Welcome to the UnitedHealthcare Care Provider Administrative Guide for Commercial and Medicare Advantage (MA) products. This guide has important information on topics such as claims and prior authorizations. It also has protocol information for health care providers. This guide has useful contact information such as addresses, phone numbers and websites. More policies and electronic tools are available on UHCprovider.com.
- If you are looking for a Community and State manual, go to UHCprovider.com/guides > Community Plan Care Provider Manuals and select the state
- If you are a UnitedHealthcare or Optum participating care provider or facility with an active Department of Veterans Affairs Community Care Network (VA CCN) agreement, you can find more information about VA CCN, including the VA CCN Provider Manual, at vacommunitycare.com.
This 2020 UnitedHealthcare Care Provider Administrative Guide (this “guide”) applies to covered services you provide to our members or the members of our affiliates* through our benefit plans insured by or receiving administrative services from us, unless otherwise noted.
This guide is effective April 1, 2020, for physicians, health care professionals, facilities and ancillary providers currently participating in our Commercial and MA networks. It is effective now for care providers who join our network on or after Jan. 1, 2020. This guide is subject to change. We frequently update content in our effort to support our health care provider networks.
Terms and definitions as used in this guide:
- “Member” or “customer” refers to a person eligible and enrolled to receive coverage from a payer for covered services as defined or referenced in your Agreement.
- “Commercial” refers to all UnitedHealthcare medical products that are not MA, Medicare Supplement, Medicaid, CHIP, workers’ compensation, or other governmental programs. “Commercial” also applies to benefit plans for the Health Insurance Marketplace, government employees or students at public universities.
- “You,” “your” or “provider” refers to any health care provider subject to this guide. This includes physicians, health care professionals, facilities and ancillary providers, except when indicated. All items are applicable to all types of health care providers subject to this guide.
- “Your Agreement,” “Provider Agreement” or “Agreement” refers to your Participation Agreement with us.
- “Us,” “we” or “our” refers to UnitedHealthcare on behalf of itself and its other affiliates for those products and services subject to this guide.
- 'Any reference to “ID card” includes both a physical or digital card.
MA policies, protocols and information in this guide apply to covered services you provide to UnitedHealthcare MA members, including Erickson Advantage members and most UnitedHealthcare Dual Complete members, excluding UnitedHealthcare Medicare Direct members. We indicate if a particular section does not apply to such MA members.
If there is a conflict or inconsistency between a Regulatory Requirements Appendix attached to your Agreement and this guide, the provisions of the Regulatory Requirements Appendix controls for benefit plans within the scope of that appendix.
If there is an inconsistency between your Agreement and this guide, your Agreement controls (except where your Agreement provides protocols for our affiliates). If those protocols are in a supplement to this guide, those protocols control for services you give to a member subject to that supplement.
Per your Agreement, you must comply with protocols. Payment will be denied, in whole or in part, for failure to comply with a protocol.