2020 Care Provider Manual - Physician, Health Care Professional, Facility and Ancillary Care Washington Apple Health
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2020
Care Provider Manual
Physician, Health Care Professional, Facility and
Ancillary Care
Washington Apple Health
Doc#: PCA-1-016498-01022020_01212020
v42
Welcome
Welcome
Welcome to the UnitedHealthcare Community Plan
provider manual. This up-to-date reference PDF (manual/
Important Information about
guide) allows you and your staff to find important the Use of This Manual
information such as how to process a claim and prior
authorization. This manual also includes important phone If there is a conflict between your Agreement and this
numbers and websites on the How to Contact Us page. care provider manual, use this manual unless your
Find operational policy changes and other electronic tools Agreement states you should use it, instead. If there is
on our website at UHCprovider.com. a conflict between your Agreement, this manual and
applicable federal and state statutes and regulations and/
CLICK THE FOLLOWING LINKS TO ACCESS or state contracts, applicable federal and state statutes
DIFFERENT MANUALS: and regulations and/or state contracts will control.
• UnitedHealthcare Administrative Guide for UnitedHealthcare Community Plan reserves the right
Commercial and Medicare Advantage member to supplement this manual to help ensure its terms and
information. Some states may also have Medicare conditions remain in compliance with relevant federal and
Advantage information in their Community Plan state statutes and regulations.
manual. This manual will be amended as policies change.
• A different Community Plan manual: go to
Terms and definitions as used in this manual:
UHCprovider.com. Click Menu on top left, select
• “Member” or “customer” refers to a person eligible
Administrative Guides and Manuals, then Community
and enrolled to receive coverage from a payer for
Plan Care Provider Manuals, select state..
covered services as defined or referenced in your
EASILY FIND INFORMATION IN THIS MANUAL USING Agreement.
THE FOLLOWING STEPS: • “You,” “your” or “provider” refers to any health care
1. Press CTRL+F. provider subject to this manual, including physicians,
2. Type in the key word. health care professionals, facilities and ancillary
providers; except when indicated and all items are
3. Press Enter.
applicable to all types of health care providers subject
If available, use the binoculars icon on the top right hand to this guide.
side of the PDF to search for information and topics. We • Community Plan refers to UnitedHealthcare’s
greatly appreciate your participation in our program and Medicaid plan
the care you offer our members.
• “Your Agreement,” “Provider Agreement” or
If you have questions about the information or “Agreement” refers to your Participation Agreement
material in this manual, or about our policies, with us.
please call Provider Services. • “Us,” “we” or “our” refers to UnitedHealthcare
Community Plan on behalf of itself and its other
affiliates for those products and services subject to
this guide.
• Any reference to “ID card” includes both a physical or
digital card.
2 | UnitedHealthcare Community Plan of Washington © 2020 UnitedHealthcare
Welcome PARTICIPATION AGREEMENT If you have a concern about your Agreement with us, send a letter with the details to the address in your contract. A representative will look into your complaint. If you disagree with the outcome, you may file for arbitration. If your concern relates to certain UnitedHealthcare Community Plan procedures, such as the credentialing or care management process, follow the dispute procedures in your Agreement. After following those procedures, if one of us remains dissatisfied, you may file for arbitration. If we have a concern about your Agreement, we’ll send you a letter containing the details. If we can’t resolve the complaint through informal discussions, you may file an arbitration proceeding as described in your Agreement. Your Agreement describes where arbitration proceedings are held. 3 | UnitedHealthcare Community Plan of Washington © 2020 UnitedHealthcare
Table of Contents Table of Contents Chapter 1: Introduction 5 Chapter 2: Care Provider Standards & Policies 15 Chapter 3: Care Provider Office Procedures and Member Benefits 24 Chapter 4: Medical Management 29 Chapter 5: Early, Periodic Screening, Diagnosis and Treatment (EPSDT)/Prevention 47 Chapter 6: Value-Added Services 50 Chapter 7: Behavioral Health and Substance Use 53 Chapter 8: Member Rights and Responsibilities 56 Chapter 9: Medical Records 58 Chapter 10: Quality Management (QM) Program and Compliance Information 65 Chapter 11: Billing and Submission 72 Chapter 12: Claim Reconsiderations, Appeals and Grievances 79 Chapter 13: Care Provider Communications & Outreach 89 Chapter 14: Glossary 91 4 | UnitedHealthcare Community Plan of Washington © 2020 UnitedHealthcare
Chapter 1: Introduction
Chapter 1: Introduction
UnitedHealthcare Community Plan supports the
Washington state goals of increased access, improved
Integrated Managed Care
health outcomes and reduced costs by offering Medicaid (IMC)
benefits to the following members:
As of Jan. 1, 2020, UnitedHealthcare Community Plan
• Children, from birth through 18 years of age, eligible
has Apple Health IMC membership and Behavioral
for Medicaid under expanded pediatric coverage
Health-only membership in Clallam, Cowlitz, Grays
provisions of the Social Security Act.
Harbor, Island, Jefferson, King, Kitsap, Lewis, Mason,
• Pregnant Women, eligible for Medicaid under Pacific, Pierce, San Juan, Skagit, Snohomish, Thurston,
expanded maternity coverage provisions of the Social Wahkiakum and Whatcom counties.
Security Act.
UnitedHealthcare Community Plan will not have Apple
• Children eligible for the Children’s Health Insurance
Health plans in counties other than those listed as of
Program (CHIP).
Jan. 1, 2020. A map and table identifying which managed
• Categorically Needy — Blind and Disabled Children care plans will be available in each region can be viewed
and Adults who are not eligible for Medicare. at hca.wa.gov.
• Medicaid Expansion 19–64 years old who are not
eligible for another type of Medicaid and who has an
income of less than 138% of the federal poverty level. Our Approach to Health Care
• Medicaid eligible families.
• BHO — Behavioral Health Only WHOLE PERSON CARE MODEL
• Adults — Affordable Care Act Health Care Reform The Whole Person Care (WPC) program seeks to empower
The Department of Health (DOH) will determine UnitedHealthcare Community Plan members enrolled in
enrollment eligibility. Medicaid, care providers and our community partners
to improve care coordination and elevate outcomes.
If you have questions about the information in Targeting UnitedHealthcare Community Plan members
this manual or about our policies, go to with chronic complex conditions who often use health care,
UHCprovider.com or call Provider Services at the program helps address their needs holistically. WPC
877-542-9231. examines medical, behavioral and social/environmental
concerns to help members get the right care from the right
care provider in the right place and at the right time.
How to Join Our Network The program provides interventions to members with
For instructions on joining the UnitedHealthcare complex medical, behavioral, social, pharmacy and
Community Plan provider network, go to specialty needs, resulting in better quality of life, improved
UHCprovider.com/join. There you will find access to health care and reduced expenses. WPC
guidance on our credentialing process, how to provides a care management/coordination team that
sign up for self-service tools and other helpful helps increase member engagement, offers resources to
information. fill gaps in care and develops personalized health goals
using evidence-based clinical guidelines. This approach
is essential to improving the health and well-being of the
5 | UnitedHealthcare Community Plan of Washington © 2020 UnitedHealthcare
Chapter 1: Introduction
individuals, families and communities UnitedHealthcare appropriate use of services.
Community Plan serves. WPC provides: To refer your patient who is a UnitedHealthcare
• Market-specific care management encompassing Community Plan member to WPC, call Member Services
medical, behavioral and social care. at 877-542-8997, TTY 711. You may also call Provider
• Extended care team including primary care provider Services at 877-542-9231.
(PCP), pharmacist, medical and behavioral director,
and peer specialist.
• Options that engage members, connecting them to Online Resources
needed resources, care and services.
UHCprovider.com is your home for care provider
• Individualized and multidisciplinary care plan. information with access to Electronic Data Interchange
• Assistance with appointments with PCP and (EDI), Link self-service tools, medical policies, news
coordinating appointments. The clinical health bulletins, and great resources to support administrative
advocate (CHA) refers members to an RN, behavioral tasks including eligibility, claims, claims status and prior
health advocate (BHA) or other specialists as required authorizations and notifications.
for complex needs.
Electronic Data Interchange (EDI)
• Education and support with complex conditions.
EDI is a self-service resource using your internal practice
• Tools for helping members engage with providers,
management or hospital information system to exchange
such as appointment reminders and help with
transactions with us through a clearinghouse.
transportation.
• Foundation to build trust and relationships with hard- The benefit of using EDI is it permits care providers
to-engage members. to send batch transactions for multiple members and
multiple payers in lieu of logging into different payer
The goals of the WPC program are to: websites to manually request information. This is why
• Lower avoidable admissions and unnecessary EDI is usually care providers’ first choice for electronic
emergency room (ER) visits, measured outcomes by transactions.
inpatient (IP) admission and ER rates. • Send and receive information faster
• Improve access to PCP and other needed services, • Identify submission errors immediately and avoid
measured by number of PCP visit rates within processing delays
identified time frames.
• Exchange information with multiple payers
• Identify and discuss behavioral health needs,
• Reduce paper, postal costs and mail time
measured by number of behavioral health care
provider visits within identified time frames. • Cut administrative expenses
• Improve access to pharmacy. • EDI transactions available to care providers are:
• Identify and remove social and environmental barriers -- Claims (837),
to care. -- Eligibility and benefits (270/271),
• Improve health outcomes, measured by improved -- Claims status (276/277),
Healthcare Effectiveness Data and Information -- Referrals and authorizations (278),
Set (HEDIS) and Centers for Medicare & Medicaid -- Hospital admission notifications (278N), and
Services (CMS) Star Ratings metrics.
-- Electronic remittance advice (ERA/835).
• Empower the member to manage their complex/
Visit UHCprovider.com/EDI for more information. Learn
chronic illness or problem and care transitions.
how to optimize your use of EDI at UHCprovider.com/
• Improve coordination of care through dedicated staff
optimizeEDI.
resources and to meet unique needs.
Getting Started
• Engage community care and care provider networks
to help ensure access to affordable care and the • If you have a practice management or hospital
information system, contact your software vendor for
6 | UnitedHealthcare Community Plan of Washington © 2020 UnitedHealthcareChapter 1: Introduction
instructions on how to use EDI in your system. You will conduct business with us electronically. Using
• Contact clearinghouses to review which electronic electronic transactions is fast, efficient, and supports a
transactions can interact with your software system. paperless work environment. Use both EDI and Link for
maximum efficiency in conducting business electronically.
Read our Clearinghouse Options page for more
information. Here are the most frequently used tools:
• eligibilityLink — View patient eligibility and benefits
LINK - SECURE CARE PROVIDER WEBSITE information for most benefit plans. For more
Link provides a secure online portal to support your information, go to UHCprovider.com/eligibilityLink.
administrative tasks including eligibility, claims and prior • claimsLink — Get claims information for many
authorization and notifications. To sign in to Link, go to UnitedHealthcare plans, including access letters,
UHCprovider.com and click on the Link button in the remittance advice documents and reimbursement
upper right corner. For more information about all Link policies. For more information, go to UHCprovider.
tools, go to UHCprovider.com/Link. com/claimsLink.
T
o access Link, the secure care provider • Prior Authorization and Notification — Submit
website, go to UHCprovider.com and either notification and prior authorization requests. For more
sign in or create a user ID for Link. You will information, go to UHCprovider.com/paan.
receive your user ID and password within 48 • Specialty Pharmacy Transactions — Submit
hours. notification and prior authorization requests for
certain medical injectable specialty drugs using the
The secure care provider website lets you:
Specialty Pharmacy Transaction tile on your Link
• Verify member eligibility including secondary coverage. dashboard.
• Review benefits and coverage limit. • My Practice Profile — View and update* your
• Check prior authorization status. provider demographic data that UnitedHealthcare
• Access remittance advice and review recoveries. members see for your practice. For more information,
• Review your preventive health measure report. go to UHCprovider.com/mypracticeprofile.
• Access the Early and Periodic Screening, Diagnosis, • Document Vault — Access reports and claim
and Treatment (EPSDT) toolset. letters for viewing, printing, or download. For
more information, go to UHCprovider.com/
• Search for CPT codes. Type the CPT code in the
documentvault.
header search box on UHCprovider.com, and the
search results will display all documents and/or web • Paperless Delivery Options — When you use
pages containing that code. Document Vault to access claim letters, your Link
Password Owner may turn off delivery of paper
• Find certain web pages more quickly using
copies by mail. The Paperless Delivery Options
direct URLs. You’ll see changes in the way we
tool can send daily or weekly email notifications to
direct you to specific web pages on our
alert you to new letters when we add them to your
UHCprovider.com provider portal. You can now
Document Vault. With our delivery options, you
use certain direct URLs, which helps you find and
decide when and where the emails are sent for each
remember specific web pages easily and quickly. You
type of letter. This is available to Link Password
can access our most used and popular web pages
Owners only.
on UHCprovider.com by typing in that page’s direct
URL identified by a forward slash in the web address, • UHC On Air — Watch live broadcasts and on-
e.g. UHCprovider.com/claims. When you see that demand programs on topics important to you. Find
forward slash in our web links, you can copy the instructions for adding UHC On Air to your Link
direct URL into your web page address bar to quickly dashboard at UHCprovider.com/uhconair. You
access that page. need an Optum ID to access Link and use tools
available to you. To register for an Optum ID, go to
7 | UnitedHealthcare Community Plan of Washington © 2020 UnitedHealthcareChapter 1: Introduction
UHCprovider.com/newuser. Visit the Sign Language Interpreter Contract Transition
Watch for the most current information on our self-service website at links.govdelivery.com for more information.
resources by email, in the Network Bulletin, or online at Also visit the HCA Interpreter Services website at hca.
UHCprovider.com/EDI or UHCprovider.com/Link. wa.gov.
*For more instructions, visit UHCprovider.com/Training. CARE PROVIDER PRIVILEGES
To help our members access appropriate care and
PROVIDER SERVICES minimize out-of-pocket costs, you must have privileges at
Provider Services is the primary contact for care providers applicable in-network facilities or arrangements with an
who require assistance. It is staffed with representatives in-network provider to admit and provide facility services.
trained specifically for UnitedHealthcare Community Plan. This includes full admitting hospital privileges, ambulatory
surgery center privileges and/or dialysis center privileges.
Provider Services can assist you with questions
on Medicaid benefits, eligibility, claim decision, DIRECT CONNECT
forms required to report specific services, billing
questions and more. Direct Connect is a free online portal that lets you securely
communicate with payers to address errant claims. This
Provider Services works closely with all departments in portal has the ability to replace previous methods of
UnitedHealthcare Community Plan. letters, faxes, phone calls and spreadsheets. It also helps:
• Manage overpayments in a controlled process.
NETWORK MANAGEMENT DEPARTMENT
• Create a transparent view between you and payer.
Within UnitedHealthcare Community Plan, the Network
• Avoid duplicate recoupment and returned checks.
Management Department can help you with your
contract, credentialing and in-network services. The • Decrease resolution timeframes.
department has network account managers and provider • Real-time reporting to track statuses of inventories in
advocates who are available for visits, contracting, resolution process.
credentialing and other related issues. • Provide control over financial resolution methods.
If you need to speak with a network contract All users will access Direct Connect using Link. On-site
manager about credentialing status or and online training is available.
contracting, call our Network Management Email directconnectsupport@optum.com to
Phone Team. get started with Direct Connect.
CULTURAL COMPETENCY RESOURCES
COMPLIANCE
To help you meet membership needs, we have developed
a Cultural Competency Program. Linguistic and cultural HIPAA mandates National Provider Identifier (NPI) usage
barriers can negatively affect access to health care in all standard transactions (claims, eligibility, remittance
participation. You must help us meet this obligation for advice, claims status request/response, and authorization
our members. request/response) for all health care providers who handle
business electronically.
We offer simplified materials for members with limited
English proficiency and who speak languages other than EVIDENCE-BASED CLINICAL REVIEW
English or Spanish. We also provide materials for visually CRITERIA AND GUIDELINES
impaired members.
UnitedHealthcare Community Plan uses MCG Care
HCA Interpreter Services: The Health Care Authority Guidelines (formally Milliman Care Guidelines) for medical
(HCA) has partnered with the Office of Deaf and Hard of care determinations.
Hearing (ODHH) to improve the process for requesting
sign language interpreters.
8 | UnitedHealthcare Community Plan of Washington © 2020 UnitedHealthcareChapter 1: Introduction
How to Contact Us
Topic Contact Information
Behavioral Health Behavioral Health 855-802-7089 Members have statewide access for behavioral
and Substance Use Provider Services 877-542-9231 health services. We limit out-of-state behavioral
Disorder (SUD) services to specific emergency services.
Behavioral Provider Manual and Resources:
providerexpress.com > Clinical Resource See directory for a list of in-network behavioral
> Guidelines/Policies & Manuals > State health and substance use disorder care providers.
Specific Manuals and Addendums > WA PCP referral not required.
Medicaid Addendum.
Behavioral Health WAIMC@optum.com Ask about behavioral claim disputes.
Claim Disputes
Benefits UHCprovider.com/benefits Confirm a member’s benefits and/or prior
authorization.
Cardiology Prior For prior authorization or a current list of Request prior authorization of the procedures
Authorization CPT codes that require prior authorization, and services outlined in this manual’s prior
visit UHCprovider.com/cardiology. authorization requirements.
Chiropractor Care myoptumhealthphysicalhealth.com Chiropractic services are not covered for members
hca.wa.gov age 21 and older. Limited chiropractic services are
covered for children age 20 and younger.
800-873-4575
Refer to the Washington Health Care Authority
(HCA) billing guide for billing requirements, limits
and covered services.
Claims Use the Link Provider Portal at Ask about a claim status or get information about
UHCprovider.com/claims proper completion or submission of claims.
Mailing address:
UnitedHealthcare Community Plan
P.O. Box 31361
Salt Lake City, UT 84131-0361
For FedEx (use for large
packages/more than 500 pages):
UnitedHealthcare Community Plan
1355 S 4700 West, Suite 100
Salt Lake City, UT 84104
9 | UnitedHealthcare Community Plan of Washington © 2020 UnitedHealthcareChapter 1: Introduction
Topic Contact Information
Claim Overpayments See the Overpayment section for Ask about claim overpayments.
requirements before sending your request.
Sign in to
UHCprovider.com/claims to access Link,
then select the UnitedHealthcare Online
app
Mailing address:
UnitedHealthcare Community Plan
ATTN: Recovery Services
P.O. Box 740804
Atlanta, GA 30374-0800
Crisis Services — Clallam, Kitsap County - Salish BHO: 800- • 24/7/365 regional crisis hotline for mental
Behavioral Health 843-4793 health and SUD crises.
and Short-Term SUD Grays Harbor County - Great Rivers BHO: • Mental health crisis services, including the
800-685-6556 dispatch of mobile crisis outreach teams,
staffed by mental health professionals and
Cowlitz County - Great Rivers BHO: 360-
certified peer counselors.
425-6064
• Short-term SUD crisis services for people
Greater Columbia BH-ASO: 888-544-9986 intoxicated or incapacitated in public.
Jefferson County - Salish BHO: 877-410- Application of mental health and SUD involuntary
4803 commitment statutes, available 24/7/365 to
King County BH-ASO – Crisis conduct Involuntary Treatment Act assessments
Connections: 866-427-4747 or 206-461- and file detention petition.
3222
Lewis County - Great Rivers BHO: 800-
559-6696
Mason & Thurston Counties - Thurston-
Mason BHO: 800-270-0041
North Sound Counties (Island, San Juan,
Snohomish, Skagit & Whatcom): 800-584-
3578
Pacific County - Great Rivers BHO: 800-
884-2298
Pierce ‒ Beacon Health Options: 800-576-
7764, TTY 711
South West WA ‒ Beacon Health Options:
800-626-8137, TTY 866-835-2755
Spokane County BH-ASO: Regional
Behavioral Health: 877-266-1818
Wahkiakum County - Great Rivers BHO:
800-635-5989
10 | UnitedHealthcare Community Plan of Washington © 2020 UnitedHealthcareChapter 1: Introduction
Topic Contact Information
Electronic Data ac_edi_ops@uhc.com Ask about claims issues or questions.
Intake Claim Issues 800-210-8315
Electronic Data 800-842-1109 Information is also available at
Intake Log-on Issues UHCprovider.com/edi.
Eligibility To access the app, sign in to Confirm member eligibility.
UHCprovider.com/eligibility to access
Link, then select the UnitedHealthcare
Online app
waproviderone.org
Enterprise Voice 877-842-3210 The Enterprise Voice Portal provides self-service
Portal functionality or call steering prior to speaking with
a contact center agent.
Fraud and Abuse 800-455-4521 or 877-401-9430 Notify us of suspected fraud or abuse by a care
provider or member.
Healthy First Steps/ 800-599-5985 Refer high-risk OB members.
Obstetrics (OB) Fax initial prenatal visit form.
Referral
Laboratory Services Preferred Lab Network LabCorp and/or Quest Diagnostics are network
Quest Diagnostics: questdiagnostics. laboratories.
com
LabCorp 800-833-3984
Medical and Sign in to Claim issues include overpayment, underpayment,
Behavioral Claim, UHCprovider.com/claims to access Link, payment denial, or an original or corrected claim
Reconsideration and then select the UnitedHealthcare Online determination you don’t agree with.
Appeal app
Reconsiderations mailing address:
UnitedHealthcare Community Plan
P.O. Box 31361
Salt Lake City, UT 84131-0361
Appeals mailing address:
UnitedHealthcare Community Plan
Grievances and Appeals
P.O. Box 31364
Salt Lake City, UT 84131-0364
11 | UnitedHealthcare Community Plan of Washington © 2020 UnitedHealthcareChapter 1: Introduction
Topic Contact Information
Member Services 877-542-8997 Assist members with issues or concerns. Available
8 a.m. – 5 p.m. Pacific Time, Monday through
Friday.
Multilingual/ TTY 711 Available 8 a.m. – 5 p.m. Pacific Time, Monday
Telecommunication through Friday, except state-designated holidays.
Device for the Deaf
(TDD) Services
National 877-842-3210 Self-service functionality to update or check
Credentialing Center credentialing information.
(VETTS line)
National Plan nppes.cms.hhs.gov Apply for a National Provider Identifier (NPI).
and Provider 800-465-3203
Enumeration System
(NPPES)
NurseLine 877-543-3409 Available 24 hours a day, seven days a week.
Obstetrics and Baby Healthy First Steps Links for pregnant moms and newborn babies.
Care 800-599-5985
Fax: 877-353-6913
Pregnancy Notification Form
Prenatal risk assessment form
UHCBabyBlocks.com
Optum Support LinkSupport@optum.com Available 7 a.m. – 9 p.m. Central Time, Monday
Center 855-819-5909 through Friday; 6 a.m. – 6 p.m. Central Time,
Saturday; and 9 a.m. – 6 p.m. Central Time,
Sunday.
Pharmacy Services UHCprovider.com > Menu > Health Plans OptumRx oversees and manages our network
by State > Washington > Community pharmacies.
Plan of Washington Home > Pharmacy Use Link to access the PreCheck MyScript
Resources and Physician Administered tool. Request prior authorization and receive
Drugs results, and see which prescriptions require prior
877-305-8952 (OptumRx) authorization or are not covered or preferred
Pharmacy Help Desk 888-306-3243 Check coverage and price, including lower-cost
alternatives.
Customer Service (Provider) 800-711-4555
Preferred Drug List 877-542-9231
12 | UnitedHealthcare Community Plan of Washington © 2020 UnitedHealthcareChapter 1: Introduction
Topic Contact Information
Prior Authorization/ UHCprovider.com/priorauth Request authorization for medications as required.
Notification for 800-310-6826
Pharmacy
Fax: 866-940-7328
Prior Authorization/ UHCprovider.com/priorauth Request authorization/notify of the procedures
Notification of Health 877-542-9231 and services outline in the prior authorization/
Services notification requirements section of this manual.
Complete and current list of prior authorizations.
Prior Authorization UHCprovider.com/priorauth > Prior The process for completing the notification/prior
Notification Tool, Authorization Notification Tool authorization request and time frames remains
Quick References 877-842-3210 the same. Learn how to use the prior authorization
and Other Helpful advanced notification (PAAN) tool, complete the
Resources notification/prior authorization process or confirm
a coverage decision.
Call 7 a.m. to 7 p.m. local time, Monday through
Friday.
Provider Services UHCprovider.com/WAcommunityplan Use the automated system to:
877-542-9231 • Get answers to general questions.
• Verify member eligibility.
• Check claims status.
• Ask questions about your participation.
• Notify us of demographic and practice
changes.
• Request credentialing information.
Radiology Prior UHCprovider.com/priorauth Request prior authorization of the procedures
Authorization 866-889-8054 and services outlined in this manual’s prior
authorization requirements.
Complete and current list of prior authorizations.
Referral Submission/ UHCprovider.com > Click Menu on top
Notifications left, then select Referrals or use Link.
866-604-3267
Reimbursement UHCprovider.com/wacommunityplan > Reimbursement policies that apply to
Policy Bulletins and Newsletter UnitedHealthcare Community Plan members.
Visit this site often to view reimbursement policy
updates.
Tobacco Free Quit 800-784-8669 Ask about services for quitting tobacco/smoking.
Line
13 | UnitedHealthcare Community Plan of Washington © 2020 UnitedHealthcareChapter 1: Introduction
Topic Contact Information
Transportation hca.wa.gov The Washington HCA pays for transportation
services to get members to and from
non-emergency health care appointments.
Utilization 877-542-8997 UM helps avoid overuse and under-use of medical
Management services by making clinical coverage decisions
based on available evidence-based guidelines.
Request a copy of our UM guidelines or
information about the program.
Vaccines for 360-236-4501 Care providers must participate in the VFC
Children (VFC) Program administered by the Department of
program Health (DOH) and must use the free vaccine
when administering vaccine to qualified eligible
children (18 years and younger). Providers must
enroll as VFC providers with DOH to bill for the
administration of the vaccine.
Vision Services marchvisioncare.com Apple Health covers routine eye exams. However,
MARCH Vision Care 888-493-4070 we do not cover eyeglasses or fittings. Prior
authorization is required for all routine eye exams.
TTY 877-627-2456 Authorizations must be obtained from MARCH
Vision Care. Call Monday through Friday, 8 a.m. to
5 p.m. Pacific Time.
March Vision processes claims for services by
March Vision. We process claims for services our
care providers furnish.
Website for UHCprovider.com/WAcommunityplan Access your state-specific Community Plan
UnitedHealthcare information on this website.
Community Plan of
Washington
Whole Person Care 877-542-8997 Refer high-risk members (e.g., asthma, diabetes,
Person-Centered obesity) and members who need private-duty
Care Model (Care nursing.
Management/
Disease
Management)
14 | UnitedHealthcare Community Plan of Washington © 2020 UnitedHealthcareChapter 2: Care Provider Standards & Policies
Chapter 2: Care Provider
Standards & Policies
General Care Provider This includes any self-administered alternative
or information that may help them make care
Responsibilities decisions.
4. Recognize members (and/or their representatives)
NON-DISCRIMINATION have the right to choose the final course of action
You can’t refuse an enrollment/assignment or disenroll among treatment options.
a member or discriminate against them solely based on 5. Collaborate with the plan care manager in
race, color, or national origin; gender; gender identity; developing a specific care plan for members
age; veteran or military status; sexual orientation; the enrolled in High Risk Care Management.
presence of any sensory, behavioral or physical disability;
PROVIDE OFFICIAL NOTICE
or the use of a trained guide dog or service animal by a
person with a disability, type of illness or condition. You Write to us within 10 calendar days if any of the following
may only direct the member to another care provider events happen:
type if that illness or condition may be better treated by 1. Bankruptcy or insolvency.
someone else. 2. Indictment, arrest, felony conviction or any criminal
charge related to your practice or profession.
COMMUNICATION BETWEEN CARE PROVIDERS
AND MEMBERS 3. Suspension, exclusion, debarment or other sanction
from a state or federally funded health care program.
The UnitedHealthcare Community Plan Agreement is not
intended to interfere with your relationship with members 4. Loss or suspension of your license to practice.
as patients or with UnitedHealthcare Community 5. Departure from your practice for any reason.
Plan’s ability to administer its quality improvement, 6. Closure of practice.
utilization management or credentialing programs. You may use the care provider demographic information
Instead, we require communication between PCPs and update on form for demographic changes or update NPI
other participating care providers. This helps ensure information for care providers in your office. This form
UnitedHealthcare Community Plan members receive both is located at UHCprovider.com > Menu > Find a Care
quality and cost-effective health services. Provider > Care Provider Paper Demographic Information
UnitedHealthcare Community Plan members and/ Update Form.
or their representative(s) may take part in the planning
and implementation of their care. To help ensure TRANSITION MEMBER CARE FOLLOWING
members and/or their representative(s) have this chance, TERMINATION OF YOUR PARTICIPATION
UnitedHealthcare Community Plan requires you: If your network participation ends, you must transition
1. Educate members, and/or their representative(s) your UnitedHealthcare Community Plan members to
about their health needs. timely and useful care. This may include providing
2. Share findings of history and physical exams. service(s) for a reasonable time at our in-network rate.
Provider Services is available to help you and our
3. Discuss options (without regard to plan coverage),
members with the transition.
treatment side effects and symptoms management.
15 | UnitedHealthcare Community Plan of Washington © 2020 UnitedHealthcareChapter 2: Care Provider Standards & Policies
ARRANGE SUBSTITUTE COVERAGE • Completing the Provider Demographic Change Form
If you cannot provide care and must find a substitute, and faxing it to the appropriate number listed on the
arrange for care from other UnitedHealthcare Community bottom of the form.
Plan care providers and care professionals. • Calling our Enterprise Voice Portal.
For the most current listing of network care AFTER-HOURS CARE
providers and health care professionals, review
Life-threatening situations require the immediate services
our care provider and health care professional
of an emergency department. Urgent care can provide
directory at UHCprovider.com > Find Dr.
quick after-hours treatment and is appropriate for
infections, fever, and symptoms of cold or flu.
ADMINISTRATIVE TERMINATIONS FOR INACTIVITY
If a member calls you after hours asking about urgent
Up-to-date directories are a critical part of providing our
care, and you can’t fit them in your schedule, refer them to
members with the information they need to take care of
an urgent care center.
their health. To accurately list care providers who treat
UnitedHealthcare Community Plan members, we: PARTICIPATE IN QUALITY INITIATIVES
1. End Agreements with care providers who have not You must help our quality assessment and improvement
submitted claims for UnitedHealthcare Community activities. You must also follow our clinical guidelines,
Plan members for one year and have voluntarily member safety (risk reduction) efforts and data
stopped participation in our network. confidentiality procedures.
2. Inactivate any tax identification numbers (TINs)
UnitedHealthcare Community Plan clinical quality
with no claims submitted for one year. This is not
initiatives are based on optimal delivery of health care for
a termination of the Provider Agreement. Call
particular diseases and conditions. This is determined
UnitedHealthcare Community Plan to reactivate a
by United States government agencies and professional
TIN.
specialty societies. See Chapter 10 for more details on
CHANGING AN EXISTING TIN OR ADDING A HEALTH the initiatives.
CARE PROVIDER
PROVIDE ACCESS TO YOUR RECORDS
Please complete and email the Care Provider
You must provide access to any medical, financial or
Demographic Information Update Form and your W-9
administrative records related to services you provide
form to the address listed on the bottom of the form. The
to UnitedHealthcare Community Plan members within
W-9 form and the Care Provider Demographic Information
14 calendar days of our request. We may request you
Update Form are available at UHCprovider.com >
respond sooner for cases involving alleged fraud and
Menu > Find a Care Provider > Care Provider Paper
abuse, a member grievance/appeal, or a regulatory or
Demographic Information Update Form.
accreditation agency requirement. Maintain these records
Otherwise, complete detailed information about the for six years or longer if required by applicable statutes or
change, the effective date of the change and a W-9 regulations.
on your office letterhead. Email this information to the
number on the bottom of the demographic change PERFORMANCE DATA
request form. You must allow the plan to use care provider performance
data.
UPDATING YOUR PRACTICE OR FACILITY
INFORMATION SUBMIT TO CLINICAL DATA REPOSITORY
You can update your practice information through the The Clinical Data Repository (CDR) is a database that
Provider Data Management application on collects and indexes clinical content for specific uses.
UHCprovider.com. Go to UHCprovider.com > Menu > The CDR is a direct response by the Washington State
Find a Care Provider > Care Provider Paper Demographic HCA to help you share data. The CDR connects different
Information Update Form. Or submit your change by: electronic health record (EHR) platforms and places
16 | UnitedHealthcare Community Plan of Washington © 2020 UnitedHealthcareChapter 2: Care Provider Standards & Policies
clinical information in one location. It helps the care FOLLOW MEDICAL RECORD STANDARDS
team gain a more comprehensive understanding of Please reference Chapter 9 for Medical Record Standards.
the patient’s medical history. This helps improve health
care quality, better manage costs and improve health INFORM MEMBERS OF ADVANCE DIRECTIVES
outcomes. The federal Patient Self-determination Act (PSDA) gives
Contracted provider organizations with certified patients the legal right to make choices about their
EHRs, who see an Apple Health or Integrated medical care before incapacitating illness or injury
Managed Care member, are required to send a care through an advance directive. Under the federal act, you
summary (CCDA) from your EHR to the CDR. You must must provide written information to members on state
submit a CCDA to the CDR for a minimum of 80 percent law about advance treatment directives, about members’
of submitted claims. right to accept or refuse treatment, and about your own
To learn more about the CDR, visit onehealthport.com/ policies regarding advance directives. To comply with
clinical-portal and click on Getting Started. this requirement, we inform members of state laws on
advance directives through Member Handbooks and
COMPLY WITH PROTOCOLS other communications.
You must comply with UnitedHealthcare Community Members are not required to have an advance directive
Plan’s and Payer’s Protocols, including those contained in or physician orders for life-sustaining treatment (POLST).
this manual. You cannot refuse care or otherwise discriminate against
a member based on whether they have executed an
You may view protocols at UHCprovider.com. advance directive or POLST. Document in a member’s
medical record whether they have one and include a
OFFICE HOURS copy. Do not send a copy to us.
Provide the same office hours of operation to Mental health advance directives will be documented the
UnitedHealthcare Community Plan members as those same as any other type of advance directive.
offered to commercial members. A mental health advance directive form is
available at hca.wa.gov > Behavioral Health and
PROTECT CONFIDENTIALITY OF MEMBER DATA
Recovery (under Health Care Services and
UnitedHealthcare Community Plan members have a right Supports) > Mental Health Services > Mental
to privacy and confidentiality of all health care data. We Health Advance Directives.
only give confidential information to business associates
and affiliates who need that information to improve Members may also call the Office of Consumer
our members’ health care experience. We require our Partnerships at 800-446-0259 for a copy of the
associates to protect privacy and abide by privacy law. If form.
a member requests specific medical record information,
Members may file a complaint with our medical director,
we will refer the member to you. You agree to comply
our physician reviewer, and/or the state survey and
with the requirements of the Health Insurance Portability
certification agency about non-compliance with an
and Accountability Act of 1996 (“HIPAA”) and associated
advance directive or POLST requirement.
regulations. In addition, you will comply with applicable
state laws and regulations. If a member asks to appeal a clinical or coverage
determination on their behalf, follow the appeal
UnitedHealthcare Community Plan uses member
process in the member’s benefit contract or
information for treatment, operations and payment.
handbook. You may locate the Member Handbook at
UnitedHealthcare Community Plan has safeguards to stop
UHCCommunityPlan.com.
unintentional disclosure of protected health information
(PHI). This includes passwords, screen savers, firewalls Also reference Chapter 12 of this manual for information
and other computer protection. It also includes shredding on provider claim reconsiderations, appeals, and
information with PHI and all confidential conversations. All grievances.
staff is trained on HIPAA and confidentiality requirements.
17 | UnitedHealthcare Community Plan of Washington © 2020 UnitedHealthcareChapter 2: Care Provider Standards & Policies
Appointment Standards Care providers must evaluate members to determine if
Access to Care Standards are met. If criteria is met, refer
(Washington Access and the member to the Behavioral Health Organization (BHO)
for services. Access to Care Standards can be found at
Availability Standards) dshs.wa.gov.
Comply with the following appointment availability
PRENATAL CARE
standards:
Prenatal care providers should arrange OB/GYN
PRIMARY CARE appointments for:
PCPs should arrange appointments for: • First trimester: within three weeks of request.
• After-hours care phone number: 24 hours, 7 days • Second trimester: within two weeks of request.
a week. • Third trimester: within one week of request.
• Emergency care: Immediately or referred to an UnitedHealthcare Community Plan periodically conducts
emergency facility. surveys to check appointment availability and access
• Urgent care appointment: within 24 hours. standards. All care providers must participate in all
• Non-urgent, symptomatic (i.e., routine care) activities related to these surveys.
appointment: within 20 calendar days.
• Transitional PCP appointment: within seven calendar
days of discharge from inpatient or institutional Care Provider Directory
care for physical or behavioral health disorders or
You are required to tell us, within five business days,
discharge from a substance use disorder treatment
if there are any changes to your ability to accept new
program.
patients. If a member, or potential member, contacts you,
• Routine care appointment: within 30 calendar days. and you are no longer accepting new patients, report
• Physical exam: within 180 calendar days. any Provider Directory inaccuracy. Ask the potential new
• EPSDT appointments: within six weeks. patient to contact UnitedHealthcare Community Plan for
• New member appointment: within 30 calendar days. additional assistance in finding a care provider.
• In-office waiting for appointments: not to exceed one We are required to contact all participating care providers
hour of the scheduled appointment time. annually and independent physicians every six months.
We require you to confirm your information is accurate or
SPECIALTY CARE
provide us with applicable changes.
Specialists should arrange appointments for:
• Urgent care: within 24 hours. If we do not receive a response from you within 30 business
days, we have an additional 15 business days to contact you.
• Non-urgent sick visit: within 48–72 hours.
If these attempts are unsuccessful, we notify you that if you
• Non-urgent care: within four to six weeks.
continue to be non-responsive we will remove you from our
BEHAVIORAL HEALTH AND SUBSTANCE USE care provider directory after 10 business days.
Behavioral health care providers should arrange If we receive notification the Provider Directory information
appointments for: is inaccurate, you may be subject to corrective action.
• Emergency care (non-dangerous to self or others):
In addition to outreach for annual or bi-annual attestations,
immediately upon presentation.
we are required to make outreach if we receive a report of
• Urgent problems: within 48 hours of request. incorrect provider information. We are required to confirm
• Non-urgent problems: within 10 days of request. your information.
• Following an ER visit or hospitalization: within seven
days or as medically necessary.
18 | UnitedHealthcare Community Plan of Washington © 2020 UnitedHealthcareChapter 2: Care Provider Standards & Policies
To help ensure we have your most current provider
directory information, submit applicable changes to:
Home Health Services and
For Delegated providers, email your changes to
Medical Equipment Physician
Pacific_DelProv@uhc.com or delprov@uhc.com. Signature Requirements
For Non-delegated providers, visit UHCprovider.com Washington HCA requires physicians to sign prescriptions
for the Provider Demographic Change Submission Form for home health services and medical equipment.
and further instructions. Non-physician practitioners (i.e. advanced nurse
practitioners [ARNPs], physician [PAs]) may order
PROVIDER ATTESTATION supplies and equipment if within their scope of practice
Confirm your provider data every quarter through Link without a physician signature/co-signature. The items
or by calling Provider Services. If you have received the must be necessary for, or ancillary to, the administration
upgraded My Practice Profile and have editing rights, of pharmaceuticals or monitoring their effectiveness.
access Link’s My Practice Profile App to make many of This includes glucose monitors or test strips, lancets and
the updates required in this section. lancet devices, pen needles, syringes, inhalation masks,
and spacers. This applies to medical equipment (Chapter
182-543 WAC) dispensed at a pharmacy. It includes
diabetic supplies (glucose monitors, glucose test strips,
Prior Authorization Request lancet devices, lancets, pen needles, and syringes),
inhalation masks, and spacers.
Prior authorization requests may include procedures,
services, and/or medication. Pharmacy claims will not reject or stop for a physician’s
signature. However, pharmacies must comply with this
Coverage may only be provided if the service or
requirement.
medication is deemed medically necessary, or meets
specific requirements provided in the benefit plan.
You should take the following steps before providing Exception to Rule and
medical services and/or medication to UnitedHealthcare
Community Plan members: Limitation Extension
• Verify eligibility using Link at
An Exception to Rule (ETR) is a request for a non-covered
UHCprovider.com/eligibility or by calling Provider
service. To request an ETR, submit documentation
Services. Not doing so may result in claim denial.
showing the member’s condition requires the service. A
• Check the member’s ID card each time they visit. Limitation Extension (LE) is a request to extend covered
Verify against photo identification if this is your office services beyond the Apple Health benefit. Examples
practice. include other limited benefit requests or coverage for a
• Get prior authorization from Link: member outside the usual age limit. Submit ETR requests
1. To access the Prior Authorization app, go to within 90 days of receiving the denial for the service.
UHCprovider.com, then click Link.
2. Select the Prior Authorization and
Notification app on Link. Timeliness Standards for
3. View notification requirements. Notifying Members of Test
Identify and bill other insurance carriers when appropriate.
Results
If you have questions, please call the UnitedHealthcare
Connectivity Help Desk at 866-842-3278, option 3, After receiving results, notify members within:
7 a.m. ‒ 9 p.m. Central Time, Monday through Friday. • Urgent: 24 hours
• Non-urgent: 10 business days
19 | UnitedHealthcare Community Plan of Washington © 2020 UnitedHealthcareChapter 2: Care Provider Standards & Policies
Requirements for PCP and authorization) to any network OB/GYNs, midwives,
physician assistants, or nurse practitioners for women’s
Specialists Serving in PCP health care services and any non-women’s health care
issues discovered and treated in the course of receiving
Role women’s health care services. This includes access
to ancillary services ordered by women’s health care
SPECIALISTS INCLUDE: INTERNAL MEDICINE, providers (lab, radiology, etc.) in the same way these
PEDIATRICS, OR OBSTETRICIAN/GYNECOLOGY services would be ordered by a PCP.
PCPs are an important partner in the delivery of care, and UnitedHealthcare Community Plan works with members
Washington HCA members may seek services from any and care providers to help ensure all members
participating care provider. The HCA program requires understand, support, and benefit from the primary care
members be assigned to PCPs. We encourage members case management system. The coverage will include
to develop a relationship with a PCP who can maintain availability of 24 hours a day, seven days a week.
all their medical records and provide overall medical During non-office hours, access by telephone to a live
management. These relationships help coordinate care voice (i.e., an answering service, care provider on-call,
and provide the member a “medical home.” hospital switchboard, PCP’s nurse triage) will immediately
The PCP plays a vital role as a case manager in the page an on-call medical professional so referrals can be
UnitedHealthcare Community Plan system by improving made for non-emergency services. Recorded messages
health care delivery in four critical areas: access, are not acceptable.
coordination, continuity and prevention. As such, the Consult with other appropriate health care professionals
PCP manages initial and basic care to members, makes to develop individualized treatment plans for
recommendations for specialty and ancillary care, and UnitedHealthcare Community Plan members with special
coordinates all primary care services delivered to our health care needs.
members. The PCP must provide 24 hours a day, seven
• Use lists supplied by the UnitedHealthcare
days a week coverage and backup coverage when they
Community Plan identifying members who appear to
are not available.
be due preventive health procedures or testing.
Medical doctors (M.D.s), nurse practitioners (NPs)* and • Submit all accurately coded claims or encounters
PAs* from any of the following practice areas can be PCPs: timely.
• General practice • Provide all well baby/well-child services.
• Internal medicine • Coordinate each UnitedHealthcare Community Plan
• Family practice member’s overall course of care.
• Pediatrics • Accept UnitedHealthcare Community Plan members
• Obstetrics/gynecology at your primary office location at least 16 hours a
week for a one MD practice.
Nurse practitioners may enroll with the state as solo
providers, but physician assistants cannot; they must be • Be available to members by telephone any time.
part of a group practice. • Respond to after-hour patient calls within 45 minutes
for non-emergent symptomatic conditions and within
Members may change their assigned PCP by
15 minutes for emergency situations.
contacting Member Services at any time during
the month. Customer Service is available • Tell members about appropriate use of emergency
8 a.m. – 6 p.m., Monday through Friday. services.
• Discuss available treatment options with members.
We ask members who don’t select a PCP during
• Provide culturally competent care and services. You
enrollment to select one. UnitedHealthcare Community
must have a cultural competency program to educate
Plan may auto-assign a PCP to complete the enrollment
and train your staff on addressing cultural and
process.
linguistic barriers to delivering health care services to
Females have direct access (without a referral or members of all cultures.
20 | UnitedHealthcare Community Plan of Washington © 2020 UnitedHealthcareChapter 2: Care Provider Standards & Policies
• Tell members about the Washington Department Community Plan Clinical, or Pharmacy Department
of Social and Health Services (DSHS) substance as appropriate.
use disorder services, including a list of substance • Inform our Case Management Department at
use disorder clinics and contact information in the 877-542-8997 of any member showing signs of
counties we serve. end-stage renal disease.
• Advise enrollees on the availability of DSHS long- • Admit UnitedHealthcare Community Plan members
term care services including availability of home and to the hospital when necessary. Coordinate their
community based services. medical care while they are hospitalized.
• Take part in educational opportunities for PCPs, • Respect members’ advance directives. Document in
such as those produced by the Washington State a prominent place in the medical record whether or
Department of Health Collaborative, the Washington not a member has an advance directive form.
State Medical Association or the Washington State -- Provide covered benefits consistently with
Hospital Association. professionally recognized standards of health
• Help ensure services delivered to individuals with care and in accordance with UnitedHealthcare
special health care needs are appropriate to their needs. Community Plan standards. Document procedures
• Refer all pregnant members to the DSHS First Steps for monitoring members’ missed appointments as
Maternity Support Services/Infant Case Management well as outreach attempts to reschedule missed
and the Healthy First Steps programs. appointments.
-- Transfer medical records upon request. Provide
copies of medical records to members upon
Responsibilities of PCPs and request at no charge.
Specialists Serving in PCP -- Allow timely access to UnitedHealthcare
Community Plan member medical records
Role per contract requirements. Purposes include
medical record keeping audits, HEDIS or other
SPECIALISTS INCLUDE INTERNAL MEDICINE, quality measure reporting, and quality of care
PEDIATRICS, AND/OR OBSTETRICIAN/ investigations. Such access does not violate HIPAA.
GYNECOLOGY -- Maintain a clean and structurally sound office
In addition to meeting the requirements for all care that meets applicable Occupational Safety and
providers, PCPs must: Health Administration (OSHA) and Americans with
Disabilities (ADA) standards.
• Offer office visits on a timely basis, according to the
standards outlined in the Timeliness Standards for -- Complying with the HCA Access and Availability
Appointment Scheduling section of this guide. standards for scheduling emergency, urgent care
and routine visits. Appointment Standards are
• Conduct a baseline examination during the
covered in Chapter 2 of this manual.
UnitedHealthcare Community Plan member’s first
appointment.
• Treat UnitedHealthcare Community Plan members’
general health care needs. Use nationally recognized
Rural Health Clinic, Federally
clinical practice guidelines. Qualified Health Center or
• Screen members for behavioral health problems
using the Behavioral Health Toolkit for the Health Primary Care Clinic
Care Professional found on UHCprovider.com. File Members may choose a care provider who meets the
the completed screening tool in the patient’s medical PCP requirements and performs PCP-type services within
record. a Rural Health Clinic (RHC) or Federally Qualified Health
• Refer services requiring prior authorization to the Center (FQHC) as their PCP.
Prior Authorization Department, UnitedHealthcare • Rural Health Clinic: The RHC program helps increase
21 | UnitedHealthcare Community Plan of Washington © 2020 UnitedHealthcareYou can also read
