcare Dual Complete members, but excluding UnitedHealthcare Medicare Direct members and MA members enrolled in UnitedHealthcare Community Plan Medicare Advantage plans, and UnitedHealthcare Dual Complete members in Arizona, Massachusetts, New Jersey, New York and Tennessee. If a particular section does not apply to such MA members, it is indicated. If there is a conflict or inconsistency between a Regulatory Requirements Appendix attached to your agreement and this guide, the provisions of the Regulatory Requirements Appendix controls for benefit plans within the scope of that appendix. If there is an inconsistency between your agreement with us and this guide, your agreement controls (except where your agreement with us provides protocols for our affiliates). If those protocols are in a supplement to this guide, those protocols control for services you give to a member subject to that supplement.

*UnitedHealthcare affiliates offering commercial and Medicare Advantage benefit plans and other services, are outlined in Chapter 1: Introduction.

i | 2018 UnitedHealthcare Care Provider Administrative Guide

Contents

Welcome to UnitedHealthcare . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

Chapter 1: Introduction

1

Manuals and Benefit Plans Referenced in This Guide. . . . . . . . . 1

Online Resources and How to Contact Us. . . . . . . . . . . . . . . . . . 3

Chapter 2: Provider Responsibilities and Standards 6

Electronic Data Interchange (EDI) . . . . . . . . . . . . . . . . . . . . . . . . . 6 Verifying Eligibility, Benefits and Your Network Participation Status. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6 Health Care Identification (ID) Cards. . . . . . . . . . . . . . . . . . . . . . . 6 Access Standards. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8 Primary Care Physicians (PCP) Responsibilities. . . . . . . . . . . . . . 9 Demographic Changes. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9 Administrative Terminations for Inactivity . . . . . . . . . . . . . . . . . 11 Continuity of Care Following Termination of Your Participation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11 Medicare Opt-Out . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11 Additional MA Requirements. . . . . . . . . . . . . . . . . . . . . . . . . . . 11 Filing of a Lawsuit by a Member. . . . . . . . . . . . . . . . . . . . . . . . . 13

Chapter 3: Commercial Products

14

Commercial Product Overview Table. . . . . . . . . . . . . . . . . . . . . 14

Benefit Plan Types. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16

Primary Care Providers (PCP) Selection . . . . . . . . . . . . . . . . . 16

HRAs and HSAs Consumer-Driven Health Benefit Plans. . . . . 16

Chapter 4: Medicare Products

17

Medicare Product Overview Tables. . . . . . . . . . . . . . . . . . . . . . 17

Coverage Summaries and Policy Guidelines

MA Members . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20

Medicare Supplement Benefit Plans. . . . . . . . . . . . . . . . . . . . . 20

Chapter 5: Referrals

22

Commercial Products Referrals. . . . . . . . . . . . . . . . . . . . . . . . . 22

Non-Participating Care Provider Referrals

(All Commercial Plans) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23

Medicare Advantage (MA) Referral Required Plans. . . . . . . . . 24

Chapter 6: Medical Management

25

Benefit Plans Not Subject to this Protocol. . . . . . . . . . . . . . . . . 25

Advance Notification/Prior Authorization Requirements. . . . . 25

Advance Notification/Prior Authorization List. . . . . . . . . . . . . . 26

Facilities: Standard Notification Requirements. . . . . . . . . . . . . 27

Facility Denial Process . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28

How to Submit Advance or Admission Notifications/

Prior Authorizations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29

Updating Advance Notification or Prior Authorization

Requests . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29

Coverage and Utilization Management Decisions . . . . . . . . . . 29

Pre-Service Appeals. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31

Clinical Trials, Experimental or Investigational Services. . . . . . 31

Medical Management Denials/Adverse Determinations. . . . . 31 MA Part C Reopenings. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32 Outpatient Cardiology Notification/Prior Authorization Protocol . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33 Outpatient Radiology Notification/Prior Authorization Protocol . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37 Trauma Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40

Chapter 7: Specialty Pharmacy

and Medicare Advantage Pharmacy

42

Commercial Pharmacy. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42

Specialty Pharmacy Requirements for Certain Specialty

Medications (Commercial Plans ? not applicable to

UnitedHealthcare West) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42

MA Pharmacy. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43

Drug Utilization Review Program. . . . . . . . . . . . . . . . . . . . . . . . 45

Medication Therapy Management (MTM). . . . . . . . . . . . . . . . . 46

Transition Policy. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46

Chapter 8: Specific Protocols

47

Air Ambulance, Fixed-Wing Non-Emergency Transport . . . . . 47

Laboratory Benefit Management Program Administered by

BeaconLBSTM (Florida Only). . . . . . . . . . . . . . . . . . . . . . . . . . . . 47

Laboratory Services Protocol. . . . . . . . . . . . . . . . . . . . . . . . . . . 47

Non-Participating Providers Consent Form . . . . . . . . . . . . . . . 48

Nursing Home and Assisted Living Plans. . . . . . . . . . . . . . . . . 49

Chapter 9: Our Claims Process

51

Electronic Payments and Statements (EPS). . . . . . . . . . . . . . . 51

Claims and Encounter Data Submissions. . . . . . . . . . . . . . . . . 52

Risk Adjustment Data ? MA and Commercial. . . . . . . . . . . . . . 53

National Provider Identification (NPI). . . . . . . . . . . . . . . . . . . . . 54

Medicare Advantage Claim Processing Requirements. . . . . . 54

Hospital Responsibilities. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55

Claim Submission Tips. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55

Pass-through Billing/CLIA Requirements/Reimbursement

Policy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56

Special Reporting Requirements for Certain Claim Types . . . 57

Overpayments. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57

Subrogation and Coordination of Benefits . . . . . . . . . . . . . . . . 58

Claim Correction and Resubmission. . . . . . . . . . . . . . . . . . . . . 59

Claim Reconsideration, Appeals Process

and Resolving Disputes. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59

Resolving Disputes ? Concern or Complaint . . . . . . . . . . . . . . 61

Member Appeals, Grievances or Complaints. . . . . . . . . . . . . . 63

Medical Claim Review. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63

Chapter 10: Compensation

64

Reimbursement Policies. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 64

Charging Members. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 64

Member Financial Responsibility. . . . . . . . . . . . . . . . . . . . . . . . 66

Preventive Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 66

Provider Audits - Extrapolation. . . . . . . . . . . . . . . . . . . . . . . . . . 66

Hospital Audit Services. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 66

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Contents

Notice of Medicare Non-Coverage (NOMNC). . . . . . . . . . . . . . 67

Chapter 11: Medical Records

Standards and Requirements

69

Chapter 12:

Health and Disease Management

71

Health Management Programs. . . . . . . . . . . . . . . . . . . . . . . . . . 71

Case Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 71

Wellness and Behavioral Health Programs. . . . . . . . . . . . . . . . 72

Consumer Transparency Tools: MyHealthcareCostEstimator

(myHCE). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 72

Behavioral Health Information . . . . . . . . . . . . . . . . . . . . . . . . . . 73

Chapter 13:

Quality Management (QM) Program

74

UnitedHealth Premium? Designation Program

(Commercial Plans). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 75

Star Ratings for MA and Prescription Drug Plans. . . . . . . . . . . 75

Member Satisfaction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 76

Imaging Accreditation Protocol . . . . . . . . . . . . . . . . . . . . . . . . . 76

Chapter 14:

Credentialing and Re-Credentialing

77

Credentialing/Profile Reporting Requirements. . . . . . . . . . . . . 77

Care Provider Rights Related to the Credentialing Process . . 77

Initial Credentialing Process. . . . . . . . . . . . . . . . . . . . . . . . . . . . 78

Recredentialing Process. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 79

Credentialing Committee Decision Making Process

(Non-Delegated). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 79

Monitoring of All Network Care Providers. . . . . . . . . . . . . . . . . 79

Chapter 15:

Member Rights and Responsibilities

81

Chapter 16:

Fraud, Waste and Abuse (FWA)

82

Medicare Compliance Expectations and Training . . . . . . . . . . 82

Exclusion Checks . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 82

Examples of Potentially Fraudulent, Wasteful,

or Abusive Billing (not an inclusive list). . . . . . . . . . . . . . . . . . . 83

Prevention and Detection. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 83

Corrective Action Plans. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 83

Beneficiary Inducement Law . . . . . . . . . . . . . . . . . . . . . . . . . . . 83

Reporting Potential Fraud, Waste or Abuse

to UnitedHealthcare. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 84

Chapter 17: Provider Communication

85

Network Bulletin and Provider News . . . . . . . . . . . . . . . . . . . . 85

Medical Policy Update Bulletin. . . . . . . . . . . . . . . . . . . . . . . . . . 85

Other Communications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 85

All Savers Supplement

86

How to Contact All Savers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 86

Capitation and/or Delegation Supplement 88

Capitated Providers. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 88 Delegated Providers and Accountable Care Organizations. . . 88 How to Contact Us. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 89 Verifying Eligibility and Effective Dates . . . . . . . . . . . . . . . . . . . 89 Commercial Eligibility, Enrollment, Transfers, and Disenrollment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 89 Medicare Advantage (MA) Enrollment, Eligibility and Transfers, and Disenrollment . . . . . . . . . . . . . . . . . . . . . . . 93 Eligibility/Authorization Guarantee. . . . . . . . . . . . . . . . . . . . . . . 97 Provider Responsibilities. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 98 Delegated Credentialing Program. . . . . . . . . . . . . . . . . . . . . . 102 Virtual Visits (Commercial HMO Plans CA only). . . . . . . . . . . 104 Referrals & Referral Contracting . . . . . . . . . . . . . . . . . . . . . . . 105 Medical Management. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 107 Pharmacy. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 114 Facilities. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 114 Claims Processes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 119 Medicare Advantage (MA)Delegated or Capitated. . . . . . . . . 123 Claims Disputes and Appeals. . . . . . . . . . . . . . . . . . . . . . . . . . 123 Contractual and Financial Responsibilities. . . . . . . . . . . . . . . 127 Capitation Payments and Reporting . . . . . . . . . . . . . . . . . . . . 131 CMS Premiums and Adjustments . . . . . . . . . . . . . . . . . . . . . . 133 Appeals and Grievances. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 136

Leased Networks

138

Medica HealthCare Supplement

139

How to Contact Us. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 139

Confidentiality of Protected Health Information (PHI). . . . . . . 142

Prior Authorizations and Referrals. . . . . . . . . . . . . . . . . . . . . . 142

Appeal and Reconsideration Processes. . . . . . . . . . . . . . . . . 146

Member Rights and Responsibilities . . . . . . . . . . . . . . . . . . . 146

Documentation and Confidentiality of Medical Records. . . . 147

Provider Reporting Responsibilities. . . . . . . . . . . . . . . . . . . . . 149

Mid-Atlantic Regional Supplement

151

Provider Responsibilities. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 152

Referrals. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 153

Prior Authorizations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 153

Capitation. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 156

Claims Process . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 156

Neighborhood Health Partnership

Supplement

158

How to Contact NHP. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 158

Discharge of a Member from Participating Provider's Care . 160

Laboratory Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 160

Referrals. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 161

Utilization Management (UM). . . . . . . . . . . . . . . . . . . . . . . . . . 162

Claims Reconsiderations and Appeals. . . . . . . . . . . . . . . . . . 163

Capitated Health Care Providers . . . . . . . . . . . . . . . . . . . . . . . 163

OneNet PPO Supplement

164

Discontinuation of the OneNet PPO Medical Network

Product. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 164

How to Contact OneNet PPO. . . . . . . . . . . . . . . . . . . . . . . . . . 165

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Contents

OneNet General Provider Administrative Requirements . . . . 166 Referrals. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 166 Utilization Review Components for Workers' Compensation. 167 Workers' Compensation Claims Process . . . . . . . . . . . . . . . . 167 Resolving Disputes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 169 Medical Records Standards and Requirements. . . . . . . . . . . 170 Quality Management and Health Management Programs. . . 170 Participant Rights and Responsibilities. . . . . . . . . . . . . . . . . . 170

Oxford Commercial Supplement

171

Oxford Commercial Product Overview . . . . . . . . . . . . . . . . . . 171

How to Contact Oxford Commercial . . . . . . . . . . . . . . . . . . . . 171

Care Provider Responsibilities and Standards . . . . . . . . . . . . 176

Referrals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 180

Utilization Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 181

Using Non-Participating Health Care Providers or Facilities . 183

Radiology And Cardiology Procedures. . . . . . . . . . . . . . . . . . 187

Emergencies and Urgent Care. . . . . . . . . . . . . . . . . . . . . . . . . 193

Utilization Reviews . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 194

Claims Process . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 200

Member Billing. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 202

Claims Recovery, Appeals, Disputes and Grievances. . . . . . 203

Quality Assurance. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 207

Case Management and Disease Management Programs. . . 208

Clinical Process Definitions . . . . . . . . . . . . . . . . . . . . . . . . . . . 208

Member Rights and Responsibilities. . . . . . . . . . . . . . . . . . . . 210

Medical and Administrative Policy Updates . . . . . . . . . . . . . . 210

Preferred Care Partners Supplement

211

About Preferred Care Partners. . . . . . . . . . . . . . . . . . . . . . . . . 211

How to Contact Us. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 211

Confidentiality of Protected Health Information (PHI). . . . . . . 214

Prior Authorizations and Referrals. . . . . . . . . . . . . . . . . . . . . . 214

Clinical Coverage Review. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 216

Appeal & Reconsideration Processes. . . . . . . . . . . . . . . . . . . 217

Member Rights and Responsibilities . . . . . . . . . . . . . . . . . . . 218

Documentation and Confidentiality of Medical Records. . . . 218

Case Management and Disease Management Program

Information. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 220

Special Needs Plans. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 220 Care Provider Reporting Responsibilities. . . . . . . . . . . . . . . . 221

River Valley Entities Supplement

222

Eligibility. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 222

How to Contact River Valley . . . . . . . . . . . . . . . . . . . . . . . . . . . 222

Reimbursement Policies. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 224

Referrals. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 224

Utilization Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 225

Claims Process . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 228

UnitedHealthcare West Supplement

232

UnitedHealthcare West Information Regarding

our Care Provider Website . . . . . . . . . . . . . . . . . . . . . . . . . . . . 233

How to Contact UnitedHealthcare West Resources. . . . . . . . 234

Care Provider Responsibilities. . . . . . . . . . . . . . . . . . . . . . . . . 236

Utilization and Medical Management. . . . . . . . . . . . . . . . . . . . 240

Hospital Notifications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 242

Pharmacy Network . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 245

Claims Process . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 247

Care Provider Claims Appeals and Disputes . . . . . . . . . . . . . 249

California Language Assistance Program

(California Commercial Plans) . . . . . . . . . . . . . . . . . . . . . . . . . 253

Member Complaints & Grievances . . . . . . . . . . . . . . . . . . . . . 253

California Quality Improvement Committee . . . . . . . . . . . . . . 253

UnitedHealthOne Individual Plans

Supplement

254

How to Contact UnitedHealthOne Resources. . . . . . . . . . . . . 254

Claims Process . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 255

Member Complaints & Grievances . . . . . . . . . . . . . . . . . . . . . 258

Glossary

261

iv | 2018 UnitedHealthcare Care Provider Administrative Guide

Chapter 1: Introduction

Chapter 1: Introduction

Manuals and Benefit Plans Referenced in This Guide

Some benefit plans included under your agreement may be subject to requirements found in other health care provider guides or manuals or to the supplements found in the second half of this guide.

This section provides information about some of the most common UnitedHealthcare products. Your agreement may use "benefit contract types", "benefit plan types" or a similar term to refer to our products.

Visit plans for more information about our Products and Individual Exchange benefit plans offered by state.

If a member presents a health care ID card with a product name you are not familiar with, use Link's self-service tools to quickly find information you may need for most UnitedHealthcare benefit plans. You may also call us at 877-842-3210.

You are subject to the provisions of additional guides when providing covered services to a member of those benefit plans, as described in your agreement with us and in the following table. We may make changes to care provider guides, supplements and manuals that relate to protocol and payment policy changes.

We may change the location of a website, a benefit plan name, branding or the member health care ID card. We inform you of those changes through one of our care provider communications resources.

Benefit Plans Subject to this Guide

Plan Name All Savers: All Savers Insurance Company

Location of Most Members Subject to Additional Guides

All Markets

Location of Plan Information

Advance Notification/Prior Authorization Requirements to this guide

MDIPA: MD Individual Practice Association, Inc.

DC, DE, MD, VA, WV Some Counties in: Southeastern PA

Mid-Atlantic Regional Supplement to this guide.



Medica HealthCare

FL counties: Broward and Miami-Dade

Medica HealthCare Supplement to this guide.

Capitated and/or Delegated Providers Commercial and MA

All Markets

Capitation and/or Delegation Supplement to this guide.

NHP:

FL

Neighborhood Health Partnership, Inc.

Neighborhood Health Partnership Supplement to this guide.



OCI: Optimum Choice Inc.

DC, DE, MD, VA, WV Some Counties in: PA

Mid-Atlantic Regional Supplement to this guide.



OneNet PPO:

DC, DE, MD, NC, PA, VA, WV Limited Network in: FL, GA, SC, TN

OneNet PPO Supplement to this guide.



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Chapter 1: Introduction

Plan Name

Oxford:

? Oxford Health Plans, LLC ? Oxford Health Insurance, Inc. ? Investors Guaranty Life

Insurance Company, Inc. ? Oxford Health Plans (NY), Inc. ? Oxford Health Plans (NJ), Inc. ? Oxford Health Plans (CT), Inc.

Location of Most Members Subject to Additional Guides

CT, NJ, NY (except up-state) Some Counties in: PA.

Location of Plan Information

Oxford Commercial Supplement to this guide. For commercial benefits: For Medicare benefits:

Preferred Care Partners

FL counties: Broward, Miami-Dade and Palm Beach

Preferred Care Partners Supplement to this guide.

River Valley:

? UnitedHealthcare Services Company of the River Valley, Inc.

? UnitedHealthcare Plan of the River Valley, Inc., and

? UnitedHealthcare Insurance Company of the River Valley

Parts of AR, GA, IA, IL TN, WI, VA

Your UnitedHealthcare contract specifically references River Valley or John Deere Health protocols or Guides; and

You are located in AR, GA, IA, TN, VA, WI or the following counties in Illinois: Jo Daviess, Stephenson, Carroll, Ogle, Mercer, Whiteside, Lee, Rock Island, Henry, Bureau, Putnam, Henderson, Warren, Knox, Stark, Marshall, Livingston, Hancock, McDonough, Fulton, Peoria, Tazewell, Woodford, McLean, and

You are providing services to a River Valley Commercial member and not a River Valley Medicare Advantage, Medicaid or CHIP member.

Note: River Valley also offers benefit plans in LA, NC, OH & SC, but the River Valley Additional Guide does not apply to those benefit plans.

River Valley Entities Supplement to this guide.



Sierra or Health Plan of Nevada:

? Sierra Health and Life Insurance Co., Inc. ? Health Plan of Nevada, Inc. ? Sierra Healthcare Options, Inc.

Outside NV only:

The health care ID card identifies the Sierra or Health Plan of Nevada members who access the UnitedHealthcare network outside of Nevada, and includes the following reference:

UnitedHealthcare Choice Plus Network Outside Nevada.

Services rendered outside of Nevada to Sierra or Health Plan of Nevada members with the health care ID card reference described in this row are subject to your UnitedHealthcare agreement and to this guide unless you are in Arizona or Utah and have a contract directly with Sierra or Health Plan of Nevada.

UnitedHealthcare West:

(Formerly referenced in this guide as "PacifiCare")

? UHC of California dba UnitedHealthcare of California (hereinafter referred to as UnitedHealthcare of California)

? UnitedHealthcare Benefits Plan of California ? UnitedHealthcare of Oklahoma, Inc. ? UnitedHealthcare of Oregon, Inc. ? UnitedHealthcare Benefits of Texas, Inc. ? PacifiCare of Arizona, Inc. ? PacifiCare of Colorado, Inc.+ ? PacifiCare of Nevada, Inc.

+ Medicare Advantage benefit plans only.

AZ, CA, CO, NV, OK, OR, TX, WA

UnitedHealthcare West Supplement to this guide.



UnitedHealthOne:

? Golden Rule Insurance Company Group #705214

? Oxford Health Insurance, Inc. Group #908410

All Markets New Jersey

UnitedHealthOne Individual Plans Supplement to this guide.

and

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Chapter 1: Introduction

Benefit Plans Not Subject to this Guide Empire Plan: In most states, we have a separate care provider network for The Empire Plan members. If you have a direct contract for our Empire Plan Network (The UnitedHealthcare Empire Plan Agreement), this guide does not apply. If you do not have an Empire Plan contract and are a care provider in AZ, CT, DC, FL, IL, MD, NJ, NC, PA, SC, VA, or WV, or if you are a national care provider, your agreement with us allows Empire Plan members to access your services (unless it specifically excludes Empire Plan). In those cases, this guide applies.

Plan name

Sierra: ? Sierra Health and Life Insurance Co., Inc. ? Sierra Healthcare Options, Inc. ? Health Plan of Nevada, Inc. ? Health Plan of Nevada Medicaid/

Nevada Check Up

Location of most members Additional guide/ website subject to additional guides

NV

Benefit plans for Sierra Health and Life Insurance

Company, Inc.:

provider

Benefit plans for Health Plan of Nevada, Inc.:

provider

Provider

UnitedHealthcare Community Plan Medicaid, CHIP and Uninsured

Multiple States

UnitedHealthcare Community Plan Physician, Health Care Professional, Facility and Ancillary Administrative Guide for Medicaid, CHIP, or Uninsured.

and

UnitedHealthcare Community Plan Medicare Advantage

including references to older brand names such as AmeriChoice, Great Lakes Health Plan, Unison, Arizona Physicians IPA (APIPA)

Multiple States

UnitedHealthcare Community Plan Physician, Health Care Professional, Facility and Ancillary Administrative Guide for Medicare .

UMR



Online Resources and How to Contact Us

Self Service is your home for care provider information with access to Link self-service tools, medical policies, news bulletins, and great resources to support administrative tasks including eligibility, claims and prior authorizations and notifications. replaces and as these sites are being retired.

Link Link provides online resources to support your administrative tasks including eligibility, claims and prior authorization and notifications.

To sign in to Link, go to and click on the Link button in the upper right corner. For more information about all Link apps, go to Link.

Our contracts generally require you to conduct business with us electronically. Using electronic transactions is fast, efficient, and supports paperless work environment. Link is your gateway to our online tools and is accessible on .

After submitting your transaction using Electronic Data Interchange (EDI), use Link apps to quickly find transaction

and documentation information related to our members and your submissions.

You can use Link to access information for:

? UnitedHealthcare Commercial

? UnitedHealthcare Medicare Advantage

? UnitedHealthcare Community Plan (as contracted by state)

? UnitedHealthcare West

? UnitedHealthcare of the River Valley

? UnitedHealthcare Oxford Commercial

Available benefit plan information varies for each of our Link applications.

There are several Link apps to choose from. Here is a list of our most frequently used apps.

? eligibilityLink--View patient eligibility and benefits information for most benefit plans. For more information go to eligibilityLink.

? claimsLink--Get claims information for many UnitedHealthcare plans, including access letters, remittance advice documents and reimbursement policies. For more information go to claimsLink.

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