PROVIDERS

Providers-persons and entity that is authorized to provide medical care or supplies.

MEMBERS EXPERIENCE:

FACILITIES: Hospice Centers-terminal patients Nursing Facilities-service for the long-lives patients Rehabilitations

Inpatient-admitted in the hospital more than 24 hours Outpatient-admitted but less than 24 hours

Physicians-operate independently from hospital or group practice -can be considered a primary -MD or Medical Doctor

Primary Care Physicians: -a physician who provides both the FIRST CONTACT for a person with a health concern. They also coordinate all care to needed specialist. COLLECTS and stores the members medical records.

Types of PCP: 1.Internal Medicine-the only doctors that we can assigned. For adults 2.Family Practice 3.Pediatrician-0 to 18 years old(once reaches 19 then they need to look for other PCP) 4.General Practitioner-nurses only but can provide prescriptions

PCP Responsibilities: 1.Complete the initial assessment required by Medicaid members 2.Perform ongoing basic and preventive care 3.Remain available 24 hours a day, 7 days a week and provide back up coverage during their absences. 4. Refer members to specialists when necessary 5.Admit patients to the hospital when necessary 6.Coordinate the care of patients requiring inpatient care

SPECIALTIES: -physicians that focus on a specific clinic area

FACILITY SPECIALTIES: Hospitals Surgery center Skilled nursing facility Nursing Home Urgent and Emergency Care Centers

Emergency Care-Life Threatening cares Urgent Care-not life threatening but needs doctor ASAP

Provider Contracting Participating-provider has a contractual arrangement with UHC Non-Participating- provider has chosen not to enter into a contractual agreement with UHC(out of network)

Provider Contracts *help determine the payment made to the provider for services or products *has a direct effect on the members financial responsibility on a claim for medical services or products

Contiguous Market *expands the member network across the state borders

Members Benefit: A participating provides agrees to: 1.Maintain the highest medical standards and level of care 2.Accepts a contractual amount for each medical service 3.Bill United HealthCare first. Provider charged United Heath care first before charging the Member. 4.Write off the difference between contracted and billed charge

For example: in 500 regular price, since the member needs only to pay for 10 dollars and UHC will be charged 190 dollars total to 200 dollars for the contracted price so the 300 remaining amount will be WRITTEN OFF.

PROVIDER INQUIRIES-INDEX(IFP)

Assign a Provider

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Provider Inquiries-Specialist Search Cardiologist

Do you have doctor in your mind that we can check and look into? 2.Change the zipcode in rally: 3.People: Specialty 4.More Filter Call first the doctor before providing information Probing Questions: ( call to ask if they accept new patients under Texas Individual Exchange Benefit Plan-This is an HMO plan coming from the marketplace) 2.May I know if you want me to schedule an appointment 3.May I know when are you going to visit the doctor office?

If appointment scheduled then that is the time that you can tell to the member the information about the doctor

To avoid long hold, ask the provider if can member talk to them so the appointment will be set up completely. Connect the member to the provider then ask the 2&48

If the provider needs referral from the member then offer to the member to connect them with the Primary Care Physicians to process the referral TAT 24-48 hours then once the referral posted in the members account then member can call the doctors that we provided to set up an appointment.

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PCP ASSIGNMENT

ASSIGN PCP: -select NO Identify the member’s state/plan type: all others/ifp -lock in file? No -would like to assign as PCP? No -Provider recommendation: -do you need to do additional research to locate a provider: yes

IN RALLY: -Change the zipcode -if there is specific name of the doctor then just search it -People -primary Care -What kind of Primary care do you need? -If regular doctor, select family doctor -how far can you travel? 10 miles -do you have gender preferences or language preferences? -If member talking to you in Spanish then proactive to choose Spanish doctor -Would you like me to set up an appointment for you? -If yes, then call the doctor if they are accepting new patients -If yes then process the appointment using maestro -before assigning the mmeber advocate needs to provide the PCP informations -to assign both of the member under one PCP then REQUIRES verbal authorization. -After the verbal authorization then update both but if not then only for the primary -Reason for Change: Member then Select Request Convenient -Another screen pop out, select either Mail or Email but proactively tell through email then SUBMIT. -after submitting then complete the disposition -After you assign then tell proactively the SR-**** or reference number to show proof that already assigned a doctor.

To send it through email:

save ---close---back---click saved---print/email providers

PRE-EFFECTIVE(not active yet) -did not pay the binder payment yet -cannot assign but can look for available PCP -payment should be posted first -they can assign in the members portal in the website(just provide the name of the doctors)

Active Members:

*Provider Inquiries - PCP Search (IFP) -If cannot find an available doctor, offer the callback(do not provide any specific date and time)

*Assign a PCP -they have one month to assign a PCP once the plan activated. -If after 1 month still have no PCP assigned to the member then UHC will automatically assign a PCP for them. -Maestro will not allow to back date a PCP's effective date. Escalation Team should not be engaged.

Important Tips while assigning a PCP -if assigning doctors to multiple members then needs verbal authorization.

FOR EXAMPLE: Called: October 9 Effective Date for the PCP: October 15 -it means that the member can only visit the doctor starting October 15 onwards.

*ASSIGN SPECIALIST AS PCP -If provider is already contracted and showing as a PCP in the system then we can assign through Maestro. However, if NOT then engage to the escalation team.

IMPORTANT NOTE: If a provider is not contracted with UHC, do not contact the office to provide instruction on becoming a participating provider. Use resource in this section to submit the discrepancy.

*Provider Inquiries - Reporting Provider Discrepancies (IFP) -Use rally to report Incorrect Information -members can report using the members portal -if the providers appear as INN and accepting new patients but do not show in rally, advice the providers office to contact UHC provider Service for assistance updating their network profile

*******Indian Health Care Providers -IHCP exist in 35 states heavy presence in Arizona (AZ), New Mexico (NM), Oklahoma (OK), and Washington (WA) -commonly serving native indian -Individual physicians are not loaded -Only native Indian american can use the out of network. -use rally to determine the IHCP the provider is affiliated with -Authorizations; To locate an Out of Network PCP or Specialist, use CSP Facets. Advise the member to have his or her PCP submit an authorization for the out-of-network exception

KELSEY SEYBOLD**

-Use this section to assist members who are in plans delegated to Kelsey-Seybold with related provider inquiries.

-Members in Kelsey-Seybold plans are auto-assigned Kelsey-Seybold Clinic as their PCP. -Kelsey Seybold members can assign a medical group/clinic/facility as their PCP but for no Kelsey Seybold ,they cannot because it has to be a specific provider -assist by the UHC advocates -assist the members from this plan before transferring

Who is Kelsey-Seybold Clinic? -its like a branches of Medical City located in every Malls to give services

Provider Access -MyKelseyOnline website and app. -they can choose on any specialist as long as under Kelsey Seybold -if they called to get assistance for look up on specialist but you provided a specialist not under Kelsey Seybold then the claim will be DENIED.

ID Cards

Your ID card has 3 logos on the top:

1.The UHC logo which indicates that UHC is your health plan. 2.The Optum logo which indicates that your prescription drugs are through Optum Rx 3.A Kelsey-Seybold logo in the top right because you selected a UHC copay focus plan where Kelsey-Seybold is the network.

*Fulfillment and Communications *Member Experience 1.Appeals: -------------processed and filed by United Healthcare

2.Authorizations

3.Claims -------------claims for pediatric dental, pediatric vision, hearing, behavioral health, transplant and OOA(out of area)

4.Grievances -------------filed and reviewed by UHC

5.Referrals -------------only services handled by UHC will be the only referrals to processed by UHC

6.Direct member reimbursement DMRs are processed by UHC

*OUTREACH *MAESTRO NAVIGATION

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Behavioral Health (IFP) -for member that -you can only find behavioral

DENTAL PROVIDER VISION PROVIDERS DME PROVIDERS PCP FACILITIES SPECIALISTS

Referral-document introducing the patient to any specialist otherwise the claim will be denied. Referral is not required for Kelsey-Seybold plan.

Non-Gated----meaning the referral is NOT required to se a specialist Gated----required a referral to see specialist All non-Kelsey Seybold plans will be gated Kelsey-Seybold are gated when seeing non-KSC specialists. Members may see Kelsey-Seybold specialists without a referral. Check Kelsey-Seybold Index for information.

-----Referral Look-up Process -does not apply to Kelsey Seybold Plan

Role of Primary Care Physician (PCP) ----You can change your PCP anytime (not more than once every 24 hours) through your online account at myuhc.com/exchange or by calling Member Services

Referral Exception Process ----Member must meet one of the five criteria listed below. ----Do not proactively offer an exception to members. The member must mention one of the qualifications unprompted. ----This process does not apply to members in Kelsey-Seybold plans.

Qualifications for Exceptions for Referral: 1.The member had late or retroactive enrollment into the plan. 2.The member was given a paper referral by their PCP. 3.The member needs follow up care as a result of an urgent care or emergency room visit or an inpatient stay. 4.The member is a new member who has ongoing treatments with an INN (In- Network) specialist. 5.The current PCP was unaware of the plan’s referral requirements.

NOTE: -If denied because there is no referral on file: FILE AN APPEAL! -Paper referral provided on file---when is the start and end date of the referral -TAT 24-48 hours for the referral processing -PCP can backdate up to 5 days from the date of service -Referrals must be submitted electronically at UHCPROVIDER.COM by the members PCP -If no recorded claim on file then proceed with the appointment then advice to contact the PCP for the backdated referral up to 5 days

Two types of Referral:

1.STANDARD - up to 6 visits for 6 months for short-term care/treatment. -------Your PCP will determine the number of visits. Each referral may include up to six visits. Unused visits expire six months from the referral start date. After the six visits are used or expire, the PCP may submit another referral to the network specialist.

2.STANDING-up to 99 visits for 6 months for long-term care/treatment. -------f the member has one of the chronic conditions listed below, their PCP can submit a standing referral for an additional number of visits.

Referrals to out-of- network specialists 1.Offer to locate a participating provider within the same specialty for the member.(claim will be denied because UHC is using HMO so it means it requires an INN)

2.Offer to contact the member's PCP office to provide the name(s) of participating providers within the same specialty and advise the provider they can submit the referral online through their provider portal.

3.If the member insists on seeing the non-participating provider the PCP is wanting to refer the member to, you MUST advise the member of the following: ------The member will not have coverage for the out-of-network provider ------There is a risk of the member being responsible for all costs incurred. *The office visit *Any services or DME provided through the office. *Services performed *Follow-up visits.

******************Referral Exemptions ---The information below does not apply to Kelsey-Seybold plan members. ---Referrals are not required when billed by a participating provider

Specialty Exceptions:

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