2017/2018 care provider manual pca-1-009300-01052018_02082018 2017/2018 care provider manual...

Doc#: PCA-1-009300-01052018_02082018

2017/2018Care Provider ManualPhysician, Health Care Professional, Facility and Ancillary

Florida M*Plus MMA Medicaid

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AHCA-B-N-NAN 4/14-12/18-267 Confidential and Proprietary

Copyrighted by UnitedHealthcare 20182 Florida Provider Manual

UHCCommunityPlan.com

WelcomeWelcome to the Community Plan manual. This complete and up-to-date reference PDF (manual/guide) allows you and your staff to find important information such as processing a claim and prior authorization. This manual also includes important phone numbers and websites on the How to Contact Us page. Operational policy changes and other electronic tools are ready on our website at UHCprovider.com. Click the following links to access different manuals:

• UnitedHealthcare Administrative Guide for Commercial and Medicare Advantage member information. Some states may also have Medicare Advantage information in their Community Plan manual.

• A different Community Plan manual – go to UHCCommunityPlan.com, click For Health Care Professionals at the top of the screen. Select the desired state.

You may easily find information in the manual using the following steps:

1. Press CTRL+F.

2. Type in the keyword.

3. Press Enter.

If available, use the binoculars icon on the top right hand side of the PDF.

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

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

Important Information about the use of this manualIn the event of a conflict between your agreement and this care provider manual, the manual controls unless the agreement dictates otherwise. In the event of a conflict between your agreement, this manual and applicable federal and state statutes and regulations and/or state contracts, applicable federal and state statutes and regulations and/or state contracts will control. UnitedHealthcare Community Plan reserves the right to supplement this manual to help ensure its terms and conditions remain in compliance with relevant federal and state statutes and regulations.

This manual will be amended as policies change.

http://UHCprovider.com

https://www.unitedhealthcareonline.com/b2c/CmaAction.do?channelId=ca174ccb4726b010VgnVCM100000c520720a____

http://www.uhccommunityplan.com/


Copyrighted by UnitedHealthcare 2018Florida Provider ManualUHCCommunityPlan.com

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Practice Matters: TX - Summer 2013 Customer Service Center: 888-362-33681 UnitedHealthcare Community Plan Louisiana Acute Care 2015 UHCCommunityplan.com

1© 2014 UnitedHealthcare

PENDING ADDITIONAL UPDATES AND STATE OF LOUISIANA DEPARTMENT OF HEALTH AND HOSPITALS APPROVAL

Table of Contents• Chapter 1: UnitedHealthcare Corporate Overview 1

• Our Approach to Health Care 1

• Welcome to UnitedHealthcare Community Plan 1

• UnitedHealthcare Community Plan Mission Statement 1

• Vision 2

• How to Contact Us 3

• Louisiana Provider Quick Reference Guide 4

• Benefits 6

• Value-Added Benefits 14

• Chapter 2: Member Services and Eligibility 16

• Eligibility 16

• Identification Cards 16

• Verifying Member Enrollment and Eligibility 16

• UnitedHealthcare Community Plan Welcome Packet 16

• Members’ Rights 17

• UnitedHealthcare Community Plan has No Policies Which Preventthe Provider From Advocating on Behalf of the Member 17

• MEDICAID Enrollee Responsibilities 17

• Member Grievances 17

• Member Appeals 18

• Primary Care Provider (PCP) Assignment 18

• How to Reassign an Enrollee to Another PCP 18

• Chapter 3: Provider Complaint Process 20

• Receiving, Investigating and Resolving Provider Complaints 20

• Complaint Process 20

• How and Under What Circumstances Providers May File a Complaint 21

• Corrective Actions 21

• System to Track the Receipt and Resolution of Provider Complaints 21

• Appeals 21

• Grievances and the State Fair Hearing Process 22

• Provider’s Bill of Rights 24

• Chapter 1: Introduction 1

• Welcome 1

• Important Information Regarding the Use of this Manual 1

• What is Medicaid? 1

• Important Information Regarding the Statewide Medicaid Managed Care Program 1

• Contact Information 2

• Online Resources 3

• Chapter 2: Our Claims & Encounter Process 4

• Claims Processing Rules and Resources 4

• Encounter Data (Capitated Care Providers Only) 4

• Complete Claims 4

• Taxonomy Codes 5

• NPI Number Required on Claims 5

• National Correct Coding Initiative Guidelines 6

• Electronic Remittance Advice and Paper Remittance Advice 6

• Electronic Payments & Statements 6

• Claim Adjustments 6

• Claims Disputes 6

• Mid-Level Claims Reimbursement 7

• Anesthesia Unit Billing Guidelines 7

• Subrogation and Coordination of Benefits 7

• Retroactive Eligibility Changes 7

• Protections for Indian Health Care Providers 7

• Chapter 3: Member Identification Card 8

• UnitedHealthcare ID Card 8


Copyrighted by UnitedHealthcare 2018Florida Provider ManualUHCCommunityPlan.comPractice Matters: TX - Summer 2013 Customer Service Center: 888-362-33682

© 2015 UnitedHealthcare2 UnitedHealthcare Community Plan Louisiana Acute Care 2015UHCCommunityplan.com

PENDING ADDITIONAL UPDATES AND STATE OF LOUISIANA DEPARTMENT OF HEALTH AND HOSPITALS APPROVAL

• Chapter 4: Physician and Health Care Provider Responsibilities 25

• Responsibilities and Expectations 25

• PCP as Medical Manager 26

• Prior Authorization 26

• Advance Notification Requirements for Louisiana Effective Feb. 1, 2015 27

• Outpatient Radiology Prior Authorization Program 28

• Specialists Responsibilities 28

• Confidentiality and Release of Medical Records 28

• Appointment Standards 29

• Waiting Times 29

• Interpreter Service 29

• Cultural Competency 30

• Member Advisory Councils 30

• Physician Standards and Policies 30

• 24-Hours, Seven-Day-a-Week Coverage 32

• Medical Record Documentation Standards Audit Tool 38

• Medical Record Charting Standards

• Chapter 5: Covered Services 47

• UnitedHealthcare Community Plan Covered Services 47

• Acute Care Health Services 47

• Emergency Services 48

• Direct Access to Women’s Health Care 48

• Non-Covered Services 49

• Medical Supplies Included in Home Health Nursing Visits 49

• Pharmacy Services 50

• Chapter 6: Behavioral Health Services 51

• Making a Referral for Behavioral Health Services 51

• Role of the UnitedHealthcare Community Plan Case Manager in Behavioral Health Services 51

• Coordination of Care With Providers 51

• Role of the Non Behavioral Health Care Provider 52

• Initial Behavioral Health Evaluation Consultation 52

• Ongoing Behavioral Health Evaluation Consultation 52

• Psychotropic Medication Management 52

• Chapter 7: Utilization Management 53

• Medical Necessity 53

• Concurrent Review 53

• Chapter 4: Notification Requirements 9

• Referrals 9

• Determination of Medical Necessity 9

• Care Provider Notification Requirements 9

• Notify Health Services Within the Following Time Frames 9

• Prior Notification and Medical Necessity 9

• Hospital Notification Requirements 9

• Clinical Peer Review 10

• Inpatient Concurrent Review: Clinical Information 10

• Chapter 5: Network Participation 12

• Provide Official Written Notice 13

• Transition Patient Care Following Termination of Your Participation 14

• Arrange Substitute Coverage 14

• Participate in Quality Enhancements 14

• Protect Confidentiality of Patient Data 14

• Provide Access to Your Records 14

• Follow Medical Record Standards 15

• Inform Patients of Advance Directives 15

• Follow Practice Protocols 17

• Cultural Competency 17

• Resolving Disputes 17

• Arbitration 18

• Uphold Member “Bill of Rights” 18

• Care Provider Complaint System 18

• Care Provider Credentialing and Contracting 19

• Rights Related to the Credentialing Process 19

• Subcontractor Responsibilities 19

• Other Contract Requirements 20

• Chapter 6: Compliance 21

• Regulatory Compliance 21

• False Claims Acts 22

• HIPAA 23

Practice Matters: TX - Summer 2013 Customer Service Center: 888-362-33683AHCA-B-N-NAN 4/14-12/18-267

Confidential and Proprietary Copyrighted by UnitedHealthcare 2018

Florida Provider ManualUHCCommunityPlan.com

• Chapter 7: Medicaid Appendix 24

• Helpful Administrative Information 24

• Medicaid Care Providers are Requested to do the Following 24

• Outreach and Marketing Guidelines 24

• Member Grievances and Appeals 25

• Medicaid State Fair Hearings 26

• Helpful Benefit Information 26

• Summary of Member Services 27

• Expanded Benefits 38

• Pregnancy-related Requirements 39

• Other Benefits 41

• Children’s Medical Services (CMS) 41

• Chapter 8: Online Care Provider Resources 42

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

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

If you have questions about the information or material in this manual, or about any of our policies or procedures, call Provider Services at 877-842-3210.

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

Important Information Regarding the Use of this ManualIn the event of a conflict or inconsistency of information between your agreement and the manual, the manual controls unless the agreement dictates otherwise.

In the event of a conflict or inconsistency between your participation agreement, this manual and applicable federal and state statutes and regulations, applicable federal and state statutes and regulations will control. UnitedHealthcare Community Plan reserves the right to supplement this manual to help ensure its terms and conditions remain in compliance with relevant federal and state statutes and regulations. This care provider manual will be amended as operational policies change.

What is Medicaid? Medicaid is a program that provides medical coverage to low-income individuals and families. The state and federal government share the cost of the Medicaid Program. Medicaid services in Florida are administered by the Agency for Health Care Administration.

Medicaid eligibility in Florida is determined either by the Department of Children and Families (DCF) or the Social Security Administration (for SSI recipients).

DCF determines Medicaid eligibility for:

• Parents and caretakers relatives of children

• Children

• Pregnant women

• Former foster care individuals

• Non-citizens with medical emergencies

• Aged or disabled individuals not currently receiving Supplemental Security Income (SSI)

Important Information Regarding the Statewide Medicaid Managed Care ProgramFlorida has offered Medicaid services since 1970. Medicaid provides health care coverage for eligible children, seniors, disabled adults and pregnant women. It is funded by both the state and federal governments. The 2011 Florida Legislature passed House Bill 7107 (creating part IV of Chapter 409, F.S.) to establish the Florida Medicaid program as a statewide, integrated managed care program for all covered services, including long-term care services. This program is referred to as statewide Medicaid Managed Care (SMMC) and includes two programs: one for medical assistance (MMA) and onefor long-term care (LTC). Only members who meet eligibility requirements and are living in a region with authorized Managed Care plans are eligible to enroll and receive services. UnitedHealthcare Community Plan serves members in the following regions:

Region 3: Alachua, Bradford, Citrus, Columbia, Dixie, Gilchrist, Hamilton, Hernando, Lafayette, Lake, Levy, Marion, Putnam, Sumter, Suwannee, and Union.Region 4: Baker, Clay, Duval, Flagler, Nassau, St. Johns,and Volusia.Region 7: Brevard, Orange, Osceola, and Seminole.Region 11: Miami-Dade and Monroe.

Chapter 1: Introduction






Provider Services 877-842-3210UHCCommunityPlan.com

UHCprovider.com

• Ask about a patient’s eligibility or benefits, check claim status, or for translations or TDD services.

• Ask about your participation.

• Notify us of demographic and practice changes.

• Address claims issues.

• File a care provider complaint.

• Request a copy of the Plan’s Cultural Competency Plan at no charge.

• Request a copy of the Physician Administrative Guide.

Prior-AuthorizationNotification

866-894-5796UHCprovider.com

Notify us of the procedures and services outlined in the prior authorization requirements section of this manual.

Pharmacy Services UHCCommunityPlan.comTel: 877-842-1508

• Tel: 800-310-6826

• Tel: 888-900-3232

• Tel: 866-528-1758

• Fax: 877-265-4976

• Fax: 800-757-2617

View or request a copy of the Preferred Drug List (PDL).

• Medications requiring notification.

• Self-injectable medications.

• IV infusions/IV medications.

• For easy prescription fax service.

• Pharmacy appeals (must be in writing).

Mental Health Substance Abuse, Vision, Transplant orDental Services

See member’s ID card for carrier information or call Customer Service.

Ask about a patient’s behavioral health, vision, transplant ordental benefits.

Statewide Abuse Hotline Tel: 800-96-ABUSE Abuse, neglect, and exploitation of enrollee’s can be reported by calling the statewide, toll-free telephone number.

Claims Address UnitedHealthcare Community PlanP.O. Box 31365Salt Lake City, UT 84131

For claims with dates of service before June 1, 2017, please use the previous mailing address:

UnitedHealthcare of FloridaP.O. Box 31362Salt Lake City, UT 84131

Fraud, Waste, and Abuse UHC Fraud, Waste and Abuse Hotline Tel: 877-401-9430

To report suspected fraud and/or abuse.

Contact Information

http://UHCCommunityPlan.com







Online ResourcesLink and UHCprovider.comUse Link ‒ your gateway to UnitedHealthcare’s online tools ‒ to perform secure transactions for UnitedHealthcare Community Plan members:

• View patient eligibility and benefits

• Check the status of a claim

• Submit a claim reconsideration

• Submit referrals

To submit a single CMS-1500 claim form, go to UHCprovider.com.

The following reports are also available at UHCprovider.com:

• PCP Panel Report

• Capitation (CAP) Reports

• Claim Trends

• Provider Profile

• Early and Periodic Screening, Diagnosis, and Treatment

• Preventive Health Measures

To access Link and reports that require secure access, sign in to UHCprovider.com using your Optum ID. If you don’t have an Optum ID or need help remembering your ID or password, the sign-in screens will help guide you through the process.

To learn more about Link, please visit UnitedHealthcareOnline.com > Quick Links > Link: Learn More. Or call the UnitedHealthcare Connectivity Help Desk at 866-842-3278, option 3, 7 a.m. ‒ 9 p.m., Central Time, Monday through Friday.






http://UnitedHealthcareOnline.com

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You want to be paid promptly for the services you provide. Here’s what you can do to help ensure prompt payment:

1. Register on UHCprovider.com, our free website for network physicians and health care professionals. There, you can check eligibility and claims status – and submit claims electronically for faster claims payment. To register, call 866-UHC-FAST (842-3278).

2. Once you’ve registered, review the patient’s eligibility on the website.

To check patient eligibility by phone, call 877-842-3210.

3. Notify us of planned procedures and services on our prior authorization list.

4. Prepare a complete and accurate claim form(see “Complete Claims” section.)

5. Submit the claim online at UHCprovider.com or one of other options.

• WebMD or another clearinghouse vendor - If you currently use WebMD or another vendor to submit claims electronically, use our electronic payer ID 87726 to submit claims to us. For more information, contact your vendor or our EDI unit at 800-842-1109. To become a registered user of WebMD, call 877-469-3263, select option I.

• UnitedHealthcare of FloridaP.O. Box 31365Salt Lake City, UT 84131

Claims Processing Rules and ResourcesAutomated Claims Adjudication and PRAsThe process to correct claims that require additional information or had missing information will be automated to reduce the need to retroactively correct claims. When a claim needs correction, you’ll no longer receive letters when claims can’t be paid due to missing or inaccurate information. The RA will include a description of the information needed to pay the claim, eliminating the need for a separate letter.

Facility and Professional Claim TypesWe will process claims according to coverage and billing rules for facility and professional claim types.

To access our policies for these claim processing rules, please use the following resources:

• UHCCommunityPlan.com > Health Professionals > Florida> Bulletins

• UHCCommunityPlan.com > Health Care Professionals>Florida > Provider Administrative Manual

• UHCCommunityPlan.com > Health Care Professionals >Florida > Reimbursement Policy

Encounter Data (Capitated Care Providers Only)

• Encounter data should be submitted using the claimssubmission process.

• As a capitated care provider, you must submit encounter claims when services are rendered to our members. This information is vital to our ability to report the Healthcare Effectiveness Data and Information Set (HEDIS), Child Health Check Up and other quality incentives required by the state of Florida.

• UnitedHealthcare Community Plan is contractually obligatedto submit accurate, detailed, and complete encounterinformation to the Agency for Healthcare Administration(AHCA). Consequently, our capitated participating careproviders are required to submit accurate, detailed, andcomplete encounter information to us. Encounter submissionconstitutes the care provider’s certification of the servicesrendered.

Complete ClaimsWhether you use an electronic or paper form, complete a CMS 1500 (formerly HCFA 1500) or UB-04 form. A complete claim includes the following information:

• Member’s name, sex, date of birth and relationship tosubscriber.

• Subscriber’s employer group name and group number.

• Name, signature, “remit to” address and phone number ofphysician or care provider performing the service, as in yourcontract document.

• Your federal tax ID number.

• Date of service(s), place of service(s) and number of services(units) rendered.

• Current CPT-4 and HCPCS procedure codes with modifierswhere appropriate.

• Current ICD-10 diagnostic codes by specific service code tothe highest level of specificity.

• Referring physician’s name (if applicable).

• Charges per service and total charges.

• Information about other insurance coverage, including job-

Chapter 2: Our Claims & Encounter Process



http://www.UHCCommunityPlan.com







related, auto or accident information, if available.

• Attach operative notes for claims submitted with modifiers 22, 62, 66 or any other team surgery modifiers as well as CPT 99360 (physician standby).

• Attach an anesthesia report for claims submitted with a 23 QS, G8 or G9 modifier.

• Attach a detailed description of the procedure or service provided for claims submitted with unlisted medical or surgical CPT or “other” revenue codes as well as experimental or reconstructive services.

• Attach nursing notes and treatment plan for claims submitted for home health care, nursing or skilled nursing services.*

• Purchase price for durable medical equipment (DME) rental claims exceeding $1,000.*

• If you need to correct and re-submit a claim, submit a new CMS 1500 or UB-04 indicating the correction being made. Hand-corrected claim re-submissions will not be accepted.

Additional information may be required by us for particular types of services or based on particular circumstancesor state requirements.

* Home health, infusion therapy and DME services are rendered by a capitated network. These services need to be coordinated and paid by the contracted network.

Additional information needed for a complete UB-04 form:

• Date and hour of admission and discharge, as well as member status-at-discharge code.

• Type of bill code.

• Type of admission (e.g., emergency, urgent, elective, newborn).

• Current revenue code and description.

• Current principal diagnosis code (highest level of specificity).

• Current other diagnosis codes, if applicable (highest level of specificity).

• Attending physician ID.

• Bill all outpatient surgeries with the appropriate revenue and CPT code if reimbursed according to ambulatory surgery groupings.

• Provide specific CPT and appropriate revenue code (e.g., laboratory, radiology, diagnostic or therapeutic) for services reimbursed based on a contractual fee maximum.

• Itemized list of services or complete box 45 for physical, occupational or speech therapy services (revenue code 420-449) submitted on a UB-04.

• Itemized statement if submitting a claim that will reach the contracted stop/loss.

• Any special billing instructions that may be indicated in your agreement (or letter of agreement).

Taxonomy CodesTaxonomy codes are required with claim submissions. This 10-digit alphanumeric code indicates the type, classification and specialty of the care provider. The taxonomy code submitted on claims should match one of the taxonomy codes you registered with Medicaid included in your Provider Registration data.

You can verify the taxonomy code(s) you registered with Medicaid:

• Online: Referring to the Florida Provider Master List (PML) spreadsheet at mymedicaid-florida.com > Managed Care

• Phone: Florida Medicaid Provider Enrollment Call Center at 800-289-7799, Option 4.

• Contact your provider advocate or Provider Services at 877-842-3210.

Taxonomy codes only apply to care providers who directly render health care services to our members.

NPI Number Required on ClaimsIf you provide direct health care services to members, you need to add your national provider identifier (NPI) number to claims. Be sure to:

• Use the NPI you registered with Florida Medicaid

• Bill for services as you are registered on the Florida PML.

You can verify this information:

• Online: mymedicaid-florida.com

• Phone: Florida Medicaid Provider Enrollment Call Center at 800-289-7799, Option 4.

NPI information can be faxed to 866-943-0517, emailed to [email protected] or mailed to UnitedHealthcare DBM Claims, P.O. Box 16900, Phoenix, AZ 85011.

Claims may be rejected or denied when submitted without an NPI or with an invalid NPI, depending on the method of submission. If you have not yet applied for and received your NPI, visit nppes.cms.hhs.gov. If you have not yet provided your NPI to UnitedHealthcare or any of the UnitedHealthcare Community Plan government programs health plans, you must do so immediately.

http://www.mymedicaid-florida.com

http://www.mymedicaid-florida.com

mailto:americhoice_dbm_npi%40uhc.com?subject=

http://www.nppes.cms.hhs.gov




• Receive claims payments by direct deposit.

• Access your explanations of benefits (EOBs) online orthrough 835 ERA files.

Care providers enrolled in EPS are automatically enrolled with the new ERA Payer ID 04567.

Claim AdjustmentsIf you believe you were underpaid, please call Provider Services and request an adjustment as soon as possible. If a claim issue is not resolved through the standard process, submit a reconsideration request through the normal processes:

• Website: UHCprovider.com

• Provider Service toll-free number: 877-842-3210.

• Allow 30 days and check status through the appropriatewebsite or by calling Provider Services.

• Call Center can assist you with (and up to 20) claims on onetelephone call.

If you or our staff identifies a claim where you were overpaid, we ask that you send us the overpayment within 30 calendar days from the date of your identification of the overpayment or our request. If your payment is not received by that time, we may apply the overpayment against future claim payments.

We typically make claim adjustments without requesting additional information from the network physician. You will see the adjustment on the Explanation of Benefits (EOB) orProvider Remittance Advice (PRA). When additional or correct information is needed, we will ask you to provide it.

If you disagree with a claim adjustment, you can appeal the determination (see Claims Disputes).

If you are submitting corrected claims by mail, complete the Adjustment Request Form. Submit it with required documentation to:

UnitedHealthcare Community PlanP.O. Box 31365Salt Lake City, UT 84131

If you submit corrected claims online, complete the required UnitedHealthcare Claim Reconsideration Request Form on UHCprovider.com. Check the appropriate reason for submission, and attach required documents.

Claims DisputesIf you disagree with a claim payment determination, senda letter of appeal to the claim office at:

UnitedHealthcare Community PlanP.O. Box 31365Salt Lake City, UT 84131

Your appeal must be submitted to us within 90 days of the date of the denial notice or in accordance with your contract, whichever is sooner.

If you are disputing a claim that was denied because filing was not timely, for:

1. Electronic claims: include confirmation UnitedHealthcare orone of its affiliates received and accepted your claim.

2. Paper claims: include a copy of a screen print from youraccounting software to show the date you submitted theclaim.

You are reimbursed on the Medicaid fee schedule amount. If you disagree with the outcome of the claim dispute, an arbitration proceeding may be filed as described in your agreement.


National Correct Coding Initiative GuidelinesUnitedHealthcare Community Plan follows National Correct Coding Initiative (NCCI) guidelines and other applicable coding guidance from the Centers for Medicare & Medicaid Services (CMS). This includes but is not limited to the Official ICD-10-CM Guidelines for Coding and Reporting.

We follow NDC Coding Guidelines. If you have questions about submitting claims to us, please contact our Provider Services helpline.

Electronic Remittance Advice and Paper Remittance AdviceThe Electronic Remittance Advice (ERA) Payer ID number is 04567. For dates of service before June 1, 2017, use the previous ERA Payer ID number 87726.

If you are signed up to receive ERAs, you’ll receive both paper and electronic remittance advices for 31 days after your first payment. For example, if your first payment is June 15, you’ll receive ERAs and paper remittance advices until July 16. You’ll only receive ERAs thereafter. You can still view, save and print the paper version at UHCprovider.com.

Electronic Payments & StatementsElectronic Payments & Statements (EPS) is UnitedHealthcare’s solution for electronic funds transfers (EFT) and ERAs. Your posting method does not change, and you do not need special software. By enrolling in EPS, you can:


https://www.optumhealthfinancial.com/physicianshealthcareproviders/electronicpaymentsstatements/






Mid-Level Claims ReimbursementUnitedHealthcare Community Plan has updated how mid-level claims are reimbursed for the following care providers:

• Nurse practitioners

• Physician assistants

• Registered nurse first assistants

In accordance with your provider agreement, you will be reimbursed using the Florida Medicaid fee schedule. The affected services and codes may be found at ahca.myflorida.com.

Anesthesia Unit Billing GuidelinesWhen using UnitedHealthcare Community Plan’s enrollment and claims payment system, be sure to:

• Submit claims with the number of units based on the total anesthesia service time. Any portion of a 15-minute increment equals one unit.

• Include the appropriate HCPCS modifiers. These modifiers identify monitored anesthesia and whether a procedure was:

– Personally performed,

– Medically directed, or

– Medically supervised.

We validate this information for reimbursement. In addition, bill according to Florida Medicaid guidelines to avoid a payment reduction.

To review the reimbursement guidelines and anesthesia policies, go to: UHCCommunityPlan.com > Health Care Professionals > Florida > Reimbursement Policy.

Subrogation and Coordination of BenefitsOur benefits contracts are subject to subrogation and coordination of benefits (COB) rules.

1. Subrogation - We reserve the legal right to recover benefits paid for a patient’s health care services when a third party causes the patient’s injury or illness.

2. COB - Coordination of benefits is administered according to the patient’s benefit contract and in accordance with applicable statutes and regulations.

Retroactive Eligibility ChangesEligibility under a benefit contract may change retroactively if:

1. We receive information an individual is no longer a patient.

2. The individual’s policy/benefit contract has been terminated.

3. The eligibility information we receive is later determined to be false.

If you have submitted a claim(s) affected by a retroactive eligibility change, a claim adjustment may be necessary. The reason for the claim adjustment will be reflected on the EOB or PRA.

Medical policies and coverage determination guidelines can be found at UHCCommunityPlan.com > For Health Care Professionals > Florida > Provider Information > UnitedHealthcare Community Plan Medical Policies and Coverage Determination Guidelines.

Protections for Indian Health Care Providers The Managed Care plan may not impose enrollment fees, premiums, or similar charges on Indians served by an Indian health care provider; Indian Health Service; an Indian Tribe, Tribal Organization, or Urban Indian Organization; or through referral under contract health services, in accordance with the American Recovery and Reinvestment Act of 2009.


http://www.ahca.myflorida.commedicaid/review/Reimbursement/2017_01_01_Practitioner_Fee_Schedule.pdf



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UnitedHealthcare Community Plan members receive an ID card containing information that helps you process claims accurately.

Be sure to check their ID card at each visit.

Sample Medicaid ID card: (This is a sample card. Members may receive a card that looks different than the following card.)

UnitedHealthcare Community Plan ID CardThis card includes the member’s name, UnitedHealthcare Community Plan ID number (a 10-digit state-generated Medicaid ID number and alphabetical group number), effective date, and the primary care provider (PCP) name and phone number.

Please verify the name of the PCP providing services and the name of the PCP on the card are the same.

This card does not verify eligibility. You need to confirm eligibility before rendering services.

Verify eligibility at least once a month because patients keep these cards even during months when they are not eligible for Medicaid. Check monthly for status changes through the Provider Services line at 877-842-3210.

Chapter 3: Member Identification Card

ID Cards

MMA:

Front Back

MMA Limited RX:

Front Back

MMA Comprehensive:

Front Back

ID Cards

MMA:

Front Back

MMA Limited RX:

Front Back

MMA Comprehensive:

Front Back

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Chapter 4: Notification Requirements

Referrals UnitedHealthcare Community Plan adheres to the “gatekeeper model” for most services, and PCPs coordinate the care for their members. They also generate referrals to network specialists. Additional information on when a referral is necessary and how to submit a referral can be found in this manual under “PCP Responsibilities” as well as on UHCprovider.com.

Determination of Medical Necessity“Medically necessary” or “medical necessity” means the medical or allied care, goods, or services furnished or ordered must meet the following conditions:

1. Be necessary to protect life, to prevent significant illness or significant disability, or to alleviate severe pain.

2. Be individualized, specific, and consistent with symptoms or confirmed diagnosis of the illness or injury under treatment, and not in excess of the patient’s needs.

3. Be consistent with generally accepted professional medical standards as determined by the Medicaid program, and not experimental or investigational.

4. Be reflective of the level of service that can be safely furnished, and for which no equally effective and more conservative or less costly treatment is available statewide.

5. Be furnished in a manner not primarily intended for the convenience of the recipient, the recipient’s caretaker, or the care provider.

Care Provider Notification RequirementsYou must verify prior authorization. All physicians, facilities, and agencies providing services that require authorization should contact the Prior Authorization Department at 866-894-5796 or request prior authorization through UHCCommunityPlan.com in advance of performing the procedure or providing service(s) to verify UnitedHealthcare Community Plan has issued an authorization.

Detailed information on covered procedures and services, limitations, and CPT codes can be found under the Prior Authorization section at UHCCommunityPlan.com > For Health Care Professionals > Florida > Provider Information.

To request prior authorization, submit your request online, by phone or fax:

• Online: UHCprovider.com

• Phone: 866-604-3267

• Fax: 866-607-5975; fax form is available at UHCCommunityPlan.com > For Health Care Professionals > Florida > Provider Forms > Florida Prior Authorization Fax Request Form

Notify Health Services Within the Following Time Frames

• Emergency Admission

– Within one business day of an emergency or urgent admission.

• After Ambulatory Surgery

– Within one business day of an inpatient admission after ambulatory surgery.

• Non-Emergency Care (except maternity)

– At least 14 business days prior to non-emergent, non-urgent hospital admissions and/or outpatient services.

Return calls to case managers and medical directors and provide complete health information within one business day.

Failure to notify Health Services may result in denial of payment for non-notified admission dates.

Prior Notification and Medical NecessityUnitedHealthcare Community Plan provides all medically necessary services for its members younger than age 21, even if the service is not a covered benefit or has a limit. As long as a service is medically necessary, services are not bound by coverage, monetary, or time limits. Request prior authorization for non-Medicaid covered services medically necessary using the stated guidelines.

Hospital Notification RequirementsWe contract with hospitalist groups within our network hospitals to handle all admissions and emergency room presentations by our Medicaid members. Working with these groups facilitates the management and coordination of care for your patients and our members.










The hospitalist program is a dynamic one. We regularly review hospitalist performance to help ensure the hospitalists continue their dedication to quality of care and resource efficiency. All hospitals must contact our participating hospitalist groups for all potential (emergency room presentations) and necessary admissions; unless the patient’s PCP or treating specialist indicates otherwise.

Clinical Peer ReviewHealth professionals who conduct peer clinical reviews are available by telephone to discuss review determinations with the attending physician, or other ordering care providers. If the original clinical peer reviewer making the initial determination is not available within one business day, we will provide an alternate clinical peer for discussion.

Inpatient Concurrent Review: Clinical InformationYour cooperation is required with all UnitedHealthcare Community Plan requests for information, documents or discussions related to concurrent review and discharge planning including: primary and secondary diagnosis, clinical information, treatment plan, admission order, patient status, discharge planning needs, barriers to discharge and discharge date. When available, provide clinical information by access to Electronic Medical Records (EMR).

Your cooperation is required with all UnitedHealthcare Community Plan requests from the interdisciplinary care coordination team and/or medical director to support requirements to engage our members directly face-to-face or by phone.

You must return/respond to inquiries from our interdisciplinary care coordination team and/or medical director. You must provide all requested and complete clinical information and/or documents as required within four hours of receipt of our request if it is received before 1 p.m. local time, or make best efforts to provide requested information within the same business day if the request is received after 1 p.m. local time (but no later than 12 p.m. local time the next business day).

UnitedHealthcare uses MCG (formally Milliman Care Guidelines), CMS guidelines, or other nationally recognized guidelines to assist clinicians in making informed decisions in many health care settings. This includes acute and sub-acute medical, long-term acute care, acute rehabilitation, skilled nursing facilities, home health care and ambulatory facilities.



Florida Provider ManualUHCCommunityPlan.comPractice Matters: TX - Summer 2013 Customer Service Center: 888-362-33681010 Florida Provider Manualwww.uhccommunityplan.com


Copyrighted by UnitedHealthcare 2016

Chapter4:NotificationRequirements

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PCP Responsibilities/Procedures/New Member ProcessingTo encourage members to visit their PCP, our Member Services department mails each new member an introductory letter with the name, address, and phone number of the member’s PCP. The mailing includes information regarding UnitedHealthcare benefits. It requests members to make an appointment with their PCP for an initial health assessment.

In addition to this contact, PCPs should welcome their new members and request they seek an initial health screening. At the first visit, members should be requested to authorize the release of their medical records to you if they are seeking services from you for the first time or after a break in service. Once received, you can identify if the members have received past screenings according to the AHCA-approved periodicity schedules and national/UnitedHealthcare Community Plan clinical guidelines and recommended preventive health service schedules. This will also allow PCPs to identify which services need completing.

PCPs are responsible for coordinating care for members and for generating referrals to network specialists using the referral Link tool on UHCprovider.com prior to the members seeking care with any specialty network physician. To generate a referral, the PCP should follow these steps on UHCprovider.com:

1. Log on using your practice’s assigned login information.

2. Select the “referralLink Florida Community Plan” tile.

3. Click option for Create New Referral.

4. Search and select member needing referral.

5. Select referring care provider contact details.

6. Search and select participating specialist.

7. Enter the referral details (dates, number of visits, diagnosis code, notes, etc.), and then submit.

Once submitted, you will receive a status and certification ID. Existing referrals can be viewed by selecting the search option on the main member referral page.

Referrals must be entered through the referral Link tool on UHCprovider.com prior to the specialist service being received. Retroactive referrals are not accepted. Each referral may include up to six months of visits to a given network specialist. After the six months of visits have been used, an additional referral to that network specialist may be entered for up to another six months of visits.

More information on the referral submission process can be found at UHCprovider.com.

Services not requiring a referral

• Services from a participating network obstetrician/gynecologist.

• Routine refractive eye exam from a participating network care provider.

• Mental health/substance abuse services with participating network behavioral health clinicians.

• Services rendered in any emergency room or network urgent care center or convenience clinic.

• Physician services for emergency/unscheduled admissions.

• Services from inpatient consulting physicians.

• Consultation and treatment with participating network dermatologists.

• Consultation and treatment with participating network podiatrists.

• Any other services for which applicable law does not allow us to impose a referral requirement.

PCPs are strongly encouraged to participate in the Florida SHOTS program, a free, statewide, online immunization registry sponsored by the Florida Department of Health. This program provides you with an easy tracking tool. It prospectively forecasts upcoming immunizations needs and can produce the 680 form required by law for schools and child care centers, eliminating additional work.

Panel RosterPCPs may print a monthly PCP Panel Roster by visiting UnitedHealthcareOnline.com.

Sign in to UnitedHealthcareOnline.com. Select the UnitedHealthcare Online application on Link. Select Reports from the Tools & Resources. From the Report Search page, select the Report Type (PCP Panel Roster) from the pull-down menu. Complete additional fields as required. Click on the available report you want to view.

The PCP Panel Roster provides a list of UnitedHealthcare Community Plan members currently assigned to the care provider.

Chapter 5: Network Participation





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Females have direct access (without a referral or authorization) to any OB/GYNs, midwives, physician assistants, or nurse practitioners for women’s health care services and any non-women’s health care issues discovered and treated in the course of receiving women’s health care services. This includes access to ancillary services ordered by women’s health care providers (lab, radiology, etc.) in the same way these services would be ordered by a PCP. UnitedHealthcare Community Plan works with members and care providers to help ensure all participants understand, support, and benefit from the primary care case management system. The coverage shall include availability of 24 hours, 7 days per week. During non-office hours, access by telephone to a live voice (i.e., an answering service, physician on-call, hospital switchboard, PCP’s nurse triage) which will immediately page an on-call medical professional so referrals can be made for non-emergency services or information can be given about accessing services or managing medical problems. Recorded messages are not acceptable.

Assignment to PCP Panel RosterOnce a member has been assigned to a PCP, panel rosters can be viewed electronically on the UnitedHealthcare Community Plan Provider Portal at UHCprovider.com. The portal requires a unique user name and password combination to gain access.

Sign in to UnitedHealthcareOnline.com. Select UnitedHealthcare Online application on Link. Select Reports from the Tools & Resources. From the Report Search page, select the Report Type (PCP Panel Roster) from the pull-down menu. Complete additional fields as required. Click on the available report you want to view.

PCP Responsibilities WithNon-Compliant MembersPCPs have a responsibility to respond to members who either fail to keep appointments or fail to follow your plan of care, as either can interrupt continuity of care and lead to a delay or failure on the part of the member to get medical diagnosis or treatment. We expect your sites to have a procedure for dealing with non-compliant enrollees and enrollee notification. While the member should keep appointments and comply with the plan of care prescribed by the PCP, you, in turn, have responsibilities when this does not occur. The member must be notified of their non-compliance, and you need to document whether this activity was done orally or in writing. This is further required should you need to involuntarily disenroll an enrollee from their panel for non-compliance. Both UnitedHealthcare Community Plan and AHCA monitor this activity.

Failure to show

Failure to show is defined as a member who has missed three consecutive appointments within a six-month time period with the same health care provider or facility. The member does not notify the health care provider they cannot keep the scheduled appointment.

Failure to follow plan of care

This is when a member chooses not to comply with a prescribed plan of care. Seek assistance from Member Services at the phone number on the back of the Member ID card.

Removing a Member from PCP Panel

Make a reasonable effort to establish and maintain an appropriate relationship with our members. When such a relationship cannot be established or a breakdown occurs, the PCP has the right to request termination of the relationship by withdrawing as the member’s PCP.

To request a member removal from your panel, please call your provider relations representative at 877-842-3210.

To request involuntary disenrollment from a PCP panel, the PCP must keep appropriate records documenting the reasons for failure to establish and maintain a relationship. Prior to requesting a disenrollment, the PCP must make every effort to assist the member in correcting the situation. If the situation is not resolved, the PCP must notify the member and the UnitedHealthcare Enrollee Services department by certified mail of their intention to terminate the relationship. This letter must include an intended effective date of the change, which must be at least 30 days following the date of the letter, and an explanation that care will continue at the current PCP office until the date of change. The letter must also refer the member to seek additional assistance, including a change of PCP by calling Member Services department at the phone number on the back of the Member ID card.

Provide Official Written NoticeYou must notify Network Management of the following events, in writing, within 10 calendar days of your knowledge of

their occurrence:

1. Material changes in, cancellation or termination of liability insurance.

2. Change in practice ownership, name, address, phone or federal tax ID number.

3. Bankruptcy or insolvency.



UnitedHealthcareOnline.com





4. Any indictment, arrest or conviction for a felony or any criminal charge related to your practice or profession;

5. Any suspension, exclusion, debarment or other sanction from a state or federally funded health care program.

6. Loss or suspension of your license to practice.

Network Management for:

South Florida: 3100 SW 145th Avenue, Miramar, FL 33027

Central Florida: 495 North Keller Road, Suite 200, Maitland, FL 32751

North Florida: 10151 Deerwood Park Blvd, Bldg 100, Suite 420, Jacksonville, FL 32256

West Florida: 9009 Corporate Lakes Drive, Suite 200, Tampa, FL 33634

You must also provide an annual attestation of active patient load. “Active” is defined by a patient who has been seen at least three times in a year. Active patient load includes all patients, not just UnitedHealthcare members, and should not exceed 3,000. If your total active patient load exceeds 3,000, your panel will be closed to new enrolleeship until a new attestation form is received.

Federal regulations require use of your NPI on all electronic claims and paper claims for many Medicaid agencies, including AHCA. Claims may be rejected or denied when submitted without an NPI or with an invalid NPI. You are also required to have a valid Medicaid Provider Number. The health plan is authorized to take whatever steps are necessary to help ensure you are recognized by the state Medicaid program, including its choice counseling/enrollment broker contractor(s), as a participating care provider of the health plan and your submission of encounter data is accepted by the Florida MMIS and/or the state‘s encounter data warehouse.

Transition Patient Care Following Termination of Your ParticipationIf your network participation terminates for any reason, you are required to participate in the transition of your patient toward timely and effective care. This may include providing service(s) for a reasonable time, at our contracted rate. Customer Service is available to help you and your patient with the transition.

Arrange Substitute CoverageIf you are unable to provide care and want to arrange for a substitute, we ask that you try to arrange for care from other physicians and health care professionals who are contracted to participate with UnitedHealthcare Community Plan Medicaid products. For the most current listing of network physicians and health care professionals, visit UHCCommunityPlan.com. A non-network physician or health care professional will need to apply for participation and, if accepted, sign a participation agreement.

Participate in Quality EnhancementsUnitedHealthcare Community Plan’s quality enhancement programs are designed to help our community be as healthy as possible, including children’s wellness, domestic violence, pregnancy prevention, prenatal/postpartum, and behavioral health programs.

You are expected to cooperate with our quality assessment and improvement activities, and to comply with our clinical guidelines, patient safety (risk reduction) efforts and data confidentiality procedures. We are allowed to use your performance data to conduct quality activities. For further details about our quality initiatives, please contact Customer Service.

Protect Confidentiality of Patient DataUnitedHealthcare Community Plan members have a right to privacy and confidentiality of all records and information about their health care. We disclose confidential information only to business associates and affiliates who need that information to fulfill our obligations and to facilitate improvements to our members’ health care experience. We require our affiliates and business partners to protect privacy and abide by privacy law. If a member requests specific medical record information, we refer the member to you as the holder of the medical records.

Provide Access to Your RecordsYou must provide access to any medical, financial or administrative records related to the services you provide to UnitedHealthcare Community Plan members within 14 calendar days of our request, or sooner for cases involving alleged fraud and abuse, an enrollee grievance/appeal, or a regulatory or accreditation agency requirement. Such records must be maintained for six years, or longer if required by applicable statutes or regulations.






Follow Medical Record StandardsYou must minimally adhere to the following medical record standards. Medical record documentation tools can be found in Medicaid Handbooks and upon request to the UnitedHealthcare of Florida, Quality Management Department.

• Each record must contain identifying information, including member name, member identification number (Medicaid #), date of birth, gender, and legal guardianship (if any).

• Each record must have the member’s name and identification number on each page.

• Each record must include past medical history, including significant illnesses and medical conditions on a problem list. Include dates of onset and resolution.

• Each record must be organized, legible and maintained in detail.

• Each record must contain a summary of significant surgical procedures, past and current diagnoses or problems, allergies, untoward reactions to drugs and current medications. For children and adolescents, history includes prenatal care, birth, operations and childhood illnesses.

• All entries in each record must be dated and signed by the appropriate party.

• All entries in each record must indicate the chief complaint or purpose of the visit and your objective, diagnosis, medical findings or impressions.

• Each record must include diagnoses consistent with findings and treatment plans consistent with diagnoses.

• All entries in each record must indicate studies ordered, for example: lab, X-ray, EKG, and referral reports.

• All entries in each record must indicate therapies administered and prescribed. For medication records, include the name of medication, dosage, amount dispensed and dispensing instructions.

• All entries in each record must include the name and profession of the practitioner rendering services, for example: M.D., D.O., O.D., including signature or initials of practitioner.

• All entries in each record must include the disposition, recommendations, instructions to the patient, evidence of whether there was follow-up, and outcome of services.

• Each record must contain an immunization history.

• Each record must contain information on smoking/ETOH (ethyl alcohol)/substance abuse.

• Each record must contain summaries of all emergency services and care and hospital discharges with appropriate medically-indicated follow-up.

• All records must have documented all referral services.

• Records must include documentation of all services provided. Such services must include, but not necessarily be limited to, family planning services, preventive services and services for the treatment of sexually transmitted diseases.

• All records must reflect the primary language spoken by the member and any translation needs.

• All records must identify members needing communication assistance in the delivery of health care services.

• Give prominence to notes on medication allergies and adverse reactions. Also note if the patient has no known allergies or adverse reactions.

• All records, for members 18 years and older, must contain documentation the member was provided written information concerning their rights regarding advanced directives (written instructions for living will or power of attorney) and whether they have executed one. Do not, as a condition of treatment, require the member to execute or waive an advanced directive, in accordance with Section 765.110, F.S.

Inform Patients of Advance DirectivesThe federal Patient Self-determination Act (PSDA) gives individuals the legal right to make choices about their medical care in advance of incapacitating illness or injury through advance directive.

Under the federal act, physicians and care providers, including hospitals, skilled nursing facilities, hospices, home health agencies and others must provide written information to patients on state law about advance treatment directives, about a patient’s right to accept or refuse treatment, and about your own policies regarding advance directives.

To comply with this requirement, we also inform our members of state laws on advance directives through our member handbooks and other communications.

UnitedHealthcare Community Plan Quality Improvement Program

UnitedHealthcare Community Plan of Florida has as its mission to improve the quality of care to Medicaid recipients, to provide a high standard of health care and education, to improve the health status of the community, and to have satisfied enrollees and care providers.

Many areas can determine how successfully we provide care. The quality indicators assessed will depend on your practice type and the plan the member is in. Your performance on indicators will be assessed at least annually. These indicators are largely determined by the state of Florida and/or our accrediting body, and include:




• Breast Cancer Screening.

• BMI Assessment.*

• Lipid Profile Annually.

• Use of Angiotensin-Converting Enzyme (ACE) Inhibitors/Angiotensin Receptor (ARB) Therapy.

• Lead Screening in Children (Lead Blood Test).*

• Persistence of Beta-Blocker Treatment after a Heart Attack.

• Frequency of HIV Disease Monitoring Lab Tests.

• Highly Active Anti-Retroviral Treatment.

• HIV-Related Medical Visits.

• Child Health Check-Up.*

• Cervical Cancer Screening.*

• Childhood Immunization Status.*

• Immunizations for Adolescents.*

• Well Child first 15 Months.*

• Well Child Years 3-6.*

• Adolescent Well Care.*

• Mental Health Readmission Rate.

• F/U After Hospitalization for Mental Illness.

• Antidepressant Medication Management.

• Follow-up Care for Children Prescribed ADHD Medication.*

• Use of Appropriate Rx in Asthma.

• Controlling HBP.*

• Comprehensive Diabetes Care.*

• Adult Access to Preventive/Ambulatory Health Services.

• Annual Dental Visits.

• Prenatal & Postpartum Care.

• Prenatal Care Frequency.

• Ambulatory Care (Includes ER measure).

• Mental Health Utilization-Inpt D/C & Avg LOS.

• Mental Health Utilization-Inpt, Intermediate & Ambulatory Services.

• Access/Availability.

• Member Satisfaction.

• Care Provider Satisfaction.

• Pediatric Preventive Care.*

• Adult Preventive Care.*

*Refer to the UnitedHealthcare Community Plan Preventive Health Guidelines.

Member Availability/Accessibilityto Services

You must meet the following access to care standards:

• Emergency medical care - available 24 hours a day/seven days a week.

• Urgent care - within one day.

• Routine sick care - within one week.

• Well care - within one month.

You must offer the same number of office hours to Medicaid members as you do for commercial members.

After-Hours Availability/Call Coverage• Access to the PCP or licensed clinician must be 24 hours a

day/seven days a week.

• After-hours access must be with someone who is licensed to render a clinical decision.

• After-hours access does not include an answering machine unless it results in a prompt callback by a licensed clinician.

UnitedHealthcare Community Plan does not currently participate in telemedicine. The UnitedHealthcare Community Plan Quality Monitoring Program Minimally Incorporates

• The generation of utilization reports for services provided by hospitals, emergency rooms, physician services, mental health facilities, home health agencies, DME companies, and pharmacies.

• Facility audits and medical record reviews to monitor services provided by PCPs and high-volume specialists (OB-GYNs).

• Monitoring practice guidelines through medical record reviews and utilization reports.

• The monitoring of high-volume/high-risk services based on review of demographic and epidemiological distribution of members.

• Review of acute and chronic care services.

• Continuity and coordination of care.

• Over- and under-utilization of medical resources.

• Care provider and member satisfaction surveys.

• Complaint and grievance monitoring and analysis.

• Compliance with practice guidelines, including preventive health guidelines.





Follow Practice ProtocolsUnitedHealthcare Community Plan has adopted preventive, chronic, and complex practice protocols for children, adolescents, and adults. The guidelines are updated minimally once per year. They include preventive health, immunization, mental health, and other clinical guidelines and preventive health schedules. To view our guidelines, visit UHCCommunityPlan.com for other authoritative medical sources. A printable version is available online for downloading. To request a copy of our practice protocols by phone, please call Provider Services.

Cultural CompetencyUnitedHealthcare Community Plan has a comprehensive written Cultural Competency Plan describing how the health plan will help ensure services are provided in a culturally competent manner to our members, including those with limited English proficiency. You may request, at no charge, a copy of our Cultural Competency Plan by calling Provider Services at 877-842-3210 or visit UHCCommunityPlan.com.

Resolving DisputesContract concern or complaint regarding policies, procedures or administrative functions. If you have a concern or complaint about your agreement with us, send a letter containing the details to:

South Florida UnitedHealthcare - Miramar Office 3100 SW 145th AvenueMiramar, FL 33027

Central FloridaNetwork Management495 North Keller Road, Suite 200Maitland, FL 32751

North Florida10151 Deerwood Park BlvdBldg 100, Suite 420Jacksonville, FL 32256

West FloridaNetwork Management9009 Corporate Lakes Drive, Suite 200Tampa, FL 33634

A representative will try to resolve your complaint through informal discussions. If you disagree with the outcome of this discussion, an arbitration proceeding may be filed as described and in our agreement.

If your concern or complaint relates to a matter generally administered by certain UnitedHealthcare Community Plan procedures, such as the credentialing or Health Services process, we will follow the procedures set forth in those plans to resolve the concern or complaint.

Participation Appeal – Is a written request you send to the Provider Affairs Subcommittee to reconsider a care provider’s participation decision.

The Provider Affairs Subcommittee must provide a fair hearing appeal opportunity for care providers in a timely manner according to set policies and procedures, and to render judgment.

• To request an appeal hearing, make the request in writing to the chair of the Provider Affairs Subcommittee within 30 days from the date of notification of the termination.

• The plan provides you with a summary of the rights in the hearing in accordance with the Health Care Quality Improvement Act of 1986.

• The plan furnishes written notice of the time, place, and date of any hearing on the proposed action.

• The plan provides you with a list of witnesses to be called against you at the hearing.

• All hearings occur before at least three board-certified practitioners. One of them is not otherwise involved in network management, and the other will be a clinical peer of the participating care provider who filed the appeal.

• The plan informs you your right to a hearing will be forfeited if you do not appear at the hearing.

• The plan grants you the following rights:

– The right to have a record of the hearing made.

– The right to call and cross-examine witnesses.

– The right to present evidence.

– The right to submit a written statement.

– The right to be represented by an attorney.

• After the hearing, the plan provides you with a copy of the written recommendation of the hearing committee within 10 days.

• After the hearing, the plan provides you with a written decision, including the basis for the decision within 30 days. The decision contains the right to a second-level hearing.

• All peer review activities and data collected for such purposes are confidential pursuant to Florida State Law.

• The plan offers you a second-level hearing, if necessary. The hearing committee will be composed of three entirely different board-certified care providers. One of them will not otherwise be involved in network management, and the other will be a clinical peer of the participating care provider who filed the appeal.







• Standards for written recommendations, written decisions and basis for the decision, and notifications are the same as the first-level appeal.

• There is no further appeal for the decision of the second-level appeal.

If we have a concern or complaint about our agreement with you, we’ll send you a letter containing the details. If we can’t resolve the complaint through informal discussions with you, an arbitration proceeding may be filed as described and in our agreement.

ArbitrationAny arbitration proceeding under your agreement will be conducted in Broward County, Florida under the auspices of the American Arbitration Association, as further describedin our agreement.

For more information on the American Arbitration Association guidelines, visit their website at adr.org.

In the event a member has authorized you to appeal a clinical or coverage determination on their behalf, that appeal follows the process governing member appeals outlined in the member’s handbook):

Uphold Member “Bill of Rights”The state must help ensure each member is free to exercise their rights, and the exercise of those rights does notadversely affect the way the health plan and its care providers or the state agency treat the member.

We tell our members they have the following rights and responsibilities, all of which are intended to help uphold the quality of care and services they receive from you. These rights and responsibilities are reprinted from our member handbook.

Members have the right to:

• Receive information about us, our services and network physicians and health care professionals in accordance with federal and state regulations.

• Be treated with respect and with due consideration for their dignity and privacy by UnitedHealthcare Community Plan personnel, network physicians, and health care professionals, as well as privacy and confidentiality for treatments, tests or procedures received.

• Voice concerns about the service and care they receive, as well as register complaints and appeals concerning their health plan or the care provided to them and receive timely responses to their concerns.

• Make suggestions about UnitedHealthcare Community Plan’s member rights and responsibilities policies

• Receive information on available treatment options and alternatives, presented in a manner appropriate to the member’s condition and ability to understand, regardless of cost or benefit coverage.

• Participate with their doctor and other caregivers in decisions about their health care, including the right to refuse treatment.

• Be informed of, and refuse to participate in, any experimental treatment.

• Have coverage decisions and claims processed according to regulatory standards.

• Choose an advance directive to designate the kind of care they wish to receive should they be unable to express their wishes.

• Be free from any form of restraint or seclusion used as a means of coercion, discipline, convenience, or retaliation.

• Request and receive a copy of their medical records, and request they be amended or corrected.

Members have the responsibility to:

• Know and confirm their benefits before receiving treatment.

• Contact an appropriate health care professional when they have a medical need or concern.

• Show their identification card before receiving health care services.

• Verify the physician or health care professional they receive services from is in the UnitedHealthcare Community Plan network.

• Use emergency room services only for injury or illness that, if not treated immediately, could post serious threat to their life or health.

• Keep scheduled appointments.

• Provide information needed for their care.

• Work with their doctor to set treatment goals. Follow the treatment plan you and your doctor agree upon.

• Ask their doctor questions about their health so they can understand their health problems and help make goals for treatment.

• Notify UnitedHealthcare Community Plan Customer Service of a change in address, family status or other coverage information.

Care Provider Complaint SystemUnitedHealthcare Community Plan has established a care provider complaint system that permits you to dispute the policies, procedures, or administrative functions, including proposed actions, claims, billing disputes, and service authorizations which have been established. UnitedHealthcare Community Plan’s process for care provider complaints


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concerning claims issues has been developed in accordance with s. 641.3155, F.S. Care provider complaint system policies and procedures, including claims issues, are available to care providers, including out-of-network care providers, upon request. This information is available to you free of charge.

As a part of the care provider complaint system, you may contact UnitedHealthcare Community Plan by telephone, email, or in person, to ask questions, file a provider complaint and resolve problems. You have 45 calendar days to file a written complaint for issues not about claims. Within three business days of receipt of a complaint, a notification is provided (verbally or in writing) the complaint has been received and the expected date of resolution. Each complaint is investigated using applicable statutory, regulatory, contractual and care provider contract provisions, collecting all pertinent facts from all parties and applying UnitedHealthcare Community Plan’s written policies and procedures.

Care Provider Credentialing and ContractingWe are responsible for the credentialing and recredentialing of our care provider network. Credentialing and recredentialing policies and procedures include the following:

• Formal delegations and approvals of the credentialing process.

• Require all direct service care providers to complete abuse, neglect and exploitation training.

• Identification of care providers who fall under its scope of authority.

• A process that provides for the verification of the credentialing and recredentialing criteria required.

• Approval of new care providers and imposition of sanctions, termination, suspension and restrictions on existing care providers.

• Identification of quality deficiencies that result in UnitedHealthcare Community Plan’s restriction, suspension, termination or sanctioning of a care provider.

We may request a copy of your current medical license for medical care providers, or occupational or facility license as applicable to care provider type, or authority to do business, including documentation of care provider qualifications.

• Evidence of your professional liability claims history.

• Any sanctions imposed on you by Medicare or Medicaid.

• Disclosure related to ownership and management (42 CFR 455.104), business transactions (42 CFR 455.105) and conviction of crimes (42 CFR 455.106).

• A satisfactory level II background check for all treating care providers not currently enrolled in Medicaid’s fee-for-service program, in accordance with the following:

Care providers not currently enrolled in Medicaid’s fee-for-service program must submit fingerprints electronically following the process described on the AHCA’s Background Screening website. Medicaid eligibility is verified through this background screening system. We will not contract with any care provider who has a record of illegal conduct; i.e., found guilty of, regardless of adjudication, or who entered a plea of nolo contendere or guilty to any of the offenses listed in s. 435.04, F.S.

Individuals already screened as Medicaid care providers or screened within the past 12 months by another Florida agency or department using the same criteria as the agency are not required to submit fingerprints electronically but shall document the results of the previous screening.

Individuals listed in s. 409.907(8)(a), F.S., for whom criminal history background screening cannot be documented must provide fingerprints electronically following the process described on AHCA’s background screening website.

Rights Related to the Credentialing ProcessPhysicians and other health care providers applying for the UnitedHealthcare network have the following rights regarding the credentialing process:

• To review the information submitted to support your credentialing application;

• To correct information; and

• To be told the status of your credentialing or recredentialing application, upon request. You can check on the status of your application by calling 407-659-7241 or emailing [email protected].

Subcontractor ResponsibilitiesWe enter into subcontractor arrangements, as appropriate, and agree to make payment to all subcontractors pursuant to all state and federal laws, rules and regulations.

All model and executed subcontracts and amendments used by the Managed Care plan under this contract shall meet the following requirements with respect to provisions for monitoring and inspections:

• Provide for inspections of any records pertinent to the Contract by the Agency and DHHS.

• Care providers and subcontractors agree to comply with record retention requirements for practitioner or care


mailto:FL_LTC_Network%40uhc.com?subject=




provider licensure, require records be maintained for a period no less than 10 years from the close of the contract and retained further if the records are under review or audit until the review or audit is complete (prior approval for the disposition of records must be requested and approved by UnitedHealthcare Community Plan if the subcontract is continuous).

• Subcontractor agrees to provide assurance all licensed medical professionals are credentialed in accordance with state credentialing requirements, credentialing activities have been delegated. Additionally, subcontractors are required to secure and maintain, during the life of the subcontract, workers’ compensation insurance for all of its employees connected with the work under this contract unless such employees are covered by the protection afforded by the Managed Care plan. Such insurance shall comply with Florida’s Workers’ Compensation Law.

This subcontractor must help ensure ability for enrollee’s to obtain services, and provide monitoring of services provided to the Managed Care plan enrollee’s by the subcontractor.

Other Contract RequirementsSubcontractors are subject to background checks. UnitedHealthcare Community Plan will consider the nature of the work a subcontractor or agent will perform in determining the level and scope of the background checks. Documentation of compliance certification (business-to-business) testing of transaction compliance with HIPAA for any subcontractor receiving member data is required.


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1. Written Standards, Policies and Procedures

2. High Level Oversight – Governance

3. Effective Training and Education

4. Effective Lines of Communication/Reporting Mechanisms

5. Enforcement and Disciplinary Guidelines

6. Auditing and Monitoring

7. Response to Identified Issues

Examples of applicable regulations and requirements include but are not limited to:

• Medicaid: Title 42 CFR Part 438 Managed Care, andexecuted state contracts.

• Federal Health Insurance Portability and Accountability Actof 1996 (“HIPAA”) and state health information privacy laws;federal and state False Claims Acts.

We have compliance program staff, led by the Chief Medicaid compliance officer, which is responsible for oversight and management of the Ethics and Integrity Program. A compliance committee, consisting of senior managers from each of our key organizational functions provides direction and oversight for the program. UnitedHealthcare Community Plan also has compliance officers or compliance contacts located in each health plan or business unit who report to the senior management of their assigned entity.

Reporting and AuditingAny unethical, unlawful or otherwise inappropriate activity by a UnitedHealthcare Community Plan employee which comes to the attention of a care provider should be reported to a senior manager in the health plan or directly to the Ethics and Compliance Help Center at 800-455-4521.

An important aspect of the Ethics and Integrity Program is assessing high-risk areas of UnitedHealthcare Community Plan operations and implementing periodic reviews and audits to help ensure compliance with law, regulations, and contracts. When informed of potentially, irregular, inappropriate or potentially fraudulent practices within the plan or by our care providers, UnitedHealthcare Community Plan will conduct an appropriate investigation. You are expected to cooperate with the company and government authorities in any such inquiry, both by providing access to pertinent records (as required by the participating provider agreement) and access to provider office staff. If activity in violation of law or regulation is established, appropriate governmental authorities will be advised.

If a care provider becomes the subject of a governmental inquiry or investigation, or a government agency requests or subpoenas documents relating to the provider’s operations (other than a routine request for documentation from a regulatory agency), the care provider must advise us of the details of this and of the factual situation which gave rise to the inquiry.

Chapter 6: Compliance

Regulatory ComplianceIntroductionAs a business segment of UnitedHealth Group, UnitedHealthcare Community Plan implements and is governed by the UnitedHealth Group Ethics and Integrity Program. UnitedHealthcare Community Plan is dedicated to conducting business honestly and ethically with members, care providers, suppliers and governmental officials and agencies. The need to make sound, ethical decisions as we interact with physicians, other health care providers, regulators and others has never been greater. It’s not only the right thing to do, it is necessary for our continued success and that of our business associates.

The Ethics and Integrity Program promotes compliance with applicable legal requirements, fosters ethical conduct within UnitedHealthcare Community Plan and provides guidance to its employees and contractors. Additionally, the Ethics and Integrity Program focuses on increasing the likelihood of preventing, detecting, and correcting violations of law or UnitedHealthcare Community Plan policy. The implementation of such a program, however, cannot guarantee the total elimination of improper employee or agent conduct. If misconduct occurs, we will investigate the matter, take disciplinary action, if necessary, and implement corrective measures to prevent future violations. Preventing, detecting and correcting misconduct safeguards our reputation, assets and the reputation of our employees.

Ethics and Integrity ProgramThe Ethics and Integrity Program incorporates recommended compliance program guidance from the Department of Health and Human Services Office of the Inspector General (OIG), the Centers for Medicare and Medicaid Services (CMS), and the Federal Sentencing Guidelines for Organizations (revised and amended, 2010). The purpose of the Ethics and Integrity Program is to help ensure operational accountability and to provide standards of conduct for compliance with the obligations that govern our federal and state programs.

Ethics and Integrity Program activities support the following seven key elements that facilitate prevention, early detection and remediation of violations of law and UnitedHealthcare policies.




Fraud, Waste and AbuseOur Anti-Fraud, Waste and Abuse Program focuses on proactive prevention, detection, and investigation of potentially fraudulent and abusive acts committed by care providers and plan members. A toll-free Fraud, Waste and Abuse Hotline 877-401-9430 has been set up to facilitate the reporting process of any questionable incidents involving plan members or care providers.

Reports can also be made directly to the state of Florida by contacting the State Consumer Hotline at 888-419-3456 or the Florida Attorney General’s office at 866-966-7226.

Through the Anti-Fraud, Waste and Abuse Program, our mission is to prevent paying fraudulent, wasteful and abusive health care claims, as well as identify, investigate and recover money it has paid for fraudulent, wasteful or abusive claims through evolving policies and initiatives to detect, prevent and combat fraud, waste and abuse. UnitedHealthcare Community Plan will also appropriately refer suspected fraud, waste and abuse (FWA) cases to law enforcement, regulatory, and administrative agencies pursuant to state and federal law. UnitedHealthcare Community Plan seeks to protect the ethical and fiscal integrity of the company and its employees, members, care providers, government programs, and the public, as well as safeguard the health and well-being of its members.

UnitedHealthcare Community Plan is committed to compliance with its Anti-Fraud, Waste and Abuse Program and all applicable federal and state regulatory requirements governing its Anti-Fraud, Waste and Abuse Program. UnitedHealthcare Community Plan recognizes state and federal health plans are particularly vulnerable to fraud, waste and abuse and strives to tailor its efforts to the unique needs of its members and Medicaid, Medicare and other government partners.

All suspected instances of fraud, waste and abuse in any way and in any form are thoroughly investigated. In appropriate cases, the matter is reported to law enforcement and/or regulatory authorities, in accordance with federal and state requirements. UnitedHealthcare Community Plan cooperates with law enforcement and regulatory agencies in the investigation or prevention of fraud, waste and abuse.

The Deficit Reduction Act of 2005 (DRA) contains many provisions reforming Medicare and Medicaid are aimed at reducing fraud within the health care programs funded by the federal government. Under Section 6032 of The DRA, every entity that receives at least $5 million in Medicaid payments annually must establish written policies for all employees of the entity, and for all employees of any contractor or agent of the entity, providing detailed information about false claims, false

statements and whistleblower protections under applicable federal and state fraud and abuse laws.As a participating care provider with UnitedHealthcare Community Plan, you and your staff are subject to this provision. The UnitedHealth Group policy titled “Integrity of Claims, Reports and Representations to Government Entities” can be found at the “For Health Care Professionals” section of UHCCommunityPlan.com under “Provider Information.” This policy details our commitment to compliance with the federal and state false claims acts, provides a detailed description of these acts and of the mechanisms in place within our organization to detect and prevent fraud, waste and abuse, as well as the rights of employees to be protected as whistleblowers.

False Claims ActsUnitedHealthcare Community Plan complies with federal and state law to prevent and detect fraud, waste, and abuse in government health care programs.

UnitedHealthcare Community Plan complies with Section 6032 of the federal Deficit Reduction Act of 2005 (DRA).

UnitedHealthcare Community Plan is required to comply with Section 6032 of the DRA. UnitedHealthcare Community Plan provides the following information in accordance with the DRA.

Federal False Claims ActThe False Claims Act (31 USC § 3279-33) is a federal statute that covers fraud involving any federally funded contract or program, including the Medicare and Medicaid programs. The act establishes liability for any person who knowingly presents or causes to be presented a false claim to the U.S. government for payment.

The term “knowingly” is defined to mean a person, with respect to information, has actual knowledge of the falsity of information in the claim; acts in deliberate ignorance of the truth or falsity of the information in a claim; or acts in reckless disregard of the truth or falsity of the information in a claim.

The act does not require proof of a specific intent to defraud. Instead, people can be prosecuted for a wide variety of conduct that leads to the submission of fraudulent claims to the government, such as knowingly making false statements, falsifying records, double-billing for items or services, submitting bills for services never performed or items never furnished, or otherwise causing a false claim to be submitted.

Penalties can be up to three times the value of the false claim, plus from $5,500 to $11,000 in fines, per claim.






Whistleblower Provisions To encourage individuals to come forward and report misconduct involving false claims, the act includes a whistleblower provision. This provision essentially allows any person with actual knowledge of false claims activity to file a lawsuit on behalf of the U.S. government. Individuals seeking whistleblower status must meet several criteria to prevail as outlined.

Original SourceThe whistleblower must be the “original source” of the information reported to the U.S. government. Specifically, the whistleblower must have direct and independent knowledge of the false claims activities, must voluntarily provide this information to the government, and the matter disclosed cannot already be the subject of a federal investigation.

Rights of Parties to Whistleblower ActionsIf the government determines the lawsuit has merit and decides to join, the lawsuit will be directed by the U.S. Department of Justice. At this point, the government will be the “plaintiff,” or party suing. If the government decides not to intervene. The whistle-blower can continue with the lawsuit on their own.

Award to WhistleblowersIf the lawsuit is successful (after being prosecuted by the government), the whistle-blower may receive an award ranging from 15 to 30% of the amount recovered by the government. The whistleblower may also be entitled to reasonable expenses, including attorneys’ fees and costs for bringing the lawsuit.

No Retaliation Protection for WhistleblowersIn addition to a financial award, the act entitles whistleblowers to additional relief, including employment reinstatement, back pay, and any other compensation arising from retaliatory conduct against a whistleblower for filing an action under the act or committing other acts, such as providing testimony of assisting in a False Claims Act action. UnitedHealthcare Community Plan’s employees are protected from retaliation (e.g., discharge, demotion, suspension, threat, harassment, discrimination, or anything similar thereto), in the event any employee files a claim pursuant to the act or otherwise makes a good faith report alleging fraud, waste or abuse in a federal health care program, including the Medicare and Medicaid programs, to UnitedHealthcare Community Plan or the proper authorities, subject to the terms and conditions of UnitedHealthcare Community Plan’s Compliance Plan.

State LawsStates where UnitedHealthcare Community Plan does business have laws that contain civil or criminal penalties for false claims and statements in addition to the penalties provided in the act.

Certain states also have whistleblower protections similar to the act. In Florida the applicable laws are codified in F.S. 68.081-68.092 (“FFCA”). For more information on a specific state law, please contact the UnitedHealthcare Community Plan compliance officer or legal department.

HIPAAUnitedHealthcare Community Plan is proud of its success in implementing the required Health Insurance Portability and Accountability Act (HIPAA) standards. UnitedHealthcare Community Plan is Clear Data Interchange (Clearinghouse for Electronic Data Interchange) certified as to the administrative simplification standards for transactions and code sets. We can interact directly with you through HIPAA-compliant EDI transactions. UnitedHealthcare Community Plan also contracts with a clearinghouse which you can use to submit and receive non-compliant EDI transactions. If you are interested in communicating with us through EDI, please contact Provider Services at 877-842-3210.

The UnitedHealthcare Community Plan companies adopted ‘affiliated entity’ status for purposes of the HIPAA privacy standards. The health plan Notices of Privacy Practices (NPP) outlines how we may use member health information, when we can share member health information with others, and what rights members have to access their health information. We use and disclose our members’ protected health information (PHI) only for purposes of treatment, payment and health care operations. Copies of the notices that describe our privacy practices for each UnitedHealthcare Community Plan managed care product can be found in the member handbook, accessed at UHCCommunityPlan.com, or can be provided as a hard-copy upon request. You are obligated, both by applicable law and the standard provider participation agreement, to obtain the consent of our member, as it relates to the use of PHI for any purposes other than those permitted by law. You are also required to timely inform UnitedHealthcare Community Plan about any breach of the HIPAA privacy rules and cooperate with reasonable actions designed to remediate the adverse effects of such a breach.

Like all members of the health care industry, UnitedHealthcare Community Plan is aware of the significant HIPAA security challenges we all face. UnitedHealthcare Community Plan is committed to adopting and updating its physical, electronic and administrative safeguards to protect our members’ PHI. We encourage you to adopt similar safeguards suitable to the associated risks and their individual environments to further secure PHI.



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The UnitedHealthcare Community Plan Medicaid product is available to Florida Medicaid participants residing within the approved service area. One or all of the plan participants of a family may be enrolled. An individual must maintain current eligibility with the Florida Medicaid program to remain a plan participant with UnitedHealthcare Community Plan. The plan is a PCP-based product, in which the plan participant must select a PCP who participates in the plan.

The designated PCP coordinates all of the plan participant’s care and services.

Helpful Administrative InformationDetermining Eligibility

Every plan participant is sent a UnitedHealthcare Community Plan ID card at the beginning of the first month they are effective with the program, along with a plan participant handbook and instructions regarding obtaining services.

Member eligibility can be verified by:

• Checking eligibility online at UHCprovider.com or by calling 877-842-3210.

• Checking your monthly PCP plan participant roster for plan participants assigned to you, if you are a PCP.

• Calling the toll-free customer service number listed on the back of the member’s ID card.

Medicaid Care Providers are Requested to do the Following

• Provide immunization information to the DCF upon receipt of the member’s written permission and DCF’s request, for members requesting temporary cash assistance from DCF to document they have met the immunization requirements for recipients receiving temporary cash assistance.

• Post the Florida Patient’s Bill of Rights and Statewide Consumer Call Center telephone number in the patient waiting room.

• Provide an annual attestation of active patient load. “Active” is defined by a patient who has been seen at least three times in a year. Active patient load includes all patients, not just our patients, and should not exceed 3,000. If your total active patient load exceeds 3,000, your panel will be closed to new enrolleeship until a new attestation form is received.

• Enroll in the Vaccine For Children program.

• Encourage your new patients to come into your office for a health risk assessment within the first 90 days of enrollment with UnitedHealthcare Community Plan.

• Assist new patients in the transfer of their previous medical records.

• Provide physical examination within 72 hours or immediately, if required, for children taken into protective custody, emergency shelter or into the foster care program by DCF.

• Hospitals are required to advise the plan of all births by plan participants, complete the required DCF-ES 2039 form and indicate the name of the plan as the referring agency.

• Report all child health check-up encounters or claims.

• Obtain a Medicaid ID number.

Outreach and Marketing GuidelinesYou are permitted to make available and/or distribute Managed Care plan marketing materials as long as you and/or the facility distributes or makes available marketing materials for all Managed Care plans with which you participate.

If you agree to make available and/or distribute Managed Care plan marketing materials, you should do so knowing you must accept future requests from other Managed Care plans with which you participate. You are also permitted to display posters or other materials in common areas such as the waiting room. Additionally, long-term care facilities are permitted to provide materials in admission packets announcing all Managed Care plan contractual relationships.

Through education, outreach and monitoring, we work with you to help ensure you are aware of and comply with the following:

1. You may engage in discussions with recipients should a recipient seek advice. However, you must remain neutral when assisting with enrollment decisions.

2. You may not:

a. Offer marketing/appointment forms.

b. Make phone calls or direct, urge or attempt to persuade recipients to enroll in a Managed Care plan based on financial or any other interests you may have.

c. Mail marketing materials on behalf of a Managed Care plan.

d. Offer anything of value to induce recipients/members to select them as their care provider.

Chapter 7: Medicaid Appendix





e. Offer inducements to persuade recipients to enroll in a Managed Care plan.

f. Conduct health screenings as a marketing activity.

g. Accept compensation directly or indirectly from a Managed Care plan for marketing activities.

h. Distribute marketing materials within an exam room setting.

i. Furnish to Managed Care plans, lists of their Medicaid patients or the membership of any Managed Care plan.

3. You may:

a. Provide the names of the Managed Care plans with which they participate.

b. Make available and/or distribute Managed Care plan marketing materials.

c. Refer your patients to other sources of information, such as the Managed Care plan, the enrollment broker or the local Medicaid area office.

d. Share information with patients from the AHCA website or CMS website.

4. Care Provider Affiliation Information

a. You may announce new or continuing affiliations with a Managed Care plan through general advertising (e.g., radio, television, websites).

b. You may make new affiliation announcements within the first 30 calendar days of the new provider agreement.

c. You may make one announcement to patients of a new affiliation that names only that Managed Care plan when such announcement is conveyed through direct mail, email, or phone.

d. Additional direct mail and/or email communications from care providers to their patients regarding affiliations must include a list of all Managed Care plans with which you contract.

e. Any affiliation communication materials that include Managed Care plan-specific information (e.g., benefits, formularies) must be prior approved by the agency.

5. You may distribute printed information provided by a Managed Care plan to their patients comparing the benefits of all of the different Managed Care plans with which you contract. The Managed Care plans will help ensure:

a. Materials do not “rank order” or highlight specific Managed Care plans and include only objective information.

b. Such materials have the concurrence of all Managed Care plans involved in the comparison and are approved by the agency prior to distribution.

c. The Managed Care plans identify a lead Managed Care plan to coordinate submission of the materials.

Member Grievances and AppealsIf member is not satisfied with a service or care provider and would like to file a grievance, they may do so by calling Member Services at the phone number listed on back of their member ID card. A grievance may also be submitted by letter/surface mail. The following outlines the procedure.

We send the member a letter approximately five days after we receive the grievance to let them know their rights and our procedures. If we have resolved the grievance within that time, we tell the member the result of our investigation. We investigate the grievance and provide the member with a written explanation of our findings within 90 days.

Grievance Department Office Hours: 7 a.m. – 8 p.m., Monday – Friday, Central Time

Member AppealsIf the member receives a notice of Adverse Benefit Determination, they have the right to appeal. An action is any denial, limitation, reduction, suspension, or termination of service, denial of payment, or failure to act in a timely manner.

A member has 60 calendar days from the date on the Notice of Adverse Benefit Determination to file an appeal. Members can appeal by calling Member Services at the phone number listed on back of the member ID card.

An appeal requested by telephone must be followed in writing, except for expedited appeals, within 10 calendar days of the phone appeal. You must have the member’s permission in writing to appeal on their behalf.

UnitedHealthcare Community Plan Attention: Appeals and Grievances P.O. Box 31364 Salt Lake City, UT 84131 888-716-8787 (toll-free) or 711 (TTY) 800-757-2617 (fax)





We review the appeal and tell the member what we found no later than 30 days after we receive the request. The appeal is reviewed by different doctors than those who made the first decision. If the appeal was in writing only, the 30 days starts from the day we receive the written appeal. If the appeal was by phone and then by letter, the 30 days starts the day of the verbal appeal. We notify the member in writing if we need an additional 14 days to process the appeal.

To have the member’s services continue during the plan appeal, the member, or you on the member’s behalf, MUST file the plan appeal AND ask to continue the services within this time frame:

File a request for the services to continue with UnitedHealthcare Community Plan no later than 10 days after our Notice of Adverse Benefit Determination letter was mailed OR on or before the first day the member’s services are scheduled to be reduced, suspended, or terminated, whichever is later. You can ask for a plan appeal by phone. If you do this, you must then also make a request in writing. Be sure to tell us if you want the member’s services to continue.

To have your services continue during the fair hearing, the member, or you as an authorized representative MUST file the fair hearing request AND ask for continued services within this time frame:

If the member was receiving services during the plan appeal, the member, or you on behalf of the member, can file the request for services to continue with the Agency for Health Care Administration (Agency) no later than 10 days from the date on the notice of plan appeal resolution OR on or before the first day the services are scheduled to be reduced, suspended, or terminated, whichever is later.

We will resolve the appeal in 30 days. We will let the member know if we need more time to resolve your appeal. We will only take more time if it will help your case.

Expedited AppealsExpedited appeals are appeals that need a faster review because of the member’s health, and should be used when taking time for a standard resolution could seriously jeopardize the member’s life or health or ability to attain, maintain, or regain maximum function. An expedited appeal can be requested by phone by calling Member Services at the phone number listed on back of the enrollee ID card. We notify you and the member of our decision within 72 hours. We try to call you and the member about the results right away. We also mail the member a letter within two working days.

Subscriber Assistance ProgramMedicaid members have the right to appeal to the Subscriber Assistance Program (SAP) as an additional level of appeal. The member can access the SAP after exhausting UnitedHealthcare Community Plan’s Grievance and Appeals process, except when the member has requested or is participating in a Medicaid Fair Hearing for the matter. The SAP must receive the request for review from the member (or their designee with appropriate documentation for representation) within one year of the receipt of the final decision letter from UnitedHealthcare Community Plan.

A review by the SAP can be requested in writing or by phone at:

Agency for Health Care Administration Subscriber Assistance Program Building 3, MS #45 2727 Mahan Drive Tallahassee, FL 32308 850-412-4502 888-419-3456 (toll-free)

Medicaid State Fair HearingsIf Medicaid members are not satisfied with the outcome oftheir appeal after completion of the process, they may file for a State Fair Hearing within 120 calendar days of receiving the appeal resolution which can be requested by writing to:

Agency for Health Care Administration Medicaid Hearing Unit P.O. Box 60127 Ft. Myers, FL 33906 877-254-1055 (toll-free) 239-338-2642 (fax) [email protected]

At this hearing, you can also represent the member with their written permission.

Medikids enrollees are not able to request Medicaid State Fair Hearings.

Helpful Benefit InformationDelivery of Medical ServicesUnitedHealthcare Community Plan members must obtain referrals for some specialty care services and ancillary services. For hospital-related services, please consult this manual. Payment may be withheld if proper referrals or prior notification is not obtained. In the case of an emergency, immediate treatment


mailto:MedicaidHearingUnit%40ahca.myflorida.com?subject=




should be provided and contact made with the PCP as soon as possible, preferably within 24 hours.

UnitedHealthcare Community Plan provides a summary of services to our members. This information is shown in the following table and in the member handbook.

Summary of Member ServicesMembers may receive covered services which are performed, prescribed, or directed by a participating care provider. The member should check if a care provider is participating. Since the network changes, members are instructed to contact Member Services or use our online provider directory available at UHCCommunityPlan.com to make sure the care provider they choose is a UnitedHealthcare of Florida (Medicaid) participating care provider.

Services are limited to Medicaid-covered services as specified in the contract with the State of Florida Agency for Health Care Administration. The following is a summary of the plan’s health services and limitations on covered services. Please call Customer Service to verify covered services. Services considered experimental and cosmetic are not covered.

For a counseling or referral service the health plan does not cover because of moral or religious objections, the health plan need not furnish information on how and where to obtain the service.






Type of Service Description

Abortion An abortion may be performed because the life of the mother is, or would be, endangered if the fetus were carried to term. It must be documented in the medical record by the attending physician stating why the abortion is necessary or if the pregnancy is the result of an act of rape or incest. Abortions must be documented with a completed Abortion Certification Form. Refer to the online resource section of this guide for the website address for this form, which will satisfy federal and state regulations.

Ambulatory Surgical Center (ASC) Services

Coverage for most medically necessary procedures; services not covered under the Florida Medicaid Physician Services Program are also not covered under the Florida Medicaid ASC services program.

Child Health Check-Up (CHCUP) • Health Education (including anticipatory guidance).

In addition, Child Health Check-Up service includes:

Periodic Informing:UnitedHealthcare Community Plan will inform plan participants of screenings due in accordance with the periodicity schedule as specified in the Medicaid Child Health Check-Up Provider Handbook.

Referral:When indicated, direct members to appropriate participating service care providers for further assessment and treatment of conditions found in the examination within an outer limit of six months after the request for a Child Health Check-Up.

Assistance:Plan participants must be offered scheduling assistance in making treatment appointments and obtaining transportation.

PLEASE NOTE: Child Health Check-Up services are provided by the plan participant’s PCP. When medically indicated, the plan participant’s PCP will refer the plan participant to the appropriate UnitedHealthcare Community Plan participating specialty care provider.

Periodic Screenings (CHCUP)Periodic screenings, which are appropriate to the child’s age, are required under the Child Health Check-Up program. The state of Florida uses the following periodic schedule as recommended by the American Academy of Pediatrics and the Florida Pediatric Society:• Birth or neonatal examination. The neonatal examinations can be considered as an initial

Child Health Check-Up screening for Medicaid plan participants.• Two to four days if the newborn is discharged in less than 48 hours.• Subsequent newborn examinations to include one, two, four, six, nine, 12, 15, and 18

months.• Once per year for ages two through 20.

Additional screenings may be performed as medically indicated.





Child Health Check-Up (CHCUP) (continued)

Additional screenings may be performed as medically indicated.

After the initial screening, the plan participant may pick up the periodic screening schedule at any time. For example, if a plan participant has an initial screening at age 6, then the next periodic screening could be performed at age 7.

If plan participants require a screening at 10 months and were not screened previously or missed the six-month screening, then the 10-month screening is counted as initial. The member will continue with the periodic schedule thereafter.

These screenings are not optional and must be performed. Submit encounter or claim information on a CMS 1500, and use CPT codes appropriate for Child Health Check-up. Encounter capitated visits are documented in a CMS 1500 form.

A CMS 1500 should be completed for every office visit or procedure.

The completed CMS 1500 Forms should be forwarded at the end of each week to:

UnitedHealthcare of FloridaP.O. Box 31362Salt Lake City, UT 84131

Circumcision –Requires Medical Necessity Determination

All Medicaid members younger than 12 weeks of age without an authorization; older than 12 weeks of age requires prior authorization.

Dental Services Adults:Adult services include medically necessary emergency dental procedures to alleviate pain or infection. Emergency dental care shall be limited to emergency oral examinations, necessary radiographs, extractions, and incisions and drainage of abscesses. Adult dental services shall also include dentures.

UnitedHealthcare Community Plan’s dental program for adult members is provided through Dental Benefit Providers (DBP), which contracts with dentists in private offices. Members may pick a DBP dentist and make an appointment by calling the dentist’s office and saying they are a member. If they have questions about their dental services, participating dentists, or want to change dentists, they may call DBP at 877-816-3596.

Children:Full dental services for all enrollee’s age 20 and younger.

Diabetes Supplies and Education Coverage for medically appropriate and necessary equipment, supplies and, services used to treat diabetes, including outpatient self-management training and educational services, if the treating care provider says these services are necessary.

Durable Medical Equipment The PCP must notify UnitedHealthcare Community Plan for services or equipment provided home.

Equipment includes but is not limited to canes, crutches, walkers, commodes, wheelchairs, oxygen and oxygen-related equipment.





Emergency Services Includes emergency medical care 24 hours a day, seven days a week. Emergency behavioral health services are covered in or out of network, or out of UnitedHealthcare’s service area. Emergency service facilities should have one or more physicians and one or more nurses on duty at the facility at any given time. Members do not need approval from UnitedHealthcare Community Plan or their PCP to go to the emergency room if they are having a medical situation.

Family Planning Services To help plan a family size or space the time between having children. Family Planning Services includes information, referral education, counseling, diagnostic procedures and contraceptive drugs and supplies. Services are voluntary, and members are permitted full freedom of choice of methods for Family Planning. These services may not be provided to recipients younger than age 18 unless one of the following is met:• Married.• A parent.• Pregnant.• Has written consent by a parent or legal guardian.• In the opinion of a care provider, the plan participant may suffer health hazards if services

are not provided.

ATTENTION: The Family Planning Services Program DOES NOT include sterilization.

Members can go to any care provider that participates with Medicaid for these services without a referral from a PCP, including any county health department.

You must make available and encourage all pregnant women and mothers to receive, and provide documentation in the medical records to reflect the following:• Scheduled postpartum visit for the purpose of voluntary family planning including

discussion of all methods of contraception as appropriate.• Counseling and services for family planning to all women and their partners.

NOTE: The provisions of this subsection shall not be interpreted so as to prevent a care provider or other person from refusing to furnish any contraceptive or family planning service, supplies, or information for medical or religious reasons and the care provider or other person shall not be held liable for such refusal.

Freestanding Dialysis Facility Services Includes routine laboratory test, dialysis-related supplies, ancillary and other items. Services included all services and procedures rendered by a participating care provider when needed for preventive, diagnostic, therapeutic, or to treat a particular injury, illness or disease.

Hearing Services Hearing services include examinations and evaluations necessary for the furnishing of one standard hearing aid per ear every three years.





Healthy Behaviors Programs We offer programs to help our members who want to stop smoking, lose weight, or get help with drug abuse. The programs are:• Substance Abuse Incentive Program• Smoking Cessation• Health Coaching for Weight Loss• Baby Blocks

For more information about our Healthy Behaviors Programs, members may call Customer Service.

Home Health Care Includes intermittent or part-time nursing services (R.N. or L.P.N), personalcare services by a home health aide, if there are skilled needs and medical items (limitations apply). All services must be provided by a participating care provider. The PCP must notify UnitedHealthcare Community Plan of services requiring home health care. Home health care does not include homemaker services, Meals on Wheels, companion, sitter or social services.

• Home Health Services have limited annual amount of visits.• Durable Medical Equipment has an annual cap.

Members may call Customer Service with questions about these services.





Hospice Services Florida Medicaid reimburses for services that meet all of the following: • Are determined medically necessary • Do not duplicate another service • Meet the criteria as specified in this policy Florida Medicaid reimburses for 365/6 days of hospice services per year, per recipient, when the following criteria are met: • The care provider conducts an initial assessment in accordance with 42 CFR 418.54 • The care provider develops and maintains a plan of care in accordance with section

400.6095, F.S. • Services are rendered in accordance with 42 CFR 418.202 and 42 CFR 418.302

You must provide or arrange for the provision of necessary care and services to manage a recipient’s terminal illness or related condition including:

Core Services The following services, included in the per diem payment, must be provided in accordance with 42 CFR 418.64: • Counseling services • Dietitian services • Medical social services • Nursing services • Care provider services

Non-Core Services The following services, included in the per diem payment, must be provided when specified in the recipient’s plan of care and in accordance with 42 CFR 418.70-78 and 42 CFR 418.106-108: • Hospice aide services • Medical supplies and durable medical equipment • Pharmacy services • Therapy services • Volunteer services • Any other item or service specified in the plan of care as reasonable and necessary for

the palliation and management of the recipient’s terminal illness or related condition in accordance with 42 CFR 418.202

Please contact Customer Service if you have questions about these services.

Hysterectomy UnitedHealthcare Community Plan covers a hysterectomy when it is non-elective and medically necessary and must meet the following requirements:

• The plan participant or her representative must have been informed verbally and in writing the hysterectomy shall render her permanently incapable of reproduction.

• The plan participant or her representative has signed and been given a copy of the Acknowledgment of Receipt of Hysterectomy Information form. (Refer to the online resource section of this guide for website address for this form.)





Immunizations In accordance with Section 1905 (r)(I) of the Social Security Act, the plan shall direct its care providers to participate in the Vaccines for Children program (VFC), the program administered by the Department of Health, Bureau of Immunizations, which provides vaccines at no charge to care providers, and eliminates any need to refer children to county health departments for immunizations.

The plan is required to:Provide immunizations in accordance with the childhood immunization schedule as approved by the Advisory Committee on Immunization Practices of the U.S. Public Health Service and the American Academy of Pediatrics or when it is shown to be medically necessary for the child’s health in accordance with Section 409.912 (32)(d), F.S.

The care provider is required to:Provide immunization information to the DCF upon receipt of the member’s written permission and DCF’s request for members requesting temporary cash assistance from the DCF to document the member has met the immunization requirements for beneficiaries receiving temporary cash assistance.

To enroll in the Vaccine for Children program, please send a letteron your letterhead to:

Department of Health Bureau of Immunization Vaccines for ChildrenHSDI 4052 Bald Cypress Way, BIN A11Tallahassee, FL 32399-1719

Or call 800-483-2543, or visit the website and click on immunization services: immunizeflorida.org/vfc.

Please consult the following website for the current recommended immunization schedule at cdc.gov/nip.

NOTE: MediKids participants do not qualify for the VFC. For immunizations provided to MediKids participants, care providers must bill Medicaid fee-for-service directly at a rate determined by the agency. The plan will however, pay for the administration of the vaccine. The current reimbursement amounts can be found on the Agency for Health Care Administration website. For more information, please consult the online resources section of this manual.

Independent Laboratory and Portable X-ray Services

Includes laboratory and X-ray services when ordered by a participating care provider.


http://www.floridahealth.gov/programs-and-services/immunization/vaccines-for-children/

http://www.cdc.gov/nip/




Inpatient Hospital Services For all child/adolescent members (up to age 21) and pregnant adults, the Managed Care Plan (MCP) shall be responsible for providing up to 365 calendar days of health-related inpatient care, including behavioral health, for each state fiscal year. For all non-pregnant adults, the MCP shall be responsible for 45 calendar days of inpatient coverage and up to 365 calendar days of emergency inpatient care, including behavioral health, in accordance with the Medicaid Hospital Services Coverage and Limitations Handbook, for each state fiscal year. The MCP shall count inpatient days based on the lesser of the actual number of covered days in the inpatient hospital stay and the average length of stay for the relevant All Patient Refined Diagnosis Related Group (APR-DRG or DRG).

This requirement applies whether or not the MCP uses DRGs to pay the care provider. DRGs can are available at: ahca.myflorida.com/Medicaid/cost_reim/index.shtml

If the member has not yet met their 45 day hospital inpatient limit per state fiscal year for non-pregnant adults at the start of a new hospital admission the entire new stay must be covered by the MCP in which the member was enrolled on the date of admission. This requirement applies even if the actual or average length of stay for the DRG puts the person over the inpatient limit. There is no proration of inpatient days.

All inpatient stays will be reviewed for medical necessity and denied if not medically necessary.

Interpreter Services If members need Interpreter Services or are vision and hearing impaired, have them call the customer service phone number on the back of their ID card. These services are free of charge for all foreign languages.

Lead Screening Federal regulations require that all children receive a screening blood level test at:• 12 months.• 24 months.• Children between the ages of 36 months and 72 months who have not been previously

screened for lead poisoning.

Maternity Services Maternity services include the following: nursing assessment and counseling, Florida’s Healthy Start Prenatal Risk Screening, nutrition assessment, delivery and follow-up care, Florida’s Healthy Start Infant (postnatal) Screening, and follow-up care.

As soon as a member knows they are pregnant and again after the baby is born, have them call:1. Their Department of Children and Families Case Worker; AND2. The plan’s Customer Service department3. If they want to enroll their baby into the plan, they can call their DCF case worker or

contact the Medicaid Enrollment & Disenrollment Services Hotline at 888-367-6554.

Members must call their case worker to get Medicaid benefits for their baby. If they don’t, the plan will not pay for their baby’s health care bills.

The Women, Infant, and Children (WIC) Program includes referrals for all pregnant breast-feeding and post-partum women, infants and children up to the age of 5. Have members call their case worker for more information.

NOTE: See Unborn ID Activation process in this manual for further information regarding the newborn enrollment process.


http://ahca.myflorida.com/Medicaid/Finance/finance/index.shtml




Mental Health Services If members need mental health, counseling and referral services, a participating psychiatrist will evaluate them. If they need further services, the care provider will refer them to the Community Health per Admission Center.

Nursing Facility Services Nursing Facility Services are covered for enrollees younger than 18 years old only.

OB/GYN • Maternity services include the following:• Nursing assessment and counseling, Florida’s Healthy Start prenatal Risk Screening,

nutrition assessment, delivery and follow-up care, Florida’s Healthy Start Infant (Postnatal) Screening, and follow-up care.

• The plan needs to be notified for the following:• Hospital should notify us of admissions for pregnancy-related diagnosis.• If mother and/or baby remains in the hospital after 48 hours for vaginal delivery and after

four days for cesarean section.• If mother is not discharged home with the baby. Notification should begiven on the day of the mother’s discharge.

Notification is required for all deliveries. The network care provider is responsible for obtaining notification.

Outpatient Services Outpatient services provided in an outpatient hospital setting. The PCP can obtain prior notification for health care services which may require notification. Circumcision requires prior authorization for medical necessity review.

Outpatient Services - None other Specialty (NOS)

Services remaining after all other categories are removed from the hospital outpatient claims.

Over the Counter (OTC) Have members call Customer Service if they have questions about how to receive these services.

Physician Services Includes all services and procedures rendered by a participating care provider when needed for preventive, diagnostic, therapeutic, or to treat a particular illnessor disease. Excludes experimental procedures and cosmetic surgery. These physicians services includes:

a. Advanced Registered Nurse Practitioner (ARNP).b. Physician assistant, (under supervision of a Licensed Physician or OB-GYN).c. Podiatry Ambulatory surgical centers.d. Community health departments.e. Rural health clinic services.f. Federally qualified health centers.g. Birth centers, (approved for non-risk pregnancy).h. Certified midwives, (working with cooperation with an OB GYN).i. Chiropractic.j. Psychiatrists.

Podiatry Services • Foot care is covered when rendered by a participating doctor.• No referral is necessary however; inpatient and select outpatient services and outpatient

surgeries require prior notification.Please refer to the Podiatry Services Handbook.






Post-Stabilization Services Post-stabilization services are covered without prior services authorization. These services are medically necessary after an emergency medical condition has been stabilized.

Prescribed Drugs Includes prescribed drugs currently covered by the Medicaid program, when ordered by a participating care provider and supplied by a licensed participating pharmacy.

Primary Care Case Management& Specialty Care Case Management

A case manager in the Health Services department or Optum, nurse or a social worker will help members receive the best care and health education for their medical problem(s).

This service includes the maintenance of a coordinated system to follow the plan participant through the entire range of screening and treatment.

Disease Management Program available i.e. asthma, CHF, diabetes, cancer and others. Please call Customer Service for information or 800-825-8792 Ext. 84562 or 84436.

Sterilization Non-therapeutic sterilization must be documented with a completed Sterilization Consent Form (Refer to the online resource section of this guide for website address for this form) to satisfy federal and state regulations. A non-therapeutic sterilization is any procedure or operation with the primary purpose of rendering an individual permanently incapable of reproduction and is neither:

A necessary part of the treatment of an existing illness or injury, nor medically indicated as an accompaniment of an operation of the female genitourinary tract.

The plan participant must be at least 21 years of age, mentally competent, and not institutionalized in a correctional, penal, rehabilitative or mental health facility. The plan participant MUST WAIT AT LEAST 30 DAYS after signing the consent form to have the operation, except in the instance of premature delivery or emergency abdominal surgery that takes place at least 72 hours after the consent is obtained.

The consent for sterilization cannot be obtained while the plan participant is in the hospital for labor, childbirth, abortion, or under the influence of alcohol or other substances that affect the plan participant’s state of awareness. The consent is effective for 180 days from the date the consent form is signed by the plan participant. A new consent form is required if 180 days have passed before the surgery is provided.

Therapy Service - Physical, Respiratory,Occupational and Speech Therapies

When medically necessary, physical therapy, occupational therapy, respiratory therapy, and speech language-pathology (speech therapy) are provided to members from birth through age 20, in accordance with the Medicaid Therapy Handbook. Adults 21 and older are covered for speech therapy pertaining to the provision of augmentative and alternative communication systems.

Occupational therapy – Does not have limitation.

Physical and respiratory therapy – Annual dollar limit for these services.

Transplants Members should call their health plan Case Management department for guidance andinformation on transplant benefit coverage.





Transportation Transportation is covered for some medical care if the enrollee has no other way to get to the doctor, they live in an area with no public transport, and/or cannot use public transport due to a health condition or disability.

Vision Services Benefits are limited to a visual examination; fitting, dispensing and adjustment ofeyeglasses. Follow-up examinations by an optometrist.

Limited to no more than two pairs of glasses per member, per year or a pair ofspecialized contact lenses per year, if medically necessary. Contact lenses only covered for the following diagnoses:

• Keratoconous – contact lens for unilateral aphakia or bilateral aphakia but not psudo aphakia unless they have one or more keratoconous.

• Irregular Cornea/Irregular Stigmatism – significant symphomatic aniso metropia visual service coverage with limitation in the handbook.

• Refractive error that are plus or minus 7.00D and over any meridian, either/eye spectacle prescription.




Expanded Benefit Limitations Prior AuthorizationRequired

Expanded Primary Care Visits for Non-pregnant Adults

No. No.

Expanded Home Health Visits for Non-pregnant Adults

Provides for one additional home health visit a day up to a total of four a day.

No.

Expanded Physician Home Visits Up to four additional visits per month for Comprehensive LTC members only.

No.

Expanded Prenatal/Perinatal Visits None. No.

Expanded Outpatient Hospital Services Pneumonia vaccine. No.

Over-the-Counter Medication/Supplies Provides up to $25 of OTC medicines/products per MMA household per month.

No.

Expanded Adult Dental Services MMA members must be 21 or older and must use in-network care providers. Prophylaxis cleanings are limited to two per year.

No.

Waived Copayment None; Care providers may not charge enrollee’s copayments based on the fact that copayments are waived under the expanded benefits..

No.

Expanded Vision Services Expanded adult vision services are available to all eligibility populations age 21 and older. UnitedHealthcare Community Plan provides up to two vision exams and two pairs of glasses annually. The additional vision exams and glasses includes up to one vision exam and one pair of glasses every two years covered under the required benefits.

No.

Expanded Adult Hearing Services We provide up to one additional fitting and hearing aidevery three years.

No.

Newborn Elective Circumcisions UnitedHealthcare Community Plan covers elective circumcision during the first 12 weeks of life.

No.

Pneumonia Vaccine UnitedHealthcare Community Plan covers the influenza vaccine for all eligible populations following evidence-based clinical guidelines.

No.

Influenza Vaccine UnitedHealthcare Community Plan covers the influenza vaccine for all eligible populations following evidence-based clinical guidelines.

No.

Shingles Vaccine UnitedHealthcare Community Plan covers the shingles vaccine for all eligible populations following evidence-based clinical guidelines.

No.

Post-Discharge Meals Ten home-delivered meals post discharge. Eligibility limited to SSI (no Medicare), dual eligible, HIV, HIV dual eligible members only.

Yes.

Expanded Benefits





Pregnancy-related RequirementsYou must provide the most appropriate and highest level of quality care for pregnant members. Required care includes the following:

1. Florida’s Healthy Start Prenatal Risk Screening – We offer Florida’s Healthy Start prenatal risk screening to each pregnant member as part of her first prenatal visit, as required by Section 383.14, F.S. and 64C-7.009, F.A.C.

a. Use the DOH prenatal risk form (DH Form 3134), which can be obtained from the local CHD.

b. Retain a copy of the completed screening instrument in the member’s medical record and provide a copy to the member.

c. Submit the completed DH Form 3134 to the CHD in the county in which the prenatal screen was completed within 10 business days of completion.

d. Collaborate with the Healthy Start care coordinator within the member’s county of residence to assure risk appropriate care is delivered.

2. Florida’s Healthy Start Infant (Postnatal) Risk Screening Instrument – You must complete the Florida Healthy Start Infant (Postnatal) Risk Screening Instrument (DH Form 3135) with the Certificate of Live Birth and transmit the documents to the CHD in the county in which the infant was born within 10 business days of completion. You must retain a copy of the completed DH Form 3135 in the member’s medical record and provide a copy to the member.

3. Pregnant enrollees or infants who do not score high enough to be eligible for Healthy Start care coordination may be referred for services, regardless of their score on the Healthy Start risk screen, in the following ways:

a. If the referral is made at the same time the Healthy Start risk screen is administered, you may indicate on the risk screening form the member or infant is invited to participate based on factors other than score.

b. If the determination is made subsequent to risk screening, you may refer the member or infant directly to the Healthy Start care coordinator based on assessment of actual or potential factors associated with high risk, such as HIV, hepatitis B, substance abuse or domestic violence.

4. Refer all pregnant women, breast-feeding and postpartum women, infants and children up to age 5 to the local WIC office.

a. You must provide the following:i. A completed Florida WIC program Medical Referral

Form with the infant’s current height or length and weight (taken within 60 Calendar Days of the WIC appointment).

ii. Hemoglobin or hematocrit.

iii. Any identified medical/nutritional problems.

b. For subsequent WIC certifications, you must coordinate with the local WIC office to provide the referral data from the most recent CHCUP.

c. Each time you complete a WIC Referral Form, you should give a copy of the WIC Referral Form to the Enrollee and retain a copy in the Enrollee’s Medical Record.

5. Provide all women of childbearing age HIV counseling and offer them HIV testing. See Chapter 381,F.S.

a. Offer all pregnant women counseling and HIV testing at the initial prenatal care visit and again at 28 to 32 weeks, in accordance with Florida law.

b. Attempt to obtain a signed objection if a pregnant woman declines an HIV test. See Section 384.31, F.S. and 64D-3.019,F.A.C.

c. Help ensure all pregnant women infected with HIV are counseled about and offered the latest antiretroviral regimen recommended by the U.S. Department of Health & Human Services (U.S. Department of Health & Human Services, Public Health Service Task Force Report entitled Recommendations for the Use of Antiretroviral Drugs in Pregnant HIV-1 Infected Women for Maternal Health and Interventions to Reduce Perinatal HIV-1 Transmission in the United States. To receive a copy of the Guidelines, contact the DOH, Bureau of HIV/AIDS at 850-245-4334, or go to aidsinfo.nih.gov/guidelines/).

6. Screen all pregnant women receiving prenatal care for the Hepatitis B surface antigen (HBsAg) during the first prenatal visit.

a. Perform a second HBsAg test between 28 and 32 weeks of pregnancy for all pregnant women who tested negative at the first prenatal visit and are considered high-risk for Hepatitis B infection. This test shall be performed at the same time the other routine prenatal screening is ordered.

b. All HBsAg-positive women shall be reported to the local CHD and to Healthy Start, regardless of their Healthy Start screening score.


https://aidsinfo.nih.gov/guidelines/




7. Help ensure infants born to HBsAg-positive women receive Hepatitis B Immune Globulin (HBIG) and the Hepatitis B vaccine once they are physiologically stable, preferably within 12 hours of birth, and complete the Hepatitis B Maxine series according to the recommended vaccine schedule established by the Recommended Childhood Immunization Schedule for the United States.

a. You must test infants born to HBsAg- positive members for HBsAg and Hepatitis B surface antibodies (anti-HBs) six months after the completion of the vaccine series to monitor the success or failure of the therapy.

b. Report to the local CHD a positive HBsAg result in any child aged 24 months or less within 24 hours of receipt of the positive test results.

c. Infants born to members who are HBsAg-positive should be referred to Healthy Start regardless of their Healthy Start screening score.

8. You must report to the Perinatal Hepatitis B Prevention Coordinator at the local CHD all prenatal or postpartum members who test HBsAg-positive. You should also report said members’ infants and contacts to the Perinatal Hepatitis B Prevention Coordinator at the local CHD.

a. You must report the following information – name, date of birth, race, ethnicity, address, infants, contacts, laboratory test performed, date the sample was collected, the due date or EDC, whether or not the member received prenatal care, and immunization dates for infants and contacts.

b. You should use the Perinatal Hepatitis B Case and Contact Report (DH Form 1876) for reporting purposes.

9. You must maintain all documentation of Healthy Start screenings, assessments, findings and referrals in the members’ medical records, and you must provide the health plan quick access to them per your contract.

10. Additional services which must be provided for pregnant members, include the following:

a. Prenatal Care –i. A pregnancy test and a nursing assessment

with referrals to a physician, PA or ARNP for comprehensive evaluation.

ii. Case Management through the gestational period according to the needs of the member.

iii. Any necessary referrals and follow-up.

iv. Return prenatal visits at least every four weeks until the 32nd week, every two weeks until the 36th week, and every week thereafter until delivery, unless the member’s condition requires more frequent visits.

v. Contact those members who fail to keep their prenatal appointments as soon as possible, and arrange for their continued prenatal care.

vi. Assist members in making delivery arrangements, if necessary.

vii. Screen all pregnant members for tobacco use and make available to the pregnant members smoking cessation counseling and appropriate treatment as needed.

b. Nutritional Assessment/Counseling – Supply nutritional assessment and counseling to all pregnant members.i. Help ensure the provision of safe and adequate

nutrition for infants by promoting breast-feeding and the use of breast milk substitutes.

ii. Offer a mid-level nutrition assessment.

iii. Provide individualized diet counseling and a nutrition care plan by a public health nutritionist, a nurse or physician following the nutrition assessment.

iv. Documentation of the nutrition care plan in the medical record by the person providing counseling.

c. Obstetrical Delivery – Use generally accepted and approved protocols for both low risk and high risk deliveries which reflect the highest standards of the medical profession, including Healthy Start and prenatal screening.i. You must document preterm delivery risk

assessments in the member’s medical record by the 28th week.

ii. If you determine the member’s pregnancy is high risk, help ensure obstetrical care during labor and delivery includes preparation by all attendants for symptomatic evaluation and the member progresses through the final stages of labor and immediate postpartum care.

d. Newborn Care – Provide the highest level of care for the newborn beginning immediately after birth. The health plan shall inform hospital, the newborn’s attending and consulting physician the newborn is a member only if the health plan verified the newborn has an unborn record on the system awaiting activation. Such level of care shall include, but not be limited to, the following:





i. Instilling of prophylactic eye medications into each eye of the newborn.

ii. When the mother is Rh negative, the securing of a cord blood sample for type Rh determination and direct Coombs test.

iii. Weighing and measuring of the newborn.

iv. Inspecting the newborn for abnormalities and/or complications.

v. Administering of one half milligram of vitamin K.

vi. APGAR scoring.

vii. Any other necessary and immediate need for referral in consultation from a specialty physician, such as the Healthy Start (postnatal) infant screen.

viii. Any necessary newborn and infant hearing screenings (to be conducted by a licensed audiologist pursuant to Chapter 468, F.S., a physician licensed under Chapters 458 or 459, F.S., or an individual who has completed documented training specifically for newborn hearing screenings and who is directly or indirectly supervised by a licensed physician or a licensed audiologist).

e. Postpartum Care – You must:i. Provide a postpartum examination for the member

within six weeks after delivery.

ii. Supply voluntary family planning, including a discussion of all contraception methods.

iii. Help ensure eligible newborns are enrolled with the health plan and continuing care of the newborn be provided through the CHCUP program component.

Other BenefitsSmoking Cessation: Our members can obtain smoking cessation products through their pharmacy benefits. Please encourage members to use them if needed.

Domestic Violence: Call the Florida DomesticViolence Hotline at 800-500-1119 anytime, 24 hours a day, and seven days a week. Members can also get substance abuse help from: Alcoholics Anonymous at: 800-859-1767, aa.org or Narcotics Anonymous at: na.org.

Children’s Medical Services (CMS)Children with special health care needs expected to last 12 months or longer (i.e. spina bifida, leukemia, diabetes, severe behavioral health conditions) may be eligible for a Florida program that provides a network of specialty care doctors and intensive case management. This program is available for children ages birth through 19 years and medical eligibility is determined by a CMS nurse or case manager.

Should you identify a patient with chronic issues and that may benefit from a plan referral to CMS, please contact our Health Services at 800-825-8792 Ext. 84562 and Ext. 84436 or contact CMS directly at 850-245-4200 or cms-kids.com.


http://www.aa.org/

http://www.na.org/

http://www.cms-kids.com/

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Chapter 8: Online Care Provider Resources:Plan and State Forms are available online at UHCCommunityPlan.com

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Practice Matters: TX - Summer 2013 Customer Service Center: 888-362-336837 Florida Provider Manual www.uhccommunityplan.com

37AHCA-B-N-NAN 4/14-12/18-267

Confidential and ProprietaryCopyrighted by UnitedHealthcare 2016

Chapter7:OnlineProviderResources: Plan and State Forms are available online at UHCCommunityPlan.com






Chapter7:OnlineProviderResourcesChapter 8: Online Care Provider Resources






STATE OF FLORIDA ABORTION CERTIFICATION FORM

SECTION I

1. Recipient’s Name:

2. Address:

3. Medicaid Identification Number:

SECTION II

4. On the basis of my professional judgment, I have performed an abortion on the above namedrecipient for the following reason:

■ The woman suffers from a physical disorder, physical injury, or physical illness, including a life- endangering physical condition caused or arising from the pregnancy itself that would placethe woman in danger of death unless an abortion is performed.

■ Based on all the information available to me, I concluded that this pregnancy was the result ofan act of rape.

■ Based on all the information available to me, I concluded that this pregnancy was the result ofan act of incest.

I have documented in the patient’s medical record the reason for performing the abortion; and I understand that Medicaid reimbursement to me for this abortion is subject to recoupment if medical record documentation does not reflect the reason for the abortion as checked above.

5. 6. Physician’s Name Physician’s Signature

7. 8. Physician’s Medicaid Provider Number Date of Signature







AMERICHOICE – OBSTETRICAL RISK ASSESSMENT FORM UnitedHealthcare – Obstetrical Risk Assessment Form

Name: Phone: ( ) D.O.B

Most Current Address:

Member ID#: Date of Initial Prenatal Visit:

Gravida Para LMP EDC Blood Type

CURRENT PREGNANCY Current Pre-Term Labor Yes ■ No ■ < 18 yrs. Or > 35 yrs. Yes ■ No ■

Uterine/Cervical Abnormalities Yes ■ No ■ Premature or Prolonged Rupture of Membranes Yes ■ No ■Multiple Gestation Yes ■ No ■ Pregnancy Induced Hypertension Yes ■ No ■Gestational Diabetes Yes ■ No ■ Fetal Anomalies Yes ■ No ■

Psycho/Social Risk Yes ■ No ■ I.U.G.R. Yes ■ No ■Nutritional Risk Yes ■ No ■ HIV Tested?

HIV Counseling Done? Yes Yes

■

■ No No

■

■

PREVIOUS PREGNANCIES Previous Pre-Term Labor Wks Yes ■ No ■

Previous Pre-Term Delivery Wks Yes ■ No ■ Placenta Previa Yes ■ No ■Incompetent Cervix Previous Spontaneous Ab Wks

Yes Yes

■

■ No No

■

■ Prior C/Section—Year Why?

Previous Fetal Demise Wks Yes ■ No ■ Ectopic Pregnancy Previous Uterine Surgery Yes ■ No ■ Date of last birth Previous Birth weight<2500 gms. Yes ■ No ■

Yes ■ No ■

MEDICAL CONDITIONS – MEDICATIONS Yes ■ No ■

Chronic Hypertension Yes ■ No ■ Diabetes Mellitus Yes ■ No ■Renal Disease Yes ■ No ■ Cardiac Disease Yes ■ No ■Respiratory Conditions Yes ■ No ■ Neurologic Disorders Yes ■ No ■Mental Illness Yes ■ No ■ Asthma Yes ■ No ■

List Medications S.T.D. Status Past/Present Domestic Violence? Yes ■ No ■ Other

SOCIAL: Years of Schooling Completed Has the mother ever been homeless or without permanent housing? Yes ■ No ■

Is mother a current user of tobacco (10 cigarettes per day) Yes ■ No ■ Has mother used alcohol during pregnancy? Yes ■ No ■

Has mother used marijuana during pregnancy? Yes ■ No ■

Was WIC Referral Issued? Yes ■ No ■

Healthy Start? Yes ■ No ■

Referral is from a pediatrician Yes ■ No ■

Name Telephone #

Comments

Expected Place of Delivery:_________________________________________________________________________________

Physician/Provider Signature:_______________________________________________________________________________

Provider Name/Facility: Contact Nurse:

Date: Phone #: Fax:

Note: When the physician signs this Risk Assessment, he/she authorizes a well mother/baby postpartum visit, as per UnitedHealthcare guidelines.

Healthy Start Risk screening Instrument should be completed at the first prenatal visit on all pregnant women. W.I.C. may be available and should be offered to all pregnant women. Both programs are mandated by AHCA and require documentation of these programs as part of the member’s medical record. UnitedHealthcare of Florida requires that these programs be offered to all Medicaid members and copies of the completed forms should be forwarded to the plan at fax # 414-921-4605/800- 843-7135 or 888-803-9234, Attn: OB Case Manager. Please advise the member to contact the Florida Department of Children and Families to notify them of her pregnancy and obtain an “Unborn ID Number” and then notify customer service with this number.


Note: When the physician signs this Risk Assessment, they authorize a well mother/baby postpartum visit, as perUnitedHealthcare guidelines.

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