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UnitedHealthcare Commercial Medical & Drug Policies and Coverage Determination Guidelines
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Laboratory Services Policy, Professional - Reimbursement Policy - UnitedHealthcare Commercial Plans
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testing various policy types
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Administrative Guide for Commercial, Medicare Advantage and DSNP
Welcome to UnitedHealthcare 2020 UnitedHealthcare Administrative Guide
Introduction
Introduction
Manuals and Benefit Plans Referenced in the Guide
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Online Resources and How to Contact Us
Provider Responsibilities and Standards
Provider Responsibilities and Standards
Verifying Eligibility, Benefits and Your Network Participation
Healthcare Identification (ID) Card
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Demographic Changes
Notification of Practice or Demographic Changes (Applies to Commercial Benefit Plans in California)
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Commercial Products
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Free Medicare Education for Your Staff and Patients
Referrals
Referrals
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Medical Management
Medical Management
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Advance Notification/Prior Authorization Requirements
Advance Notification/Prior Authorization List
Facilities: Standard Notification Requirements
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Updating Advance Notification or Prior Authorization Requests
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MA Part C Reopenings
Outpatient Cardiology Notification/Prior Authorization Protocol
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Medication-Assisted Treatment (MAT)
Specialty Pharmacy and Medicare Advantage Pharmacy
Specialty Pharmacy and Medicare Advantage Pharmacy
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Specialty Pharmacy Requirements for Certain Specialty Medications (Commercial Plans - Not Applicable to UnitedHealthcare West) - Chapter 7, 2020 UnitedHealthcare Administrative Guide
MA Pharmacy
Drug Utilization Review Program
Medication Therapy Management (MTM)
Transition Policy
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Specific Protocols
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Nursing Home and Assisted Living Plans
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Commercial Consumer Transparency Tools
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Quality Management (QM) Program
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Star Ratings for MA and Prescription Drug Plans
Member Satisfaction
Imaging Accreditation Protocol
Credentialing and Re-Credentialing
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Care Provider Rights Related to the Credentialing Process
Credentialing Committee Decision Making Process (Non-Delegated)
Monitoring of All Network Care Providers
Member Rights and Responsibilities
Fraud, Waste and Abuse (FWA)
Fraud, Waste and Abuse (FWA)
Medicare Compliance Expectations and Training
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All Savers Supplement
All Savers Supplement
How to Contact All Savers, All Savers Supplement
Capitation and/or Delegation Supplement
Capitation and/or Delegation Supplement
What is Capitation?
What Is a Delegated ACO?
How to Contact Us, Capitation and/or Delegation
Verifying Eligibility and Effective Dates, Capitation and/or Delegation
Commercial Eligibility, Enrollment, Transfers and Disenrollment, Capitation and/or Delegation
Medicare Advantage (MA) Enrollment, Eligibility and Transfers, and Disenrollment, Capitation and/or Delegation
Authorization Guarantee, Capitation and/or Delegation
Care Provider Responsibilities, Capitation and/or Delegation
Delegated Credentialing Program, Capitation and/or Delegation
Service Standards
Virtual Visits
Referrals & Referral Contracting
Medical Management, Capitation and/or Delegation
Pharmacy, Capitation and/or Delegation Supplement
Facilities, Capitation and/or Delegation Supplement
Claims Processes, Capitation and/or Delegation Supplement
Claims Disputes and Appeals, Capitation and/or Delegation Supplement
Contractual and Financial Responsibilities, Capitation and/or Delegation Supplement
Capitation Reports and Payments, Capitation and/or Delegation Supplement
CMS Premiums and Adjustments, Capitation and/or Delegation Supplement
Delegate Performance Management Program, Capitation and/or Delegation Supplement
Appeals and Grievances, Capitation and/or Delegation Supplement
Leased Networks
Medica Healthcare Supplement
Medica Healthcare Supplement
How to Contact Us, Medica
Confidentiality of Protected Health Information (PHI)
Referrals
Prior Authorizations
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Documentation and Confidentiality of Medical Records
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Mid-Atlantic Regional Supplement
Mid-Atlantic Regional Supplement
Provider Responsibilities
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Neighborhood Health Partnership Supplement
Neighborhood Health Partnership Supplement
How to Contact NHP
Discharge of a Member from Participating Provider's Care
Laboratory Services
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Utilization Management (UM)
Claims Reconsiderations and Appeals
Capitated Health Care Provider
OneNet PPO Supplement
OneNet PPO Supplement
Who to Contact
Bills Process
Referrals
Provider Responsibilities and Workflows
Medical Records Standards and Requirements
Quality Management and Health Management Programs
Participant Rights and Responsibilities
Oxford Commercial Supplement
Oxford Commercial Supplement
Oxford Commercial Product Overview
How to Contact Oxford Commercial
Care Provider Responsibilities and Standards, Oxford
Referrals, Oxford
Utilization Management, Oxford
Using Non-Participating Health Care Providers or Facilities, Oxford
Radiology, Cardiology and Radiation Therapy Procedures
Emergencies and Urgent Care
Utilization Reviews, Oxford
Claims Process, Oxford
Member Billing
Claims Recovery, Appeals, Disputes and Grievances
Quality Assurance, Oxford
Case Management and Disease Management Programs
Clinical Process Definitions
Member Rights and Responsibilities
Medical and Administrative Policy Updates, Oxford
Preferred Care Partners Supplement
Preferred Care Partners Supplement
About Preferred Care Partners
How to Contact Preferred Care Partners
Confidentiality of Protected Health Information (PHI), Preferred Care Partners
Prior Authorizations and Referrals, Preferred Care Partners
Clinical Coverage Review, Preferred Care Partners
Appeal & Reconsideration Processes, Preferred Care Partners
Member Rights and Responsibilities
Documentation and Confidentiality of Medical Records, Preferred Care Partners
Case Management and Disease Management Program Information, Preferred Care Partners
Special Needs Plans, Preferred Care Partners
Care Provider Reporting Responsibilities, Preferred Care Partners
River Valley Entities Supplement
River Valley Entities Supplement
Eligibility, River Valley
How to Contact River Valley
Reimbursement Policies, River Valley
Referrals, River Valley
Utilization Management, River Valley
Claims Process, River Valley
UnitedHealthcare West Supplement
UnitedHealthcare West Supplement
UnitedHealthcare West Information Regarding our Care Provider Website
How to Contact UnitedHealthcare West Resources
Care Provider Responsibilities, UnitedHealthcare West
Utilization and Medical Management, UnitedHealthcare West
Hospital Notifications, UnitedHealthcare West
Pharmacy Network, UnitedHealthcare West
Claims Process, UnitedHealthcare West
Care Provider Claims Appeals and Disputes, UnitedHealthcare West
California Language Assistance Program (California Commercial Plans), UnitedHealthcare West
Member Complaints & Grievances, UnitedHealthcare West
California Quality Improvement Committee, UnitedHealthcare West
UnitedHealthOne Individual Plans Supplement
UnitedHealthOne Individual Plans Supplement
How to Contact UnitedHealthOne Resources
Claims Process, UnitedHealthOne
Member Complaints & Grievances, UnitedHealthOne
Glossary
Reports and Quality Programs
Reports and Quality Programs
Home Health and SNF High-Performing Provider Initiative Lists
Hospital Performance
PATH
Peer Comparison Reports
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Quality-Based Physician Incentive Program (QPIP)
Quality-Based Shared Savings Program (QSSP)
Star Ratings Program
UnitedHealthcare Capitation, Claim, Quality, Roster and Profile Reports
UnitedHealthcare West Capitation, Settlement, Shared Risk Claims, Eligibility, and Patient Management Reports
UnitedHealth Premium® Program
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