25-Jun-15 United HealthCare Optum has been contracted with UHC to deliver case management and nursing home model of care with a NP and RN. NP/RN is responsible for authorizing Part A and Part B skilled events. Facility should notify Optum NP/RN to obtain an authorization. Optum has ben contracted with UHC to provide the Monthly Bio-Psych-Social Survey through RNs and LPNs. Optum is not responsible for authorizations of skilled time Part A. The facility will manage through Traditional Medicare or alternative health plan. Member type UHC Opt In (Dual Medicare/Medicaid) UHC - Opt Out (Medicaid Only) NOMNC Optum is providing NOMNC letter to facilities for skilled care for long-term residents N/A Authorization (DME, Hospitalizations ) # 800-366-7304 800-366-7304 Authorization Fax# 866-839-6454 866-839-6454 Authorization (Part A Skilling for Long term resident in SNF) Contact your Optum Nurse Practitioner N/A Claims # 800-600-9007 800-600-9007 Member Matters Customer Service 800-393-0993 800-393-0993 SCENARIOS CUSTODIAL AUTHORIZATIONS As of 6/1/2015 United Healthcare will no longer require authorization for custodial, long term care stays for United Healthcare Connected for MyCare OH members within skilled nursing facilities. This change does include claims with dates of service beginning 5/1/2015. Please direct any questions to Provider Service unit at 800-600- 9007. As of 6/1/2015 United Healthcare will no longer require authorization for custodial, long term care stays for United Healthcare Connected for MyCare OH members within skilled nursing facilities. This change does include claims with dates of service beginning 5/1/2015. Please direct any questions to Provider Service unit at 800-600- 9007. Revenue code 0101 for custodial care does not require an auth. Revenue code 0101 for custodial care does not require an auth. HOSPICE AUTHORIZATIONS As of 6/1/2015 revenue code 0658 and CPT code T2046 for Hospice, no longer require an auth.
PART A AUTHORIZATION (Current LTC resident with or without 3 day qualifying hospital stay) Optum NP will evaluate member and determine skilled benefit eligibility. Authorization numbers will come from the Optum NP or designee in Optum Client Services to your facility representative. NOMNCS will be faxed to the facility fax number that Optum has on record. If there is an issue with the fax number on record, please email optumohio.clientservices@optum.com Optum is not responsible for authorizations of skilled time Part A. The facility will manage through Traditional Medicare or alternative health plan. 3 day Hospital stay is required by Medicare. CONTINUATION OF SKILLED TIME How does the provider communicate a need for continued skilled care for a LTC member? NEW TO FACILITY FROM HOSP OR COMMUNITY New Fully Integrated Dual Member being admitted to your facility for the first time from the hospital or community: CURRENT MEMBER READMIT TO FACILITY Current member is being readmitted to facility following a hospitalization Facility to communicate through collaboration with Optum NP/RN. Extension of skilled benefit will be determined by the appropriate Medicare and MMP guidelines and communicated to the facility by Optum clinician. Facility representative to contact UCS Intake (800-366- 7304) for custodial authorization. If there is a delay, please contact client services at ohiooptum.clientservices.com Inpatient Care Manager to notify Optum NP to see member when readmitted. Optum NP will determine skilled care and submit clinical information once the member returns to facility to determine skilled benefit. Optum Benefit Determination will provide facility with authorization number. Medicare process. Facility representative to contact UCS Intake (800-366- 7304)for custodial authorization. Facility representative to contact UCS intake (800-366- 7304) SHORT TERM FROM HOSP TO FACILITY If the member is new to the facility short term care or transitional care needed. (Member discharged from the hospital as skilled; Medicare benefits). How does the provider get a prior authorization number to put on the claim for reimbursement? Provider should call UM intake Department (800-366- 7304) for an Authorization. It is important to notify intake department if the member is an inpatient in a hospital. Optum NP/RN will collaborate in clinical management upon arrival to facility. Medicare process.
CONTINUATION OF SKILLED TIME FOR NEW SHORT- TERM MEMBER (PAS - Post Acute Services). How does the provider communicate a need for continued skilled care for a Short Term member? Provider should call UM Intake Department (800-366- 7304) or the assigned ICM. Medicare process or Medicare Advantage Plan as appropriate. AFTER HOURS/HOLIDAY AUTHORIZATIONS How can authorizations be obtained after hours, holidays and weekends? RETROACTIVE AUTHORIZATIONS Are retroactive authorization requests for Part A skilled? BED HOLD AUTHORIZATION Is an authorization required for Bed Hold days when member is admitted to hospital or on LOA? HOSPITAL ADMIT AUTHORIZATION When members are admitted to the hospital from the facility, is the Hospital responsible for obtaining an authorization for the hospitalization? 911 ADMISSION What are the requirements for an emergency 911 admission? Contact the Optum NP on-call 1-877-282-2165 Up to 30 days; if after 30 days the facility can appeal NO bed hold authorization is needed Yes, the hospital is responsible. They should contact UM Intake Department If the facility determines that a member requires emergency care, please follow emergency protocols. Please notify the Optum NP/RN upon a patient transfer Yes, the hospital is responsible. They should contact UM Intake Department If the facility determines that a member requires emergency care, please follow emergency protocols. Please notify the Optum NP/RN upon a patient transfer PART B AUTHORIZATION PHYSICIAN APPOINTMENTS When members are sent out for physician appointments or other services, is the facility responsible for obtaining authorization for those services? Notification: Therapist completes evaluation and submit via the Part B Portal https://cpm.secure.force.com/facility/. NP approves and provides reference number. Optum will provide authorization number facility. Facilities can call their Optum CM or NP for authorization numbers.
DME / OUTPATIENT SERVICES AUTHORIZATION Will the facility be required to obtain authorization for services such as DME, Outpatient Services when provided and billed by the facility for skilled and/or LTC? PSYCH AUTHORIZATIONS WHEN PLAN IS SECONDARY PAYER, will the facility receive a paid claim EOP for the Medicaid portion of the benefit even if there is a $0 payment? This is needed for Medicare cost reporting. Facility/Provider will contact Heath Plan for preauthorization benefits. Facility can contact United Behavioral Health at 866-261- 7692 Claims submitted for $0 payment will get back denial codes on the PRA that explain $0 payment that should be used for bad debt reporting. Facility can contact United Behavioral Health at 866-261- 7692 EXPEDITE APPEAL PROCESS TRANSPORTATION Process, documentation to distribute If an urgent request is needed, the facility may request an urgent authorization. Please contact Optum NP/RN or Provider Relations Advocate for help in communication. A peer to peer discussion can be requested within 48 hours. Please reach out to the Optum NP/RN who will direct you to the appropriate health plan or Optum Medical Director A peer to peer discussion can be requested within 48 hours. Please reach out to the Optum NP/RN who will direct you to the appropriate health plan or Optum Medical Director LEVEL OF CARE Custodial auth (post-hospitalization) Custodial authorizations are not required for stays as of 5/1/15. Facilities should not bill until after 6/1/15 so the programming can take place. Optum will issue a Level of Care for the following events: 1. Returning to a different SNF (transferring facilities) 2. Going from short term to long term (funding change) 3. Bed Hold days are exhausted
REPATRIATION Optum will notify UHC Case Manager via email (cacmmp@uhc.com) that a member is appropriate for Repatriation Optum will notify UHC Case Manager via email (cacmmp@uhc.com) that a member is appropriate for Repatriation