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Nebraska 2015

Physician, Health Care Professional, Facility and Ancillary

UHCCommunityPlan.com

Welcome Kit

Doc#: PCA19546_20151223

Practice Matters: TX - Summer 2013 Customer Service Center: 888-362-3368Welcome to UnitedHealthcare Community Plan – NebraskaUnitedHealthcare Provider Welcome Kit of Nebraska 11/15

Dear Provider:

On behalf of UnitedHealthcare,® I’d like to welcome you as a participating provider in Nebraska’s UnitedHealthcare Community Plan Medicaid program. We are committed to working with you and your staff to achieve the best possible health outcomes for our members.

This welcome kit contains valuable information about important contacts, policies, procedures and services to help you conduct business with us as efficiently as possible.

You also can download the Nebraska Provider Administrative Guide on the Nebraska physicians’ website at UHCCommunityPlan.com > Health Professionals > Nebraska > Provider Information > Administrative Guide. This is a comprehensive reference source for the information you and your staff need regarding claims, benefits, prior authorization, medical management and other plan components.

If you are also a contracted provider for our UnitedHealthcare commercial and Medicare products, you can access more information on UnitedHealthcareOnline.com.

Again, we are pleased to add you to the list of participating providers delivering quality care to UnitedHealthcare Communty Plan members. If you have any questions about your participation with UnitedHealthcare Communty Plan, or need a printed copy of this welcome kit, please contact Provider Services at 866-331-2243.

Sincerely,

Kathy MallattPlan President

Welcome to UnitedHealthcare Community Plan

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• Chapter 1: Corporate Overview . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

• Chapter 2: Key Plan Benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2

• Chapter 3: Quick Reference Guide . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3

• Chapter 4: Local Health Plan Contact List . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6

• Chapter 5: Member Cards . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7

• Chapter 6: Provider Website . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8

• Chapter 7: Care Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15

• Chapter 8: Services that Require Prior Authorization . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16

• Chapter 9: Frequently Asked Questions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17

Table of Contents

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UnitedHealthcare Community Plan is a business unit of UnitedHealth Group.

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

Our Approach to Health Care The Patient-Centered Care Model (PCCM): Ensures that holistic member needs, including medical, behavioral and social/environmental needs, are addressed. The primary goal is to ensure the person receives the right care from the right providers in the right place and at the right time.

At a member level, this Care Model ultimately leads to the development of Patient-Centered Care, which leverages interdisciplinary teams and combines the resources of UnitedHealth Group with medical homes and other integrated care organizations to reduce costs and improve outcomes.

The PCCM seeks to empower members, providers and our community partners to improve care coordination and improve outcomes for individuals with the most complex conditions by providing: Market designated, field-based care management with integration of medical/behavioral/social/environmental Integrated care management team, including Registered Nurses (RN), behavioral health advocates (BHA) and community health workers (CHW).

The community health worker employs field-based interventions to locate and engage members, connecting them to their Primary Care Physician and coordinating appointments as necessary. The community health worker refers members to an RN or Behavioral Health Advocate for complex needs.

The community health worker works with the member to remove barriers to care, access community resources and ultimately improve the ability for the member to access care.

Focus on increasing engagement of the top 5 percent of higher risk members and/or individuals with chronic and/or complex illnesses.

The goal of the program is to:

• Reduce avoidable admissions and ER visits Measured byAdmit and ER rates

• Improve access to Primary Care Physician (PCP)Measured by PCP visits rates

• Identify and address Behavioral Health needs Measuredby Behavioral Clinician visit rates for those with primarybehavioral needs

• Improve access to pharmacy

• Identify and remove social and environmental barriers tocare

• Improve health outcomes

Specialty Care Managers include: Maternal and Child Health Care Managers, who follow pregnant women in the Healthy First Steps® program. A care manager coordinates the member’s care, including health education and outreach from the onset of pregnancy through the postpartum checkup; Care Managers for members that have qualifying conditions. Care Managers for members requiring Private Duty Nursing.

Chapter 1: Corporate Overview

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• Doctor visits

• Outpatient hospital services

• Well child visits and immunizations

• Adult physical exams and immunizations

• Circumcisions for all ages of males

• Sterilization for males – vasectomies with signed consent form

• Emergency care

• Inpatient hospital services

• Eye glasses and vision exams

• Hospice care; includes in Home Hospice and Short Stay Inpatient Hospice.

• Speech, physical, and occupational therapy

• Ambulance services

• Nursing care services

• Durable medical equipment

• Hearing exams

• Home health care

• Chiropractic care

• Additional Benefits

– Care Management

– Disease Management programs

– Comprehensive provider network

– Excellent customer service with local Physician Advocates and Hospital and Facility Advocates

– Timely claims processing

– Free In Office Telephonic Interpreter Services Contact Member Services at 800-641-1902 for assistance if language is other than English.

Chapter 2: Key Plan Benefits

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Our Claims ProcessTo help ensure prompt payment for services:

1. Review and copy both sides of the member’s UnitedHealthcare Community Plan ID card their State Medicaid ID card.

2. Notify Health Services of planned procedures and services on our Prior Authorization list.

3. Prepare a complete and accurate electronic or paper claim form (see ‘complete claims’ at right). Complete a CMS 1500 (formerly HCFA) or UB-04 form.

4. Submit claims electronically on UnitedHealthcareOnline.com.

Be sure to use our electronic payer ID number (87726) to submit claims to us. For more information, contact your vendor or our Electronic Data Interchange (EDI) unit at 800-210-8315.

If you do not have access to internet services, you can mail the completed claim to:

UnitedHealthcare Community Plan in NebraskaP.O. Box 31365Salt Lake City, UT 84131

Complete ClaimsA complete claim includes the following:

• Patient’s name, date of birth, address and ID number.

• Name, signature, address and phone number of physician or physician performing the service, as stated in your contract document.

• National Provider Identifier (NPI) number.

• Physician’s tax ID number.

• CPT-4 and HCPCS procedure codes with modifiers where appropriate.

• ICD-10 diagnostic codes.

• Revenue codes (UB-04 only).

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

• Referring physician’s name (if applicable).

• Information about other insurance coverage, including job-related, auto or accident information, if available.

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

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

• Attach a description of the procedure/service provided for claims submitted with unlisted medical or surgical CPT codes or experimental or reconstructive services (if applicable).

• EPSDT – correct referral indicator must be indicated. Indicators are: AV, S2, NU, ST.

• Include the exact NDC that appears on the product administered.

IMPORTANT NOTE: Claims must be submitted within your timely filing limit.

UnitedHealthcareOnline.com/Link ApplicationThis secure website allows providers to process the following transactions:

• Claims Management

• Claims Reconsideration

• Eligibility & Benefits

• Provider Data Management

• Reports

UHCCommunityPlan.comThis website allows providers to get updated provider information that includes:

• Provider newsletters.

• Provider administrative manual.

• Clinical practice guidelines.

• Provider bulletins.

• Reimbursement policies.

Provider Services (866-331-2243)Available from 7:00 a.m. to 5:00 p.m. CST, Monday through Friday. This is an automated system. Please have your Tax ID and NPI number ready. Call Provider Services to:

• Ask questions about benefits.

• Verify member eligibility.

• Check claim status.

Chapter 3: Quick Reference Guide

Practice Matters: TX - Summer 2013 Customer Service Center: 888-362-33684 UnitedHealthcare Provider Welcome Kit of Nebraska 09/15Welcome to UnitedHealthcare Community Plan - Nebraska

• Ask questions about your participation or notify us of demographic and practice changes.

• Request information regarding credentialing.

Prior Authorization Health Services For a complete and current list of prior authorizations, go to: UHCCommunityPlan.com/Provider Information/Prior Authorization or call 866-604-3267. Fax prior authorizations to 866-622-1428.

Prior Authorization RadiologyOutpatient Imaging Procedures - For a complete and current list of prior authorizations, go to: UHCCommunityPlan.com/Radiology Tab or call 866-889-8054.

Care Management/Disease Management (877-856-6351)

• Private Duty Nursing call 402-445-5546 or email to [email protected]

Nebraska Provider AdvocateWhen assistance is needed to answer a question or resolve an issue related to claims payment. [email protected]

Healthy First StepsHigh Risk OB Members 877-813-3417 or Fax 877-353-6913

Pharmacy Assistance (DME/Medical Supplies received at Pharmacy)Pharmacies must file claims to OPTUM RX. 877-305-8952 Ex: diabetic supply, breast pump, nebulizer, gauze, vaporizer . Prescription medication covered by Nebraska DHHS. Call 800-358-8802.

Member Services/Interpreter Services (800-651-1902)7:00 AM to 7: 00 PM Monday - Friday. Member Services is available to assist members with any issues or concerns.

Additional Contact InformationNon Emergent Transportation - IntelliRide844-531-3783 (Toll Free) - 402-401-6999 (Omaha local) www.iridenow.com

Dental ServicesAnesthesia and facility charges associated with dental procedures performed at hospital/ASC must meet medical necessity and be prior authorized to be considered.

Routine dental services not covered by UnitedHealthcare Community Plan but by Nebraska DHHS

Mental Health & Substance Abuse (Magellan Behavorial Health)To refer members, call 800-424-0333. A PCP referral is not required.

Superior Vision866-819-4298 or www.blockvisiononline.com

e-Business SupportEDI Claims [email protected]

EDI Log-on Issues800-842-1109UnitedHealthcareOnline.com

Fraud, Waste and Abuse Division UnitedHealthcare Community Plan1-800-455-4521 or 1-866-242-7727

OPTUMHealth Nurseline 24/7 Assistance 877-543-4293

Other Important InformationProvider & Member Appeals Mailing Address UnitedHealthcare Community PlanP.O. Box 31364Salt Lake City, UT 84131

Provider & Member Grievance Mailing Address UnitedHealthcare Community PlanP.O. Box 31364Salt Lake City, UT 84131



Provider Administrative Appeals: Claim DisputesUnitedHealthcare Community PlanProvider Claim DisputesPO Box 31365Salt Lake City, UT 84131

Providers should call the Provider Service Center at 866-331-2243 about appeal inquiries

Claims Submission AddressUnitedHealthcare Community PlanP.O. Box 31365Salt Lake City, UT 84131

Utilize the UnitedHealthcare ICD-10-CM Code Lookup Tool to determine a diagnosis code from ICD-9 to ICD-10 and vice versa. Tool developed using CMS General Equivalence Mappings (GEMs) as a baseline.

Please utilize the following link: https://icd10codelookup.smartbaselink.com/

Notify Health Services Within the Following Time Frames:Emergency AdmissionOne business day of an emergency or urgent admission

Admission After Ambulatory SurgeryOne business day of an inpatient admission

Non-Emergency Care (except maternity) At least 14 calendar days prior to non-emergent non-urgent facility admissions and/or outpatient services

Call 866-604-3267 or fax prior authorizations to 866-622-1428

NMES: 800-642-6092To verify Medicaid eligibility with the State of Nebraska

Medicaid Enrollment Center:888-255-2605Local in Lincoln: 402-477-4600

ComplianceHIPAA mandates the adoption and use of NPI in all standard transactions (claims, eligibility, remittance advice, claims status request/response, and authorization request/response) for all health care providers who conduct business electronically.

Evidence Based Clinical Review Criteria and GuidelinesUnitedHealthcare utilizes Milliman Care Guidelines for determinations of appropriateness of care.


https://icd10codelookup.smartbaselink.com/

https://icd10codelookup.smartbaselink.com/

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Chapter 4: Local Health Plan Contact List

Plan President: Kathy Mallatt [email protected] 402-445-5591

Director of Operations: Heather Johnson

[email protected] 402-445-5711

Medical Director: Michael Horn [email protected] 402-445-5586

Director Health Services: Barbara Palmer


Director of Provider Network Programs: Jeremy Sand


Sr. Provider Relations Advocate LeAnn Ortmeier


Sr. Provider Relations Advocate Sue Chaka


Director of Marketing: Kim Manning


UnitedHealthcare Community Plan FAX: (Omaha)

402-445-5730

Nebraska Provider Advocate:When assistance is needed to answer a question, resolve a problem or issue related to claim payment or process.

[email protected]

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Health Care ID CardUnitedHealthcare Community Plan members should receive a new membership identification (ID) card prior to his/her effective date. However, if a member does not receive an ID card prior to their effective date, using provider e-services, you can access member eligibility information at UHCCommunityPlan.com or contact Provider Services at 866-331-2243 to verify eligibility.

The ID card does not guarantee eligibility. It is for identification purposes only. Eligibility must be verified every time services are received. Most recent member eligibility information can be accessed on the health plan’s website or by phone 24 hours a day. This procedure is essential because:

• Member may no longer be eligible.

• Benefits may be altered.

• Fraudulent use may occur.

Sample Health Member ID Card The following is a sample card. Information on the card is subject to change, therefore you should check the member ID card at every appointment.

Chapter 5: Member Cards

Health Plan/Plan de salud (80840) 911-87726-04

Member ID/ID del Miembro: 999999999Member/Miembro:SUBSCRIBER BROWN

PCP Name/Nombre del PCP:DR. PROVIDER BROWN PCP Phone/Teléfono del PCP: (999)999-9999 Effective Date/

Fecha de vigencia 12/31/9999

0501 Administered by UnitedHealthcare of the Midlands, Inc.

3 0 1

2 3

2 2

2 0

0 0

0 0

0 2

0 0

0 0

0 0

0 0

0 0

0 1

9 5

4 6

9 5

1 1 6 1

Payer ID/ID del Pagador: 87726Group/grupo:

Rx Bin: 610494 Rx Grp: ACUNE Rx PCN: 9999

Medicaid Number: 99999999999

Copays may apply.

In an emergency go to nearest emergency room or call 911. Printed: 04/11/11

For Members/Para Miembros: 800-641-1902 TTY 800-833-7352

For Providers: www.uhccommunityplan.com 866-331-2243Medical Claims: PO Box 31365, Salt Lake City, UT 84131

En caso de emergencia, acuda a la sala de emergencia más cercana o llame al 911.This card does not guarantee coverage. For coordination of care call your PCP. Toverify benefits or to find a provider, visit the website www.uhccommunityplan.com or call.

Vision: 800-879-6901 TTY 711

NESHAD

Transportation: 844-531-3783 TTY 711NurseLine/Línea de enfermeras: 877-543-4293TTY 711

Diabetic Testing Supplies Covered

Health Plan/Plan de salud (80840) 911-87726-04

Member ID/ID del Miembro: 999999999Member/Miembro:SUBSCRIBER BROWN

PCP Name/Nombre del PCP:DR. PROVIDER BROWN PCP Phone/Teléfono del PCP: (999)999-9999 Effective Date/

Fecha de vigencia 12/31/9999

0501 Administered by UnitedHealthcare of the Midlands, Inc.

3 0 1

2 3

2 2

2 0

0 0

0 0

0 2

0 0

0 0

0 0

0 0

0 0

0 1

9 5

4 6

9 5

1 1 6 1

Payer ID/ID del Pagador: 87726Group/grupo:

Rx Bin: 610494 Rx Grp: ACUNE Rx PCN: 9999

Medicaid Number: 99999999999

Copays may apply.

In an emergency go to nearest emergency room or call 911. Printed: 04/11/11

For Members/Para Miembros: 800-641-1902 TTY 800-833-7352

For Providers: www.uhccommunityplan.com 866-331-2243Medical Claims: PO Box 31365, Salt Lake City, UT 84131

En caso de emergencia, acuda a la sala de emergencia más cercana o llame al 911.This card does not guarantee coverage. For coordination of care call your PCP. Toverify benefits or to find a provider, visit the website www.uhccommunityplan.com or call.

Vision: 800-879-6901 TTY 711

NESHAD

Transportation: 844-531-3783 TTY 711NurseLine/Línea de enfermeras: 877-543-4293TTY 711

Diabetic Testing Supplies Covered

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UHCCommunityPlan.comHave you visited UHCCommunityPlan.com today?

If you’re on UnitedHealthcareOnline.com and are looking to get to Nebraska’s UnitedHealthcare Community Plan page, please do the following:

Go to “Tools & Resources” > UnitedHealthcare Community Plan Resources > Nebraska

Chapter 6: Provider Website

http://www.UnitedHealthcareOnline.com


If you’re already on UHCCommunityPlan.com and are in search of Nebraska’s page, please do the following:

1. Scroll over to “For Health Care Professionals”.

2. Scroll down the list until you see Nebraska and click it. To locate the Nebraska Provider Administrative Manual as well as the Nebraska Provider Welcome Kit, click on Provider Information on the left-hand side of the screen on Nebraska’s UnitedHealthcare Community Plan page. Then, click on Administrative Guide.

Other links on the UnitedHealthcare Community Plan page are:• Provider Information: Includes:

– Contacts to Provider Call Center,

– Mailing addresses for Claims, Utilization Denial & Appeal Department, and Claim Appeals.

– Forms for Prior Authorization, Factor Prescription Fax Form, Radiology Prior Authorization Form and Radiology Crosswalk.

– State of Nebraska Medical Necessity website

– Medical Policies and Coverage Determination Guidelines

– Medical Injectable

– Integrity of Claims, Reports, and Representatives to the Government link

– Disclaimer

– Magellan PCP Toolkit link

• Pharmacy Program: Includes the Pharmacy Bulletins. Pharmacy prior authorization forms are also located on this page.

• Reimbursement Policy: Includes information about UnitedHealthcare Community Plan’s reimbursement policies.

• Newsletters: Includes UnitedHealthcare Community Plan Nebraska newsletters, which are published quarterly.

• Bulletins: Includes up-to-date news, policy changes and other issues important to your practice.

• Provider Forms: Includes UnitedHealthcare Community Plan forms (provider demographic change form, claim reconsideration form, disclosure of ownership and control of interest, numerous prior authorizations, medical prior authorization fax form, FAQ for sleep test optimization program, etc.).


http://www.UHCCommunityPlan.com


• Clinical Practice Guidelines: Includes non-preventive clinical practice guidelines to help practitioners and members make decisions about appropriate health care for specific clinical circumstances.

• Electronic Data Interchange (EDI): Includes companion guides and informational materials on EDI, EFT and ERA. You can also sign up for EDI training. If you are not currently signed up, learn how to save time and money.

• Radiology: Includes CPT (Current Procedural Terminology) Codes, The Online Portal Link, and information concerning Prior Authorizations

To access the member information page when on Nebraska’s UnitedHealthcare Community Plan page, click on “Claims and Member Information.” Scroll to the middle of the page to find UnitedHealthcare Community Plan information. Click on “access secure provider website.” This will take you to UnitedHealthcareOnline.com


To access the member information page when on Nebraska’s UnitedHealthcare Community Plan page, click on “Claims and Member Information.” Scroll to the middle of the page to find UnitedHealthcare Community Plan information.

Log on Today to Check

• Verify patient eligibility and benefits• Claims Status – allows you to locate specific claims and obtain claim summary and line item detail information.

Our secure online service, UHCCommunityPlan.com, is designed to save time and improve efficiency for contracted providers. Refer to the next page for more instructions on how to register an account, or contact Provider Services for assistance at 866-331-2243.

Welcome to UnitedHealthcare Community Plan - Nebraska � 11

Provider Website (Continued)

UnitedHealthcare Provider Welcome Kit of Nebraska 05/14


Login to: • Verify patient eligibility

• Check claim status – allows you to locate specific claims and obtain claim summary and line item detail information.

If you are not yet enrolled on UnitedHealthcareOnline.com, click on Enroll Today and follow instructions.

Primary Care Provider Panel Roster – This report provides a list of UnitedHealthcare Community Plan members currently assigned to the provider.

AccessThe website can be accessed by going to UHCCommunityPlan.com > Health care Professionals > Nebraska > Claims and Member Information. Under UnitedHealthcare Community Plan, select “Access secure provider website.” The website requires a unique user name and password combination to gain access.

New Users: Click on “New User” and follow instructions. Follow these instructions to locate your PCP Panel Roster.


http://www.UHCCommunityPlan.com

Tools & ResourcesReports

QUICK REFERENCE

UnitedHealthcareOnline.com © 2015 UnitedHealthcare Services, Inc. All rights reserved. v20151002

Reports are specific to UnitedHealthcare Community Plan members in certain states, unless otherwise specified, with the exception of the PCP Panel Roster (also available for the UnitedHealthcare Navigate, Charter and Compass products) and the Hospital Monitoring Report (available to all).

View a Report1. Sign In to UnitedHealthcareOnline.com

2. Select the UnitedHealthcare Online application on Link

3. Select Reports from the Tools & Resources

View a Report (continued)

4. From the Report Search page, select the Report Type from the pull-down menu

5. You may choose from several selections

Note: Above Reports Types are available for UnitedHealthcare Community Plan members in certain states, unless otherwise specified.Exceptions: PCP Panel Roster is also available for Navigate,Charter and Compass Hospital Monitoring Reports are available to all users

Note: For Capitation reports there are additional helps under the Related Links section

UnitedHealthcareOnline.com © 2015 UnitedHealthcare Services, Inc. All rights reserved. v20151002

View a Report (continued)

6. After selecting the Report Type you want, complete the required information and click on Search

Note: If you choose the PCP Panel Roster, you will need to complete additional fields, PCP Panel Roster Report Type (either Community Plan or UnitedHealthcare Navigate, Charter or Compass products) and State.

7. Click on the available report you want to view

Additional Quick Reference available on UnitedHealthcareOnline.com.

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Chapter 7: Care Management

Members may be eligible for care management services if they have serious injuries, chronic or high risk illnesses.

Care management services offered (not required):

• High Risk Pregnancy

• Asthma

• Diabetes

• Congestive Heart Failure (CHF)

• Chronic Obstructive Pulmonary Disease (COPD)

• Coronary Artery Disease (CAD)

• Sickle Cell

• Obesity

• Special needs children and adults

• Hypertension (HTN)

• End Stage Renal Disease (ESRD)

• Transplant

This list is a guide for possible diagnoses to be referred to care management; it should not be considered allinclusive. There will be special circumstances and conditions that should be considered as possible referrals.

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Medical Services Advanced Notification Requirements: You can submit your prior authorization request for UnitedHealthcare Community Plan members online at UnitedHealthcareOnline.com>Notifications/Prior Authorizations>Notification/Prior Authorization Submission.

Call Provider Services for questions related to prior authorization at 866-331-2243. Please reference the Provider Manual for required information to submit prior authorization requests.

The below list is not all-inclusive. The Advanced Notification Requirements are located at UHCCommunityPlan.com. Click on Health Care Professionals, select State, Provider Information Tab, Prior Authorization. The list provides more information about the services that require prior authorization.

• Prior authorizations are required for:

– Select medical procedures.

– Cosmetic and reconstructive surgery.

– Durable medical equipment and supplies that exceed $500.

– Prosthetics and orthotics that exceed $500.

– Home health care services.

– Hospice services; in Home Hospice and Short Stay Inpatient Hospice.

– Hospital inpatient services.

– Skilled nursing facility services.

– Transplant services.

Advanced Outpatient Imaging Procedures Notification Requirments:To find the CPT Code list of Radiology procedures that require a prior authorization and the online portal link to initiate a prior authorization, go to UHCCommunityPlan.com. Click on Health Care Professionals, select State, Radiology.

You can also submit your prior authorization request for UnitedHealthcare Community Plan members on line at UnitedHealthcareOnline.com>Notifications/Prior Authorizations>Radiology Notification & Authorization - Submission & Status.

Call Provider Services for questions related to prior authorization at 866-331-2243. Please reference the Provider Manual for required information to submit prior authorization requests.

Chapter 8: Services That Require Prior Authorization

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Question: What identification card willmembers carry?

Answer: Each member receives a nine-digit UnitedHealthcare Community Plan member identification number. This number is used to communicate with UnitedHealthcare of the Midlands regarding a specific subscriber/member. The Nebraska DHHS Medicaid Number is also provided on the member ID card.

The members ID card reflect the members’ PCP assignment on the front of the card.

Be sure to check the member’s ID card at each visit – and to copy both sides of the card for your files. Providers may also take the precaution of verifying the identity of the person presenting the ID card against some form of photo ID, such as a driver’s license, if this is your office practice.

Question: What provider types are considered Primary Care Providers (PCPs)?

Answer: Provider types that can be considered a PCP aremedical doctors (M.D.), doctors of osteopathy (DO), nurse practitioners (NP), and physician assistants (PA) from any of thefollowing practice areas:

• General Practice

• Internal Medicine

• Family Practice

• Pediatrics

• Obstetrics/Gynecology

Nurse practitioners are allowed to enroll with the state as solo providers; physician assistants cannot. Physician assistants must be part of a group practice.

For services rendered by a nurse practitioner or physician assistant, the claim should be submitted under the nurse practitioner or physician assistant, not the supervising physician.

Question: How do I submit claims to UnitedHealthcare Community Plan?

Answer: You may send claims electronically to Payer 87726 through UnitedHealthcare Community Plan’s provider website atwww.uhccommunityplan.com or you may file paper claims.

Question: What is the claims address for UnitedHealthcare Community Plan?

Answer: The claims address is as follows:UnitedHealthcare Community PlanP.O. Box 31365Salt Lake City, UT 84131

Question: What is the provider servicecenter phone number?

Answer: Provider service representatives can bereached at 866-331-2243.

Question: What resources are available to providers to check eligibility?

Answer: You may check eligibility by using our online provider portal at UHCCommunityPlan.com or by calling ProviderServices at 866-331-2243.

Question: What resources are available to providers for assistance with issues involving claim payments?

Answer: For assistance with issues involving claimpayments, you may contact a Nebraska ProviderAdvocate by sending an email [email protected].

Question: Can I bill using the patient’sMedicaid ID number?

Answer: Yes. You can file claims using themember’s UnitedHealthcare Community PlanID number or the member’s Nebraska MedicaidID number. If you do not have the member’sUnitedHealthcare Community Plan IDnumber, you may look up the number usingUHCCommunityPlan.com.

Question: How many people can register from my office to have access to UHCCommunityPlan.com?

Answer: There is no limit to the number of staffmembers in your office that can register online.

Chapter 9: Frequently Asked Questions


Question: What is my timely filing criteria?

Answer: Timely filing is based upon your contract. Please check your contract for this information.

Question: Can I bill a UnitedHealthcare Community Plan member?

Answer: Please be aware that physicians must not balance-bill members for any of the following reasons:

• If there is a difference between the charge amount and the UnitedHealthcare fee schedule.

• If a claim has been denied for late submission, unauthorized service, or as not medically necessary.

• If a member requests a service that is not covered by UnitedHealthcare Community Plan.

• When claims are pending review by UnitedHealthcare.

If you wish to bill the member for non-covered services, you must discuss this with the member prior to rendering the services and obtain a signed waiver of liability from that member that specifies the service and specific amount in question.

Question: How do I request a Primary Care Provider-initiated transfer?

Answer: To initiate a transfer of the member, the PCP must contact the health plan in writing via fax at 402- 445-5730 or mail with the specific documentation of the event(s) that occurred. (Documentation includes DHHS form MS-24, the date(s) of failed appointments or a detailed accounting of reasons for termination request, patient name, date of birth, Medicaid number, current address, current telephone number and the physician’s name.)

UnitedHealthcare Community Plan Attn: Health Services 2717 N 118th ST, STE 300 Omaha, NE 68164

Please refer to the Provider Administrative Guide for more information on this process.

Question: Do I need to verify UnitedHealthcare Community Plan eligibility?

Answer: Yes. You can verify eligibility through the following methods:

• UHCCommunityPlan.com

• NEMS by calling 800-642-6092 to verify Medicaid eligibility with the Department of Health and Human Services (DHHS) Nebraska Medicaid Eligibility System

• UnitedHealthcare Provider Services: 866-331-2243

Chapter 9: Frequently Asked Questions

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