Chapter 3: Care Provider Office Procedures and Member Benefits

Once a member is assigned a PCP, view the panel rosters electronically on the UHCprovider.com application on Link. The portal requires a unique user name and password combination to gain access.

Each month, PCP panel size is monitored by reviewing PCP to member ratio reports. When a PCP’s panel approaches the max limit, it is removed from auto- assignment. The state requires PCPs to send notice when their panels reach 85% capacity. To update the PCP panel limits, send a written request.

On the report, an asterisk indicates members are new to the practice. An additional column of the roster indicates if a member is due for a Healthchek exam.

Sign in to UHCprovider.com > select Link > select the UnitedHealthcare Online application on Link > select Reports from the Tools & Resources. From the Report Search page, select the Report Type (PCP Panel Roster) from the pull-down menu > complete additional fields as required > click on the available report you want to view.

Members using UnitedHealthcare Connected for MyCare Ohio must choose a PCP to coordinate their care.

Each enrolled UnitedHealthcare Community Plan member either chooses or is assigned a PCP. The assignment considers the distance to the PCP, the PCP’s capacity and if the PCP is accepting new members. UnitedHealthcare Community Plan will assign members to the closest and appropriate PCP.

Depending on the member’s age, medical condition and location, the choice of PCP may cover a variety of practice areas, such as family practice, general practice, internal medicine, pediatrics and obstetrics. If the member changes the initial PCP assignment, the effective date will be the day the member requested the change.

Members can change their PCPs monthly. If the member requests a PCP change after the first month, the change will be effective on the first day of the next month. A new identification card will be issued and sent to the member’s residence indicating the new PCP’s name and the date the member can begin seeing the new PCP.

Medicaid members have no copays for covered services.

However, MyCare members may have to pay a “patient liability” for nursing facility or waiver services that are covered through their Medicaid benefit. The County Department of Job and Family Services determines if a member’s income and certain expenses require you to have a patient liability.

UnitedHealthcare Community Plan only pays for medically necessary services.

Medically Necessary Definition

Medically necessary health care services or supplies are medically appropriate and:

  • Necessary to meet members’ basic health needs.
  • Cost-efficient and appropriate for the covered services.

Assignment to UnitedHealthcare Community Plan

ODM assigns eligible members to UnitedHealthcare Community Plan daily. We manage the member’s care on the date the member is enrolled until the member is disenrolled from UnitedHealthcare Community Plan. ODM makes disenrollment decisions, not UnitedHealthcare Community Plan. Disenrollment usually takes effect at month’s end, but at times may occur mid-month.

At enrollment time, each member receives a welcome packet that includes a copy of the UnitedHealthcare Community Plan Member Handbook. The handbook explains the member’s health care rights and responsibilities through UnitedHealthcare Community Plan.

Obtain copies of the Member Handbook online by contacting Provider Services.

An enrollment verification representative also contacts each new member within one week of enrollment. They verify the member’s demographic information and PCP selection. They tell members about their responsibilities and the PCP’s role contact Provider Services.

Immediate Enrollment Changes

Immediate enrollment into managed care means the responsible payer for members, including newborns, may change from Fee for Service (FFS) to Medicaid Managed Care during hospitalization. To avoid delays in claims processing and payment, have the payer assignment of newborns checked daily.

Get eligibility information by calling the Medicaid Inquiry line.

Unborn Enrollment Changes

Encourage your members to notify the Ohio county offices when they know they are expecting. The offices notify Managed Care Organizations (MCOs) daily of an unborn when Ohio Medicaid learns a woman associated with the MCO is expecting. The MCO or you may use the online change report through the Ohio website to report the baby’s birth. With that information, ODM verifies the birth through the mother. The MCO and/or the care provider’s information is taken as a lead. To help speed up the process, the mother should notify ODM when the baby is born.

Members may call ODM.

UnitedHealthcare Community Plan must first notify ODM of the birth. Prior to enrollment and assignment of a member ID number, bill for services rendered to the newborn using the mother’s UnitedHealthcare Community Plan ID number. Eligibility begins on the date of birth and continue through the end of the 12th month. Sometimes newborns are added effective on the date of their birth.

Newborns may get UnitedHealthcare Community Plan- covered health services beginning on their date of birth. Check eligibility daily until the mother has enrolled her baby in a managed care plan.

PCP Selection

Although unborn children cannot be enrolled with an MCO until birth, ask your members to select and contact a PCP for their baby prior to delivery. This will help avoid the delays and confusion that can occur with deferred PCP selections.

UnitedHealthcare Community Plan Members can go to myuhc.com/communityplan to look up a care provider.

UnitedHealthcare Community Plan serves members enrolled with ODM. It determines program eligibility. An individual who becomes eligible for the ODM program either chooses or is assigned to one of the ODM- contracted health plans.

  • Enrollment is effective for new members on the first of the month. Members may check their eligibility at benefits.ohio.gov.

Check the member’s ID card at each visit, and copy both sides for your files. Verify the identity of the person presenting the ID card against some form of photo ID, such as a driver’s license, if this is your office practice.

If a fraud, waste and abuse event arises from a care provider or a member, notify UnitedHealthcare Community Plan in writing, as discussed in Chapter 12 of this manual. Or you may call the Fraud, Waste, and Abuse Hotline.

The member’s ID card also shows the PCP assignment on the front of the card. If a member does not bring their card, call Provider Services. Also document the call in the member’s chart.

Member Identification Numbers

Each member receives a nine-digit UnitedHealthcare Community Plan member identification number. Use this number to communicate with UnitedHealthcare Community Plan about a specific subscriber/member. The Ohio Medicaid Number is also on the member ID card.

A PCP may transfer a UnitedHealthcare Community Plan member due to an inability to start or maintain a professional relationship or if the member is non-

compliant. The PCP must provide care for the member until a transfer is complete.

  1. To transfer the member, call Provider Services, or mail with the specific events documentation. Documentation includes the dates of failed appointments or a detailed account of reasons for termination request, member name, date of birth, Medicaid number, current address, current phone number and the care provider’s name
  2. Mailing address:
    UnitedHealthcare Community Plan
    Attn: Health Services
    5900 Parkwood Place, 5th Floor Dublin, OH 43016

  3. UnitedHealthcare Community Plan prepares a summary within 10 business days of the request. We try to contact the member and resolve the issue to develop a satisfactory PCP-member relationship.
  4. If the member and UnitedHealthcare Community Plan cannot resolve the PCP member issue, we work with the member to find another PCP. We refer the member to care management, if necessary.
  5. If UnitedHealthcare Community Plan cannot reach the member by phone, the health plan sends a letter (and a copy to the PCP) stating they have five business days to contact us to select a new PCP. If they do not choose a PCP, we will choose one for them. A new ID card will be sent to the member with the new PCP information.

Verify member eligibility prior to providing services. Determine eligibility in the following ways:

  • Provider Portal: access the Link portal through UHCprovider.com/eligibility
  • Electronic data interchange (EDI): Use the Eligibility & Benefit Inquiry & Response (270/271).
  • Phone: Call the United Voice Portal at 877-842- 3210. Or call the Customer Care number on the back of the members’ ID card.

Go UHCCommunityplan.com/oh > Medicaid Plans to view plan details for both Medicaid and MyCare.

We do not cover any health care services received while out of the country. Medicaid cannot pay for any medical services received outside of the United States.

For information about UnitedHealthcare Dual Complete, please see Chapter 4 of the Administrative Guide for Commercial, Medicare Advantage and DSNP. For state-specific information, go to UHCprovider.com > Menu > Health Plans by State.