Nebraska Physician, Health Care Professional, Facility and Ancillary. Welcome Kit. UHCCommunityPlan.com. Doc#: PCA19546_

Transcription

1 Nebraska 2015 Physician, Health Care Professional, Facility and Ancillary Welcome Kit Doc#: PCA19546_ UHCCommunityPlan.com

2 Welcome to UnitedHealthcare Community Plan Dear Provider: On behalf of UnitedHealthcare, I d like to welcome you as a participating provider in Nebraska s UnitedHealthcare Community Plan Medicaid program. We are committed to working with you and your staff to achieve the best possible health outcomes for our members. This welcome kit contains valuable information about important contacts, policies, procedures and services to help you conduct business with us as efficiently as possible. You also can download the Nebraska Provider Administrative Guide on the Nebraska physicians website at UHCCommunityPlan.com > Health Professionals > Nebraska > Provider Information > Administrative Guide. This is a comprehensive reference 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 more information on UnitedHealthcareOnline.com. Again, we are pleased to add you to the list of participating providers delivering quality care to UnitedHealthcare Communty Plan members. If you have any questions about your participation with UnitedHealthcare Communty Plan, or need a printed copy of this welcome kit, please contact Provider Services at Sincerely, Kathy Mallatt Plan President Practice UnitedHealthcare Matters: Provider Welcome TX - Kit Summer of Nebraska /15 Welcome Customer UnitedHealthcare Service Community Center: Plan Nebraska

3 Table of Contents Chapter 1: Corporate Overview Chapter 2: Key Plan Benefits Chapter 3: Quick Reference Guide Chapter 4: Local Health Plan Contact List Chapter 5: Member Cards Chapter 6: Provider Website Chapter 7: Care Management Chapter 8: Services that Require Prior Authorization p.1 Chapter 9: Frequently Asked Questions Practice UnitedHealthcare Matters: Provider Welcome TX - Kit Summer of Nebraska /15 Welcome Customer UnitedHealthcare Service Community Center: Plan Nebraska

4 Chapter 1: Corporate Overview 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. Our Approach to Health Care The Patient-Centered Care Model (PCCM): Ensures that holistic member needs, including medical, behavioral and social/environmental needs, are addressed. The primary goal is to ensure the person receives the right care from the right providers in the right place and at the right time. At a member level, this Care Model ultimately leads to the development of Patient-Centered Care, which leverages interdisciplinary teams and combines the resources of UnitedHealth Group with medical homes and other integrated care organizations to reduce costs and improve outcomes. The PCCM seeks to empower members, providers and our community partners to improve care coordination and improve outcomes for individuals with the most complex conditions by providing: Market designated, field-based care management with integration of medical/behavioral/social/environmental Integrated care management team, including Registered Nurses (RN), behavioral health advocates (BHA) and community health workers (CHW). The goal of the program is to: Reduce avoidable admissions and ER visits Measured by Admit and ER rates Improve access to Primary Care Physician (PCP) Measured by PCP visits rates Identify and address Behavioral Health needs Measured by Behavioral Clinician visit rates for those with primary behavioral needs Improve access to pharmacy Identify and remove social and environmental barriers to care Improve health outcomes Specialty Care Managers p.1 include: Maternal and Child Health Care Managers, who follow pregnant women in the Healthy First Steps program. A care manager coordinates the member s care, including health education and outreach from the onset of pregnancy through the postpartum checkup; Care Managers for members that have qualifying conditions. Care Managers for members requiring Private Duty Nursing. The community health worker employs field-based interventions to locate and engage members, connecting them to their Primary Care Physician and coordinating appointments as necessary. The community health worker refers members to an RN or Behavioral Health Advocate for complex needs. The community health worker works with the member to remove barriers to care, access community resources and ultimately improve the ability for the member to access care. Focus on increasing engagement of the top 5 percent of higher risk members and/or individuals with chronic and/or complex illnesses. 1 Practice UnitedHealthcare Matters: Provider Welcome TX - Kit Summer of Nebraska /15 Welcome Customer UnitedHealthcare Service Community Center: Plan Nebraska

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 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. p.1 2 Practice UnitedHealthcare Matters: Provider Welcome TX - Kit Summer of Nebraska /15 Welcome Customer UnitedHealthcare Service Community Center: Plan Nebraska

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 their State Medicaid ID card. 2. Notify Health Services of planned procedures and services on our 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 jobrelated, 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. p.1 IMPORTANT NOTE: Claims must be submitted within your timely filing limit. UnitedHealthcareOnline.com/Link Application This secure website allows providers to process 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 administrative manual. Clinical practice guidelines. Provider bulletins. Reimbursement policies. Provider Services ( ) Available from 7:00 a.m. to 5:00 p.m. CST, Monday through Friday. This is an automated system. Please have your Tax ID and NPI number ready. Call Provider Services to: Ask questions about benefits. Verify member eligibility. Check claim status. 3 Practice UnitedHealthcare Matters: Provider Welcome TX - Kit Summer of Nebraska /15 Welcome Customer UnitedHealthcare Service Community Center: Plan Nebraska

7 Chapter 3: Quick Reference Guide Ask questions about your participation or notify us of demographic and practice changes. Request information regarding credentialing. Prior Authorization Health Services For a complete and current list of prior authorizations, go to: UHCCommunityPlan.com/Provider Information/Prior Authorization or call Fax prior authorizations to Prior Authorization Radiology Outpatient Imaging Procedures - For a complete and current list of prior authorizations, go to: UHCCommunityPlan.com/Radiology Tab or call Care Management/Disease Management ( ) Private Duty Nursing call or to NE_ CareManagement@uhc.com Nebraska Provider Advocate When assistance is needed to answer a question or resolve an issue related to claims payment. Nebraska_PR_Team@uhc.com Healthy First Steps High Risk OB Members or Fax Pharmacy Assistance (DME/Medical Supplies received at Pharmacy) Pharmacies must file claims to OPTUM RX Ex: diabetic supply, breast pump, nebulizer, gauze, vaporizer. Prescription medication covered by Nebraska DHHS. Call Member Services/Interpreter Services ( ) 7:00 AM to 7: 00 PM Monday - Friday. Member Services is available to assist members with any issues or concerns. Additional Contact Information Non Emergent Transportation - IntelliRide (Toll Free) (Omaha local) Dental Services Anesthesia and facility charges associated with dental procedures performed at hospital/asc must meet medical necessity and be prior authorized to be considered. Routine dental services not covered by UnitedHealthcare Community Plan but by Nebraska DHHS Mental Health & Substance Abuse (Magellan Behavorial Health) To refer members, call A PCP referral is not required. Superior Vision or e-business Support EDI Claims Issues ac_edi_ops@uhc.com EDI Log-on Issues UnitedHealthcareOnline.com Fraud, Waste and Abuse Division UnitedHealthcare Community Plan or OPTUMHealth Nurseline 24/7 Assistance 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 Welcome Practice to UnitedHealthcare Matters: TX Community - Summer Plan - Nebraska 2013 UnitedHealthcare Customer Provider Service Welcome Center: Kit of Nebraska /15

8 Chapter 3: Quick Reference Guide Provider Administrative Appeals: Claim Disputes UnitedHealthcare Community Plan Provider Claim Disputes PO Box Salt Lake City, UT Providers should call the Provider Service Center at about appeal inquiries Claims Submission Address UnitedHealthcare Community Plan P.O. Box Salt Lake City, UT Utilize the UnitedHealthcare ICD-10-CM Code Lookup Tool to determine a diagnosis code from ICD-9 to ICD-10 and vice versa. Tool developed using CMS General Equivalence Mappings (GEMs) as a baseline. Please utilize the following link: smartbaselink.com/ Notify Health Services Within the Following Time Frames: 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 Call or fax prior authorizations to NMES: To verify Medicaid eligibility with the State of Nebraska Medicaid Enrollment Center: Local in Lincoln: 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. 5 Welcome Practice to UnitedHealthcare Matters: TX Community - Summer Plan - Nebraska 2013 UnitedHealthcare Customer Provider Service Welcome Center: Kit of Nebraska /15

9 Chapter 4: Local Health Plan Contact List Plan President: Kathy Mallatt Director of Operations: Heather Johnson Medical Director: Michael Horn Director Health Services: Barbara Palmer Director of Provider Network Programs: Jeremy Sand Sr. Provider Relations Advocate LeAnn Ortmeier Sr. Provider Relations Advocate Sue Chaka Director of Marketing: Kim Manning p UnitedHealthcare Community Plan FAX: (Omaha) Nebraska Provider Advocate: When assistance is needed to answer a question, resolve a problem or issue related to claim payment or process. Nebraska_PR_Team@uhc.com 6 Practice UnitedHealthcare Matters: Provider Welcome TX - Kit Summer of Nebraska /15 Welcome Customer UnitedHealthcare Service Community Center: Plan Nebraska

10 Chapter 5: Member Cards Health Care ID Card UnitedHealthcare Community Plan members should receive a new membership identification (ID) card prior to his/her effective date. However, if a member does not receive an ID card prior to their effective date, using provider e-services, you can access member eligibility information at UHCCommunityPlan.com or contact Provider Services at to verify eligibility. The ID card does not guarantee eligibility. It is for identification purposes only. Eligibility must be verified every time services are received. Most recent member eligibility information can be accessed on the health plan s website or by phone 24 hours a day. This procedure is essential because: Member may no longer be eligible. Benefits may be altered. Fraudulent use may occur. Sample Health Member ID Card The following is a sample card. Information on the card is subject to change, therefore you should check the member ID card at every appointment. p.1 In an emergency go to nearest emergency room or call 911. Printed: 04/11/11 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: Rx Bin: Rx Grp: ACUNE (999) Effective Date/ Fecha de vigencia Rx PCN: Diabetic Testing /31/9999 Supplies Covered 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 Vision: TTY 711 Transportation: TTY 711 NurseLine/Línea de enfermeras: TTY 711 For Providers: Medical Claims: PO Box 31365, Salt Lake City, UT Copays may apply Administered by UnitedHealthcare of the Midlands, Inc. 7 Practice UnitedHealthcare Matters: Provider Welcome TX - Kit Summer of Nebraska /15 Welcome Customer UnitedHealthcare Service Community Center: Plan Nebraska

11 Chapter 6: Provider Website UHCCommunityPlan.com Have you visited UHCCommunityPlan.com today? p.1 If you re on UnitedHealthcareOnline.com and are looking to get to Nebraska s UnitedHealthcare Community Plan page, please do the following: Go to Tools & Resources > UnitedHealthcare Community Plan Resources > Nebraska 8 Practice UnitedHealthcare Matters: Provider Welcome TX - Kit Summer of Nebraska /15 Welcome Customer UnitedHealthcare Service Community Center: Plan Nebraska

12 Chapter 6: Provider Website If you re already on UHCCommunityPlan.com and are in search of Nebraska s page, please do the following: 1. Scroll over to For Health Care Professionals. 2. Scroll down the list until you see Nebraska and click it. To locate the Nebraska Provider Administrative Manual as well as the Nebraska Provider Welcome Kit, click on Provider Information on the left-hand side of the screen on Nebraska s UnitedHealthcare Community Plan page. Then, click on Administrative Guide. Other links on the UnitedHealthcare Community Plan page are: Provider Information: Includes: Contacts to Provider Call Center, Mailing addresses for Claims, Utilization Denial & Appeal Department, and Claim Appeals. Forms for Prior Authorization, Factor Prescription Fax Form, Radiology Prior Authorization Form and Radiology Crosswalk. State of Nebraska Medical Necessity website Medical Policies and Coverage Determination Guidelines Medical Injectable Integrity of Claims, Reports, and Representatives to the Government link Disclaimer Magellan PCP Toolkit link Pharmacy Program: Includes the Pharmacy Bulletins. Pharmacy prior authorization forms are also located on this page. Reimbursement Policy: Includes information about UnitedHealthcare Community Plan s reimbursement policies. Newsletters: Includes UnitedHealthcare Community Plan Nebraska newsletters, which are published quarterly. Bulletins: Includes up-to-date news, policy changes and other issues important to your practice. Provider Forms: Includes UnitedHealthcare Community Plan forms (provider demographic change form, claim reconsideration form, disclosure of ownership and control of interest, numerous prior authorizations, medical prior authorization fax form, FAQ for sleep test optimization program, etc.). 9 Welcome Practice to UnitedHealthcare Matters: TX Community - Summer Plan - Nebraska 2013 UnitedHealthcare Customer Provider Service Welcome Center: Kit of Nebraska /15

13 Chapter 6: Provider Website Clinical Practice Guidelines: Includes non-preventive clinical practice guidelines to help practitioners and members make decisions about appropriate health care for specific clinical circumstances. Electronic Data Interchange (EDI): Includes companion guides and informational materials on EDI, EFT and ERA. You can also sign up for EDI training. If you are not currently signed up, learn how to save time and money. Radiology: Includes CPT (Current Procedural Terminology) Codes, The Online Portal Link, and information concerning Prior Authorizations To access the member information page when on Nebraska s UnitedHealthcare Community Plan page, click on Claims and Member Information. Scroll to the middle of the page to find UnitedHealthcare Community Plan information. Click on access secure provider website. This will take you to UnitedHealthcareOnline.com 10 Welcome Practice to UnitedHealthcare Matters: TX Community - Summer Plan - Nebraska 2013 UnitedHealthcare Customer Provider Service Welcome Center: Kit of Nebraska /15

14 Chapter 6: Provider Website Login to: Verify patient eligibility Check claim status allows you to locate specific claims and obtain claim summary and line item detail information. If you are not yet enrolled on UnitedHealthcareOnline.com, click on Enroll Today and follow instructions. Primary Care Provider Panel Roster This report provides a list of UnitedHealthcare Community Plan members currently assigned to the provider. Access The website can be accessed by going to UHCCommunityPlan.com > Health care Professionals > Nebraska > Claims and Member Information. Under UnitedHealthcare Community Plan, select Access secure provider website. The website requires a unique user name and password combination to gain access. New Users: Click on New User and follow instructions. Follow these instructions to locate your PCP Panel Roster. 11 Welcome Practice to UnitedHealthcare Matters: TX Community - Summer Plan - Nebraska 2013 UnitedHealthcare Customer Provider Service Welcome Center: Kit of Nebraska /15

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 UnitedHealthcareOnline.com 2015 UnitedHealthcare Services, Inc. All rights reserved. v

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. UnitedHealthcareOnline.com 2015 UnitedHealthcare Services, Inc. All rights reserved. v

17 Chapter 6: Provider Website 14 Welcome Practice to UnitedHealthcare Matters: TX Community - Summer Plan - Nebraska 2013 UnitedHealthcare Customer Provider Service Welcome Center: Kit of Nebraska /15

18 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 offered (not required): 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 p.1 This list is a guide for possible diagnoses to be referred to care management; it should not be considered allinclusive. There will be special circumstances and conditions that should be considered as possible referrals. 15 Practice UnitedHealthcare Matters: Provider Welcome TX - Kit Summer of Nebraska /15 Welcome Customer UnitedHealthcare Service Community Center: Plan Nebraska

19 Chapter 8: Services That Require Prior Authorization Medical Services Advanced 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. Call Provider Services for questions related to prior authorization at Please reference the Provider Manual for required information to submit prior authorization requests. The below list is not all-inclusive. The Advanced Notification Requirements are located at UHCCommunityPlan.com. Click on Health Care Professionals, select State, Provider Information Tab, Prior Authorization. The list provides more information about the services that require prior authorization. Advanced Outpatient Imaging Procedures Notification Requirments: To find the CPT Code list of Radiology procedures that require a prior authorization and the online portal link to initiate a prior authorization, go to UHCCommunityPlan.com. Click on Health Care Professionals, select State, Radiology. You can also submit your prior authorization request for UnitedHealthcare Community Plan members on line at UnitedHealthcareOnline.com>Notifications/Prior Authorizations>Radiology Notification & Authorization - Submission & Status. Call Provider Services for questions related to prior authorization at Please reference p.1 the Provider Manual for required information to submit prior authorization requests. 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. 16 Practice UnitedHealthcare Matters: Provider Welcome TX - Kit Summer of Nebraska /15 Welcome Customer UnitedHealthcare Service Community Center: Plan Nebraska

20 Chapter 9: Frequently Asked Questions Question: What identification card will members carry? Answer: Each member receives a nine-digit UnitedHealthcare Community Plan member identification number. This number is used to communicate with UnitedHealthcare of the Midlands regarding a specific subscriber/member. The Nebraska DHHS Medicaid Number is also provided on the member ID card. The members ID card reflect the members PCP assignment on the front of the card. Be sure to check the member s ID card at each visit and to copy both sides of the card for your files. Providers may also take the precaution of verifying the identity of the person presenting the ID card against some form of photo ID, such as a driver s license, if this is your office practice. Question: What provider types are considered Primary Care Providers (PCPs)? Answer: 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 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. Question: How do I submit claims to UnitedHealthcare Community Plan? Answer: You may send claims electronically to Payer through UnitedHealthcare Community Plan s provider website at or you may file paper claims. Question: What is the claims address for UnitedHealthcare Community Plan? Answer: The claims address is as follows: UnitedHealthcare Community Plan P.O. Box Salt Lake City, UT Question: What is the provider service center phone number? Answer: Provider service representatives can be reached at Question: What resources are available to providers to check eligibility? p.1 Answer: You may check eligibility by using our online provider portal at UHCCommunityPlan.com or by calling Provider Services at Question: What resources are available to providers for assistance with issues involving claim payments? Answer: For assistance with issues involving claim payments, you may contact a Nebraska Provider Advocate by sending an to Nebraska_PR_Team@uhc.com. Question: Can I bill using the patient s Medicaid ID number? Answer: Yes. You can file claims using the member s UnitedHealthcare Community Plan ID number or the member s Nebraska Medicaid ID number. If you do not have the member s UnitedHealthcare Community Plan ID number, you may look up the number using UHCCommunityPlan.com. Question: How many people can register from my office to have access to UHCCommunityPlan.com? Answer: There is no limit to the number of staff members in your office that can register online. 17 Practice UnitedHealthcare Matters: Provider Welcome TX - Kit Summer of Nebraska /15 Welcome Customer UnitedHealthcare Service Community Center: Plan Nebraska

21 Chapter 9: Frequently Asked Questions Question: What is my timely filing criteria? Answer: Timely filing is based upon your contract. Please check your contract for this information. Question: Can I bill a UnitedHealthcare Community Plan member? Answer: Please be aware that physicians must not balance-bill members for any of the following reasons: If there is a difference between the charge amount and the UnitedHealthcare fee schedule. If a claim has been denied for late submission, unauthorized service, or as not medically necessary. If a member requests a service that is not covered by UnitedHealthcare Community Plan. When claims are pending review by UnitedHealthcare. Question: Do I need to verify UnitedHealthcare Community Plan eligibility? Answer: Yes. You can verify eligibility through the following methods: UHCCommunityPlan.com NEMS by calling to verify Medicaid eligibility with the Department of Health and Human Services (DHHS) Nebraska Medicaid Eligibility System UnitedHealthcare Provider Services: If you wish to bill the member for non-covered services, you must discuss this with the member prior to rendering the services and obtain a signed waiver of liability from that member that specifies the service and specific amount in question. Question: How do I request a Primary Care Provider-initiated transfer? Answer: To initiate a transfer of the member, the PCP must contact the health plan in writing via fax at or mail with the specific documentation of the event(s) that occurred. (Documentation includes DHHS form MS-24, the date(s) of failed appointments or a detailed accounting of reasons for termination request, patient name, date of birth, Medicaid number, current address, current telephone number and the physician s name.) UnitedHealthcare Community Plan Attn: Health Services 2717 N 118th ST, STE 300 Omaha, NE Please refer to the Provider Administrative Guide for more information on this process. 18 Welcome Practice to UnitedHealthcare Matters: TX Community - Summer Plan - Nebraska 2013 UnitedHealthcare Customer Provider Service Welcome Center: Kit of Nebraska /15

22 M / United HealthCare Services, Inc.