Introduction to UnitedHealthcare Community Plan of California/Medi-Cal
Welcome/Agenda: Mission/Vision UnitedHealthcare Community Plan of California/Medi-Cal Member Eligibility and Benefits Notification and Prior Authorization Pharmacy Services Doing Business With Us Care Provider Resources Your Physician Advocate Questions
Mission and Vision Our Mission To help people live healthier lives and 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
UnitedHealthcare Community Plan of California Medi-Cal Overview Product/program: Medi-Cal Availability: San Diego county Program launch date: Oct. 1, 2017
Member Eligibility Beneficiaries who must enroll in managed Medi-Cal plans: Families with children Low-income adults People with disabilities Pregnant women Seniors Beneficiaries who may voluntarily enroll into managed Medi-Cal plans: Native Americans who obtain health care services from an Indian Health Provider Beneficiaries of a Medicare medical plan Beneficiaries who are in foster care
Member Eligibility Some members may qualify for exemptions: Beneficiaries can apply for an exemption with the Department of Health Care Services (DHCS) if they are being treated for a complex medical condition, such as: A disease that affects more than one organ system, such as diabetes Cancer HIV Organ transplantation, or scheduled organ transplantation Pregnancy Renal disease with dialysis at least twice per week DHCS determines who qualifies for an exemption.
Program Benefits Standard Benefits include: Emergency services Hospitalization Laboratory services Maternity and newborn care Mental health and substance use disorder services Outpatient (ambulatory) services Pediatric services, including oral and vision care Prescription drugs Preventive and wellness services, and chronic disease management Programs such as physical and occupational therapy and devices To review the full list of benefits, go to UHCprovider.com/manuals > California > View the UnitedHealthcare Community Plan of California Care Provider Manual.
Transportation Benefits Helping Members Connect With You National Med Trans makes it easy for members and their care providers to order non-emergency medical transport and non-medical transportation services. To make a reservation for a member, call 833-217-4747. There are three ways members can make a reservation: Online: natmedtrans.com > Members > Select Your State > CA Mobile App: Download the National Med Trans Frances Member app on Google Play or the App Store Call: 844-772-6623, 6 a.m. 6 p.m. Pacific Time, Monday Friday
Additional Program Benefits Vision Benefits Medi-Cal covers these vision services: Eye tests and eyeglass tests to support a prescription Eye disease tests to confirm the need for contact lenses Exams to check eye health or low vision Medi-Cal covers new eyeglasses once every 24 months, and lenses for: Children younger than 21 Adults ages 21 and older who are either pregnant or live in a nursing home March Vision Care administers vision benefits. For more information, call 844-336-2724. Laboratory Services LabCorp administers lab services. Visit labcorp.com for more information and locations.
Palliative and Hospice Care Palliative Care Members with qualifying conditions can request a referral to a palliative care provider from their primary care provider (PCP) or treating specialty provider, or by calling their health plan. Members receiving palliative care can continue to receive treatment for their condition. Hospice Care Members with a life-limiting diagnosis and who no longer respond to treatment can request a referral to hospice care by their PCP or treating specialty provider.
California Language Assistance Program Our Program We offer free language assistance services for all members. For interpretive services, call 866-270-5785. Care Provider Requirements You re required to ensure members understand the availability of free language services. As part of this requirement, we ask that you do the following: Post written notice in your waiting room regarding the availability of free language services. Offer free language assistance to Limited English Proficiency (LEP) members, even if a translator is available. Document LEP offer and the member s response to language assistance services. For more information, go to UHCprovider.com/manuals > California > View the UnitedHealthcare Community Plan of California Care Provider Manual > Chapter 7.7.
IHA Care Provider Training All care providers are required to compete Initial Health Assessment (IHA) training. The IHA identifies preventive care needs, including timely screening and detection of chronic and serious illnesses. How to Complete Training: Online: Go to UHCprovider.com/training and click on Initial Health Assessment Requirements California UnitedHealthcare Community Plan. Complete the training and email the attestation form to us at UHCCSCAQualityDepartment_DL@ds.uhc.com by Oct. 1, 2018. For questions, email our Quality Department at UHCCSCAQualityDepartment_DL@ds.uhc.com.
Verifying Member Eligibility and Benefits Since members can select their Medi-Cal Managed Care Plan and change it at any time, it s important to check eligibility and benefits before providing services to UnitedHealthcare Community Plan members. There are two ways to verify member eligibility and check benefits: Online: Use the eligibilitylink tool on Link. To access eligibilitylink, sign in to Link by clicking on the Link button in the top right corner of UHCprovider.com. Call: Provider Services: 866-270-5785
Sample Member ID Cards To help ensure you re submitting claims accurately, check the information on members ID cards at each visit and copy both sides for your files. You can also view member ID cards using the eligibilitylink tool on Link. To access eligibilitylink, sign in to Link by clicking on the Link button in the top right corner of UHCprovider.com. Sample member ID cards for illustration only; actual information varies depending on payer, plan and other requirements.
Member Responsibilities Members select an in-network PCP at enrollment. If a member doesn t select a PCP, we will assign one. Individual members in the same household can choose their own PCP. Members can change their PCP at any time. Members assigned to a delegated medical group have a waiting period, while members in nondelegated groups don t. We won t interrupt claims payments or access to care while non-delegated changes are processed. Non-delegated members don t need a referral before seeing another innetwork care provider or specialist, though some services require advance notification and prior authorization.
Prior Authorization Requirements We usually require prior authorization when a member s benefit document states that services must be medically necessary to be covered. You can view the prior authorization list at UHCprovider.com/CAcommunityplan > Prior Authorization and Notification > UnitedHealthcare Community Plan Prior Authorization Requirements If prior authorization is required, we ll conduct a clinical review to determine if the service is medically necessary based on evidence-based guidelines. If the clinical review finds that a service is not medically necessary, we ll offer the care provider a peer-to-peer review with the reviewing UnitedHealthcare physician. We don t guarantee payment based on a request for service. We ll send you a written decision of coverage based on medical necessity. Confirmation of eligibility and benefits on the date of service is critical.
Prior Authorization Resources and Contacts How to Request Prior Authorization: Call 866-270-5785, Monday Friday, 7 a.m. 7 p.m. Pacific Time; available 24 hours for emergencies Fax: 855-432-2828 To download the prior authorization fax request form, go to UHCprovider.com/CAcommunityplan > Prior Authorization and Notification Resources > Prior Authorization Paper Fax Forms > Prior Authorization Paper Fax Request Form.
Prior Authorization Review Process If you submit insufficient clinical information, we ll fax or call you to request additional information. If we receive information within the requested timeframe, we ll conduct a prior authorization clinical review to determine medical necessity. We ll deny the request for authorization if we don t receive sufficient information within the requested timeframe. If medical necessity criteria is not met for a prior authorization or precertification request, we ll send a clinical denial notice to the member and care provider with the option to appeal.
Prior Authorization Decisions Please schedule procedures as far in advance as possible. We ll provide a decision for standard/non-emergency requests within 14 days of receiving clinical information, and within 72 hours for emergency requests. We may require additional information for some requests, and turnaround times may be affected if we don t receive that information on time. If you submit requested information after the time limit in your contract, we will deny the authorization request.
Radiology Prior Authorization Requirements All advanced imaging procedures that require advance notification also require prior authorization. We require care providers and facilities to obtain authorization before performing certain inpatient, outpatient and office-based procedures. We do not require prior authorizations for radiology procedures ordered through an: Emergency room visit Inpatient stay Observation unit Urgent care facility Exception: We do require prior authorization for electrophysiology implants, like pacemakers, in an inpatient setting.
Requesting Radiology Prior Authorization You can initiate prior authorization using the Prior Authorization and Notification tool on Link. To sign in to Link, go to UHCprovider.com and click on the Link button in the top right corner. View additional information and a Quick Reference Guide at UHCprovider.com > Prior Authorization and Notification > Radiology. To check prior authorization status: Use the Prior Authorization and Notification tool on Link. Call 866-270-5785.
Pharmacy OptumRx, our pharmacy benefits manager, oversees pharmacy network contracting and claims processing. The UnitedHealthcare Community Plan Pharmacy and Therapeutics Committee has approved the drugs listed in the PDL. Our preferred drug list (PDL) is available at UHCprovider.com/CAcommunityplan > Pharmacy Resources and Physician Administered Drugs > Prescription Drug Lists, Drug Search and Updates > UnitedHealthcare Community Plan of California Medi-Cal Preferred Drug List.
E-Prescribing E-prescribing can help care providers save time and money, and can help avoid medication confusion. We offer e-prescribing for pharmacy claims through Surescripts. E-prescribing allows care providers to: Access a member s medication history. Access the formulary. Check a member s eligibility. Send real-time electronic prescriptions.
Pharmacy Prior Authorization You can prescribe an emergency fiveday supply of medication when drug therapy must start without delay and prior authorization is not available. This applies to non-preferred drugs on the PDL and to any drug that is affected by a clinical or prior authorization edit. To request pharmacy prior authorization, call our Pharmacy Help Desk at 800-310-6826, or fax your authorization request to 866-940-7328. We ll notify you of a prior authorization review within 24 hours.
Reconsideration Processes We ll review additional clinical information as long as it meets state turnaround timeframe guidelines. Peer-to-Peer Review The phone numbers to request a peer-to-peer review will be on the notice of adverse determination (denial) letter. These numbers differ for each clinical area. The utilization management nurse reviewer will also provide this number at the time of notification of denial. Timeframe for Peer-to-Peer Reviews Pre-service/outpatient: 14 calendar days from notice of denial Inpatient: 14 calendar days from notice of denial or three business days after discharge, whichever comes first
Notification Timeframes Notification must include all items and services needed to give appropriate care during a stay at a participating hospital, including room and board, nursing care, medical supplies and all diagnostic and therapeutic services. Notification Timeframes Emergency/Urgent Admission: Within two business days of the admission After Ambulatory Surgery: Within two business days of the admission We don t require notification for observation unless the member s level of care is adjusted to inpatient.
Notification Options Here s how you can notify us of a hospital admission: Online: Use the Prior Authorization and Notification tool on Link. Call: 866-270-5785 Fax: 855-432-2828 We may deny claims for late notification.
Claims Submission Electronic Submission Options To submit a claim, use the claimslink tool on Link. To access claimslink, sign in to Link by clicking on the Link button in the top right corner of UHCprovider.com. The primary Payer ID is 87726. You, or your Clearinghouse, may enroll in EDI 835: Electronic Remittance Advice (ERA). The ERA, or 835, is the electronic transaction that provides claim payment information to your practice. Electronic Data Interchange (EDI) Using EDI for all eligible transactions can help your organization improve efficiency, reduce costs and increase cash flow. We encourage you to use the available tools and resources to help you get started with electronic transactions. For more information, go to UHCprovider.com/edi or call EDI Support at 800-842-1109. You can also contact your vendor.
Claims Submission cont d Mail claims to: UnitedHealthcare Community Plan of California P.O. Box 30884 Salt Lake City, UT 84130-0884 Standard timely filing is 180 days from date of service.
Submitting a Claims Reconsideration If you believe a claim was paid incorrectly, you can submit a claims reconsideration request. Here s how: Online: Use the claimslink tool on Link. To access claimslink, sign in to Link by clicking on the Link button in the top right corner of UHCprovider.com. Mail: Send a paper claim reconsideration request to the address on the back of the member s ID card. To access the form, go to UHCprovider.com/claims > Submit a Corrected Claim, Claim Reconsideration / Begin Appeal Process > Single Paper Claim Reconsideration Request Form.
Submitting a Corrected Paper Claim On the Claim Reconsideration Form, check box #4, Resubmission of a corrected claim. Complete the comments section, clearly stating what data elements have been corrected and why. Send the claim and Claim Reconsideration Request Form to the address on the Explanation of Benefits (EOB) or back of the member s ID card.
EPS With Electronic Payments & Statements (EPS), you ll receive an electronic funds transfer (EFT) for claim payments, plus EOBs are delivered online. Using EPS: Lessens administrative costs and simplifies bookkeeping. Reduces reimbursement turnaround time. Makes funds available as soon as they re posted to your bank account. To receive direct deposit and electronic statements through EPS, go to myservices.optumhealthpaymentservices.com > Enroll Now. What you ll need: Bank account information for direct deposit Either a voided check or a bank letter to verify bank account information A copy of your practice s W-9 form
EPS cont d If you re already signed up for EPS, you ll automatically receive direct deposit and electronic statements from UnitedHealthcare Community Plan of California. For more information: Call 866-842-3278, option 5. Go to UHCprovider.com/eps.
Appeals and Grievances You can submit a claims appeal when you wish to challenge a decision or request an exception. Here s how: Online: Use the claimslink tool on Link. To access claimslink, sign in to Link by clicking on the Link button in the top right corner of UHCprovider.com. Mail: Send written appeals to: UnitedHealthcare Community Plan of California Attention: Provider Disputes P.O. Box 31364 Salt Lake City, UT 84131 To access the appeal form, go to UHCprovider.com/CAcommunityplan > Provider Dispute Resolution and Member Grievance and Appeals > Provider Dispute Resolution (PDR) Form. Be sure to document on your cover letter that you re appealing a decision, and include all relevant information. Call: 866-270-5785. You ll need to submit a written request as well.
Expedited Appeals Submitting an Expedited Appeal on Behalf of a Member You can submit an expedited appeal on behalf of a member by calling Provider Services at 866-270-5785. We ll urgently route the expedited appeal for clinical staff to review. If the case doesn t qualify for urgent status, we ll reclassify it as a standard appeal and process accordingly. The analyst assigned to the case will call the care provider to notify them of the change and will follow up in writing.
Link Overview Link is your gateway to UnitedHealthcare s online self-service tools. Use Link to check member eligibility and benefits, manage claims, submit claim reconsideration requests and more. To sign in to Link, go to UHCprovider.com and click on the Link button in the top right corner. If you need help using Link: Call: 866-842-3278, Option 1. Email: providertechsupport@uhc.com.
Sign In to UHCprovider.com to Access Link 37
Use Your Optum ID to Sign In If you can t remember your Optum ID or password, select Forgot Optum ID or Forgot Password. Don t have an Optum ID yet? Register for one by selecting Create an Optum ID. 38
Link Resources To learn more about Link, go to UHCprovider.com/link.
Care Provider Resources Visit UHCprovider.com for resources including: Care Provider Manual: Go to UHCprovider.com/manuals > California > View the UnitedHealthcare Community Plan of California Care Provider Manual. Practice Matters Newsletter: Will be published quarterly beginning in the fourth quarter of 2018 Network Bulletin Newsletter: Alerts you to any change in policies or procedures, as well as updates to the Administrative Guide and Care Provider Manuals View Network Bulletin at UHCprovider.com > News and Network Bulletin > Sign up to receive Network Bulletin. Reimbursement Policy Updates: Alerts you to any change in the reimbursement policies or procedures
Communicating Care Provider Demographic Changes You re required to notify us of changes to your practice information at least 30 days in advance. Please see the examples below to help your practice notify us of changes including: Addresses, phone numbers, email addresses and office hours for all your practice locations Any care providers who have left your practice Hospital, facility or clinic names Languages spoken/written by you and your staff Licenses, National Provider Identifier (NPI) numbers and tax ID numbers. Medical group and hospital affiliations The ages and genders you serve Whether you re accepting new patients Your specialties and board certifications
Communicating Provider Demographic Changes (cont.) To update your practice information: Use My Practice Profile on Link. To access My Practice Profile, sign in to Link by clicking on the Link button in the top right corner of UHCprovider.com. Call Provider Services at 877-842-3210.
Addressing Your Questions and Concerns Your Provider Advocate is an important resource for when you have questions. Please follow these steps before contacting your Provider Advocate with questions about claims: 1. Use the claimslink tool on Link. To sign in to Link, go to UHCprovider.com and click on the Link button in the top right corner. Submit a paper claim dispute. Call Provider Services at 866-270-5785. Be sure to obtain a tracking number for future reference. This is a 15-digit number beginning with a C.
Addressing Your Questions and Concerns cont d 2. If the issue remains unresolved after 30 days, send your Provider Advocate the member name, member ID number, date of service and tracking number or a copy of the claim. 3. Your Provider Advocate will work with market service agents and others to determine the cause and resolve your issue.
California Physician Advocates Elva A. Felix (San Diego) 858-658-8532 elva.felix@uhc.com Sonia Labrado (San Diego) TBD sonia.labrado@uhc.com
Thank you. 2018 United HealthCare Services, Inc.