2020 Care Provider Manual - Mississippi Coordinated Access Network (MississippiCAN) 2020 Physician, Health Care Professional, Facility and ...

 
2020
         Care Provider Manual
         Mississippi Coordinated Access Network
         (MississippiCAN) 2020
         Physician, Health Care Professional, Facility and Ancillary

Doc#: PCA-1-016518-02182020_02252020
Welcome

 Welcome to the Community Plan manual. This complete and 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 tools on our website at UHCprovider.com. Click the following links to access different manuals:

     •   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 UHCprovider.com. Click Menu on top left, select Administrative
         Guides and Manuals, then Community Plan Care Provider Manuals, select state.

  You may easily find information in the manual using the following steps:
     1. Press CTRL+F.
     2. Type in the keyword.
     3. Press Enter.

  If available, use the binoculars icon on the top right hand side of the PDF to search for information and topics.

  If you have any questions about the information or material in this manual or about our policies, please call
  Provider Services.

  We greatly appreciate your participation in our program and the care you offer our members.

 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.

                                                                                                               Confidential and Proprietary
MississippiCAN Administrative Guide 2020                                                             Copyrighted by UnitedHealthcare 2020
Welcome to UnitedHealthcare Community Plan

 This manual is designed as a comprehensive reference source for the information you and your staff need to conduct
 your interactions and transactions with us in the quickest and most efficient manner possible. Much of this material, as
 well as operational policy changes and additional electronic tools, are available on our website at UHCprovider.com.

 Our goal is to help ensure our members have convenient access to high-quality care provided according to the most
 current and efficacious treatment protocols available. We are committed to working with and supporting you and your
 staff to achieve the best possible health outcomes for our members.

 If you have questions about the information or material in this manual or about any of our policies or procedures, please
 call Provider Services at 877-743-8734.

 We greatly appreciate your participation in our program and the care you provide to our members.

 Important information regarding the use of this manual
 In the event of a conflict of information between your participation agreement and this manual, the terms of this
 manual will control unless the agreement dictates otherwise. UnitedHealthcare Community Plan reserves the right to
 supplement this manual to ensure that its terms and conditions remain in compliance with relevant federal and state
 statutes and regulations.

 In addition to this reference document, information is provided to members outlining their benefits, rights, and
 responsibilities at UHCprovider.com.

 This manual will be amended as operational policies change.

                                                                                                             Confidential and Proprietary
MississippiCAN Administrative Guide 2020                                                           Copyrighted by UnitedHealthcare 2020
Table of Contents

 UnitedHealthcare Community Plan Corporate Overview.................................................................................... 4
        Our Approach to Health Care
        UnitedHealthcare Dual Complete (HMO SNP)

 How to Contact Us.................................................................................................................................................... 5
        Frequently Used Information

 MississippiCAN Benefits........................................................................................................................................... 8
         Covered Services by Mississippi Medicaid
         MississippiCAN Benefit Summary

 MississippiCAN Services......................................................................................................................................... 16
         NurseLineSM Services
         Online Resources
         Pharmacy Services
         Pharmacy Prior Authorization
         Prescription Limitations
         Pharmacy – Preferred Drug List (PDL)
         Dental
         Prior Authorization
         Vision
         Behavioral Health and Substance Use Disorder

 Medical Management............................................................................................................................................. 21
        Referral Guidelines
        Emergency Care
        Medical ID Requirement

 Prior Authorization................................................................................................................................................. 23
         Determination of Medical Necessity
         Disease Management
         Member Identification
         Health Risk Assessment
         Outreach and Other Identification Processes
         DM Interventions
         Plan of Care
         Pharmacy
         Drug Utilization Review Programs
         Coordination of Care
         Case Management
         Transition of Care
         Clinical Practice Guidelines
         Concurrent Review
         Retrospective Review
         Preventive Health Care Standards

                                                                                                                                               Confidential and Proprietary
MississippiCAN Administrative Guide 2020                                          1                                                  Copyrighted by UnitedHealthcare 2020
Table of Contents

            Recommended Childhood Immunization Schedules
            Cardiology Notification/Prior Authorization Protocol

 Appeals and Grievances.................................................................................................................34
        Compliance With State Requirements

 Quality Management............................................................................................................................................. 40
         Your Participation in Quality Management
         Quality Improvement Program
         Your Satisfaction
         Credentialing and Recredentialing
         Care Provider Responsibilities
         Credentialing and Recredentialing Process
         Confidentiality
         HIPAA Compliance
         Member Rights and Responsibilities
         National Provider Identifier (NPI)
         NPI Compliance
         Fraud, Waste and Abuse
         Definitions of Fraud, Waste and Abuse
         Reporting Fraud, Waste and Abuse
         Ethics and Integrity
         Compliance Program
         Reporting and Auditing

 Claims Filing and Processing. . .............................................................................................................................. 48
        Claims Billing Procedures
        Electronic Data Interchange (EDI) Claims
        Claims Format
        Claim Processing Time
        Claims Submission Rules
        Payment Policies and Tools
        Physician Claim-Editing Tools
        Facility Claim Editing
        Tax Identification Numbers/Provider IDs
        Coordination of Benefits
        Electronic Claims Submission and Billing
        Importance and Usage of EDI Acknowledgment/Status Reports
        EDI Companion Documents
        e-Business Support
        Span Dates
        Effective Date/Termination Date
        Overpayments
        Subrogation
        Care Provider/Member Cost Sharing Responsibilities
        Timely Filing and Late Bill Criteria

                                                                                                                                            Confidential and Proprietary
MississippiCAN Administrative Guide 2020                                         2                                                Copyrighted by UnitedHealthcare 2020
Table of Contents

            Claim Reconsideration Requests
            Care Provider Appeals
            Resolving Disputes
            The Correct Coding Initiative
            Vaccines for Children (VFC) Billing
            Member Identification Cards

 Care Provider Standards and Policies.. ............................................................................................................... 57
        Role of the PCP
        Responsibilities of the PCP
        Responsibilities of Specialists
        Member Notification of Termination
        Medical Residents in Specialty Practice
        Standards for Appointment Scheduling
        Timeliness Standards for Notifying Members of Test Results
        Allowable Office Waiting Times
        Care Provider Office Standards
        Medical Record Charting Standards
        Screening and Documentation Tools
        Medical Record Review
        Medical Record Documentation Standards Audit Tool
        Advance Directives
        Protect Confidentiality of Member Data

 Care Provider Communications and Outreach.................................................................................................. 68
        Care Provider Website
        Care Provider Office Visits

                                                                                                                                     Confidential and Proprietary
MississippiCAN Administrative Guide 2020                                     3                                             Copyrighted by UnitedHealthcare 2020
UnitedHealthcare Community Plan Corporate Overview

Medicaid contracts with UnitedHealthcare Community Plan to provide services to its Mississippi Coordinated Access
Network (MississippiCAN). As a result, we provide services to pregnant women, children and adults who meet income
requirements.

UnitedHealthcare Community Plan understands that compassion and respect are essential components of a successful
health care company. UnitedHealthcare Community Plan employs a diverse workforce, rooted in the communities we
serve, with varied backgrounds and extensive practical experience that gives us a better understanding of our members
and their needs.

Our Approach to Health Care
Innovative health care programs are the hallmark of UnitedHealthcare Community Plan. Our personalized programs
encourage the utilization of services. These programs, some of them developed with the aid of researchers and clinicians
from academic medical centers, are designed to help our chronically ill members avoid hospitalizations and hospital
emergency room visits — in short, to live healthy, productive lives.

The unique UnitedHealthcare Community Plan Personal Care Model™ features direct member contact by our clinicians
trained to foster an ongoing relationship between the health plan and members suffering from serious and chronic
conditions. The goal is to use high-quality health care and practical solutions to improve members’ health and keep them
in their communities — with the resources necessary to maintain the highest possible functional status.

UnitedHealthcare Community Plan does not require or request you to enter into an exclusive relationship with us or any
of our business affiliates.

UnitedHealthcare Dual Complete (HMO SNP)
For information about UnitedHealthcare Dual Complete, please see Chapter 4 of the Physician, Health Care
Professional, Facility and Ancillary Provider Administrative Guide for Commercial and Medicare Advantage Products. For
state-specific information, go to UHCprovider.com > Menu >Health Plans by State.

                                                                                                           Confidential and Proprietary
MississippiCAN Administrative Guide 2020                     4                                   Copyrighted by UnitedHealthcare 2020
How to Contact Us

                                           UHCprovider.com                    To review a patient’s eligibility or benefits,
                                                                              check claims status, submit claims or
                                                                              review Directory of Physicians, Hospitals
                                                                              and other Health Care Professionals.

    Provider Services                      877-743-8734                       This is an automated system. Please have
                                                                              your National Provider Identifier number and
                                           Hours of Operations:
                                                                              your tax ID or the member ID ready, or you
                                           Monday – Friday 8 a.m. to 5 p.m.
                                                                              may hold to speak to a representative. The
                                                                              call center is available for you to:
                                                                              • Answer general questions
                                                                              • Verify member eligibility
                                                                              • Check status of claims
                                                                              • Ask questions about your participation
                                                                                 or notify us of demographic and practice
                                                                                 changes

    Prior Authorization                    866-604-3267                       To request prior authorization or to notify us
    Notification                                                              in accordance with the prior authorization/
                                           Fax 888-310-6858
                                                                              notification requirements section of this
                                           UHCprovider.com                    guide.

    Pharmacy Services                      877-305-8952                       OptumRx
                                                                              Pharmacy Help Desk
                                                                              Available 24 hours a day, 7 days a week

    Behavioral                             UBH Customer Service:
    Health Services                        866-673-6315
                                           Prior Authorization:
                                           877-743-8731
                                           Provider Services:
                                           877-743-8734

    Dental                                 800-508-4862

    Vision                                 844-606-2724

    Hospital Inpatient Services            866-604-3267
    and Concurrent Reviews                 Fax 888-310-6858

    Transportation                         844-525-2331

                                                                                                           Confidential and Proprietary
MississippiCAN Administrative Guide 2020                          5                              Copyrighted by UnitedHealthcare 2020
How to Contact Us
MississippiCAN Care Provider                                                                                              UHCprovider.com
                                                                                                                          Verify member eligibility, check status of claims, submit claim
                                                                                                                          adjustment requests.
Frequently Used Information                                                                                               Provider Services: 877-743-8734
                                                                                                                          This is an automated system. Please have your National Provider
                                                                                                                          Identifier number and your Tax ID or the member ID ready, or you
                                                                                                                          may hold to speak to a representative. The call center is available for
Our Claims Process                                 Complete Claims                                                        you to:
To help ensure prompt payment:                     A complete claim includes the following:
                                                                                                                          • Ask questions about benefits.
    Review and copy both sides of the              • Member’s name, date of birth, address and ID number.
                                                                                                                          • Verify member eligibility.
1   member’s ID card. UnitedHealthcare             • Name, signature, address and phone number of physician or care
    Community Plan members receive an ID                                                                                  • Check claim status.
                                                      provider performing the service, as in your contract document.
    card containing information that helps you                                                                            • Ask questions about your participation or notify us of demographic
                                                   • National Provider Identifier (NPI) number.
    process claims accurately. These ID cards                                                                                and practice changes.
    display information such as claims address,    • Physician’s or care provider’s tax ID number.
                                                                                                                          • Request information regarding credentialing.
    copayment information (if applicable),         • CPT-4 and HCPCS procedure codes with modifiers where
    and telephone numbers such as those for                                                                               Prior Authorization: 866-604-3267
                                                      appropriate.
    member and care provider services.                                                                                    Available Monday – Friday 8 a.m. – 5 p.m. (CT), 24 hours for
                                                   • ICD-10 diagnostic codes.                                             emergency. For a complete and current list of prior authorizations,
    Notify UnitedHealthcare Community Plan’s
2                                                  • Revenue codes (UB-04 only).                                          go to UHCprovider.com/priorauth.
    Health Services of planned procedures and
                                                                                                                          Fax prior authorizations to 888-310-6858
    services on the Prior Authorization list.      • Date of service(s), place of service(s) and number of services
                                                      (units) rendered.                                                   Utilization Management: 877-743-8731
    Prepare a complete and accurate electronic
3                                                                                                                         Staff is available Monday through Friday, 8 a.m. to 5 p.m. (ET), to
    or paper claim form (see “Complete claims”     • Referring physician’s name (if applicable).                          assist with routine prior authorizations, admissions, discharges and
    at right). Complete a CMS 1500 or UB-04
                                                   • Information about other insurance coverage, including job-          coordination of members’ care. On-call staff is available 24/7 for
    form.
                                                      related, auto or accident information, if available.                emergency prior authorization purposes.
    Submit claims electronically to reduce
4                                                  • Attach operative notes for claims submitted with modifiers 22,      Case Management: 877-743-8731
    costs, help ensure faster processing
                                                      62, or any other team surgery modifiers.                            Disease Management: 877-743-8731
    and reduce claim entry errors. Use our
    electronic payer (ID 87726) to submit          • Attach a description of the procedure/service provided for          Pharmacy Prior Authorization:
    claims to us. For more information, contact       claims submitted with unlisted medical or surgical CPT codes or     Go to UHCprovider.com/priorauth for a copy of the pharmacy
    your vendor or our Electronic Data                experimental or reconstructive services (if applicable).            provider authorization form. Call 800-310-6826 or fax pharmacy
    Interchange (EDI) unit at 800-210-8315. If                                                                            prior authorization to 866-940-7328
    you do not have access to internet services,   Injectable drugs provided in an office/clinic setting:
    you can mail the completed claim to:                                                                                  Vision: 800-877-7195
                                                   The health plan will be responsible for reimbursement of injectable
                                                   drugs obtained in an office/clinic setting and to care providers       Transportation: 844-525-2331
    UnitedHealthcare Community Plan
                                                   providing both home infusion services and the drugs and biologics.     Behavioral Health
    PO Box 5032
                                                   The health plan will require that all professional claims contain      BH Claims: 866-673-6315
    Kingston, NY 12402-5032
                                                   NDC (National Drug Code) 11-digit number and unit information to       BH Prior Authorization: 877-743-8731
                                                   be paid for home infusion and J codes. The NDC number must be
                                                   entered in 24D field of the CMS-1500 Form or the LIN segment of        Member Services Helpline: 877-743-8731
                                                   the HIPAA 837 electronic form. Services reimbursed by the health       Available to answer member calls Monday through Friday, 8 a.m. to
                                                   plan will not be included in any pharmacy benefit limits established   6 p.m. (CT). In addition, our interactive voice response (IVR) telephone
                                                   for pharmacy services.                                                 system is available 24 hours a day, 7 days a week, and our nurse
                                                                                                                          triage hotline is available through our IVR for health-related issues.

                                                                                                   6
MississippiCAN
 MississippiCANCare Provider
                  Care Provider
Frequently Used Information
 Quick Reference  Guide
 Other
 OtherImportant
       ImportantInformation
                   Information                             Notify   UnitedHealthcare’s
                                                            NotifyUnitedHealthcare         Health
                                                                                    Community   Plan’s Health
 Claim Reconsideration
 ClaimReconsideration    Request
                      Request                              Services
                                                            ServicesWithin the Following
                                                                      Within             Time Frames:
                                                                               the Following   Time Frames:
 UnitedHealthcareOnline.com      > Claims and
 UHCprovider.com/claims > Claims Reconsiderations
                                                           Non-Emergency
                                                            Non-Emergency     Care (except
                                                                                 Care       maternity)
                                                                                        (except    maternity)
 Payments > Claims Reconsiderations
 Claim mailing address                                     At
                                                            Atleast
                                                                leastfive business
                                                                       five        days
                                                                            business  days    to non-emergent,
                                                                                        priorprior             non-urgent
                                                                                                   to non-emergent,       hospital
                                                                                                                    non-urgent     admissions and/or outpatient
                                                                                                                               hospital
 P.O. Box 5032                                             services.
                                                            admissions and/or outpatient services.
 Claim mailing address
 Kingston,
 P.O. Box NY   12402-5032
            5032                                           Emergency
                                                            Emergency   Care:
                                                                           Care:
 Kingston, NY 12402-5032                                   Urgent
                                                            Urgentororemergent admissions
                                                                        emergent admissionsdo not  require
                                                                                              do not       a prior
                                                                                                       require     authorization.
                                                                                                                a prior           HOWEVER,
                                                                                                                        authorization.      Urgent/Emergent
                                                                                                                                       HOWEVER,    Urgent/Emergent
 Fraud and Abuse Division for
 Anonymous Reporting: 866-242-7727                         inpatient
                                                            inpatientadmissions
                                                                       admissions  require
                                                                                dodo       notification
                                                                                     require            within
                                                                                              notification     24 hours
                                                                                                            within       of admission.
                                                                                                                    24 hours  of admission.
 Fraud and Abuse Division: 866-242-7727
 (Mon-Fri 8:00 a.m. – 4:30 p.m. Central)
 (Mon-Fri 8:00 a.m. – 4:30 p.m. Central)                   Return
                                                            Returncalls from
                                                                    calls    health
                                                                           from     service
                                                                                 Health     coordinators
                                                                                         Service         and medical
                                                                                                  Coordinators     anddirectors
                                                                                                                       Medicaland
                                                                                                                                Directors
                                                                                                                                   provide and provide complete
 UnitedHealthcare
 UnitedHealthcare    Online
                  Online     Support
                         Support       Services:
                                 Services:                 complete  health information
                                                            health information    withinwithin  one business
                                                                                          one business    day.day.
 UnitedHealthcareOnline.com
 UHCprovider.com
 HelpDesk:  866-842-3278
 HelpDesk:866-842-3278

 Pharmacy
 Pharmacy                                                   NPI Compliance
                                                            NPI Compliance                                                              Medicaid   Requirement
                                                                                                                                        MedicaidIDID Requirement
 • Preferred Drug List (PDL)                               National Provider   Identification                                          You       be enrolled  in Mississippi Medicaid  and
                                                           National    Provider    Identification
                                                                                                (NPI)(NPI)                               Please
                                                                                                                                            mustnote  that all care providers   must be   enrolled
                                                                                                                                                                                             have a in
      Preferred Drug List (PDL)
 •877-743-8734                                             Federal Regulations and many state Medicaid agencies                         state          Medicaid ID     be reimbursed   for services
      877-743-8734                                                                                                                       Mississippi
                                                                                                                                              providerMedicaid,   and
                                                                                                                                                                    to have  a state provider
    UHCprovider.com/MSCommunityPlan            >Pharmacy    Federal regulations
                                                           require                and many
                                                                     the use of your    National
                                                                                              stateProvider    agencies require
                                                                                                    MedicaidIdentifier,  NPI, onthe
                                                                                                                                  all   provided    a MississippiCAN   member.
      UHCCommunityPlan.com                                                                                                               MedicaidtoID  in order to be reimbursed    for services
    Resources and Physician Administered Drugs >           electronic    NPI on
                                                            use of yourand       all electronic
                                                                             paper              and paper claim
                                                                                      claim submissions            submissions.
                                                                                                             effective May 23,          provided to a MississippiCAN member.
 •Prescription
      Pharmacy Drug
                 PriorLists, Drug Search and Updates
                        Authorization                      2008.    Therefore,
                                                            Therefore,  you must you
                                                                                   include
                                                                                       mustainclude      valid
                                                                                              valid NPIaon all claims
                                                                                                               NPI onsubmitted
                                                                                                                       all claimsto     An enhanced claim denial edit helps ensure that no
    800-310-6826                                           submitted
                                                            us for payment.
                                                                        to usTofor  payment.
                                                                                 assist us in expediting
                                                                                                To assistthis  in expediting
                                                                                                           us process, pleasethis
                                                                                                                               also     payments are made to care providers without a Mississippi
 • Pharmacy Prior Authorization
      UHCCommunityPlan.com                                 process,    please
                                                            include your  name,also   include
                                                                                  address,  andyour
                                                                                                 TIN. provider name, address,           An enhanced
                                                                                                                                        Medicaid  ID, on claim    denial
                                                                                                                                                         file. If your   edit ensures
                                                                                                                                                                       claims have denied
                                                                                                                                                                                      thatdue
                                                                                                                                                                                           no to
    800-310-6826                                           and TIN.                                                                     payments    are  made      to providers without a Mississippi
                                                                                                                                        missing Medicaid ID, and you have a current Mississippi
 • Pharmacy (OptumRx) Technical Help Desk
    UHCprovider.com/MSCommunityPlan          >Pharmacy      If you have not yet applied for and received your NPI, please do            Medicaid ID on file. If your claims have denied due to
                                                                                                                                        Medicaid ID, contact Provider Services at 877-743-8734.
      877-305-8952
    Resources and Physician Administered Drugs >                immediately
                                                           Ifsoyou have not by
                                                                             yetvisiting
                                                                                   appliednppes.cms.hhs.gov.      you have
                                                                                              for and receivedIfyour  NPI, not
                                                                                                                             please     missing Medicaid ID and you have a current
                                                                                                                                        We will update your records and adjust applicable claims.
 •Pharmacy     Pharmacy
     NetworkPrior         Locator
                   Authorization                           do
                                                            yetsoprovided  your NPI
                                                                    immediately         us, please
                                                                                   bytovisiting     do so immediately by
                                                                                                 nppes.cms.hhs.gov.        going
                                                                                                                       If you    to
                                                                                                                               have     Mississippi Medicaid ID, please contact Provider
   UHCCommunityPlan.com
                                                            UHCprovider.com
                                                           not                  and choose
                                                                 yet provided your     NPI toNational    Provider
                                                                                                us, please  do soIdentifier
                                                                                                                   immediately
                                                                                                                            from by     IfServices  hotline
                                                                                                                                           you do not  have at 877-743-8734
                                                                                                                                                            a current Mississippiso
                                                                                                                                                                                  Medicaid
                                                                                                                                                                                    that weID,can
                                                                                                                                                                                               a
 • Pharmacy (OptumRx) Technical Help Desk                  the Most
                                                           going      Visited section. Downloadable forms
                                                                   to UnitedHealthcareOnline.com           and are
                                                                                                                choose     website
                                                                                                                   on theNational        facilitate
                                                                                                                                        care        updating
                                                                                                                                              provider enrollment  records and
                                                                                                                                                              your application canadjusting
                                                                                                                                                                                    be found at
    877-305-8952                                            for you. NPI
                                                           Provider      information
                                                                      Identifier  fromcanthealso
                                                                                               Most
                                                                                                  be Visited
                                                                                                     faxed tosection. There are          applicable claims.
                                                                                                                                        ms-medicaid.com/msenvision.
                                                           downloadable       414-721-9006.
                                                            866-455-4068 orforms     on the website for you fill in the
 • Network Pharmacy Locator
    UHCCommunityPlan.com/MS > MississippiCAN >             appropriate information. NPI information can also be faxed to                If you do not have a current Mississippi Medicaid ID,
                                                           866-455-4068
                                                            You must provideor     UnitedHealthcare Community Plan the NPI
                                                                                to414-721-9006.
    Plan Details > Pharmacy Search                                                                                                      a provider Enrollment application can be found at:
                                                            that aligns with your MS Medicaid ID. Failure to do so may impact
                                                                                                                                        msmedicaid.acs-inc.com/msenvision/index.do
                                                            claims payment.
                                                           Please note that all care providers must provide to
                                                           UnitedHealthcare the NPI that aligns with their MS Medicaid
                                                           ID. Failure to do so may impact claims payment.

                                                                                         7
                                                                                                         7                                                                           Community Plan
MississippiCAN Benefits

   Covered Services by
   Mississippi Medicaid

   Federally Mandated Covered Services:                         State-Covered Optional Services:
   •   EPSDT and Expanded EPSDT Services                        •   Ambulatory Surgical Center Services
   •   Family Planning Services                                 •   Behavioral Health Services
   •   Federally Qualified Health Centers Services              •   Chiropractic Services
   •   Home Health Services                                     •   Christian Science Sanatoria Services
   •   Inpatient Hospital Services                              •   Dental Services
   •   Laboratory and X-Ray Services                            •   Disease Management Services
   •   Nurse Midwife Services                                   •   Durable Medical Equipment
   •   Nurse Practitioner Services (Pediatric and Family)       •   Eyeglasses
   •   *Nursing Facility Services                               •   Freestanding Dialysis Center Services
   •   Outpatient Hospital Services                             •   Hospice Services
   •   Physicians Services                                      •   Intermediate Care Facility for Individuals with
   •   Rural Health Clinic Services                                 Intellectual Disabilities (ICF/IID) Services
   •   Transportation Services                                  •   Inpatient Psychiatric Services
                                                                •   Physical Therapy
                                                                •   Occupational Therapy
                                                                •   Pediatric Skilled Nursing Services
                                                                •   Podiatrist Services
                                                                •   Prescription Drugs
                                                                •   Psychiatric Residential Treatment Facilities Services
                                                                •   Speech Therapy
                                                                •   State Department of Health Clinic Services
                                                                •   Targeted Case Management Services for Children
                                                                    With Special Needs
                                                                •   Long-Term Acute Care (LTAC) for Children

                                                                All benefits are subject to change at the
                                                                discretion of Mississippi Medicaid.

                                                                For more comprehensive information on
                                                                benefits, please visit the website at
                                                                medicaid.ms.gov.

                                                                                                          Confidential and Proprietary
MississippiCAN Administrative Guide 2020                    8                                   Copyrighted by UnitedHealthcare 2020
MississippiCAN Benefit Summary
 The following table includes benefits, limitations, prior authorization information and additional notes. Link is the preferred
 method to request prior authorization. Prior authorization is not a guarantee of payment. Find the most current prior
 authorization requirements at UHCprovider.com/MSCommunityPlan > Prior Authorization and Notification Resources.

                 Benefit                               Limitation                          Prior Authorization*                       Notes

   Ambulatory Surgical Center                                                       Not required
   Services
   Ambulance Services                                                               Emergency: not required
                                                                                    Non-emergency and fixed-wing
                                                                                    requires prior auth:
                                                                                    ph: 866-604-3267
                                                                                    fax: 888-310-6858
   Non-Emergency                           Limited to Medicaid-covered              Three days’ notice required by      Requests must be made at least
   Transportation Services                 services only. Excluded if service       calling Member Services at:         three business days in advance.
                                           limits have been met. Excluded           877-743-8731
                                           if beneficiary has transportation
                                           resources
   Chiropractic Services                   $700 maximum per calendar year           Not required

   Christian Science Sanitoria                                                      Not required
   Services
   Cosmetic and Reconstructive                                                      Yes
   Surgery- Outpatient                                                              ph: 866-604-3267
                                                                                    fax: 888-310-6858
   Dialysis Outpatient Center                                                       Not required
   Services

   Durable Medical Equipment               Medicaid policy restrictions apply       Yes. Prior authorization required   Additional DME information can
   (DME)                                                                            for items more than $500.           be found at: medicaid.ms.gov
                                                                                    ph: 866-604-3267
                                                                                    fax: 888-310-6858
   Medical Supplies                        Maximum of six diapers/                  Yes for more than six diapers/      Medicaid provides one month
                                           underpads per day for ages three         underpads per day for ages three    supply at a time
                                           and up with medical condition            and up
                                           causing incontinence of bowel
                                                                                    ph: 866-604-3267
                                           and/or bladder
                                                                                    fax: 888-310-6858
   EPSDT†                                  Limited to beneficiaries younger         Not required
                                           than 21
   Expanded EPSDT Services‡                Limited to beneficiaries younger         Not always required                 Prior authorization may be
                                           than 21                                                                      required to determine medical
                                                                                                                        necessity
   Family Planning Services                                                         Not required

   Federally Qualified Health                                                       Not required
   Center Services

                                                                                                                                       Confidential and Proprietary
MississippiCAN Administrative Guide 2020                                        9                                            Copyrighted by UnitedHealthcare 2020
Benefit                              Limitation                       Prior Authorization*                       Notes

   Genetic Testing                                                               Yes
                                                                                 ph: 866-604-3267
                                                                                 fax: 888-310-6858
   Health Department Services                                                    Not required                        Includes certain pharmacy
                                                                                                                     services through MS State Dept.
                                                                                                                     of Health (MSDH), Early
                                                                                                                     Intervention Program (EIP),
                                                                                                                     Perinatal High Risk Management/
                                                                                                                     Infant Services (PHRM/ISS)
   Hearing Services                        Hearing tests are covered.            Required for any services beyond    For more information, please see
                                                                                 EPSDT-covered services and all      the MS CAN prior authorization
                                           Hearing aids are limited to
                                                                                 hearing aids listed on the prior    list at UHCprovider.com/
                                           beneficiaries under 21 years of age
                                                                                 authorization requirements list     MSCommunityPlan > Prior
                                                                                                                     Authorization and Notification.
                                                                                 ph: 866-604-3267
                                                                                 fax: 888-310-6858
   Home Health Services                    Children - unlimited                  Yes                                 This does not apply to physical,
                                           Adults - 25 visits per                ph: 866-604-3267                    occupational, speech therapies,
                                           calendar year                         fax: 888-310-6858                   DME, orthotics, or prosthetics.
                                                                                                                     See those sections for additional
                                                                                                                     information
   Home Infusion                                                                 Certain medications may require     Medicaid preferred drug list can
                                                                                 prior auth. depending on Medicaid   be accessed: medicaid.ms.gov
                                                                                 preferred drug list
   Hospice                                 Limited to diagnoses that include     Yes                                 Provides benefits for Hospice
   -Inpatient                              six months or less life expectancy    ph: 866-604-3267                    Services unless concurrent of an
   -Outpatient                             as certified by physician             fax: 888-310-6858                   inpatient stay
   Hospital Services                                                             Required for admissions             To request authorization online:
   -Inpatient Days                                                               ph: 866-604-3267                    UHCprovider.com/priorauth
   -Long-Term Acute Care (LTAC)                                                 fax: 888-310-6858
     for Pediatrics
                                                                                 Not required for emergency
   -Emergency Dept
                                                                                 services
   Hysterectomy                            For age 21 years and older            Yes                                 Medicaid consent required and
                                                                                 ph: 866-604-3267                    can be accessed: medicaid.
                                                                                 fax: 888-310-6858                   ms.gov/resources/forms/
   Imaging                                                                       Yes                                 Additional information:
                                                                                 ph: 866-604-3267
   -Nuclear Studies                                                                                                  UHCprovider.com/
                                                                                 fax: 888-310-6858
   -Computed Tomography (CT,                                                                                        MSCommunityPlan > Prior
     SPECT Scans)                                                                Online authorization: carriers.     Authorization and Notification >
     -Magnetic Resonance                                                         carecorenational.com/               Radiology Prior Authorization and
     (MRI, MRA)                                                                  PreAuthorization/screens/           Notification Program
     -PET Scans                                                                  login.aspx

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MississippiCAN Administrative Guide 2020                                        10                                        Copyrighted by UnitedHealthcare 2020
Benefit                               Limitation                      Prior Authorization*                         Notes

   Laboratory                                                                   Not required

   Non-Contracted Care Provider                                                 Yes                                  Care provider and/or outpatient
   Services (Outpatient Facility &                                              ph: 866-604-3267                     facility services are payable only
   Professional)                                                                fax: 888-310-6858                    with prior authorization
   Nurse Practitioner Services                                                  Not required

   Nursing Facility Services                                                    Yes                                  Services are not administered by
                                                                                Benefits provided through Division   UnitedHealthcare Community Plan
                                                                                of Medicaid.                         although member is entitled to all
                                                                                                                     Medicaid benefits
   Orthotics and Prosthetics               Limited to beneficiaries under 21    Yes. Prior authorization required    Medicaid does not cover
                                           years of age.                        for items more than $500             treatment for flat feet (including
                                                                                                                     arch supports) for adults 21 and
                                           Coverage does not include arch
                                                                                                                     older so it is not covered service
                                           supports                             ph: 866-604-3267
                                                                                fax: 888-310-6858
   Outpatient Physical and                                                      Required for services provided by    These benefits are not covered
   Occupational Therapies                                                       home health agencies (see Home       through the home health program
   (PT, OT)                                                                     Health Services).                    for beneficiaries 21 and older
                                                                                ph: 866-604-3267
                                                                                fax: 888-310-6858
   Skilled Nursing and Private             Limited to beneficiaries younger     Yes
   Duty Nursing Services                   than 21                              ph: 866-604-3267
                                                                                fax: 888-310-6858
   Perinatal High Risk                                                          Not required
   Management Services
   Physician Assistant Services                                                 Not required

   Physician Services for                  36 visits per year                   Yes                                  Services are not administered
   Long-Term Care Visits                                                        Benefits provided through Division   by UnitedHealthcare Community
                                                                                of Medicaid.                         Plan, although member is entitled
                                                                                                                     to all Medicaid benefits
   Physician Services in Medical                                                Not required
   Offices (Primary and Specialty
   Care)
   Podiatrist Services                                                          Not required

   Prescribed Pediatric Extended           Limited to beneficiaries younger     Yes
   Care (PPEC)                             than 21                              ph: 866-604-3267
                                                                                fax: 888-310-6858

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Benefit                             Limitation                         Prior Authorization*                        Notes

   Prescription Drugs                      Members are limited to six             Yes for beneficiaries younger than    Medications can be dispensed
                                           prescription drugs per month, with     21 if therapy exceeds limitations.    as an emergency 72-hour supply
                                           no more than two of the six being      ph: 800-310-6826                      when drug therapy must not be
                                           brand-name, non-preferred drugs.       fax: 866-940-7328                     delayed and prior-authorization
                                                                                                                        is not available. This applies to
                                           Beneficiaries younger than 21 can      Note that some drugs on the
                                                                                                                        non-preferred drugs and any
                                           receive more than the monthly          preferred drug list (PDL) may still
                                                                                                                        drug affected by a need for prior
                                           limit with a medical necessity prior   require prior authorization
                                                                                                                        authorization.
                                           authorization
                                                                                                                        See: UHCprovider.com/
                                                                                                                        MSCommunityPlan >
                                                                                                                        Pharmacy Resources and
                                                                                                                        Physician Administered Drugs
                                                                                                                        > Prescription Drug Lists, Drug
                                                                                                                        Search and Updates
   Rural Health Clinic Services                                                   Not required

   Sleep Studies                                                                  Yes
                                                                                  ph: 866-604-3267
                                                                                  fax: 888-310-6858
   Speech Therapy (SLP)                                                           Yes. Speech therapy requires
                                                                                  authorization in an outpatient
                                                                                  setting.

                                                                                  ph: 866-604-3267
                                                                                  fax: 888-310-6858
   Sterilization                           For members 21 and older               Yes                                   Medicaid consent required and
                                                                                  ph: 866-604-3267                      can be accessed: medicaid.
                                                                                  fax: 888-310-6858                     ms.gov/resources/forms/
   Surgery (Inpatient)                                                            Yes
                                                                                  ph: 866-604-3267
                                                                                  fax: 888-310-6858
   Transplant Services                                                            Yes                                   Human solid organ (heart, lung,
                                                                                  ph: 866-604-3267                      liver, kidney) or bone marrow/stem
                                                                                  fax: 888-310-6858                     cell transplants are covered with
                                                                                                                        prior authorization.

              Eye Care Benefit                         Limitation                         Prior Authorization*                        Notes

   Children                                Two exams per year                     Required only for second pair of
   -Examination                                                                   glasses within the year
                                           Two pairs of glasses per year
   -Glasses
                                                                                  ph: 844-606-2724

   Adults                                  One exam per year                      Not required
   -Examination
                                           One pair of glasses every three
   -Glasses
                                           years

              Dental Benefit                           Limitation                         Prior Authorization*                        Notes

   Children                                $2,500 maximum per calendar            Required for procedures such as       Included:
                                           year for dental unless prior           crowns, root canals, orthodontics     Preventive
                                           authorization is obtained                                                    Diagnostic
                                                                                  ph: 800-508-4862
                                                                                                                        Restorative
                                           $4,200 maximum per lifetime per
                                                                                                                        Orthodontia
                                           child
                                                                                                                        Emergency pain relief

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Dental
                  Benefit
                      Benefit                         Limitation                        Prior Authorization*                             Notes

   Adults                                  $2,500 maximum per calendar          Required for procedures such as         Included:
                                           year for dental unless prior         crowns, root canals, orthodontics       Diagnostic
                                           authorization is secured                                                     Emergency pain relief
                                                                                ph: 800-508-4862
                                                                                                                        Orthodontics is not covered
                                                                                                                        for adults

            Mental Health Benefit                     Limitation                        Prior Authorization*                             Notes

   Community Mental Health                                                      Yes for some services. Refer to
   Center (CMHC) Services                                                       the most recent PA list.
                                                                                ph: 866-604-3267
                                                                                fax: 888-310-6858
   Intermediate Care Facility for          Therapeutic leave days limited to    No                                      Beneficiaries must be deemed
   Individuals with Intellectual           90 days per year                                                             eligible by MS Division of Medicaid
   Disabilities (ICF/IID) Inpatient                                                                                     to receive these services
   Services
   Inpatient Psychiatric Services                                               Yes                                     Available for children, adolescents
                                                                                                                        and adults. Care management is
                                                                                ph: 866-604-3267
                                                                                                                        also available by calling 877-743-
                                                                                fax: 888-310-6858
                                                                                                                        8731.
   Physician Psychiatry Services                                                Generally, basic physician services
                                                                                do not require PA. However, please
                                                                                consult the most recent PA list for
                                                                                a comprehensive list of services
                                                                                which do require PA.
                                                                                ph: 877-743-8731
   Psychiatric Residential                                                      No
   Treatment Facilities (PRTF)
   Psychological Evaluation                                                     Yes
   and Testing by Licensed
                                                                                ph: 866-604-3267
   Psychologist
                                                                                fax: 888-310-6858
   Therapeutic and Evaluative                                                   Generally, these services do not
   Mental Health Services for                                                   require PA. However, please
   Children                                                                     consult the most recent PA list for
                                                                                a comprehensive list of services
                                                                                which do require PA.

 *Prior authorization is initiated by the care provider performing the requested services. Prior authorization information
  is accurate only at the time of print, and is subject to change. You should always consult the most recent PA list found at
  UHCprovider.com/MSCommunityPlan.
 † EPSDT Services can only be performed by a care provider certified by the MS Division of Medicaid.
 Services include:
    ●● a comprehensive unclothed physical exam
    ●● comprehensive family/medical/developmental history
    ●● immunization status, any shots that are needed
    ●● lead assessment and testing
    ●● necessary blood and urine screening
    ●● tuberculosis (TB) skin test
    ●● developmental assessment
    ●● nutritional assessment/counseling
    ●● adolescent counseling
    ●● vision testing/screening
    ●● hearing testing/screening
    ●● dental referral services
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Benefit Exclusions

     ●● Items or services furnished gratuitously, without regard to the individual’s ability to pay and without expectation of payment
        from any source, such as free X-rays provided by a health department.

     ●● Any operative procedure, or any portion of a procedure, performed primarily to improve physical appearance and/or treat a
        mental condition through change in bodily form.

     ●● Routine physical examinations, such as school, sports, or employment physicals that are not part of the well-child screening
        program for beneficiaries younger than 21 years or are not covered.

     ●● Services of physical therapist or speech therapist are not covered for Medicaid beneficiaries 21 or older, except when
        provided as an outpatient hospital service, or as a nursing facility service. Therapy services are not covered in a nursing
        facility when performed by a home health agency.

     ●● Prosthetic and orthotic devices, and orthopedic shoes for beneficiaries 21 or older, except for crossover claims allowed by
        Medicare.

     ●● Vitamin injections, except for B-12 as specific therapy for conditions determined to be medically necessary and specifically
        covered by Medicaid.

     ●● Prescription vitamins and mineral products are excluded except for prenatal vitamins and folic acid for obstetrical patients.
        (Medically necessary nutritional supplements may be covered and are subject to inclusion criteria. See prior authorization
        requirements to determine medical necessity.)

     ●● Routine circumcisions for newborn infants.

     ●● Interest on late pay claims.

     ●● Acute freestanding psychiatric facilities for beneficiaries 21 and older.

     ●● Reimbursement for services provided to only Qualified Medicare Beneficiaries (QMB) except for Medicare/Medicaid
        crossover payments of Medicare deductibles and coinsurance.

     ●● Medicare deductibles and coinsurance will not be paid for QMBs in non-Medicaid eligible facilities.

     ●● Reimbursement for any Medicaid service for Specified Low-income Medicare Beneficiaries (SLMB) and Qualified
        Individuals (QI). These individuals are entitled only to payment or partial payment of their Medicare Part B premium.

     ●● Ambulance transport to and from dialysis treatment.

     ●● Reversal of sterilization, artificial or intrauterine insemination and in vitro fertilization.

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Benefit Exclusions

    ●● Services, procedures, supplies or drugs which are still in clinical trials and/or investigative or experimental in nature.

    ●● Routine foot care in the absence of systemic conditions.

    ●● Gastric surgery (any technique or procedure) for the treatment of obesity or weight control.

    ●● Telephone contacts/consultations and missed or cancelled appointments.

    ●● Wigs.

    ●● Services ordered, prescribed, administered, supplied or provided by an individual or entity that has been excluded by
       DHHS.

    ●● Services ordered, prescribed, administered, supplied or provided by an individual or entity that is no longer licensed by their
       governing board.

    ●● Services outside the scope and/or authority of a practitioner’s specialty and/or area of practice.

    ●● Services not specifically listed or defined by Medicaid are not covered.

    ●● Any exclusion listed elsewhere in the Mississippi Medicaid Provider Policy Manual, bulletins, or other
       Mississippi Medicaid publications. This includes:
       – Drugs that are investigational or approved for investigational purposes,
       – Drugs used for off-label indications not found in official CMS-approved compendia or generally accepted in
          peer-reviewed literature

    Acronyms

    MH - Mental Health

    MS - Medical Services

    NET - Non-Emergency Transportation

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MississippiCAN Services

 NurseLineSM Services                                             Ask medication questions.
                                                                    ●● Learn how to take medication safely and avoid
 Helping our members to make confident health care
                                                                       interactions.
 decisions.
                                                                  Members can call a NurseLine nurse any time for health
 Coping with health concerns can be time-consuming
                                                                  information and support — all at no cost — at
 and complex. With so many choices, it can be hard to
                                                                  877-370-4009. Health Information Library Pin Number:
 know where to look for trusted information and support.
                                                                  466.
 That’s why NurseLine services were developed — to
 give our members peace of mind with:
                                                                  Online Resources
    ●● Immediate answers to health questions any time,
       from anywhere — 24 hours a day at 877-370-4009             Members also have access to a wealth of information
       Health Information Library Pin Number: 466;                online. Members can visit UHCCommunityPlan.com
                                                                  for health and well-being news, tools, resources and
    ●● Access to caring registered nurses who have an
                                                                  more. Members can even chat with a nurse any time
       average of 15 years clinical experience; and
                                                                  about health questions or concerns.
    ●● Trusted, care provider-approved information to
       guide health care decisions.
                                                                  Pharmacy Services
 When a member calls, a caring nurse can help our
 members to:                                                      The following drugs and medical supplies are covered:

 Choose appropriate medical care.                                    (a) L egend drugs (federal law requires these drugs be
                                                                           dispensed by prescription only). These drugs are
    ●● Understand a wide range of symptoms;                                manufactured by companies who have a signed
    ●● Determine if the emergency room, a doctor visit or                  drug rebate agreement. The Division of Medicaid
       self-care is right for their needs;                                 and its contractors are not required to cover
                                                                           prescription drugs from manufacturers that do not
 Find a doctor or hospital.                                                participate in the federal drug rebate program;
    ●● Find doctors or hospitals that meet their needs and           (b) Compounded medication of which at least one
       preferences;                                                       ingredient is a legend drug;
    ●● Locate an urgent care center and other health                 (c) Disposable blood glucose testing agents;
       resources.
                                                                     (d) Disposable insulin needles/syringes;
 Understand treatment options.                                       (e) Growth hormones;
    ●● Learn more about a diagnosis;                                 (f) Insulin;
    ●● Explore the risks, benefits and possible outcomes             (g) Lancets;
       of treatment options;
                                                                     (h) Legend contraceptives;
 Achieve a healthful lifestyle.                                      (i) Retin-A (tretinoin topical);
    ●● Get tips on how nutrition and exercise can help the           (j) Smoking deterrent medications containing nicotine
       member maintain a healthful weight.                                or any other smoking cessation aids, all dosage
    ●● Learn about important health screenings and                        forms (e.g., Nicorette, NicoDerm).
       immunizations;

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MississippiCAN Administrative Guide 2020                     16                                         Copyrighted by UnitedHealthcare 2020
The following are excluded:                                              one year after the date of practitioner’s original
                                                                          prescription.
      (a) Anabolic steroids (e.g., Winstrol, Durabolin);

      (b) Anorectics (any drug used for the purpose of            Pharmacy Prior Authorization
           weight loss) with the exception of Dexadrine and
           Adderall for Attention Deficit Disorder;                Medications can be dispensed as an emergency
                                                                   72-hour supply when drug therapy must start without
      (c) A
           nti-wrinkle agents (e.g., Renova);                     delay and prior authorization is not available. The rules
      (d) C
           harges for the administration or injection of any      apply to non-preferred drugs on the PDL and to any drug
           drug;                                                   that is affected by a clinical prior authorization edit.

      (e) Dietary supplements;                                     To request pharmacy prior authorization, please call the
                                                                   OptumRx Pharmacy HelpDesk at 800-310-6826 or fax
      (f ) I nfertility medications (e.g., Clomid, Metrodin,      your authorization request to 866-940-7328.
            Pergonal, Profasi);
                                                                   Prior authorization requests are reviewed and notification
      (g) Minerals (e.g., Potaba);                                 is sent back within 24 hours.

      (h) M
           edications for the treatment of alopecia, e.g.
          (Rogaine);                                               Prescription Limitations
      (i) N
           on-legend drugs other than those listed as             All Medicaid beneficiaries are limited to six prescriptions
          covered;                                                 per month with no more than two being brand-name
                                                                   drugs, including refills. Preferred brands do not count
      (j) Pigmenting/de-pigmenting agents;                         toward the monthly brand service limit, but do count
      (k) Drugs used for cosmetic purposes;                        towards the drug service limit of six per month.

      (l) Therapeutic devices or appliances, including            Children younger than 21 can receive more than the
           needles, syringes, support garments and other           monthly prescription limits with a medical necessity prior
           non-medicinal substances, regardless of intended        authorization. Requests for these exceptions should be
           use, except those listed as covered, such as insulin    made either in writing by the prescriber and faxed to
           needles and syringes;                                   866-940-7328, or called into UnitedHealthcare
                                                                   Community Plan’s Pharmacy Prior Authorization Services
      (m) Any medication not proven effective in general          at 800-310-6826. A prior authorization request form is
           medical practice;                                       available at UHCprovider.com/MSCommunityPlan >
                                                                   Pharmacy Resources and Physician Administered Drugs
      (n) I nvestigative drugs and drugs used other than for      > Pharmacy Prior Authorization, and should be used for
           the FDA-approved diagnosis;                             all prior authorization requests if possible.
      (o) Drugs that do not require a written prescription;

      (p) C
           ertain prescription drugs if an equivalent product     Pharmacy - Preferred Drug List (PDL)
           is available over the counter. This exclusion does
                                                                   The Division of Medicaid (DOM) determines and
           not apply to drugs on the Medicaid preferred drug
                                                                   maintains its Universal Preferred Drug List (PDL). This list
           list; and
                                                                   applies to all MississippiCAN beneficiaries.
      (q) R
           efills in excess of the number specified by the
                                                                   For Medicaid beneficiaries, you are required to prescribe
           practitioner or any refills dispensed more than
                                                                   preferred drugs listed on the Universal PDL. For drugs

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MississippiCAN Administrative Guide 2020                          17                                   Copyrighted by UnitedHealthcare 2020
not listed on the Universal PDL, Mississippi law requires                 f. Sealants – covered through age 20 for permanent
 the DOM not reimburse for a brand-name drug if an                             first and second and pre-molars, one per every
 equally effective generic equivalent is available and is                      five years. Sealants on primary teeth with prior
 the least costly. The same applies to UnitedHealthcare                        authorization.
 MississippiCAN members. If a non-preferred medication
 is required for a member’s treatment, call the Pharmacy                 2. Benefits are also provided for restorative, endodontic,
 Prior Authorization Service at 800-310-6826, or fax a                       periodontic and surgical dental services as indicated:
 Pharmacy Prior Notification Request form to
                                                                           a. Amalgam, composite, sedative, and composite
 866-940-7328 to make the request. The request will be
                                                                               resin fillings including the replacement of an
 promptly reviewed. You will be notified of the decision.
                                                                               existing restoration;
 PDL information, including updates of when changes
                                                                           b. Stainless steel crowns on posterior and anterior
 occur, will be provided to you in advance, and a summary
                                                                               primary teeth when amalgam and composite
 of changes posted to the plan’s website. We fax advanced
                                                                               restoration are insufficient;
 notifications to you approximately one month before the
 changes become effective. You also have the option to                     c. Porcelain crowns to anterior teeth only;
 contact us for a list of your patients who are impacted by
 any PDL change. The PDL and Pharmacy Prior Notification                   d. Simple and surgical extraction;
 Request form can be found on the plan’s website at
                                                                           e. Extraction of symptomatic impacted teeth;
 UHCprovider.com/MSCommunityPlan > Pharmacy
 Resources and Physician Administered Drugs. To obtain a                   f. Pulpotomy, pulpectomy and root canal;
 print copy of the PDL, contact the Provider Service Center.
                                                                           g. Gingivectomy, gingivoplasty and gingival curettage,
                                                                               periodontal scaling and root planing once per
 Dental                                                                        quadrant per fiscal year.

    1. Benefits are provided for preventive and diagnostic              3. Orthodontic Treatment - Orthodontic services are
        dental care as recommended by the American                           restricted to Medicaid-eligible beneficiaries younger
        Academy of Pediatric Dentistry (AAPD). The                           than 21.
        following Covered Dental Services are limited to
        $2,500 per fiscal year maximum (July 1-June 30):                   UnitedHealthcare Community Plan will consider
                                                                           orthodontic authorization requests for beneficiaries
       a. Bitewing X-rays as needed but no more frequently                through age 20 who meet at least one of the
           than one per fiscal year (July 1-June 30);                      following pre- qualifying criteria:

       (b. C
            omplete mouth X-ray and panoramic X-ray – as                    ●● Cleft lip, cleft palate and other craniofacial
            needed, but no more frequently than once every                      anomalies;
            24 months;                                                       ●● Overjet of 9 millimeters or more;

       c. P
           rophylaxis- two times every fiscal year (July 1-                 ●● Reverse overjet of 2 millimeters or more;
           June 30) and must be at least five months apart;                  ●● Extensive hypodontia with restorative implications
                                                                                (more than one tooth per quadrant) requiring pre-
       d. Fluoride Treatment – two times every fiscal year (July               prosthetic orthodontics;
           1-June 30) and must be at least five months apart;
                                                                             ●● Anterior openbites greater than 4 millimeters;
       e. S pace Maintainers – limited to permanent teeth                   ●● Upper anterior contact point displacement with
            through age 20;                                                     greater than four millimeters;

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●● Individual anterior tooth cross bites with greater     UnitedHealthcare Community Plan’s contracted
            than a 2-millimeter discrepancy between                ophthalmologists as listed in the UnitedHealthcare Community
            retruded contact position and intercuspal              Plan Provider Directory. If medical eyecare is needed, please
            position. For all orthodontic services, the member     refer patients to a participating ophthalmologist.
            must complete the course of treatment by their
            21st birthday. Approved cases subject to a lifetime                                               Prior           Contact for
                                                                           Benefit       Limitation
            maximum for orthodontic services of $4,200.                                                       Auth            Prior Auth

 Adults age 21 and older have emergency dental benefits,                Eyecare (Eye   Children – two     Yes, for           Member’s
                                                                       exams and      eye exams per      children after     selected
 some limitations and prior authorizations apply.
                                                                       glasses)       fiscal year, one   first pair per     March® Vision
                                                                                      pair eyeglasses    fiscal year        Provider or
                                                                                      per fiscal                            March® Vision
 Prior Authorization                                                                  year, plus one                        directly by
                                                                                      additional pair                       calling
 Prior authorization or other limitations may apply for some                          eyeglasses                            844-606-2724
                                                                                      covered
 dental services such as crowns, periodontal or specific                               under repair/
 oral surgery procedures, and orthodontic treatment.                                  replacement
 Please contact Dental Provider Services for specific                                  coverage per
                                                                                      fiscal year
 information at 800-508-4862.
                                                                                      Adults – one
                                                                                      eye exam per
 Vision                                                                               fiscal year, one
                                                                                      pair eyeglasses
 Routine vision, which includes a comprehensive eye                                   every three
                                                                                      fiscal years
 exam and glasses or contacts, is provided through our
 third-party vendor, MARCH® Vision Care. Additionally,
 the March® Vision network of ODs and MDs provide                  Behavioral Health and
 primary eyecare services. The vision plan provides
 supplemental coverage for non-surgical medical eyecare            Substance Use Disorder
 through a March® Vision doctor. Examples of services              Members have statewide access for outpatient behavioral
 covered include diagnosis and tests for loss of vision,           health and substance use disorder (SUD) services.
 treatment for conditions such as conjunctivitis (pink eye),       Out‑of‑state services are limited to specific emergency
 and management of glaucoma and diabetic retinopathy.              services. For information on referring patients for
 March® Vision doctors may provide services, if covered,           behavioral health and SUD services, call 866-673-6315.
 up to the optometry scope of licensure in the state of            Members should also be referred to this number for
 Mississippi in accordance with the covered benefits.               assistance in finding a behavioral health care provider.
 Patients do not need a referral before the initial visit with          1. Inpatient behavioral health and SUD services
 their selected March® Vision doctor. Patients may call for                  furnished in a state-operated behavioral health
 an appointment or be seen immediately if you determine                      hospital and including residential or other 24-hour
 urgent care is necessary.                                                   therapeutically planned structural services.
 Call March® Vision at 844-606-2724 or visit                               a. Benefits for covered medical expenses are paid for
 MarchVisionCare.com.                                                          medically necessary inpatient psychiatric treatment
 Medical eyecare beyond the scope of primary eyecare                           of an enrolled child.
 services, to include surgical care, is provided through                   b. Benefits for covered medical expenses are

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provided for partial hospitalization.

       c. C
           ertification of medical necessity by the Utilization
           Management (UM) program is required for
           admissions to a hospital.

       d. B
           enefits for covered medical expenses are
          provided for the treatment of SUD, whether for
          alcohol abuse, drug abuse or a combination of
          alcohol and drug abuse.

       e. Benefits for covered medical expenses are
           provided for medically necessary inpatient
           stabilization and residential SUD treatment.

       f. C
           ertification of medical necessity by the health
          plan’s UM program is required for admissions to a
          hospital or residential treatment center.

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Medical Management

 Referral Guidelines                                              require notification to UnitedHealthcare Community Plan
                                                                  within 24 hours from admission.
 You are generally responsible for initiating and
 coordinating referrals of members for medically necessary        Care in the Emergency Room
 services beyond the scope of your practice. You are              UnitedHealthcare Community Plan members who visit
 expected to monitor the progress of referred members’            an emergency room should be screened to determine
 care and help ensure that members are returned to their          whether a medical emergency exists. Prior authorization is
 care as soon as medically appropriate. We require prior          not required for the medical screening.
 authorization of all out-of-network referrals. The request is
                                                                  UnitedHealthcare Community Plan provides coverage
 generally processed like any other authorization request.
                                                                  for these services without regard to the emergency care
 The nurse reviews the request for medical necessity
                                                                  provider’s contractual relationship with us. Emergency
 and/or service. If the case does not meet criteria,
                                                                  services (i.e., physician and outpatient services furnished
 the nurse routes the case to the medical director for
                                                                  by a qualified care provider necessary to treat an
 review and determination. Out-of-network referrals are
                                                                  emergency medical condition) are covered both within
 generally approved for, but not limited, to the following
                                                                  and outside UnitedHealthcare Community Plan’s service
 circumstances:
                                                                  area.
    ●● Continuity of care issues; and
                                                                  An emergency medical condition is defined as a medical
    ●● Necessary services are not available within network.
                                                                  condition, that manifests itself by acute symptoms of
 Only in-network care providers may initiate prior                sufficient severity, including severe pain that a prudent
 authorizations. Authorization for out-of-network services        layperson possessing an average knowledge of medicine
 should be initiated by the in-network PCP or specialist.         and health, could reasonably expect in the absence of
 Through the provider portal, the in-network provider             immediate medical attention to result in:
 should appropriately indicate the care provider who is                ●● Placing the health of the person afflicted with such
 performing the service.                                                  condition in serious jeopardy (or, with respect to a
                                                                          pregnant woman, the health of the woman or her
 Out-of-network referrals are monitored on an individual
                                                                          unborn child);
 basis and trends related to individual care provider or
 geographical locations are reported to Network Provider               ●● Serious impairment to such person’s bodily functions;
 Services to assess root causes or action planning.                       or
                                                                      Additionally, in accordance with the provisions of
                                                                      42 C.F.R. § 422.133-c, post-stabilization services
 Emergency Care                                                       are covered and provided without the need of prior
 Prior authorization is not required for emergency services.          authorization if the services are medically necessary and
 Emergency care should be rendered at once, with                      resulting from the emergency medical condition.
 notification of any admission to:

 866-604-3267 (Phone)                                             Medicaid ID Requirement
 888-310-6858 (Fax)
                                                                  You must be enrolled in Mississippi Medicaid and have a
 Admission to inpatient starts at the time the order is           state provider Medicaid ID to be reimbursed for services
 written by a care provider that a member’s condition has         provided to a MississippiCAN member.
 been determined to meet an acute inpatient level of stay.
                                                                  An enhanced claim denial edit helps ensure that
 Inpatient admissions resulting from emergency services           no payments are made to care providers without a

                                                                                                                  Confidential and Proprietary
MississippiCAN Administrative Guide 2020                         21                                     Copyrighted by UnitedHealthcare 2020
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