United Behavioral Health, operating under Optum, provides UnitedHealthcare Community Plan members with mental health and substance use disorder (SUD) benefits. The national Optum network manual generally applies to all types of business. Some sections may apply differently based on state law.
The National Optum Behavioral Health manual is located on providerexpress.com.
This chapter does not replace the national Optum network manual. Rather, it supplements the national manual by focusing on Medicaid’s specific services and procedures.
You must have a National Provider Identification (NPI) number to see Medicaid members and receive payment from UnitedHealthcare Community Plan.
UnitedHealthcare Community Plan offers covered behavioral health services for mental, emotional and substance use disorders. We offer care management to help members, clinicians, and PCPs using and offering behavioral health services. We provide information and tools for mental health and substance abuse diagnoses, symptoms, treatments, prevention and other resources in one place.
liveandworkwell.com, accessed through a link on myuhc.com, includes mental health and well-being information, articles on health conditions, addictions and coping, and provides an option for members to take self-assessments on a variety of topics, read articles and locate community resources.
For member resources, go to providerexpress.com. Go to the Live and Work Well (LAWW) clinician center. Locate Health Condition Centers at the Clinical Resources tab. The Provider Express Recovery and Resiliency page includes tools to help members addressing mental health and substance use issues.
Verify the UnitedHealthcare Community Plan member’s Medicaid eligibility on day of service before treating them. View eligibility online on the Eligibility and Benefits application on Link at UHCprovider.com.
Members may access all behavioral health outpatient services (mental health and substance use) without a referral. Prior authorization may be required for more intensive services, such as intensive outpatient program; day treatment; or partial, inpatient or residential care. Help ensure prior authorizations are in place before rendering non-emergent services.
Get prior authorization by going to UHCprovider.com/priorauth, calling 866-604-3267, or faxing 844-881-4772.
Access Link, the gateway to UnitedHealthcare Community Plan’s online tools, on this site. Use the tools to verify eligibility, review electronic claim submission, view claim status, and submit notifications/ prior authorizations.
View the Prior Authorization list, find forms and access the care provider manual. Or call the customer Service Center at 866-815-5334 to verify eligibility and benefit information (available 8 a.m. – 5 p.m. Central Time, Monday through Friday).
Update provider practice information, review guidelines and policies, and view the national Optum Network Manual. Or call Provider Services at 866-815-5334.
Call 888-380-0809 and a customer service representative will assist you with the Appeals and Grievances process. You may file an appeal with written consent from the member within 60 calendar days of the notice of adverse benefit determination.
Send written requests to:
1132 Bishop Street, Suite 400
Honolulu, HI 96813
Submit claims using the 1500 Claim Form (v 02/12) or UB-04 form, whichever is appropriate. Use applicable coding, including ICD diagnosis code(s), CPT, Revenue and HCPCS coding. Include all necessary data to process a complete claim. Find out more about filing claims in Chapter 11.
We conduct routine care provider on-site audits. These audits focus on the physical environment, policies and procedures, and quality record documentation.
Combating the opioid epidemic must include prevention, treatment, recovery and harm reduction.
It is critical you are up-to-date on the cutting edge research and evidence-based clinical practice guidelines. We keep Opioid Use Disorders (OUD) related trainings and resources available on our provider portal to help ensure you have the information you need, when you need it. For example, state-specific Behavioral Health Toolkits are developed to provide access to clinical practice guidelines, free substance use disorders/OUD assessments and screening resources, and other important state-specific resources. Additionally, Pain Management Toolkits are available and provide resources to help you identify our members who present with chronic physical pain and may also be in need of behavioral health services to address the psychological aspects of pain. Continuing education is available and includes webinars such as, “The Role of the Health Care Team in Solving the Opioid Epidemic,” and “The Fight Against the Prescription Opioid Abuse Epidemic.” While resources are available, we also work to help ensure you have the educational resources you need. For example, our Drug Utilization Review Provider Newsletter includes opioid trends, prescribing, and key resources.
Access these resources at UHCprovider.com. Then click “Drug Lists and Pharmacy”. Click Resource Library to find a list of tools and education.
Go to our Drug Lists and Pharmacy page to learn more about which opioids require prior authorization and if there are prescription limits.
Pharmacy lock-ins minimize drug abuse. Pharmacy lock-ins identify and manage members who meet criteria indicative of potential prescription medication misuse or abuse, and specific therapeutic categories with the potential for high abuse, (e.g. narcotic analgesics, narcotic containing cough and cold preparations, sedative hypnotics, central nervous system stimulants, muscle relaxants, controlled substances, etc). When lock-in is determined appropriate, a member is placed into a lock-in where they can only receive prescriptions from a single pharmacy for at least one year.
Quarterly, our data analyst’s team identifies members with potentially inappropriate patterns of medication utilization. This program is specific to pharmacy lock-in only and allows member to access ER/Urgent Care Services. It does include emergency overrides if the pharmacy is closed or there is an issue with the medication being in stock.
Members that meet the criteria and that have been approved for lock-in are sent a notification letter prior to starting. If the member does not choose an approved pharmacy within 30 days following the notice, we select a pharmacy for them. Pharmacy selection is based on the location to the member’s home and based on previous usage. We also evaluate for potential case management.
The member continues to be restricted to the designated pharmacy until the member shows a pattern of safe utilization. A member can be placed back on restriction if there is evidence of recurrent over-utilization or abuse of medical services during that period.
We have a short-acting opioid supply limit of seven days and less than 50 Morphine Equivalent Dose (MED) per day for patients new to opioid therapy. Requests for opioids beyond these limits require prior authorization.
Long-term opioid use can begin with the treatment of an acute condition. For this reason, we recommend you consider prescribing the following:
By adhering to these guidelines, you’ll be working to help minimize unnecessary, prolonged opioid use.
Studies have shown chronic opioid use often starts with a patient prescribed opioids for acute pain. The length and amount of early opioid exposure is associated
with a greater risk of becoming a chronic user. For this reason, the Centers for Disease Control and Prevention recommends when a patient is prescribed opioids for acute pain, they receive the lowest effective dose for no more than the expected.
For more information on this change to UnitedHealthcare Community Plan, please call 888-362-3368.
Evidence-based MAT treatment is central to OUD treatment. MAT takes a chronic condition approach and incorporates medication use in addition to other services, such as counseling, cognitive behavioral therapies, and recovery support, to provide a comprehensive approach to OUD. We expand MAT access and help ensure we have an adequate member MAT network.
To find a behavioral MAT provider in Hawaii:
We contract with OUD Centers of Excellence (where available), which are designated as premier facilities to help ensure people with OUD stay in treatment and receive appropriate follow-up care and supports within their communities.
To find medical MAT providers, see the MAT section in the Medical Management chapter.