• Applicable to all states except NC

Skip left navigation

Service Standards - 2020 UnitedHealthcare Administrative Guide

Service Standards

Access — When the care provider group develops Virtual Visit technology, it may offer services to assigned members who have the coverage as a part of their benefit plan. We pay for Virtual Visit primary care services delivered by care providers covered under professional capitation. Not all UnitedHealthcare West benefit plans have the Virtual Visit benefit option. The care provider group must confirm member eligibility and cost-share for Virtual Visit service. This applies only if medical group/IPA develops its own virtual visit technology.

24 Hour/Seven Day Availability — Virtual Visit technology services are available 24 hours a day, seven days a week.

Staffing Credentials — All professional staff are certified or licensed in their specialty or have a level of certification, licensure, education and/or experience based on state and federal laws.

Staff Orientation and Ongoing Training — The care provider group must take part in a written orientation plan with documented skill demonstrations. It must also have initial and ongoing training programs, including policies and procedures. The care provider group will pursue accreditation of its Virtual Visit program with the American Telemedicine Association.

Service Response Time — Within 30 minutes after a member requests a visit, the care provider group contacts the member to either schedule or hold a Virtual Visit.

Technology Security — The care provider group conducts all member Virtual Visits using interactive audio and/or video telecommunications systems on a secure technology platform that meets state and federal law requirements for security and confidentiality of electronic member information. It maintains member records in a secure medium that meets state and federal law requirements for encryption and security of electronic member information.

Professional Accreditation — The care provider group pursues applicable accreditation by the American Telemedicine Association (or other mutually agreed upon accreditation body) to become accredited within one year after the accreditation program release date.

Continuous Quality Improvement (CQI) — The care provider group must have a documented CQI program for identifying through data opportunities for time-measured improvement in areas of core competencies. There must be demonstrated ties between CQI findings and staff orientation, training, and policies and procedures.

Member Complaints — The care provider group logs, by category and type, member complaints with specific improvement action plans for any patterns. There should be complaints registered on less than 2 percent of member cases.

Regulatory Assessment Results — If we ask, the care provider will allow access to any applicable regulatory audit results.

Utilization — The care provider group submits Virtual Visit encounters with proper coding as part of its existing encounter submission process.

Electronic Billing/Encounter Coding — The care provider group will submit Virtual Visit encounters or claims with proper coding as part of its existing encounter submission process.

Eligibility Verification — The care provider group uses existing eligibility validation methods to confirm Virtual Visit benefits.

Case Communication — The care provider group will support member records management for Virtual Visits using existing EMR systems and standard forms. Keep required medical information in EMR records, including referrals and authorizations.

Joint Operating Committee — The care provider meets with us up to quarterly at our request to review data reports and quality issues. We also address any administration issues.

Professional Environment — The care provider group helps ensure that, when conducting Virtual Visits with members, the rendering care provider is in a professional and private location. The care provider group (rendering care providers) may not conduct member Virtual Visits in vehicles or public locations.

Medical Director — The care provider employs or engages a licensed care provider as medical director. The medical director is responsible for clinical direction.