UnitedHealthcare Community Plan of Missouri
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1 UnitedHealthcare Community Plan of Missouri
2 Agenda UnitedHealthcare Community Plan of Missouri Member Eligibility and Benefits Notification and Prior Authorization Claims Management Care Provider Resources 2
3 3 UnitedHealthcare Community Plan Overview
4 Mission and Vision Our Mission Our mission is to help people live healthier lives and to help make the health system work better for everyone. Our Vision To be the premier health care delivery organization in the eyes of our state partners, providing health plans that meet the unique needs of our Medicaid members as well as our members in other government-sponsored health care programs; to be effective partners with physicians, hospitals and other health care professionals in serving their patients. 4 Doc#: PCA _ Proprietary Information of UnitedHealth Group. Do not distribute or reproduce without express permission of UnitedHealth Group.
5 UnitedHealthcare Community Plan of Missouri Beginning May 1, 2017, UnitedHealthcare Community Plan of Missouri will cover Medicaid members under the MO HealthNet program. UnitedHealthcare Community Plan will serve members in all Missouri counties. 5 Doc#: PCA _ Proprietary Information of UnitedHealth Group. Do not distribute or reproduce without express permission of UnitedHealth Group.
6 Managed Care Eligibility Groups UnitedHealthcare Community Plan of Missouri will cover Medicaid members in these eligibility groups. MO HealthNet for Families MO HealthNet for Kids MO HealthNet for Pregnant Women Transitional MO HealthNet Children receiving adoption subsidies Children in care and custody of the state Children receiving refugee assistance Children s Health Insurance Program (CHIP) 6
7 Verifying Eligibility and Benefits Because member eligibility can vary by day, please verify eligibility and benefits before providing services. Visit the MO HealthNet portal at: emomed.com Sign in to UnitedHealthcareOnline.com, then select the eligibilitylink app on your Link dashboard. If you don't have an Optum ID, go to UnitedHealthcareOnline.com and select New User." Call Provider Services at or call the number on the back of the member s ID card. 7
8 Member ID Cards Information on the UnitedHealthcare Community Plan member ID card can help you submit claims more efficiently and accurately. Be sure to check the member s ID card at each visit and copy both sides of the ID card for your files. You can also view Member ID cards online using the eligibilitylink app on Link. 8
9 PCP Selection Each member selects a primary care provider (PCP) at enrollment. If a member does not select a PCP, UnitedHealthcare Community Plan will assign one. Members may change their PCP at any time by calling Member Services. The PCP Panel Roster is available on UnitedHealthcareOnline.com. Members don t need a referral before seeing another in-network physician or specialist. 9
10 Pharmacy Benefits Most pharmacy claims for all MO HealthNet Managed Care members are processed by the MO HealthNet Fee-for-Service Pharmacy Program. Pharmacy services include all injections and birth control devices administered in the physician s office or a private clinic setting. UnitedHealthcare Community Plan will process claims for: Injection administrations, including Vaccines for Children administrations Medications billed as part of an inpatient hospital or observation stay If you have questions on coverage, please contact MO HealthNet Pharmacy Services at or
11 Value-Added Program Benefits UnitedHealthcare Community Health Plan also offers members the following benefits: Asthma Care - Airwaze and hypoallergenic mattress cover and pillowcases Enhanced non-emergency transportation Quit For Life - tobacco cessation services JOIN for ME - childhood obesity program Recreational program memberships Baby Blocks - rewards pregnant women and new moms for prenatal and postpartum visits and well child visits My Money - wellness rewards program Healthify - web-based tool to deliver social services referrals 11
12 Transportation Benefits To help members access care, Medical Transportation Management provides non-emergency medical transportation. The benefit includes unlimited trips to and from methadone clinics; Women, Infants and Children service locations; inpatient behavioral health or family therapy; and pharmacies following a covered service appointment. Non-emergency medical transportation is also available for members in some medical eligibility codes that don t normally cover transportation. These codes are: 73-76, 97, 08, 52, 57 and 64. Members can arrange transportation by calling UnitedHealthcare Community Plan of Missouri Member Services at or visiting mtm-inc.net. 12
13 13 Prior Authorization and Notification
14 Requesting Prior Authorization For a list of services requiring prior authorization, please visit UHCCommunityPlan.com > For Health Care Professionals > Missouri > Advanced Notification/Prior Authorization List. You can request Prior Authorization in one of the following ways: Using your Optum ID to access Link and select UnitedHealthcareOnline.com > Notifications/Prior Authorizations > Notification/Prior Authorization Submission. Fax a request form to Call , Monday Friday, 8 a.m. 5 p.m. (Exception: state-designated holidays) You can find prior authorization request forms at UHCCommunityPlan.com > For Health Care Professionals > Missouri > Provider Forms > Prior Authorization Fax Request Form. 14
15 Prior Authorization Response Times Please schedule procedures as far in advance as possible. Request prior authorization at least 14 calendar days before the planned service date. A decision for standard/non-emergency requests will be provided within 36 hours after we receive clinical information. Decisions for urgent requests will be rendered within 24 hours. If we need additional information, response times may vary for standard/non-emergency requests. If you are emergency room staff, requesting a non-emergency service, please call to initiate prior authorization. Prior authorization is a medical necessity review, but doesn t guarantee payment. 15
16 Radiology/Cardiology Prior Authorization Requirements To view a list of radiology/cardiology CPT codes requiring prior authorization, evidence-based clinical guidelines and other helpful information, please visit UHCCommunityPlan.com > For Health Care Professionals > Missouri > Cardiology/Radiology. You can request authorization for radiology and cardiology services by: Using your Optum ID to access Link and select UnitedHealthcareOnline.com > Notifications/Prior Authorizations > Cardiology Notification & Authorization - Submission OR Radiology Notification & Authorization - Status. Calling Monday Friday, 7 a.m. to 7 p.m. We will provide a decision for standard/non-emergency requests within 36 hours from the receipt of all clinical information and no later than 14 days from the authorization request. Decisions for urgent requests will be rendered within 24 hours. 16
17 Radiology/Cardiology Prior Authorization Requirements (cont.) Prior authorizations are not required for cardiac or radiology procedures ordered through an: Emergency room treatment visit Observation unit Urgent care facility Inpatient stay Exception: Electrophysiology implants like pacemakers will require authorization in an inpatient setting. 17 Doc#: PCA _ Proprietary Information of UnitedHealth Group. Do not distribute or reproduce without express permission of UnitedHealth Group.
18 Clinical Coverage Review Process If we need additional clinical information to determine medical necessity, we ll ask you to provide it. If the information is not provided within the requested timeframe, the request for authorization will be denied. If medical necessity criteria is not met for a prior authorization request, we will issue a clinical denial. Both you and your patient will receive a denial notice with the option to appeal. If you d like to request a peer-to-peer review following a denial, the phone number and timeframe will be included on the denial letter. 18
19 Hospital Notification Hospitals and facilities are responsible for admission notification for inpatient services. Notification of planned admission should be provided at least 14 business days prior to admission. If admission is scheduled less than five business days in advance, the notification should be provided upon scheduling. Notification of an emergency or urgent admission, or an inpatient admission after ambulatory surgery, must be received within 1 business day. To find out more about submitting Admission Notifications electronically, please visit our Electronic Admission Notifications (278N) page at UnitedHealthcareonline.com >Tools & Resources > EDI Education for Electronic Transactions > Electronic Admission Notifications. 19
20 20 Claims Management
21 Claims Submission You have several options for filing claims. Our general timely filing guideline is 90 days from date of service; please check your participation agreement to confirm your timely filing limit. CMS-1500 claims only: UnitedHealthcareOnline.com > Claims & Payments > Claim Submission Clearinghouse of your choice: If you receive 835 Electronic Remittance Advice (ERAs) through a vendor, please ask them to enroll you for the 835 through OptumInsight. Use Payer ID for electronic submissions. For more information on electronic submissions, please contact your vendor or call Electronic Data Interchange (EDI) at To submit paper claims, please send them to: UnitedHealthcare Community Plan of Missouri PO Box 5240 Kingston, NY
22 Service Model for Issue Resolution If you disagree with the outcome of a claim determination, your first step is submitting a claim reconsideration request in one of the following ways: Use the Claim Reconsideration application on Link at UnitedHealthcareOnline.com. Call Provider Services at or call the number on the back of the member s ID card. Submit a paper claim reconsideration request, using the Claim Reconsideration Request Form. The Claim Reconsideration Request Form is available at UnitedHealthcareOnline.com > Tools & Resources > Forms. Be sure to obtain a tracking number for future reference. This will be an 18 digit number beginning with SF or a PTPCR number from Link. 22
23 Submitting Corrected Claims Online To submit a corrected claim online, use the claims reconsideration application on Link at UnitedHealthcareOnline.com. Any requested additional information can be submitted using the claims management application on Link. When correcting or submitting late charges on 837 institution claims, use bill type xx7, Replacement of Prior Claim. Do not submit corrected or additional information charges using bill type xx5, Late Charge Claim. 23
24 Submitting Corrected Claims By Mail If submitting by mail, check box #4 Resubmission of a corrected claim on the Claim Reconsideration Request Form. Complete the Comments section, explaining which data elements have been corrected and why. Send the claim with the Claim Reconsideration Request Form to the address on the explanation of benefits (EOB). 24
25 Service Model for Escalated Issues You have several options for filing a formal appeal such as: Online: Use the Claims Management or ClaimsLink application on Link at UnitedHealthcareOnline.com. Fax: Mail: UnitedHealthcare Grievances and Appeals PO Box Salt Lake City, UT Our Provider Advocates are available to assist you in navigating our processes. 25 There is a one year timely filing limit, from the date of the first EOB, to complete all steps in the reconsideration and appeal process..
26 Electronic Payments & Statements (EPS) Enrolling for EPS offers multiple benefits: You ll receive faster reimbursement through electronic funds transfers (EFT) Explanation of Benefits (EOBs) are delivered online Lessens administrative costs and simplifies bookkeeping To receive enroll for EPS, 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 Visit myservices.optumhealthpaymentservices.com. If you re already signed up for EPS, you ll automatically receive UnitedHealthcare Community Plan direct deposit and electronic statements. For more information, call or visit UnitedHealthcare.com > Quick Links > Electronic Payments. and Statements. 26
27 27 Resources
28 Online Provider Resources UnitedHealthcare offers many resources such as: The Network Bulletin newsletter Training resources Tools to verify eligibility and benefits Apps to check claim status and submit corrected claims and appeal requests Sign into UnitedHealthcareOnline.com using your Optum ID to access Link. UnitedHealthcare Community Plan of Missouri resources include: Provider Manuals Prior authorization requirements Reimbursement and clinical policies Practice Matters newslettter Visit UHCCommunityPlan.com > For Health Care Professionals > Missouri. 28
29 Contracted Vendor Resources UnitedHealthcare Dental/Dental Benefits Provider (DBP) Call Provider Services at or Member Services at Visit UHCProviders.com MARCH Vision Care Call Provider Services at or Member Services at Visit Marchvisioncare.com Optum Behavioral Health Call Provider Services at Visit ProviderExpress.com Medical Transportation Management Call Visit MTM-inc.net 29
30 Network Management Resources To join the UnitedHealthcare Community Plan network or check your credentialing status, call Provider Services at Need to make demographic changes to your practice information? Call You can also the Network Management Team at 30
31 Provider Relations Support To contact the Missouri Provider Relations team, Need to contact the Kansas Provider Relations team? Missouri providers in these counties can the Kansas Provider Relations team for assistance as well: Andrew, Atchison, Bates, Buchanan, Caldwell, Clay, Carroll, Cass, Clinton, Daviess, De Kalb, Harrison, Henry, Holt, Gentry, Grundy, Jackson, Johnson, Lafayette, Livingston, Linn, Nodaway, Mercer, Platte, Ray and Worth. 31
32 32 Questions?
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This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at www.sib.ok.gov or by calling 1-800-752-9475. Important Questions
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This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at www.sib.ok.gov or by calling 1-800-752-9475. Important Questions
Important Questions Answers Why this Matters:
This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at www.capitalhealth.com or by calling 1-850-383-3311. Important
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Important Questions Answers Why this Matters: What is the overall deductible? Are there other deductibles for specific services?
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