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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
10/27/2015
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LINK – replaces Optum Cloud
Effective October 19th 2015
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Proprietary Information of UnitedHealth Group. Do not distribute or reproduce without express permission of UnitedHealth Group.
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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Proprietary Information of UnitedHealth Group. Do not distribute or reproduce without express permission of UnitedHealth Group.
10/27/2015
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Proprietary Information of UnitedHealth Group. Do not distribute or reproduce without express permission of UnitedHealth Group.
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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Proprietary Information of UnitedHealth Group. Do not distribute or reproduce without express permission of UnitedHealth Group.
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
Salt Lake City, UT 84130-0991
** Always verify address on patients ID card**
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Proprietary Information of UnitedHealth Group. Do not distribute or reproduce without express permission of UnitedHealth Group.
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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Proprietary Information of UnitedHealth Group. Do not distribute or reproduce without express permission of UnitedHealth Group.
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
Salt Lake City, UT 84130-0991
Web: www.uhccommunityplan.com
**Always send to the claims address on the back of the patients ID
card**
Service Model
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Proprietary Information of UnitedHealth Group. Do not distribute or reproduce without express permission of UnitedHealth Group.
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Proprietary Information of UnitedHealth Group. Do not distribute or reproduce without express permission of UnitedHealth Group.
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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Proprietary Information of UnitedHealth Group. Do not distribute or reproduce without express permission of UnitedHealth Group.
Appeal Addresses
Commercial:
UnitedHealthcare Provider Appeals
P.O. Box 30559
Salt Lake City, UT 84130-0575
Community Plan:
Provider Appeals Department
UnitedHealthcare Community Plan
Attn: Claims Administrative Appeals
P.O. Box 30991
Salt Lake City, UT 84130-0991
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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Proprietary Information of UnitedHealth Group. Do not distribute or reproduce without express permission of UnitedHealth Group.
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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Proprietary Information of UnitedHealth Group. Do not distribute or reproduce without express permission of UnitedHealth Group.
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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Proprietary Information of UnitedHealth Group. Do not distribute or reproduce without express permission of UnitedHealth Group.
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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Proprietary Information of UnitedHealth Group. Do not distribute or reproduce without express permission of UnitedHealth Group.
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
Notification 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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Proprietary Information of UnitedHealth Group. Do not distribute or reproduce without express permission of UnitedHealth Group.
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Notification Requirements:
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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Proprietary Information of UnitedHealth Group. Do not distribute or reproduce without express permission of UnitedHealth Group.
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Proprietary Information of UnitedHealth Group. Do not distribute or reproduce without express permission of UnitedHealth Group.
• 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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Proprietary Information of UnitedHealth Group. Do not distribute or reproduce without express permission of UnitedHealth Group.
10/27/2015
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UnitedHealthcare Online New Look
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Proprietary Information of UnitedHealth Group. Do not distribute or reproduce without express permission of UnitedHealth Group.
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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Proprietary Information of UnitedHealth Group. Do not distribute or reproduce without express permission of UnitedHealth Group.
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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Proprietary Information of UnitedHealth Group. Do not distribute or reproduce without express permission of UnitedHealth Group.
10/27/2015
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Proprietary Information of UnitedHealth Group. Do not distribute or reproduce without express permission of UnitedHealth Group.
Filing Time Limit and Corrected Claims
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Proprietary Information of UnitedHealth Group. Do not distribute or reproduce without express permission of UnitedHealth Group.
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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Proprietary Information of UnitedHealth Group. Do not distribute or reproduce without express permission of UnitedHealth Group.
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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Proprietary Information of UnitedHealth Group. Do not distribute or reproduce without express permission of UnitedHealth Group.
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Proprietary Information of UnitedHealth Group. Do not distribute or reproduce without express permission of UnitedHealth Group.
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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Proprietary Information of UnitedHealth Group. Do not distribute or reproduce without express permission of UnitedHealth Group.
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Proprietary Information of UnitedHealth Group. Do not distribute or reproduce without express permission of UnitedHealth Group.
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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Proprietary Information of UnitedHealth Group. Do not distribute or reproduce without express permission of UnitedHealth Group.
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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Proprietary Information of UnitedHealth Group. Do not distribute or reproduce without express permission of UnitedHealth Group.
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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Proprietary Information of UnitedHealth Group. Do not distribute or reproduce without express permission of UnitedHealth Group.
ICD-10 How is it going?
Visit www.unitedhealthcareonline.com for additional tools and resources
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Proprietary Information of UnitedHealth Group. Do not distribute or reproduce without express permission of UnitedHealth Group.
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.
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Proprietary Information of UnitedHealth Group. Do not distribute or reproduce without express permission of UnitedHealth Group.
QUESTIONS