unitedhealthcare community plan of new jersey · pca-1-002644-07202016-08052016 proprietary...

UnitedHealthcare Community Plan of New Jersey Provider Orientation: Adult and Pediatric Day Care

Overview

• Introduction to UnitedHealthcare Community Plan • Adult and Pediatric Medical Day Care • Prior Authorization • Utilization Management • Critical Incident Reporting • Unable to Contact/Open Care Opportunities • Claims and Appeals • Claims Billing Tips • Credentialing, Re-Credentialing, Criminal Background Checks and

Demographic Changes • Provider Advocates and Other Contacts • Link Training • Important Provider Training Concepts • Questions

2 PCA-1-002644-07202016-08052016 Proprietary Information of UnitedHealth Group. Do not distribute or reproduce without express permission of UnitedHealth Group.

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Introduction to UnitedHealthcare Community Plan

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• Serves more than 2.6 million members of government health care programs in 24 states and the District of Columbia.

• Licensed in all 21 counties for NJ FamilyCare and Medicaid

• Pioneered 24/7 bilingual Member Services Helpline

• Emphasizes preventive health and education

• Developed the Personal Care Model

UnitedHealthcare Community Plan

PCA-1-002644-07202016-08052016 Proprietary Information of UnitedHealth Group. Do not distribute or reproduce without express permission of UnitedHealth Group.

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Personal Care Model

The Personal Care Model is a holistic approach to care for members who have chronic conditions and complex needs. Benefits include:

• Focused outreach • Comprehensive needs assessment including clinical and socio-

economic needs • Comprehensive treatment plan • Health education activities • Member evaluation that stratifies members according to diagnosis

and severity of the member’s medical and psychosocial conditions Member Referrals To refer a member for Personal Care Model services, please call 877-704-8871.


Member ID Cards

To verify member eligibility, please call 888-702-2168 or go to UnitedHealthcareOnline.com.


Care Provider Website

UHCCommunityPlan.com provides a convenient way to work with us. Using this website, you can: • Review benefits and coverage limits • Submit claims • Check claim status • Access capitation rosters • View your panel roster • Access remittance advice and review recoveries • Review your preventive health measures report • Submit demographic profile changes


HIPAA Guidelines and PHI

Care provider are expected to follow Health Insurance Portability and Accountability Act (HIPAA) guidelines, which were developed to: • Improve the portability and continuity of health benefits • Help ensure greater accountability for health care fraud • Standardize both medical and non-medical codes across the health care

industry

Among other types of acceptable disclosures, providers are permitted to disclose protected health information (PHI) to health plans for the purpose of quality assurance, quality improvement, and accreditation activities. No authorization is needed from the patient when both the care provider and health plan had a relationship with the patient and the information relates to that relationship.


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Adult and Pediatric Medical Day Care

Adult Medical Day Care ‒ Ages 18 and Older

• Medical day care services are limited to five days per week • Include transportation • Minimum five hours per day • Maximum 12 hours per day

• Services currently in place will continue until the member has been assessed by UnitedHealthcare Community Plan of New Jersey using criteria provided by the state

• To request continuation of services, please call 800-262-0305. • Once the member is assessed, services will be approved or denied

as indicated. • Care providers will be notified of denial decisions by phone and in

writing.


Pediatric Medical Day Care ‒ Ages 6 and Younger

• Medical day care services are limited to five days per week. • Include physical therapy, occupational therapy, speech therapy and

transportation • Minimum six hours per day

• Services currently in place will continue until the member has been assessed by UnitedHealthcare Community Plan of New Jersey using criteria provided by the state.

• To request continuation of services, please call 800-262-0305. • Once the member is assessed, services will be approved or denied

as indicated. • Care providers will be notified of denial decisions by phone and in

writing.


Medical Day Care Service Codes

Service Description New Jersey State Medicaid Fee-for-

Service Codes

UnitedHealthcare Community Plan of New Jersey Codes for Participating and

Non-Participating Care Providers

Code Unit of Measure

Code Unit of Measure

Adult day health services S5102 visit S5102 visit

Pediatric medical day care facility visit for a technology-dependent child

Z1863 visit T1024 visit

Pediatric medical day care facility visit for a medically complex child

Z1864 visit T1024 visit


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Prior Authorization Requirements

Prior Authorization Requirements

Prior authorization is required for all Long-Term Care (LTC) and Managed Long Term Services and Supports (MLTSS) services ‒ regardless of whether the care provider participates with UnitedHealthcare Community Plan of New Jersey. Please view the complete prior authorization list for Medicaid and LTC/MLTSS at UHCCommunityPlan.com under Billing & Reference Guides. To request prior authorization, please call 800-262-0305. All members receiving MLTSS services will receive a face-to-face assessment for evaluation of needs.


When New Authorization Is Required

Here are examples to illustrate when a new prior authorization must be requested after a care provider receives authorization to provide services for a member: • During the authorized timeframe the member transfers to a new agency, then

transfers back to the original agency: The agency must obtain a new authorization to resume services for the member.

• The member goes on vacation, then returns to the same agency: The agency does not need a new authorization to resume services, but must notify us that the member is on vacation to avoid an “unable to contact” issue resulting in a critical incident. The care provider should not bill for services while the member is on vacation.

• The member enters a hospital or skilled nursing facility for less than 30 days, then returns home to the same agency: The agency does not need a new authorization to resume services, but must notify us. The member may require a face-to-face assessment.

• The member enters a hospital or skilled nursing facility for 30 days or more, then returns home to the same agency: The agency must get a new authorization for services. The agency can continue to service the member at the previously approved hours until a face-to-face assessment is completed.


Utilization Management

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Utilization Management Appeals

Claim appeals based on UnitedHealthcare Community Plan’s adverse determination regarding medical necessity, experimental or investigational services should be processed under the Utilization Management appeal process within 90 days from receipt of the original Utilization Management denial letter. Stage 1 Utilization Management appeals should include: • Copy of the original Utilization Management denial letter • Copy of the member’s medical record • Additional information that supports the need for medical necessity on the

denied date of services. Utilization Management appeals should be mailed to:

UnitedHealthcare Community Plan Attention: Utilization Management Appeals Coordinator P.O. Box 31364 Salt Lake City, UT 84131


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Critical Incident Reporting

What Is a Critical Incident? • A critical incident is any event or situation that has harmed or has the

potential to harm a member, such as: o Abuse/neglect o Exploitation o Serious injury o Missing person o Medical errors o Suicide attempt o Any other incident that may cause harm to the member

• For a full list of reportable critical incidents required by the state, go to UHCCommunityPlan.com > For Health Care Professionals > Select Your State = New Jersey > Provider Administrative Manual.

• Critical incident reporting is important to help ensure the health and safety of our members.

• Any critical incidents involving one of our members must be reported within 24 hours of discovery of the incident.

o May be submitted verbally, but must be followed up with a written report within 48 hours.


Reporting Critical Incidents to UnitedHealthcare Community Plan If a critical incident is discovered, you are required to take steps within one business day to prevent further harm to all members and respond to any of their emergency needs. Then, report the critical incident to the state agency, if appropriate, BEFORE reporting it to UnitedHealthcare Community Plan of New Jersey. • All critical incidents should be reported to UnitedHealthcare Community Plan of

New Jersey. o To report a critical incident to UnitedHealthcare Community Plan of New Jersey, please call

888-702-2168 or complete the Critical Incident Reporting Form and fax it to 855-216-6408 within 24 hours of discovery of the incident. The form is available at UHCCommunityPlan.com > For Health Care Professionals > Select Your State = New Jersey > Provider Forms.

• Any verbal notification must be followed by a written report describing the incident and what the care provider did to resolve it. There is no required format for the report. Fax the report to 855-216-6408.

• Participating providers must conduct an internal critical incident investigation and submit a written report within 30 calendar days after the date of the incident advising of the root cause and what steps were taken to prevent such an incident from reoccurring. There is no required format for the report. Fax the report to 855-216-6408.


Reporting Critical Incidents to the State

Immediately report to the appropriate agency including 911, any knowledge of or reasonable suspicion of:

• Report abuse, neglect or exploitation of adults to New Jersey Adult

Protective Services at 800-792-8820. • Report abuse, neglect or exploitation of members residing in nursing

homes to the New Jersey Office of the Ombudsman for the Institutionalized Elderly at 877-582-6995.

• Report brutality, abuse or neglect of children to the Division of Child Protection and Permanency (formerly the Division of Youth and family Services) at 877-652-2873.

• Report abuse, neglect or exploitation of children residing in pediatric nursing facilities to the Division of Child Protection and Permanency at 877-652-2873.


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Unable to Contact and Open Care Opportunities

Unable to Contact

If an LTC/MLTSS member is absent, without notification, from any program or service offered and the LTC/MLTSS care provider is unable to identify their location using the contact information available, the member is considered “unable to contact”. LTC/MLTSS care providers must take the following steps to investigate and report “unable to contact” events: 1.Immediately contact the member using contact information on file. 2.If no response, immediately contact the member’s emergency contact. 3.If unsuccessful, immediately notify the member’s MLTSS care manager.


Open Care Opportunities

For LTC/MLTSS members, an open care opportunity is the difference between the number of hours or services scheduled in a member’s plan of care and the hours or services that are actually delivered to that member. • If there is an open care opportunity, the care provider must contact

the member immediately to acknowledge and explain the open care opportunity and provide an alternate plan to resolve it. The care provider must also notify the member’s LTC/MLTSS care manager about any open care opportunities.

• When care providers know about an upcoming open care opportunity, they must contact the member before the scheduled service to advise them that the regular caregiver will be unavailable. The member may choose to receive the service from a substitute caregiver, at an alternative time from the regular caregiver or from an alternate caregiver from the member’s informal support system.


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Claims Submission and Appeals

Electronic Claims Submission

Electronic Submission (Use Payer ID 86047) Electronic Data Interchange (EDI) Support Services provides support for all electronic transactions involving claims, electronic remittances and eligibility. For more information, please contact EDI Support at 800-210-8315 or [email protected]. If you do not have office software and would like to submit claims directly at no cost, submission can be done through Office Ally ‒ a secure, HIPAA-compliant solution that offers: • Direct connectivity • No installation, transaction or support fees for care providers • Ease of use for both batch and single claims • 24-hour customer support You can enroll at OfficeAlly.com. To learn more, please contact 866-575-4120 or [email protected].


Electronic Payments & Statements (EPS) With EPS, you receive electronic funds transfer (EFT) for claim payments, plus your explanations of benefits (EOBs) are delivered online. Regardless of your practice size or claims volume, EPS can provide faster payment, easier reconciliation and less paper. • Users receive payments and EOBs five to seven days faster than with paper. • View payments or EOBs for the last three months, or search a 13-month archive. • Claim adjustments will not be deducted from your account.

To enroll online, please go to myservices.optumhealthpaymentservices.com. Here’s what you’ll need: • Bank account information for direct deposit • A voided check or a bank letter to verify bank account information • A copy of your practice’s W-9 form

You can download the EPS Paper Enrollment Form at UnitedHealthcareOnline.com > Claims & Payments > Electronic Payments & Statements (EPS) and mail or fax it to the contact listed in the form instructions.

If you plan to route payments to accounts based on your national provider identifier (NPI), please call for enrollment assistance.

If you have questions or need help with EPS enrollment, please call 866-842-3278, option 5.


835 Electronic Remittance Advice

If you receive 835 Electronic Remittance Advice (ERA) through a vendor, please ask them to enroll you for the 835 through OptumInsight. Once we receive the request from your clearinghouse or EDI vendor, it takes about 30 days to set up delivery of the 835 ERA.


Claim Submission – Coordination of Benefits

New Jersey FamilyCare Managed Care Contract Guidance: Coordination of Benefits for Medicaid Managed Care Members, effective January 2016 This guidance covers coordination of benefits/explanation of benefits (EOB) for Medicaid Managed Care members with Medicare Parts A and B, Supplemental or Medicare Advantage coverage and/or members with Third Party Liability (TPL) coverage. 1. Medicaid Managed Care members with Medicare Parts A and B who have Medicare

Supplemental do not require EOBs or denial for the following Medicaid services: A. State plan services:

• Medical Day Care • Personal Care Assistance - including Personal Preference Program

B. MLTSS Waiver services: • Adult family care • Assisted living • Chore service • Community transition services • Home-based supportive care • Home-delivered meals • Medical day care

• Non-medical transport • Nursing home custodial care • Personal care assistance, including Personal Preference Program • Residential modifications • Respite • Social day care • Vehicle modifications


Claim Submission – Coordination of Benefits; continued

2. The Managed Care Organization will follow the Exceptions to the Cost Avoidance Rule outlined in the New Jersey FamilyCare contract, effective January 2015 (Article 8.7 F 2,3) for the specified State Plan and MLTSS Waiver Services for Medicaid Managed Care members with a Medicare Part A and Part B who also have a Medicare Advantage Plan and/or TPL.

8.7 F: Exceptions to the Cost Avoidance Rule:

• If the Contractor knows that the third party will neither pay for nor provide the covered service, and the service is medically necessary, the Contractor shall neither deny payment for the service nor require a written denial from the third party.

• If the Contractor does not know whether a particular service is covered by the third party, and the service is medically necessary, the Contractor shall contact the third party and determine whether or not such service is covered rather than requiring the enrollee to do so. Further, the Contractor shall require the provider or subcontractor to bill the third party if coverage is available.

A. State plan services* B. MLTSS Waiver services*

*A full listing of these services can be found on slide #37


Claim Submission – Coordination of Benefits; continued

3. For all other Medicaid State Plan and Waivers services included in New Jersey

FamilyCare member’s benefit package an EOB is required. • If you receive an EOB indicating that the service is not covered by the primary insurer,

the NJ FamilyCare Managed Care Organization will pay for the service as the primary payer. A new EOB should not be required for subsequent claims during the calendar year for the same payer, care provider, and member and service code.

• Services paid by a third party carrier may become a non-paid service if the member’s benefits are exhausted. If this happens, the care provider should submit an EOB stating the benefit is exhausted before the managed care organization pays for the service.


How Dual Eligible Special Needs Plans (DSNP) Claims Process

• If the service provided is covered by Medicare, the normal coordination of benefits occurs, as noted in the previous slides.

• The claim will process against the member’s DSNP ID then automatically move to the member’s Medicaid ID and complete processing.

• You will see two claims on your EOB for the service; one where it processed under the DSNP ID, and one where it processed under the Medicaid ID.

• If the service provided is not a covered service for Medicare, the claim

processes against the member’s DNSP ID and denies as “not a covered service”, then automatically moves to the member’s Medicaid ID and completes processing. • You will see two claims on your EOB for the service, one where it processed

under the DSNP ID and one where it processed under the Medicaid ID.


Claim Payment Appeals Process

Please follow the claim payment appeals process to resolve billing, payment or other administrative disputes such as:

• Lost or incomplete claim forms or electronic submissions • Requests for additional explanation as to services or treatment

rendered by a care provider • Inappropriate or unapproved services initiated by care providers • Any other reason for billing disputes

Claim payment disputes do not require any action by the member.


Claims Payment Appeals Submission ‒ Informal Appeals

Please submit the Paper Claim Reconsideration Form, available at UnitedHealthcareOnline.com > Tools & Resources > Forms, for the following claim appeals only: • Previously denied for additional information to process claim • Resubmission as a corrected claim • Resubmission with prior authorization information • Resubmission because it was a bundled claim • Previously denied/closed as exceeding timely filing

Please submit the form with a copy of the claim in question and any supporting documentation within 90 days from receipt of the EOB/provider remittance advice (PRA) to: UnitedHealthcare Community Plan

Attention: Claim Administrative Appeals P.O. Box 5250 Kingston, NY 12402-5250

You can also submit claim appeals at UnitedHealthcareOnline.com or by calling 888-702-2168.

Submission of an informal appeal does not replace the submission of a formal claim payment appeal.


Claims Payment Appeals Submission ‒ Formal Appeals

Formal appeals must be submitted to UnitedHealthcare Community Plan using the NJ Provider Appeal Form available at UnitedHealthcareOnline.com > Tools & Resources > Forms. • If a care provider submits a claim payment appeal using this form within

90 days following receipt of the EOB/PRA and we uphold the claim payment denial, the care provider has the right to file an external claims arbitration request using MAXIMUS, the state’s arbitration organization.

• If a care provider does not submit the original claim payment appeal on the State’s HCAPPA form, the care provider does not have the right to a claims arbitration. However, the appeal will be processed by UnitedHealthcare Community Plan of New Jersey as an informal claim payment appeal.

• The HCAPPA form can be found on the State’s website. • If we uphold a claim payment denial on an informal claim payment

appeal, there is no second level of appeal and claim payment decisions will be final.

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Claims Billing Tips

Sample: Incorrect Medical Day Care Claim

The following example of a medical day care claim has submission errors.

The date range is listed for multiple dates of service.

The number of units billed exceeds one unit. In addition, the number of units does not match the number of days represented in the date range

billed on the line.


Sample: Correct Medical Day Care Claim The following example of a medical day care claim is correct.

The date range should be for one date of service per

line.

Each line should be billed with one unit to represent one date of

service.

Place of Service should be 99.

Healthcare Common Procedure Coding System (HCPCS) code billed would either be the adult medical day care code or the

pediatric medical day care code.

Provider should bill their billed charges for each

date of service.


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Credentialing, Criminal Background Checks and Demographic Changes

Credentialing

UnitedHealthcare Community Plan of New Jersey Credentialing Requirements: 1. Complete Component Application

a) Component Attestation section must be signed and dated 2. Complete Demographic Update Information Sheet 3. Provide copy of declaration sheet and/or certificate of insurance for

current professional malpractice and comprehensive general liability insurance policies

4. Provide W-9 Form 5. Provide current and/or renewed license from the Division of Consumer

Affairs 6. Provide current Medicaid and/or Medicare numbers 7. Provide certificate of accreditation from the following, if applicable:

• Community Health Accreditation Program • Commission on Accreditation for Home Care, Inc. • The Joint Commission • National Association for Home Care/Home Care University

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Re-Credentialing

UnitedHealthcare Community Plan of New Jersey Re-Credentialing Requirements: 1. Review and update the pre-filled Component Application with any

applicable changes. 2. Sign and date the Component Attestation page. 3. Return the application with the following current documents to the

address or fax number listed on the cover letter. • Copy of current state license from the Division of Consumer Affairs • Copy of certificates of accreditation, if applicable (e.g., Community

Health Accreditation Program) • Copy of declaration sheet and/or certificate of insurance for current

professional malpractice and comprehensive general liability insurance policies


Care Provider Disclosures

• Care providers must submit certain disclosure statements to participate with UnitedHealthcare Community Plan of New Jersey, as described in the state contract.

• UnitedHealthcare Community Plan of New Jersey collects and maintains these disclosures.

• To view the disclosures, please visit UHCCommunityPlan.com > For Health Care Professionals > Select your state – New Jersey > Provider Forms > Group Disclosure of Ownership and Control of Interest Form OR Individual Disclosure of Ownership and Control of Interest Form.


Criminal Background Checks

All employees and/or agents of a provider or subcontractor and all providers who provide direct care must have a criminal background check as required by federal and state law. All contracted care providers must conduct criminal background checks on all prospective employees or providers who have direct physical access to MLTSS members.


Demographic Changes

All demographic changes must be sent to UnitedHealthcare Community Plan of New Jersey using any of the following methods: Fax: 877-382-9298 Mail: UnitedHealthcare

Attn: Adrienne Collins P.O. Box 1276 Sharon Hill, PA 19079

Email: [email protected]


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Provider Advocates and Other Resources

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Your Provider Advocate

• Serves as your primary contact • Acts as a navigational specialist to help you deal with all areas of

UnitedHealthcare Community Plan • Communicates with your practice about critical programs and processes

within UnitedHealthcare Community Plan • Specializes in issue resolution

Provider Advocate for adult and pediatric medical day care providers: Sharon Hopson Phone: 952-202-2964 Email: [email protected]


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Key Contact List

UnitedHealthcare Community Plan website (newsletters, bulletins, forms): UHCCommunityPlan.com UnitedHealthcare provider website (claims, eligibility): UnitedHealthcareOnline.com Provider Services for LTC: Call 888-702-2168 Prior Authorization/Intake for LTC: Call 800-262-0305 Health Services: Call 888-362-3368 or fax 800-766-2597 To identify a Care Manager for LTC: Call 800-645-9409 Member Services: Call 800-941-4647 (TTY:711); TTY/TDD call 800-852-7897 NurseLine: Call 888-433-1904 Demographic Changes: Fax 877-382-9298 Credentialing Center: Fax 877-620-3782 or email [email protected] Medications requiring prior authorization: Call 800-310-6826 or fax 866-940-7328 Prescription Solutions for pharmacy specialty injectables: Fax 800-853-3844


Link Training

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Link Overview

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* Based on ongoing usability studies using keystroke-level modeling when comparing Link to UnitedHealthcareOnline.com and Optum Cloud Dashboard.

• Link is your gateway to UnitedHealthcare's online tools. • It replaced Optum Cloud Dashboard. Link includes many of the same

applications as Optum Cloud Dashboard, but with a new interface that can help make your work measurably faster and easier.*

• Use Link to check member eligibility and benefits, manage claims and submit claim reconsideration requests.

• With Link, you can quickly move between UnitedHealthcare applications and websites, and even customize your screen to put your most common tasks just one click away.

• Later this year, we’ll introduce enhanced applications and additional features to help make your transactions with us even faster.


Presenter

Presentation Notes

Sign In to UnitedHealthcareOnline.com to Access Link


Presenter

Presentation Notes

UnitedHealthcareOnline.com is the entry point you use to access Link. You will need an Optum ID to sign in to Link and UnitedHealthcareOnline.com.

Use Your Optum ID

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If you can’t remember your Optum ID or password, click on Sign In, then Forgot Username or Forgot Password. If you don’t have an Optum ID yet, please register for one by clicking Register Now.


Presenter

Presentation Notes

Sign in using your Optum ID. CLICK Or, select “Forgot Username” or “Forgot Password” to recover your account information. If you don’t have an Optum ID yet, click “Register Now.” If you previously accessed Optum Cloud Dashboard, you already have an Optum ID. Please do not register for a new one.

What’s on Link?

Applications on Link include: • Eligibility & Benefits • Claims Management • Claims Reconsideration

Access other UnitedHealthcare websites: • UnitedHealthcareOnline.com • UHCWest.com • UHCCommunityPlan.com • And more


Presenter

Presentation Notes

The Link home page includes applications you can use to conduct business with us, and applications that take you to other UnitedHealthcare websites such as UnitedHealthcareOnline.com. You can use the Eligibility & Benefits, Claims Management and Claims Reconsideration applications to get the information you need for most UnitedHealthcare members and claims, without jumping between websites or calling Provider Services. These applications give you member and claim information for most UnitedHealthcare plans, including UnitedHealthcare Commercial, UnitedHealthcare Medicare Advantage and UnitedHealthcare Community Plan. Let’s review these applications in more detail.

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Eligibility & Benefits Application Use the Eligibility & Benefits application to check member eligibility and review detailed benefits information. You may also submit referrals, notifications and prior authorization requests using this application.

Features include: • Search for covered members. • View prior authorization/advance notification requirements, cost share

amounts and benefit coverage details. • Submit and check status of referrals. • View preventive care opportunities information for UnitedHealthcare

Medicare Solutions and UnitedHealthcare Community Plan members. • View detailed benefits information for multiple plans. • See coverage details and limits specific to each benefit plan. • Export or print data.


Presenter

Presentation Notes

Use the Eligibility & Benefits app to check member eligibility and review detailed benefits information, including prior authorization/advance notification requirements and cost share amounts. You can also see gaps in care for our Medicare Solutions members as well as submit prior authorizations, notifications and referrals. View detailed benefits information for multiple plans in a single application See benefits and coverage limits based on provider participation status Export or print data

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Claims Management Application With the Claims Management application, you can get the most up-to-date claims status and payment information quickly and conveniently. Claims processed within the last two years are available.

Features include: • Search for claim submissions and access claim summaries and details

for multiple UnitedHealthcare plans in a single application. • View payment information, remark codes and their descriptions. • Submit additional information requested on pended claims. • Submit appeals (only available in certain states). • View Explanations of Benefits (EOBs) and letters for UnitedHealthcare

Commercial benefit plans. • Select a claim for reconsideration. • Flag claims for future viewing.


Presenter

Presentation Notes

Let’s move on to the Claims Management application. You use the Claims Management application on Link to get the status of your claims quickly and easily. No need to call the provider service center or jump between websites to get information for UnitedHealthcare claims. You can see if when the claim was submitted, check the status, view processing details and payment summaries, and see remark codes. You can even submit more information for pended claims. In addition, you can flag claims so you can easily find them later. You can also export the data to a spreadsheet, or print it.

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Claims Reconsideration Application

Use the Claims Reconsideration application to quickly look up processed claims and submit paid or denied claims as reconsiderations with or without attachments. You will receive a ticket number and can check the status of your submission online.

Features include: • Search for paid or denied claims. • Receive instant printable confirmation of completed claim

reconsideration requests. • Search for a claim reconsideration request to check its status or view its

history. • Update previously submitted reconsideration requests. • If you selected a claim for reconsideration in the Claims Management

application, it will appear as a draft that can be completed and submitted in the Claims Reconsideration application.


Presenter

Presentation Notes

Next, let’s review the Claims Reconsideration app. You can either send claims over from the Claims Management or look up claims directly in this application. You can use this app to submit Claim Reconsiderations online and also check the status of your reconsiderations. You can also update and resubmit Reconsideration requests with additional information. And, you can view the history of all of your submitted reconsideration requests.

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Link Resources To learn more about Link, please visit the Link resources page at UnitedHealthcareOnline.com > Quick Links > Link: Learn More.


Presenter

Presentation Notes

To learn more about Link, please visit the Link resources page at UnitedHealthcareOnline.com > Quick Links > Learn More. There, you’ll find frequently asked questions, application overviews and other resources. We also encourage you to enroll in our free instructor-led webinars by clicking on Training Schedule.

Link Resources (cont.)


Presenter

Presentation Notes

You can also access Link reference materials by selecting the Quick Reference Guides application on the Link home page.

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Important Training Concepts

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Online Resources

Online resources are available to assist you with providing services to UnitedHealthcare Community Plan members, including the following topics: Cultural Competency - Resources for providing culturally competent care to a growing number of patients • UHCCommunityPlan.com > For Health Care Professionals > Select your

state – New Jersey > Cultural Competency Library Community Resources - Resources to assist you in providing care to diverse patient populations • UHCCommunityPlan.com > For Health Care Professionals > Select your

state – New Jersey > Provider Education > Managed Long-Term Care Services and Supports (MLTSS)


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Options Counseling Options Counseling is an interactive process where individuals receive guidance to make informed choices about long-term supports based on their assessed needs. • Directed by the UnitedHealthcare member or their authorized

representative • May include other people that the member chooses • Options counseling includes the following steps:

• Personal interview to discover strengths, values and preferences of the individual and the utilization of screenings for public programs.

• Facilitated decision support process that explores resources and service options to help the member weigh pros and cons

• Action steps geared toward a goal or a long term support plan, assistance in applying for and accessing support options when requested

• Quality assurance and follow-up to ensure supports and decisions are working


Options Counseling (cont.)

• For people of all income levels, but targeted for those with immediate concerns, such as:

• Those at greatest risk for institutionalization • Individuals looking to transition from long-term care facilities

• Helps ensure members are educated on the full range of LTSS and offered a choice of care (institutional/home- and community-based services) and option to choose MLTSS or Programs of All-Inclusive Care for the Elderly (PACE), if available.

Every UnitedHealthcare MLTSS Care Manager has passed the State’s Options Counseling training program.


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Thank You


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