Transcript 888-887-9003 - UHCCommunityPlan.com

Navigating UnitedHealthcare Community Plan
A Care Provider Orientation
© 2015 UnitedHealth Group. Confidential and proprietary information of UnitedHealth Group.
Any use, copying or distribution without written permission from UnitedHealth Group is prohibited.
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Introduction
UnitedHealthcare Community Plan is contracted with the Texas Department of
Health and Human Services Commission (HHSC) to serve people in Texas
who have chronic health conditions and/or qualify financially for state health
plan benefits.
We support the patient-centered Medical Home approach in which primary
care providers (PCPs) oversee health care services to help ensure they are
accessible, person-centered, sensitive to cultural differences, comprehensive,
coordinated and compassionate. Care for every member should integrate
health education, wellness and prevention.
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CHIP and STAR
Children’s Health Insurance Program (CHIP) is for children younger than 19
whose families earn too much financially to qualify for Medicaid, yet cannot
afford private health insurance.
CHIP Perinate allows for limited coverage of a woman’s prenatal and
postnatal health care as well as 12 months coverage for CHIP Perinate
newborns.
State of Texas Access Reform (STAR) covers pregnant women and children
who are 20 and younger and qualify for Medicaid.
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STAR+PLUS and Medicare
STAR+PLUS combines acute health care services with long-term services and
supports (LTSS) for Medicaid members who have disabilities or are 65 and
older. Coverage includes nursing facility long-term care.
We also offer the following plans for people 65 and older or who have
disabilities and qualify for Medicare:
• UnitedHealthcare Dual Complete® (HMO SNP)
• UnitedHealthcare Connected® (Medicare-Medicaid Plan)
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STAR Kids
We are pleased to be welcoming STAR Kids members beginning Nov. 1, 2016.
This program provides health care and LTSS services for children and
adolescents who are 20 and younger. Our STAR Kids program will integrate:
• STAR+PLUS
• Medical Dependent Children Program (MDCP) waiver program
• Intellectual and Developmental Disabilities waiver programs
• Home and Community-based Services (HCBS)
• Texas Home Living (TxHmL)
• Intermediate Care Facilities for Persons with an Intellectual Disability
(ICF/IID) program
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Our Service Areas
We serve our Medicaid programs by HHSC-defined service areas.
Plan
Service Delivery Areas
Jefferson
Harris
CHIP
X
X
STAR
X
X
STAR+PLUS
X
X
STAR Kids
X
X
Hidalgo
Medicaid Rural
Service Area
(MRSA) Central
MRSA
Northeast
Nueces
Travis
X
X
X
X
X
X
X
X
For a full list of service delivery areas and counties, go to HHSC.state.tx.us
> Medicaid/CHIP > Medicaid/CHIP > Managed Care > Expansion of
Managed Care.
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Covered Services
To see which benefits a member is eligible for, use the Eligibility & Benefits
application on Link. Go to UnitedHealthcareOnline.com and sign in to Link
to access the application.
Or, visit UHCCommunityPlan.com > Just show me all plans
in the state > Texas.
Or, call our Customer Service at 888-887-9003.
When more than one care provider is involved in a member’s care, be sure to
coordinate services, which will allow you to share assessments and treatments.
Remember to obtain member consent to release information.
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Verifying Eligibility
There are a number of ways to verify that your patient is a current member in our health
plan before you deliver services:
•
Call Texas Medicaid Automated Inquiry System at 800-925-9126.
•
Swipe the member’s Your Texas Benefits Medicaid card through a
standard magnetic card reader if your office uses that technology.
•
Do a member lookup at TexMedConnect on the Texas Medicaid & Healthcare
Partnership (TMHP) website at TMHP.com > Providers. Select “Go to
TexMedConnect” from the top right of the home page. You will need to log in.
•
Use the Eligibility & Benefits application on Link. Go to UnitedHealthcareOnline.com
and sign in to Link to access the application.
•
Call UnitedHealthcare Community Plan Customer Service at 888-887-9003.
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Early Childhood Intervention
Early Childhood Intervention (ECI) is a state and
federally-funded program created with part C of the
Individuals with Disabilities Education Act of 2011. Its
goal is to help ensure that children with developmental
delays are ready for preschool and kindergarten.
PCPs are legal reporters and parents can self-refer.
Call 800-628-5115 or send an email to
[email protected]
An easy-to-use physician referral form is located at Texas Chapter of the
American Academy of Pediatrics at TXPeds.org > Additional Resources >
Physician Resources > Forms > Statewide ECI Referral Form.
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Texas Health Steps
Medicaid-enrolled children and young adults ages 20 and younger should
receive medical check-ups and screenings according to the Texas Health Steps
(THSteps) program. This Early and Periodic Screening, Diagnostic and
Treatment (EPSDT) benefit applies to STAR, STAR+PLUS and STAR Kids.
Texas Health Steps policies and procedures are outlined in the Texas Medicaid
Provider Procedures Manual, specifically in the Children’s Services Handbook
section available at TMHP.com > Providers > Medicaid Provider Manual.
Enroll to be a THSteps provider at TMHP.com > Providers > Enroll Today!
For more information, go to UHCCommunityPlan.com > For Health Care
Providers > Texas > Provider Training > Texas Health Steps. Visit also
TXHealthSteps.com which includes continuing education credits.
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Texas Medicaid Non-emergency Transportation
Medicaid members can get a ride to the doctor, dentist or pharmacy from the
Medicaid Transportation Program.
• Hidalgo, Nueces, Travis Service Delivery Areas – Call 877-633-8747
• Central and Northeast Medicaid Rural Service Areas – Call 855-687-4786
• Harris and Jefferson Service Delivery Areas – Call 855-687-4786
When Medicaid transportation is not available, please call Customer Service
at 888-887-9003 for assistance.
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Accommodation of Services
When one of our members requires assistance to communicate with you due
to language barriers, or a need for hearing or visual aids, please call
Customer Service at 888-887-9003.
Many of our members need special accommodations to get
health services. You can learn more at ADA.gov > Technical
Assistance Materials > Access to Medical Care for Individuals
with Mobility Disabilities.
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Commitment to Culturally Considerate Care
Our members require person-centered care that is delivered with respect to
their individual preferences and abilities.
The National Standards for Culturally and Linguistically Appropriate Services
in Health and Health Care (the National CLAS Standards) are intended to
advance health equity, improve quality and help eliminate health care
disparities by providing a blueprint for culturally and linguistically appropriate
services.
Learn more at ThinkCulturalHealth.HHS.gov.
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Service Coordination
Our service coordinators work with members,
their families, PCPs and other professional care
providers to develop a person-centered plan of
care.
CommunityCare is our online service coordination
tool. Go to UnitedHealthcareOnline.com and sign
in to Link to access the application.
To reach a service coordinator to report a change
in a member’s condition or circumstances, use
the messaging functionality in CommunityCare or
call 800-349-0550. For STAR Kids members, call
877-352-7798.
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Value-added Services
Our Value-added Services supplement member benefits and are specifically
selected to support our members and help them live healthier lives.
Services include healthy weight interventions, incentive gift cards, and access
to extra services including vision. These services are offered at no cost to
members.
To see a full list, visit UHCCommunityPlan.com > For Health Care
Providers > Texas > Bulletins > Provider Reference Guides >
Value-added Services.
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Pharmacy
Online formulary and preferred drug information
The Texas Medicaid drug formulary and preferred drug list are located at
TXVendorDrug.com > Formulary/PDL or go to Epocrates.com to sign up to
view this information on a handheld device.
Electronic Prescribing
We encourage e-prescribing through SureScripts.com.
Emergency Prescriptions
If there is a need to start drug therapy without delay and prior authorization is
not available, a 72-hour supply can be issued on a one-time basis per
member per drug. For details visit TXVendorDrug.com > Submit a 72 hour
emergency override.
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DME Available at Pharmacy
Limited durable medical equipment (DME) items are available through the
medical benefits plan for pharmacies that are Medicaid DME medical providers.
Covered items include:
• Orally administered iron salts
• Insulin syringes and needles
• Aerosol holding chambers
• Blood glucose meters
• Blood glucose reagent strips
• Diabetic lancets and devices
• Hypertonic saline solution
• Oral bowel evacuants
• Oral electrolyte solution
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DME Available at Pharmacy cont’d
We encourage network pharmacies to become DME network
providers as well in order to dispense these items for our
members. For more information, visit TXVendorDrug.com > Learn
more about enrolling in the Comprehensive Care Program or
providing DME/supplies.
And call UnitedHealthcare Network Management at
866-574-6088 to contract as a DME provider in addition to being
a network pharmacy.
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Prior Authorization
Some services require prior authorization. You can request prior authorization
in a number of ways:
Online: Go to UnitedHealthcareOnline.com and sign in to Link to
access the Eligibility & Benefits application. A notification will pop
up when a service requires prior authorization. Follow the pop-up
link to submit the request online.
Fax: Submit a prior authorization form by fax to 877-940-1972.
To access the form, go to UHCCommunityPlan.com > For Health
Care Professionals > Texas > Provider Forms > Standard Prior
Authorization Form: Texas Department of Insurance.
Phone: Call 866-604-3267.
For a full list of services that require prior authorization, go to
UHCCommunityPlan.com > For Health Care Providers > Texas >
Prior Authorization.
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Non-standard Prior Authorization
Some prior authorizations are non-standard:
Medications: Access forms at UHCCommunityPlan.com > For Health Care
Professionals > Texas > Pharmacy Program to fax to 866-940-7328. Or call
Pharmacy Services at 800-310-6826.
Cardiology and Radiology: Prior authorization procedures can be found
at UHCCommunityPlan.com > For Health Care Professionals > Texas >
Cardiology or Radiology.
Long Term Services and Supports (LTSS): Prior authorizations for LTSS are
secured through the member’s service coordinator. These authorizations should
be confirmed prior to service delivery at UnitedHealthcareOnline.com >
Notifications/Prior Authorization > Notifications/Prior Authorization Status.
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Quality
Our quality program looks at services delivered according to the standards
of the Healthcare Effectiveness Data and Information Set (HEDIS®). See
more at NCQA.org > HEDIS & Quality Measurement.
PCPs can also view care opportunity reporting through CommunityCare,
our online care coordination tool. Go to UnitedHealthcareOnline.com and
sign in to Link to access the application.
Another option is through UnitedHealthcareOnline.com > sign into Link >
Eligibility & Benefits > Gaps in Care Exist.
Our adopted Best Clinical Practice Guidelines are posted to
UHCCommunityPlan.com > For Health Care Professionals >
Texas > Clinical Practice Guidelines.
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Claims Submission
Professional claims for acute health care and long term services and supports
can be submitted in a number of ways:
Online: You can submit claims through
UnitedHealthcareOnline.com > Claims Submission > Claims &
Payments or use a clearinghouse of your choice. Payer ID is 87726.
Mail: Send CMS 1500 or UB-04 forms to the applicable address:
CHIP and STAR
P.O. Box 5270
Kingston, NY,
12402-5207
STAR Kids
P.O. Box 5290
Kingston, NY
12402-5290
STAR+PLUS and DSNP
P.O. Box 31352
Salt Lake City, UT
84131-0352
As a reminder, members cannot be balance billed in any circumstances.
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Claims Submission Deadlines
Claims must be received by UnitedHealthcare Community Plan within 95 days
of the date of service to be considered for payment.
Clean claims are processed within 30 days of receipt. Clean pharmacy
claims are paid within 18 days when submitted online or otherwise paid within
21 days.
The claim address must match either the place of service or the billing address
listed in our claims processing system for the claim to be processed in a timely
manner.
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110-Day Rule
When a Medicaid member has other health
insurance, the other insurance must be billed
before billing us. If you do not get a response
within 110 days, you can submit the claim to us.
We must receive the claim within 12 months
from the date of service for it to be paid.
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Fraud, Waste and Abuse
Anyone knowing of suspicious activities that have the potential for fraud, waste
and abuse must report such suspicions.
• Fraud is intentional deception or misrepresentation of billing and services.
• Waste is overutilization, underutilization or misuse of resources.
• Abuse is financial actions that are inconsistent with sound fiscal, business
or medical practice, and that result in unnecessary cost to the Medicaid
program.
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Reporting Suspected Fraud, Waste or Abuse
Fraud, waste or abuse can be reported to:
Office of Inspector General (HHSC-OIG)
Call 800-436-6184 or go to OIG.HHSC.state.tx.us > Report Fraud.
UnitedHealthcare Community Plan
Call 888-887-9003 or mail to:
UnitedHealthcare Community Plan
Attn: Compliance
14141 Southwest Freeway, Suite 800
Sugar Land, TX 77478
Protections for those who report fraud, waste and abuse include the Federal
False Claims Act, the Texas False Claims Act and the Whistleblower Act.
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Electronic Payments & Statements
Enroll in Electronic Payments &
Statements (EPS) to receive direct
deposit payment of your claims and
access online provider remittance
advices.
Go to MyServices.OptumHealthPaymentServices.com > How to Enroll.
To learn more about EPS, go to UnitedHealthcareOnline.com > Help >
Electronic Solutions > Electronic Payments & Statements.
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Complaints and Appeals
If you are not satisfied with the outcome of a claim reconsideration, you may
submit a formal claim dispute/appeal using the process outlined in your
provider manual which can be found at UHCCommunityPlan.com > For Health
Care Professionals > Texas > Manuals.
Care providers may file complaints with UnitedHealthcare Community Plan by
submitting the Provider Complaint/Grievance Form located at
UHCCommunityPlan.com > For Health Care Professionals > Texas > Provider
Forms. If you have any questions, call our Customer Service at 888-887-9003.
Notification of receipt of request will be sent within five business days. A
decision is rendered within 30 calendar days.
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Important Resources
•
The Texas Medicaid Provider Procedure Manual is available at TMHP.com >
Providers > Medicaid Provider Manual.
•
Access the UnitedHealthcare Community Plan manuals at UHCCommunityPlan.com
> For Health Care Professionals > Texas > Manuals.
•
Network Bulletin: Monthly newsletter edition posted to UnitedHealthcareOnline.com
> Tools & Resources > News & Network Bulletin.
•
Practice Matters: Quarterly newsletter posted to UHCCommunityPlan.com > For
Healthcare Professionals > Texas > Newsletters.
•
Provider Alerts – Check regularly for updates:
• Texas Medicaid & Healthcare Partnership at TMHP.com > Providers
• The Texas Health and Human Services Commission at HHSC.state.tx.us >
News & Information > News Releases
•
UHCCommunityPlan.com > For Health Care Professional > Texas > Bulletins >
Provider Alerts
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Contact Information
Help ensure that members can find you and that payments get to you by
keeping your practice information current in our systems and directories.
Let us know if there is a change in your demographic information, such as your
name, service or billing address, phone number, National Provider
Identification number (NPI), Texas Provider Identification number (TPI) or Tax
Identification Number (TIN).
Submit your changes with the form located at UHCCommunityPlan.com > For
Health Care Providers > Texas > Provider Forms > Provider Address and Tax
Updates or call 888-887-9003.
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Contact Information cont’d
Remember to update your information with the Texas Health and Human
Services Commission, as well.
Visit TMHP.com > providers > Today I would Like To … > Provider Information
Management System (PIMS) User Guide.
Changes involving identification numbers, such as tax identification numbers,
or name need to be submitted to TMHP using a Provider Information Change
Form.
Mail the completed form to: Texas Medicaid & Healthcare Partnership,
Provider Enrollment, P.O. Box 200795, Austin, TX 78720-0795. Or you can fax
to 512-514-4214.
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Texas Medicaid Enrollment
You need to enroll to provide health
care to Texas Medicaid recipients.
You may enroll with the Texas
Medicaid through the Texas Medicaid
& Healthcare Partnership. Go to
TMHP.com > Providers > Enroll
Today!
Re-enrollment is required every three
to five years, depending on your
provider category. For more details,
go to TMHP.com > Providers >
Federal Reenrollment > Provider
Enrollment Tools Quick Reference
Guide.
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For More Information
Our Customer Service department has a team of representatives dedicated to
network care provider needs. Please call 888-887-9003 weekdays, 8:00 a.m.
to 5 p.m.
For contract issues, fee schedules or change of demographic information,
contact UnitedHealthcare Network Management at 866-574-6088. We
re-credential every three years.
Providers of Long Term Services and Supports should call 888-787-4107.
To find an in-network referral and to coordinate services for
our members, including behavioral health, please visit
UHCCommunityPlan.com > For Health Care Providers >
Texas > Find a Physician or call our Customer Service at
888-887-9003.
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New Provider Checklist
 Register as a new user with Optum Link.
 Register as a new user with UnitedHealthcareOnline.com.
 Register with Electronic Data Interchange Support Services. Learn more at
UHCCommunityPlan.com > For Health Care Providers > Texas > Electronic Data
Interchange (EDI).
 Apply for Electronic Payment & Statements. Go to
MyServices.OptumHealthPaymentServices.com > How to Enroll.
 Sign up for the monthly Network Bulletin at UnitedHealthcareOnline.com > Tools &
Resources > News & Network Bulletin.
 Get to know your physician or provider advocate:
•
Physician Advocates – Call 888-303-6162 or email
[email protected].
•
Provider Advocates for LTSS – Call 888-787-4107 or email
[email protected].
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Thank you!