The fastest way for us to talk is electronically. Electronic Data Interchange (EDI) is the preferred method for doing business transactions. Find more information on UHCprovider.com/edi.
The issues of confidentiality and objective medical observations are the key in the diagnosis and treatment of our members. Therefore, a care provider or other
licensed independent health care professional who is also a UnitedHealthcare member shall not serve as PCP for themselves or their dependents.
You are responsible for checking member eligibility within two business days prior to the date of service. You may be eligible for reimbursement under the Authorization Guarantee program described in the Capitation and/or
Delegation Supplement for authorized services if you have checked and confirmed the member’s eligibility within two business days before the date of service.
You must verify the member’s eligibility each time they receive services from you. We provide several ways to verify eligibility:
Get more details regarding a specific member’s benefit plan in the member’s Combined Evidence of Coverage and Disclosure Form, Evidence of Coverage, or Certificate of Coverage. Benefit plans may be addressed in procedures/ protocols communicated by us. Details may include the following:
Each member receives a health care ID card with information to help you submit claims accurately. Information may vary in appearance or location on the card due to payer or other unique requirements. Check the member’s health care ID card at each visit, and keep a copy of both sides of the card for your records. Sample health care ID cards specific to the member are available when you verify eligibility online.
For more detailed information on ID cards and to see a sample health care ID card, please refer to the Health Care Identification (ID) Cards section of Chapter 2: Provider Responsibilities and Standards.
If we provide eligibility confirmation indicating that a member is eligible at the time the health care services are provided, and it is later determined that the patient was not eligible, we are not responsible for payment of services provided to the member, except as otherwise required by state and/or federal law. In such event, you are entitled to collect the payment directly from the member (to the extent permitted by law) or from any other source of payment.
Eligibility Verification Guarantee (TX Commercial) We reimburse Texas care providers who request a guarantee of payment through the verification process.
The verification is based on the Agreement and the guidelines in Texas Senate Bill SB 418.
We will guarantee payment for proposed medical care or health care services if you provide the services to the member within the required time frame. We reduce the payment by any applicable copayments, coinsurance and/or deductibles.
You must include the unique UnitedHealthcare West verification number on the claim form (Field 23 of CMS 1500 or Field 63 of UB-04).
You must request eligibility prior to rendering a service. Otherwise, we are not responsible for payment of those services. You are entitled to collect the payment directly from the member to the extent permitted by law or from any other source of payment.
Submit service verification requests to:
P.O. Box 30975
Salt Lake City, UT 84130-0975
We monitor members’ access to medical and behavioral health care to make sure that we have an adequate care provider network to meet the members’ health care needs. We use member satisfaction surveys and other feedback to assess performance against standards.
We have established access standards for appointments and after-hours care. Exceptions or additions to those standards are shown in the following table.
Regular or routine
Urgent exam (PCP or Specialist)
In-office wait time
Non-urgent ancillary (diagnostic)
*As an “authorization representative” of UnitedHealthcare, physicians are responsible to notify the member about the prior authorization determination, unless State regulation requires otherwise.
For details on these access standards refer to Chapter 2: Provider Responsibilities, Timely Access to Non-Emergency Health Care Services (CA Commercial).
Report all demographic changes, open/closed status, product participation or termination to us.
For complete information please visit the Demographic Changes section of Chapter 2: Provider Responsibilities and Standards.
Complying with the Medical Management Program includes but is not limited to:
A complete library of Benefit Interpretation Policies (BIPs) and Medical Management Guidelines (MMGs) are available:
We publish monthly editions of the BIP and MMG Update Bulletins. These online resources provide notice to our network care providers of changes to our BIPs and MMGs. The bulletins are posted on the first calendar day of every month on our site:
A supplemental reminder to the detailed policy update summaries announced in the BIP and MMG Update Bulletins is also included in the monthly Network Bulletin.
Continuity of care is a short-term transition period, allowing members to temporarily continue to receive services from a non-participating care provider.
Completion of covered services provided for the period necessary to complete the active course of treatment and to arrange for a clinically safe transfer to a network care provider. The active course of treatment is determined by a UnitedHealthcare West or medical group/IPA medical director in consultation with the member, the terminated care provider or the non-network care provider and as applicable, the receiving network care provider, consistent with good professional practice. Completion of covered services for this condition will not exceed 12 months from the Agreement’s termination date, or 12 months after the effective date of coverage for a newly enrolled member.
Continuity of care does not apply when a member initiates a change of PCP or medical group/IPA. Authorizations granted by the previous medical groups shall be invalid in such situations at the commencement of the member’s assignment to the new PCP or medical group/IPA; members shall not be entitled to continuing care unless the member’s new PCP or medical group/IPA authorizes that care.
Virtual Visits (Commercial HMO Plans CA only) UnitedHealthcare of California added a new benefit for Virtual Visits to some member benefit plans. We define Virtual Visits as primary care services that include the diagnosis and treatment of low-acuity medical conditions for members through the use of interactive audio and video telecommunication and transmissions, and audio-visual communication technology.
Virtual Visit primary care services are typically delivered by the capitated care provider groups. Not all UnitedHealthcare West benefit plans will have the Virtual Visit benefit option
To read more about Virtual Visits, refer to the “Capitation and/or Delegation Supplement” .