welcome to unitedhealthcare 2015 overview for 3rd party ... · welcome to unitedhealthcare 2015...

10/27/2015

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Welcome to UnitedHealthcare 2015Overview for 3rd Party Payer Day

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Proprietary Information of UnitedHealth Group. Do not distribute or reproduce without express permission of UnitedHealth Group.

WELCOME

Service Model for UnitedHealthcare Commercial

and UnitedHealthcare Community Plan

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LINK – replaces Optum Cloud

Effective October 19th 2015

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LINK cont.…Link: The New Gateway to UnitedHealthcare’s Online Care Provider

Tools. Coming Oct 19!

Care providers and their practice managers told us they want a better way

to get the information they need to check benefits and eligibility,

determine claim status and submit claims reconsideration.

Next week, we’re introducing Link, a new website for

UnitedHealthcareOnline.com users that can help them complete

these online tasks measurably faster and easier.*

Link will replace Optum Cloud Dashboard. It includes many of the same

applications as Optum Cloud Dashboard, but with a new interface

that can help care providers and their practice team get to the

information they need with fewer clicks.

• Link was created based on feedback from UnitedHealthcareOnline.com

and Optum Cloud Dashboard users.

• Link users can quickly move between applications and even customize

the screen to put common tasks just one click away.

• Next-generation technology will allow enhanced features and new

applications.

As part of the transition to Link, care providers and their administrative

staff will sign in to UnitedHealthcareOnline.com and Link using a

single user name and password – the Optum ID. When Link

launches, the UnitedHealthcareOnline.com sign-in screens will help

guide users through the process to register for a new Optum ID,

recover an existing Optum ID or reset their password.

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How to Verify Benefits, Eligibility and Status

Claim and Payments Along with Administrative

Guides

Commercial and Community and State Plan:

Phone: 1-877-842-3210

Web: www.unitedhealthcareonline.com> Patient Eligibility

and Benefits>Patient Eligibility

Web: www.unitedhealthcareonline.com> Claims and

Payments>claims status

Community and State Plan:

Phone: 1-800-903-5253

Web: www.uhccommunityplan.com> Forms, administrative

guide

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Claims address for Paper

Submission

Commercial:

UnitedHealthcare

PO BOX 740800

Atlanta, GA 30374-0800

Medicare:

UnitedHealthcare

PO BOX 31362

Salt Lake City, UT 84131-0362

Community Plan:

UnitedHealthcare Community Plan

P.O. Box 30991


** Always verify address on patients ID card**

http://www.unitedhealthcareonline.com/


http://www.uhccommunityplan.com/

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Claims EDI address for Electronic

Submission

Commercial payer path:

87726

Medicare payer path’s:

Refer to www.unitedhealthcareonline.com >Tools and Resources>EDI education for electronic transactions>Payer list for UnitedHealthcare, Affiliates and Strategic Alliances

Community Plan payer path:

95467

** Please refer to www.unitedhealthcareonline.com >Tools and Resources>EDI education for electronic transactions>Payer list for UnitedHealthcare, Affiliates and Strategic Alliances for a complete list for all products**

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Commercial:

Phone: 1-877-842-3210

Mail: UnitedHealthcare

PO BOX 740800

Atlanta GA, 30374-0800

Web: www.unitedhealthcareonline.com

Community Plan:

Phone: 1-800-903-5253

Mail: UnitedHealthcare Community Plan

P.O. Box 30991


Web: www.uhccommunityplan.com

**Always send to the claims address on the back of the patients ID

card**

Service Model




http://www.uhccommunityplan.com/

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Service Model Cont…

What to do if you have a claims issue:

Commercial:

• Resubmit claims through UnitedHealthcareOnline.com > Link

• Contact our Customer Service department at 877-842-3210

**(Make sure to obtain your “C” reference number)**

• Mail correspondence to address on back of the member’s card

Community Plan:

• Resubmit claims through UnitedHealthcareOnline.com > Link

• Contact our Customer Service department at 800-903-5253

• Mail correspondence to address on back of the member’s card

For a claims failure please reach out to your Provider Advocate

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Appeal Addresses

Commercial:

UnitedHealthcare Provider Appeals

P.O. Box 30559


Community Plan:

Provider Appeals Department

UnitedHealthcare Community Plan

Attn: Claims Administrative Appeals

P.O. Box 30991


For all products appeals must be requested in letter form, including all supporting documentation: Claim, supporting notes, and please list in the body of the letter that this is a formal appeal.

Please note; All claims should be sent through the reconsideration process prior to filing an appeal.

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Advance / Admission Notification Process:

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Advance Notification Requirements –

Physician Commercial

Providers are responsible for advance notification for certain

planned services.

Notification is required at least five (5) business days prior to the

planned service date (unless otherwise specified within the

Notification List in Administrative Guide).

Notification for home health services is required within forty-eight

hours after physician's order.

If services are planned less than five (5) business days prior to the

service date, notification is required as soon as the service is

scheduled.

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Advance Notification Requirements –

Physician Commercial

Complete Advance Notification list is located on

www.unitedhealthcareonline.com – clinician resources-

Advanced Admission Notification Requirements – Please note

this is updated several times a year.

Submission Methods

-UnitedHealthcareOnline.com –

Notifications / Prior Authorizations / Notification Submission

-Phone – see Customer’s healthcare ID card

-Fax – Commercial: 866-756-9733

Medicare Advantage: 800-676-4798

Clinical coverage review based on medical necessity may be

required at time of submission

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Notification Requirements –

Facility Commercial

Admission Notifications

All Admissions require notifications within:

• 24 hours of weekday admission

• By 5:00 pm next business day for weekend and federal holidays

Inpatient or Outpatient services on the Advance Notification list

Facility must confirm prior to service that:

• Coverage Approval is on file

• Medical Necessity review is complete (2011 COC)

• If approval is denied – Initiate pre-service conversation & waiver


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Notification Requirements:

Community Plan

Providers are responsible for advance notification for certain

planned services.

• All services rendered by a non-contracted physician, facility, or

other non-contracted health care provider must have prior

authorization (exceptions: Orthopedic Physician Services and

Obstetrical Physician Services)

• All Inpatient Services require an authorization

• Notification Only: Routine OB/Delivery (Not exceeding 2 day

LOS for vaginal and 4 day LOS for cesarean deliveries)

• OB and Newborn Confinements Exceeding routine LOS

• All NICU admissions

• UnitedHealthcare Community Plan follows CMS OPPS “Inpatient

Only” list for surgical procedures

• Please visit www.unitedhealthcarecommunityplan.com for most

current list of required codes and additional requirements


Community Plan

Admission Notifications

All Admissions require notifications within:

• 24 hours of weekday admission

• Next business day for weekend and federal holidays

Inpatient or Outpatient services on the Prior Authorization & Precertification List

* UHC Community Plan must be notified no less than 3 business days prior to the planned service date

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http://www.unitedhealthcarecommunityplan.com/

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Community Plan

Complete Prior Authorization & Precertification List on UHCCommunityPlan.com > Find Plans By State (click on the

appropriate state) > If you are a Health Professional > Precert / Prior

Authorization Lists

Submission Methods

Referral/Certification:

-Phone – 800-903-5253

-Fax – 855-225-9847

Admission Notification:

-Phone - 800-696-8735

-Fax – 855-225-9847

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• Radiology Notification is a prior notification process for selective

outpatient, advanced imaging procedures

• UnitedHealthcareOnline.com > Clinician Resources > Radiology

> Radiology Notification Program > Reference Materials

• Effective October 15, 2015 requires Radiology Notification for

Golden Rule

Radiology Notification – Commercial

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Cardiology Notification – Commercial

• The Cardiology Notification Program is a notification protocol

required for participating physicians for select inpatient, outpatient,

and office-based procedures prior to performance

• UnitedHealthcareOnline.com > Clinician Resources > Cardiology >

Cardiology Notification Program > Reference Materials

UnitedHealthcare Online New Look

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UnitedHealthcare Online New Look

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UHCCommunityPlan.com

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UHCCommunityPlan.com > Find Plans By State (click on the appropriate state) > If you are a Health Professional

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Resources - Commercial

• UnitedHealthcareOnline.com

• Administrative Guides

• Updated annually

• Available online

• Network Bulletin (newsletter)

• Published every other month beginning in January

• Alerts you to any change in policies or protocols and

updates to the Administrative Guide

• To receive the Network Bulletin by email - enroll on the

website home page under Register.

•Direct Mailings

Resources: Community Plan

• UHCCommunityPlan.com

• Practice Matters (replaces Navigator) – published quarterly

• Compass – published monthly

• SOS Something of Significance – Fax Blast

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Filing Time Limit and Corrected Claims

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Filing Time Limit Claims Submissions:

Commercial and UHC Community Plan

What to do if you have received a denial for filing time limit

Scenarios•Patient did not inform providers office of having UHC insurance

•Patient provided providers office of another primary insurance

•UHC did not receive your original submission

What should a providers office do:•Complete a UnitedHealthCare Claim Reconsideration Request Form.

•Attach a copy of the claim.

•Attach all supporting documentation such as:

Electronic claim confirmation – include confirmation that UnitedHealthcare or one of its

affiliates received and accepted your claim.

Paper claims – include a copy of a screen print from your accounting software to show

the date you submitted the claim.

The accounting software information must also include proof that the claim is for the

correct patient and the correct visit.

Proof of timely filing could also include other insurance carrier’s denial/rejection, EOB,

letter indicating terminated coverage, not their plan participant, and any notes take at

time of registration etc.

Sent to claims address on the back of the members card.

*Please review your contract for standard filing time limits*

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UnitedHealthcare requires that all corrected claims be resubmitted on a

Claim Reconsideration Request Form

What should a providers office do:

• Complete a UnitedHealthcare Claim Reconsideration Request Form

Attach a copy of the claim.

• Select box 4 “Resubmission of a corrected claim and list changes in the

“Comments” section at the bottom of form.

• Attach copy of corrected claim and supporting documentation if

required.

• Mail to claims address on the back of the members card.

Providers office must submit corrected claim with all corrections and must include all services preformed on that day not just the code they are changing. If not all codes are present UHC will not reprocess.

Corrected Claims Submission – Commercial

Corrected Claims Submission:

UHC Community Plan

• Corrected claims must be submitted within one year of the date of service if

the original claim was received within the provider’s filing limit.

• For claim corrections submitted on a CMS-1500:

Box 22 is a split field labeled as “Medicaid Resubmission Code/Original Ref.

No.” Enter “7” in the area for the resubmission code. The original

reference number area enter the 12-digit claim number assigned to the

claim being corrected.

• For claim corrections submitted on a UB:

Form Locator 4 is labeled “Type of Bill”. The third digit is what will indicate the

frequency of the claim. Claims that have corrections to the service line items, a “7”

should be indicated as the third digit to replace a prior claim submission. Form

Locator 84 “Remarks” should indicate the reason for resubmission.

Voiding Claims – a claim billed in error, that does not require correction, must be

billed with “8”. It is inappropriate for voided claims to be followed by a claim coded

with a “7” for resubmission.

For both UB resubmission types, field 37 must be populated with the 12 digit claim number

assigned to the previous submission being addressed.

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Filing an Appeal with UnitedHealthcare –

Commercial

An appeal should be considered to be the last attempt for claims

resolution.

What a provider should do:

Once original claim has been processed and denied, provider should

resubmit a corrected claim or send supporting documentation on a

reconsideration form for additional review.

If after the claim has been resubmitted for additional review and denial

reason still upheld:

Provider should then send in a formal appeal with all supporting

documentation along with a detailed paragraph with reason you feel claim

should be paid.

Filing an Appeal with UHC Community Plan

To submit a formal appeal, submit a letter outlining your dispute, any

supporting documentation, including our response to the reconsideration

request, and the date your reconsideration stage was completed to:

Provider Appeals Department

UnitedHealthcare Community and State

P.O. Box 30991Salt Lake City, UT 84130-0991

Please indicate line of business: Medicaid, MIChild and CSHCS

Required attachments:

• Copy of PRA or EOB

• Claim form (with corrections if necessary)

• Other supporting documentation

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Reference material available on UHC Online:

www.unitedhealthcareonline.com

•Reconsideration form

•Getting started with UnitedHealthcare online

•Navigating the United Voice Portal

•Service Solutions

•Quick Reference Guide (HCPS)

•Radiology – Quick Reference – Code crosswalk

•Cardiology- Quick Reference – Code crosswalk

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Reference material available on UHC Community Plan:

www.uhccommunityplan.com

• Reconsideration Form

• Reimbursement Policies

• Newsletters

• Bulletins

• Pharmacy Program

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Narrow Network Products

Compass, WRAP

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Product Name How do Customers access

physicians and health care

professionals?

Is the treating physician and/or

facility required to give

notification when providing

certain services?

UnitedHealthcare Compass,

Compass Balanced, Compass

Plus

For each covered family member,

Customers choose a network primary

care physician to manage the

Customer’s care and generate referrals

to network specialists when required.

Compass Plus provides out-of-network

benefits.** Compass and Compass

Balanced do not (except for emergency

services).See referral requirements in

the Compass Specialist Referral

Requirement section of this Guide.

Yes, on selected procedures, see

guidelines in the Notification

requirements section of this Guide.

Effective January 1, 2016

New counties – Kalamazoo, Calhoun, Cass and Van Buren

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Compass

Service area: Wayne, Oakland, Macomb, Kalamazoo, Cass, Calhoun

and Van Buren counties only

Individual plans on and off the Exchange

Current par network: Beaumont Hospital, Bronson Methodists Hospital and

Borgess Medical Center employed/affiliated physicians

Providers excluded from this product received notice to exclude, but will be

participating in WRAP network.

Compass is not available to providers outside of Wayne, Oakland,

Macomb, Kalamazoo, Cass, Calhoun and Van Buren counties.

*****PCP required; Referrals required*****

WRAP

Provides coverage for outpatient emergency services, inpatient

services following an emergency admission, urgent care services and

services preapproved by United

Providers do not participate with Compass

Identified by “W500” on back of Customer’s ID card

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UHCCP Has Expanded

Effective January 1st 2016 UnitedHealthcare has expanded to 46 new counties in

the Lower Peninsula only

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ICD-10 How is it going?

Visit www.unitedhealthcareonline.com for additional tools and resources

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ICD-10 Frequently Asked Questions

Our FAQ gives you answers to common questions from our health care providers regarding the

ICD-10 transition. If you need more information, please send your question to

[email protected]. We're here to help!

Free ICD-10 Code Specific/ Specialty Specific Documentation Focused Webinars

The Payers Collaborative, a consortium of health care insurers including UnitedHealthcare,

Humana, Blue Cross Blue Shield of MI, HAP and Priority Health, is offering a series of free one-

hour webinars, which are code-specific, specialty-specific and focus on documentation. These

sessions are at 11 a.m. (CT) every other Thursday. Access recordings of previous webinars or

register for future webinars.

Introducing the Physician ICD-10 Coding Practice Tool

The Physician ICD-10 Coding Practice Tool, an online self-service tool to assist physicians with

the transition to ICD-10. The Physician ICD-10 Coding Practice Tool allows providers to

practice selecting ICD-10 codes for various clinical scenarios across 35 medical specialties.


mailto:[email protected]

https://www.unitedhealthcareonline.com/ccmcontent/ProviderII/UHC/en-US/Assets/ProviderStaticFiles/ProviderStaticFilesPdf/Tools and Resources/HIT/newICD_10_landing_page.pdf

https://www.unitedhealthcareonline.com/ccmcontent/ProviderII/UHC/en-US/Assets/ProviderStaticFiles/ProviderStaticFilesPdf/Introducing_the_Physician_ICD-10_Coding_Practice_Tool.pdf

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QUESTIONS

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