Nebraska Getting Started Guide for UnitedHealthcare Community Plan Care Providers

Transcription

1 Nebraska 2017 Getting Started Guide for Community Plan Care Providers Doc# PCA Getting Started Guide for UnitedHealthcare Community Plan Care Providers

2 Welcome to UnitedHealthcare Community Plan Dear Provider: On behalf of UnitedHealthcare, we d like to welcome you as a participating provider in UnitedHealthcare Community Plan of Nebraska. We are committed to working with you and your staff to achieve the best possible health outcomes for our members. This guide contains valuable information about important contacts, policies, procedures and services to help us work together as efficiently as possible. You can also download the Nebraska Provider Manual on the Nebraska physicians website at UHCCommunityPlan.com > Health Professionals > Nebraska > Provider Manual. The Provider Manual is a comprehensive source for the information you and your staff need regarding claims, benefits, prior authorization, medical management and other plan components. If you are also a contracted provider for our UnitedHealthcare commercial and Medicare products, you can access information regarding those lines of business on UnitedHealthcareOnline.com. Again, we are pleased to add you to the list of participating providers delivering quality care to UnitedHealthcare Community Plan members. If you have any questions about your participation with UnitedHealthcare Community Plan, or need a printed copy of this Getting Started Guide, please contact Provider Services at Sincerely, Kathy Mallatt Chief Executive Officer Michael Horn, M.D. Chief Medical Officer 2 Doc# PCA Getting Started Guide for UnitedHealthcare Community Plan Care Providers

3 Table of Contents Chapter 1: Our Approach to Health Care 4 Chapter 2: Key Plan Benefits 6 Chapter 3: Quick Reference Guide 7 Chapter 4: Local Health Plan Contact List 10 Chapter 5: Member Cards 11 Chapter 6: Provider Website 12 Chapter 7: Care Management 20 Chapter 8: Services that Require Prior Authorization 21 Chapter 9: Frequently Asked Questions 22 3 Doc# PCA Getting Started Guide for UnitedHealthcare Community Plan Care Providers

4 Chapter 1: Our Approach to Health Care UnitedHealthcare Community Plan is a business unit of UnitedHealth Group. Our goal is to 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. Innovating for Better Health Care Outcomes Innovative health care programs are the hallmark of UnitedHealthcare. Our personalized programs encourage the utilization of services. These programs, some 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 Personal Care Model features direct member contact by UnitedHealthcare clinicians trained to foster an ongoing relationship with 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. Designed to improve birth outcomes and reduce Neonatal Intensive Care Unit (NICU) admissions, UnitedHealthcare s Health First Steps program uses an early identification to: Help overcome common social and psychological barriers to prenatal care; Increase member understanding of the importance of early prenatal care; Increase the mother s self-efficacy by identifying and building a support system; Ensure appropriate postpartum and newborn care; Develop the physician/member partnership and relationship before and after delivery. In addition to the usual health plan reminders to get preventive care services, UnitedHealthcare employs its proprietary Universal Tracking Database to identify members who have fallen behind in schedule appointments and providers who are failing to focus on preventive care and optimal treatment. Chronic Condition Management For members with chronic conditions, we offer a collaborative approach that uses physical, behavioral, and social determinant considerations to offer care coordination, disease management and case management programs. Educational materials and newsletters are used to remind members to comply with immunizations, wellness, and EPSDT screenings. Members with chronic conditions receive recommended routine appointment frequency, necessary testing, monitoring, and self-care through our disease management (DM) program and other valuable information. All materials are written at a fifth grade reading level and available in English, Spanish and other languages. The materials can help members take responsibility for their health and provide them with the information needed to manage their condition as successfully as possible. Members at highest risk with conditions such as asthma, CHF, diabetes, COPD and CAD may receive more intense health coaching. Resources and tools are available to support members and caregivers. The health plan uses claims data such as hospital admissions, ER visits and pharmacy claims to identify members with gaps in care and/or chronic conditions, then close those gaps with coordinated care. 4 Doc# PCA Getting Started Guide for UnitedHealthcare Community Plan Care Providers

5 Chapter 2: Key Plan Benefits Doctor visits Outpatient hospital services Well child visits and immunizations Adult physical exams and immunizations Circumcisions for all ages of males Sterilization for males vasectomies with signed consent form Emergency care Inpatient hospital services Eye glasses and vision exams Hospice care; includes in home hospice and short stay inpatient hospice Speech, physical, and occupational therapy Ambulance services Nursing care services Durable medical equipment Hearing exams Home health care Pharmacy services Behavioral health services Transplant services Chiropractic care Additional benefits Care management Disease management programs Comprehensive provider network Excellent customer service with local physician advocates and hospital and facility advocates Timely claims processing Free in-office telephonic interpreter services. Contact Member Services at for assistance if language is other than English. 5 Doc# PCA Getting Started Guide for UnitedHealthcare Community Plan Care Providers

6 Chapter 3: Quick Reference Guide Our Claims Process To help ensure prompt payment for services: 1. Review and copy both sides of the member s UnitedHealthcare Community Plan ID card and their State Medicaid ID card. 2. Submit a prior authorization request for any planned procedures and services on the prior authorization list. 3. Prepare a complete and accurate electronic or paper claim form (see complete claims at right). Complete a CMS 1500 (formerly HCFA) or UB-04 form. 4. Submit claims electronically on UnitedHealthcareOnline.com. Be sure to use our electronic payer ID number (87726) to submit claims to us. For more information, contact your vendor or our Electronic Data Interchange (EDI) unit at If you do not have access to internet services, you can mail the completed claim to: UnitedHealthcare Community Plan in Nebraska P.O. Box Salt Lake City, UT Complete Claims A complete claim includes the following: Patient s name, date of birth, address and ID number Name, signature, address and phone number of physician or physician performing the service, as stated in your contract document National Provider Identifier (NPI) number Physician s tax ID number CPT-4 and HCPCS procedure codes with modifiers where appropriate ICD-10 diagnostic codes Revenue codes (UB-04 only) Date of service(s), place of service(s) and number of services (units) rendered Referring physician s name (if applicable) Information about other insurance coverage, including job- related, auto or accident information, if available Attach operative notes for claims submitted with modifiers 22, 62, 66 or any other team surgery modifiers and CPT physician standby. Attach an anesthesia report for claims submitted with 23, QS, G8 or G9 modifier. Attach a description of the procedure/service provided for claims submitted with unlisted medical or surgical CPT codes or experimental or reconstructive services (if applicable). EPSDT correct referral indicator must be indicated. Indicators are: AV, S2, NU, ST. Include the exact NDC that appears on the product administered. IMPORTANT NOTE: Claims must be submitted within the timely filing limit as specified in your provider agreement. Link Application UnitedHealthcareOnline.com This secure app helps you complete the following transactions: Claims management Claims reconsideration Eligibility & benefits Provider data management Reports UHCCommunityPlan.com This website allows providers to get updated provider information that includes: Provider newsletters Provider manual Clinical practice guidelines Provider bulletins Reimbursement policies 6 Doc# PCA Getting Started Guide for UnitedHealthcare Community Plan Care Providers

7 Chapter 3: Quick Reference Guide The Provider Service Center Please call from 7:00 a.m. to 8:00 p.m. CT or 6:00 a.m. to 7:00 p.m. MT Monday through Friday. Please have your Tax ID and NPI number ready. Ask questions about benefits Verify member eligibility Check claim status Ask questions about your participation or notify us of demographic and practice changes Request information regarding credentialing Prior Authorization Services Please fax prior authorizations to For a current list of services requiring prior authorization, call or go to: UHCCommunityPlan.com > For Health Professionals > Nebraska > Prior Authorization Care Management/Disease Management For private nursing, please call or You may also NE_ CareManagement@uhc.com. Nebraska Provider Advocate For general questions and resolving claim payment issues, please Nebraska_PR_Team@uhc.com. Healthy First Steps To help high risk obstetric members access care, please call or fax Pharmacy Prior Authorization Service Please call Member Services/Interpreter Services Members can call with issues or concerns from 7:00 a.m. to 7:00 p.m. CT or 6:00 a.m. to 6:00 p.m. MT, Monday Friday. Additional Contact Information Non Emergent Transportation - IntelliRide Please call or or visit iridenow.com. Dental Services Anesthesia and facility charges associated with dental procedures performed at hospital/asc must meet medical necessity standards. Facility changes require prior authorization. Routine dental services are not covered by UnitedHealthcare Community Plan but by Nebraska Medicaid. Superior Vision For vision services, please call or visit superiorvision.com. e-business Support For EDI claims issues, please call or visit ac_edi_ops@uhc.com. For EDI log-on issues, please call Fraud, Waste and Abuse Division Please call or OPTUMHealth Nurseline 24/7 Assistance Please call UnitedHealthcare ICD-10-CM Code Lookup Tool This tool was developed using CMS General Equivalence Mappings (GEMs) as a baseline To determine a diagnosis code from ICD-9 to ICD-10 and vice versa, visit icd10codelookup. smartbaselink.com/. 7 Doc# PCA Getting Started Guide for UnitedHealthcare Community Plan Care Providers

8 Chapter 3: Quick Reference Guide Other Important Information Provider & Member Appeals Mailing Address UnitedHealthcare Community Plan P.O. Box Salt Lake City, UT Provider & Member Grievance Mailing Address UnitedHealthcare Community Plan P.O. Box Salt Lake City, UT Provider Administrative Appeals: Claim Disputes UnitedHealthcare Community Plan Provider Claim Disputes PO Box Salt Lake City, UT Please call the Provider Service Center at about appeal inquiries. Claims Submission Address UnitedHealthcare Community Plan P.O. Box Salt Lake City, UT Notification Timeframes: Emergency Admission One business day of an emergency or urgent admission Admission After Ambulatory Surgery One business day of an inpatient admission Non-Emergency Care (except maternity) At least 14 calendar days prior to non-emergent non-urgent facility admissions and/or outpatient services Please call or fax prior authorizations to Nebraska Medicaid Eligibility Line Please call to verify Medicaid eligibility with the State of Nebraska. Heritage Health Enrollment Center: Please call the Nebraska Heritage Health Enrollment Center at Compliance HIPAA mandates the adoption and use of NPI in all standard transactions (claims, eligibility, remittance advice, claims status request/response, and authorization request/response) for all health care providers who conduct business electronically. Evidence Based Clinical Review Criteria and Guidelines UnitedHealthcare utilizes Milliman Care Guidelines for determinations of appropriateness of care. 8 Doc# PCA Getting Started Guide for UnitedHealthcare Community Plan Care Providers

9 Chapter 4: Local Health Plan Contact List Chief Executive Officer: Kathy Mallatt Chief Operating Officer: Cassandra Price Manager, Health Plan Performance: Heather Johnson Medical Director: Michael Horn, MD Director, Health Services: Barbara Palmer, RN Director, Provider Network: Jeremy Sand Sr. Provider Relations Advocate: LeAnn Ortmeier Sr. Provider Relations Advocate: Sue Chaka Director, Marketing and Community Outreach: Kim Manning Manager, Provider Service & Advocacy: Michael Steere Tribal Liaison: Josh Rogers Manager, Case Managers: Sharon Whitman, RN Nebraska Provider Advocate: UnitedHealthcare Community Plan FAX: (Omaha) Doc# PCA Getting Started Guide for UnitedHealthcare Community Plan Care Providers

10 Chapter 5: Member Cards Member ID Card UnitedHealthcare Community Plan members receive a member identification (ID) card prior to their effective dates. If a member does not have an ID card at the time of service, you can access member eligibility information at UHCCommunityPlan.com or contact the Provider Service Center at to verify eligibility. The ID card does not guarantee eligibility. Please verify member eligibility for each service to avoid fraud and confirm coverage. Sample Health Member ID Card In an emergency go to nearest emergency room or call 911. Printed: 99/99/99 Health Plan/Plan de salud (80840) Member ID/ID del Miembro: Group/grupo: NESHAD Member/Miembro: Payer ID/ID del Pagador: SUBSCRIBER BROWN Medicaid Number: PCP Name/Nombre del PCP: DR. PROVIDER BROWN PCP Phone/Teléfono del PCP: (999) Rx Bin: Rx Grp: Rx PCN: ACUNE 4444 En caso de emergencia, acuda a la sala de emergencia más cercana o llame al 911. This card does not guarantee coverage. For coordination of care call your PCP. To verify benefits or to find a provider, visit the website or call. For Members/Para Miembros: TTY 711 Vision/Servicios para la vista: NurseLine/Línea de enfermeras: Enrollment Broker/Agent de ventas: For Providers: Claims: PO Box 31365, Salt Lake City, UT For fraud and grievances, call , TTY Administered by UnitedHealthcare of the Midlands, Inc. For Pharmacist: Pharmacy Claims: OptumRx PO Box 29044, Hot Springs, AR Doc# PCA Getting Started Guide for UnitedHealthcare Community Plan Care Providers

11 Chapter 6: Provider Website UnitedHealthcareOnline.com p.1 To visit Nebraska s UnitedHealthcare Community Plan page from UnitedHealthcareOnline.com, please go to Tools & Resources > UnitedHealthcare Community Plan Resources > Nebraska > Information on UHCCommunityPlan.com 11 Doc# PCA Getting Started Guide for UnitedHealthcare Community Plan Care Providers

12 Chapter 6: Provider Website UHCCommunityPlan.com To find resources for Nebraska care providers, please visit UHCCommunityPlan.com > For Health Care Professionals > Nebraska You ll find the Nebraska Provider Administrative Manual as well as the Getting Started Guide for Providers, as well as helpful forms and resources, including: Mailing addresses for claims, utilization denial & appeal department, and claim appeals Care provider forms for prior authorization requests, claim reconsideration, provider demographic change and more Medical policies and coverage determination guidelines Integrity of claims, reports, and representatives to the government link Disclaimers Pharmacy information and prior authorization forms The Practice Matters newsletter for Nebraska Reimbursement policies Clinical practice guidelines Electronic data interchange (EDI) information such as materials on EDI, EFT and ERA and EDI training. Billing and reference guides Cultural competency library 12 Doc# PCA Getting Started Guide for UnitedHealthcare Community Plan Care Providers

13 Chapter 6: Provider Website To access the member information page from the Nebraska UnitedHealthcare Community Plan page, click on Claims and Member Information. Click on access secure provider website and you will be taken to UnitedHealthcareOnline.com. 13 Doc# PCA Getting Started Guide for UnitedHealthcare Community Plan Care Providers

14 Chapter 6: Provider Website Link Login to Link to: Verify patient eligibility Check claim status allows you to locate specific claims and obtain claim summary and line item detail information. Obtain list of UnitedHealthcare Community Plan members assigned to you. If you are not yet enrolled on UnitedHealthcareOnline.com, click Enroll Today and follow instructions. 14 Doc# PCA Getting Started Guide for UnitedHealthcare Community Plan Care Providers

15 Tools & Resources Reports QUICK REFERENCE Reports are specific to UnitedHealthcare Community Plan members in certain states, unless otherwise specified, with the exception of the PCP Panel Roster (also available for the UnitedHealthcare Navigate, Charter and Compass products) and the Hospital Monitoring Report (available to all). View a Report 1. Sign In to UnitedHealthcareOnline.com View a Report (continued) 4. From the Report Search page, select the Report Type from the pull-down menu 2. Select the UnitedHealthcare Online application on Link 5. You may choose from several selections 3. Select Reports from the Tools & Resources Note: Above Reports Types are available for UnitedHealthcare Community Plan members in certain states, unless otherwise specified. Exceptions: PCP Panel Roster is also available for Navigate, Charter and Compass Hospital Monitoring Reports are available to all users Note: For Capitation reports there are additional helps under the Related Links section 15 Doc# PCA Getting Started Guide for UnitedHealthcare Community Plan Care Providers

16 View a Report(continued) 6. After selecting the Report Type you want, complete the required information and click on Search Note: If you choose the PCP Panel Roster, you will need to complete additional fields, PCP Panel Roster Report Type (either Community Plan or UnitedHealthcare Navigate, Charter or Compass products) and State. 7. Click on the available report you want to view Additional Quick Reference available on UnitedHealthcareOnline.com. 16 Doc# PCA Getting Started Guide for UnitedHealthcare Community Plan Care Providers

17 Chapter 6: Provider Website 17 Doc# PCA Getting Started Guide for UnitedHealthcare Community Plan Care Providers

18 Chapter 6: Provider Website Online Provider Education & Training UnitedHealthcare offers free online trainings, slide presentations and reference guides. Topics include: general portal information, claims management, eligibility & benefits, claims reconsiderations, billing, prior authorization, electronic payments & statements, ICD10 and more. 18 Doc# PCA Getting Started Guide for UnitedHealthcare Community Plan Care Providers

19 Chapter 7: Care Management Members may be eligible for care management services if they have serious injuries, chronic or high risk illnesses. Care management services include: High Risk Pregnancy Asthma Diabetes Congestive Heart Failure (CHF) Chronic Obstructive Pulmonary Disease (COPD) Coronary Artery Disease (CAD) Sickle Cell Obesity Special needs children and adults Hypertension (HTN) End Stage Renal Disease (ESRD) Transplant Mental Health and/or Substance Use Disorders This list is a guide for possible diagnoses to be referred to care management; it should not be considered all inclusive. There will be special circumstances and conditions that should be considered as possible referrals. 19 Doc# PCA Getting Started Guide for UnitedHealthcare Community Plan Care Providers

20 Chapter 8: Services That Require Prior Authorization Prior Authorization and Advance Notification Requirements You can submit your prior authorization request for UnitedHealthcare Community Plan members online at UnitedHealthcareOnline.com > Notifications/Prior Authorizations > Notification/Prior Authorization Submission. For questions on prior authorization, please call our Provider Service Center at Please reference the Provider Manual for required information to submit prior authorization requests. Advance Notification Requirements are located at UHCCommunityPlan.com. > For Health Care Professionals, > Nebraska > Prior Authorization. The list provides more information about the services that require prior authorization. Prior authorizations are required for: Select medical procedures Cosmetic and reconstructive surgery Durable medical equipment and supplies that exceed $500 Prosthetics and orthotics that exceed $500 Home health care services Hospice services; in Home Hospice and Short Stay Inpatient Hospice Hospital inpatient services Skilled nursing facility services Transplant services 20 Doc# PCA Getting Started Guide for UnitedHealthcare Community Plan Care Providers

21 Chapter 9: Frequently Asked Questions Here are some common questions you may have when using the UnitedHealthcare Community Plan system. Please review these tips on managing the claim submission process, verifying member eligibility and other important aspects of being a Community Plan care provider. If you have questions, please see the Provider Administrative Guide at UHCCommunityPlan.com > For Health Professionals > Nebraska > Administrative Guide. You may also call the Provider Service Center at Member ID Cards and Eligibility Q1: What kind of identification card will UnitedHealthcare Community Plan members have? A: Each member receives a UnitedHealthcare member ID card with a unique nine-digit identification number. The member ID card will also include the Nebraska DHHS Medicaid Number and the name and phone number of the member s Primary Care Provider (PCP). Be sure to check the member s ID card at each visit and copy both sides of the card for your files. You may also choose to verify the member s identity by requesting a form of photo ID such as a driver s license. Q2: How can I check member eligibility? A: You may check eligibility several ways. You may call the Department of Health and Human Services (DHHS) Nebraska by calling to verify Medicaid eligibility; you can also call the UnitedHealthcare Provider Service Center at You may also visit UnitedHealthcareOnline.com > Eligibility and Benefits > Patient Eligibility. Q3: How can I access information about a member s coverage and benefits? A: You can review a member s plan and coverage information, print a copy of the member s ID card, and verify coordination of benefits by visiting UnitedHealthcareOnline.com > Eligibility and Benefits > Patient Eligibility. Q4: How can I submit notifications and prior authorization requests? A: You may submit a notification or prior authorization request, or check the status of those requests, through Link at UnitedHealthcareOnline.com > Notifications/Prior Authorizations. Primary Care Physicians (PCPs) Q5: What is the provider service center phone number? A: Local provider representatives can be reached at Q6: What provider types are considered Primary Care Providers (PCPs)? A: Provider types that can be considered a PCP are medical doctors (M.D.), doctors of osteopathy (DO), nurse practitioners (NP), and physician assistants (PA) from any of the following practice areas: General Practice Internal Medicine Family Practice Pediatrics Obstetrics/Gynecology 21 Doc# PCA Getting Started Guide for UnitedHealthcare Community Plan Care Providers

22 Chapter 9: Frequently Asked Questions Nurse practitioners are allowed to enroll with the state as solo providers; physician assistants cannot. Physician assistants must be part of a group practice. For services rendered by a nurse practitioner or physician assistant, the claim should be submitted under the nurse practitioner or physician assistant, not the supervising physician. Q7: How many people in my office can register for access to UHCCommunityPlan.com? A: There is no limit to the number of staff in your office that can register online. Q8: How do I request a PCP-initiated transfer? A: To initiate a transfer, the PCP must contact UnitedHealthcare Community Plan in writing with specific documentation. The documents must include Medicaid form MS-24, the date(s) of failed appointments or a detailed accounting of reasons for termination request, the patient name, date of birth, Medicaid number, current address, current telephone number and the physician s name. The documents must be faxed to or mailed to: UnitedHealthcare Community Plan Attn: Health Services 2717 North 118th Street, Suite 300 Omaha, NE Claims Management Q9: How do I submit claims to UnitedHealthcare Community Plan? A: You may send claims electronically to Payer at UnitedhealthcareOnline.com > Claims & Payments > Claim Submission. You may also file paper claims by mailing them to: UnitedHealthcare Community Plan P.O. Box Salt Lake City, UT Q10: What resources are available to providers for assistance with issues involving claim payments? A: For assistance with issues involving claim payments, please contact your provider advocate. If you aren t sure who your provider advocate is, please Nebraska_PR_Team@uhc.com and your provider advocate will respond. Q11: Can I file claims using the patient s Medicaid ID number? A: Yes. You can file claims using the member s UnitedHealthcare Community Plan ID number or the member s Nebraska Medicaid ID number. You may look up the member s UnitedHealthcare Community Plan ID number at UnitedHealthcareOnline.com > Eligibility and Benefits > Patient Eligibility. Q12: What is the deadline for filing claims? A: Timely filing is based upon your service agreement. Please check your agreement for the correct filing limits. Q13: When can I bill a UnitedHealthcare Community Plan member for a remaining balance? A: Care providers cannot bill Medicaid members for any service covered by Medicaid. To bill a Community Plan member for a noncovered service, you must obtain a signed waiver of liability from that member that specifies the service and specific cost amount in question. Q14: How can I check claim payment information? A: You can see the payment date, check number, check amount, draft number and draft amount by visiting UnitedHealthcareOnline. com > Link > Claims Management. 22 Doc# PCA Getting Started Guide for UnitedHealthcare Community Plan Care Providers

23 Chapter 9: Frequently Asked Questions Q15: How can I review the status of pended or processed claims? A: You can review claim processing information, Explanations of Benefits (EOB) and claim letters, through Link. Please visit UnitedHealthcareOnline.com > Link > Claims Management. Q16: How can I submit additional information for a pending claim? A: You can submit any requested documentation or information at UnitedHealthcareOnline.com > Link > My Actions > Submit Attachments. You can also review reimbursement and medical policy information at UnitedHealthcareOnline.com > Tools & Resources > Policies, Protocols and Guides. Q17: How can I submit corrected claims or claims reconsideration requests? A: Please visit UnitedHealthcareOnline.com > Link > Claims Management > My Actions > Create Claims Reconsideration. 23 Doc# PCA Getting Started Guide for UnitedHealthcare Community Plan Care Providers

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