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UHCprovider.com Home UHCprovider.com

Details: UnitedHealthcare's home for Care Provider information with 24/7 access to Link self-service tools, medical policies, news bulletins, and great resources to support administrative tasks including eligibility, claims and prior authorizations.

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UnitedHealthcare Provider Portal UHCprovider.com

Details: Information and resources for our online self-service tools on the UnitedHealthcare provider portal. On the portal you can get member eligibility, benefits, claims and referral information for multiple UnitedHealthcare plans, all in one location.

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Eligibility and Benefits UHCprovider.com

Details: Health Insurance Marketplace (Exchanges) - Chapter 4, 2021 Administrative Guides; Individual marketplace vs. small business health options program marketplace - 2021 Administrative Guide; UnitedHealthcare’s participation in Exchanges - 2021 Administrative Guide; What is the health insurance marketplace? - 2021 Administrative Guide

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Claims, Billing and Payments UHCprovider.com

Details: OneNet PPO maintains the OneNet PPO Workers’ Compensation Network, a network of physicians, health care practitioners, hospitals and ancillary facilities used for work-related illness and injury. The network serves workers’ compensation programs administered by employers and TPAs contracted with Procura, an Optum Company.

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Prior Authorization and Notification UHCprovider.com

Details: Health Insurance Marketplace (Exchanges) - Chapter 4, 2021 Administrative Guides; Individual marketplace vs. small business health options program marketplace - 2021 Administrative Guide; UnitedHealthcare’s participation in Exchanges - 2021 Administrative Guide; What is the health insurance marketplace? - 2021 Administrative Guide

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Get Credentialed UHCprovider.com

Details: You enter information just once and it’s available to multiple health insurers at no cost to you. For providers in Hawaii: If you are joining a Medicare or commercial plan, or a combination of Medicare, Medicaid and commercial, you will begin the credentialing process by working with MDW Hawaii. Contact MDX at 808-532-6989, option 2.

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Smart Edits UHCprovider.com

Details: Smart Edits is a claims optimization tool that identifies potential billing errors within a claim and allows care providers the opportunity to review and repair before the claim is processed. Smart Edits are sent within 24 hours of a claim submission, so you can review identified claims in a matter of hours instead of potential claims denials days later.

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UnitedHealthcare Community Plan of Kentucky Homepage

Details: Health Insurance Portability and Accountability Act (HIPAA) Information. HIPAA standardized both medical and non-medical codes across the health care industry and under this federal regulation, local medical service codes must now be replaced with the appropriate Healthcare Common Procedure Coding System (HCPCS) and CPT-4 codes.

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Home Health Care

Details: Home health services beyond benefit limits (e.g., number of visits) We will determine if benefits are available by reviewing both the skilled nature of the service and the need for Physiciandirected - medical management. A service will not be determined to be "skilled" …

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Reports and Quality Programs UHCprovider.com

Details: UnitedHealthcare’s disciplined approach to payment reform leverages years of experience with incentive-based contracting models.One component of this overall strategy is the Hospital Performance-Based Compensation (HPBC) program, which provides an incentive to hospitals for quality and efficiency improvements in the delivery of health care

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Single Paper Claim Reconsideration Request Form

Details: information using the website listed on the back of the member’s health care ID card. Physician Hospital Other health care professional (lab, durable medical equipment (DME), etc.) Member information Date form completed Member ID Control / Claim # Date of service Billed …

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Home Blood Glucose Monitors (NCD 40.2)

Details: Home Blood Glucose Monitors (NCD 40.2) Page 1 of 22 UnitedHealthcare Medicare Advantage Policy Guideline Approved 02/10/2021 Proprietary Information of UnitedHealthcare.

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Home Health Care

Details: Non-health-related services such as help with daily living activities. Examples include eating, dressing, bathing, transferring and ambulating. Health-related services that can safely and effectively be performed by trained non-medical personnel and are provided for

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ERA Payer List for UnitedHealthcare, Affiliates and

Details: Sierra Health and Life ; 76342 CA, NV; UMR 39026; ALL UnitedHealthcare; 87726 ALL; UnitedHealthcare / All Savers Alternate Funding 81400; ALL UnitedHealthcare / All Savers Insurance; 81400 ALL; UnitedHealthcare / Oxford 06111; ALL UnitedHealthcare / UnitedHealthcare of the Mid-Atlantic, MD IPA, Optimum Choice and MAMSI Life and Health (formerly

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2021 UnitedHealthcare Care Provider Administrative Guide

Details: workers’ compensation or other government 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 …

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Worksite Wellness Health Screening UHCprovider.com

Details: Beginning Jan. 1, 2017, Quest Diagnostics is administering UnitedHealthcare's Worksite Wellness Health Screening Solutions program. Offered to our Commercial market, the program is an employer-sponsored biometrics screening available to eligible employees, spouses and dependents.

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Plagiocephaly and Craniosynostosis Treatment

Details: health benefits. UnitedHeatlhcare Medci al Policies are intended to be used in connection with the independent professiona l medical judgment of a qualifei d heatlh care provider and do not constitute the practice of medicine or medical advice.

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Breast Reduction Surgery

Details: Covered Health Care Services incul de dental or orthodontic services that are an integra pl art of reconstructive surgery for cleft palate procedures. For the purposes of this section, "cleft palate" means a conditoi n that may include cleft palate, cleft lip, or other craniof acial

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02/2021: UnitedHealthcare is transitioning to InterQual

Details: Health Insurance Marketplace (Exchanges) - Chapter 4, 2021 Administrative Guides; Individual marketplace vs. small business health options program marketplace - 2021 Administrative Guide; UnitedHealthcare’s participation in Exchanges - 2021 Administrative Guide; What is the health insurance marketplace? - 2021 Administrative Guide

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Search UHCprovider.com

Details: Health Insurance Marketplace (Exchanges) - Chapter 4, 2021 Administrative Guides Individual marketplace vs. small business health options program marketplace - 2021 Administrative Guide UnitedHealthcare’s participation in Exchanges - 2021 Administrative Guide

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Mental Health Services and Procedures

Details: Outpatient mental health services are covered when following criteria are met: Services for outpatient mental health must be incidental to a physician’s service. The services or supplies are furnished as an integral, although incidental, part of the physician's personal professional services during diagnosis or treatment of an injury or illness.

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UnitedHealthcare COVID-19 billing guide

Details: health emergency period (currently scheduled to end July 19, 2021) when ordered by a physician or appropriately licensed health care professional for purposes of the diagnosis or treatment of an individual member. Scope-of-practice requirements vary by state. In some states, a pharmacist or other health care professional, such as a

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Practitioner/Provider Administrative Claim Reconsideration

Details: contact the health plan, verbally or in writing, for a review of the claims payment issue. The health plan will make every effort to clarify or explain Oxford’s actions. If the health plan determines that additional payment is justified, Oxford will reprocess the claim and remit the additional payment.

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UnitedHealthcare NexusACO

Details: Health plan coverage provided by UnitedHealthcare of Arizona, Inc., UHC of California DBA UnitedHealthcare of California, UnitedHealthcare Benefits Plan of Cali fornia, UnitedHealthcare of Colorado, Inc., UnitedHealthcare of the Mid-Atlantic, Inc., MAMSI Life and Health Insurance Company, UnitedHealthcare of New York, Inc.,

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2021 hospital policy changes: Notification updates for

Details: This change impacts UnitedHealthcare Medicare Advantage and UnitedHealthcare commercial health plans at this time. UnitedHealthcare Exchange plans, Dual Special Needs Plans and Community Plans (Medicaid) are currently out of scope for these notification requirements. Exceptions are noted below for UMR Health Plans and Neighborhood Health Plan

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Rhinoplasty and Other Nasal Surgeries

Details: Benefit coverage for health services is determined by the member specific benefit plan document and applicable laws that may require coverage for a specific service. The documentation requirements outlined below are used to assess whether the member meets the clinical criteria for coverage but do not guarantee coverage of the service requested.

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UnitedHealthcare HEDIS® 2020 Medical Record Collection

Details: the health information organization? Yes. You’re permitted to disclose protected health information (PHI) to UnitedHealthcare and to contracted data collection vendors who are acting on our behalf as business associates. Under the HIPAA privacy rule, a health care provider is permitted to share PHI with a health …

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2021 Care Provider Manual

Details: improved access to health care and reduced expenses. WPC provides a care management/coordination team that helps increase member engagement, offers resources to fill gaps in care and develops personalized health goals using evidence-based clinical guidelines. This approach is essential to improving the health and

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Policy Guidelines for Medicare Advantage Plans

Details: The appearance of a health service (e.g., test, drug, device or procedure) in the Policy Guideline Update Bulletin does not imply that UnitedHealthcare provides coverage for the health service. In the event of an inconsistency or conflict between the information provided in the Medicare Advantage Policy Guideline Update Bulletin and the posted

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Ketalar (Ketamine) and Spravato (Esketamine)

Details: Listing of a code in this policy does not imply that the service described by the code is a covered or non-covered health service. Benefit coverage for health services is determined by the member specific benefit plan document and applicable laws that may require coverage for a specific service.

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Behavioral Health Services

Details: All behavioral health providers . Reimbursement for the Behavioral Health and Evaluation and Management CPT Codes are subject to the billing requirements established by the American Medical Association (AMA) and the American Psychiatric Association (APA). CPT codes (90832-90834, 90836-90839, 90875-90876, and 90899) are time-based.

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Ambulance Services – Commercial Coverage Determination

Details: Covered Health Care Service(s) : Health care services, including supplies or Pharmaceutical Products, which UnitedHealthcare determines to be all of the following: Provided for the purpose of preventing, evaluating, diagnosing or treating a Sickness, Injury, Mental Illness, substance-

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Prolonged Services Policy

Details: rendering health care services reporting the same Federal Tax Identification number. Reimbursement Guidelines . Oxford reimburses Prolonged Services when reported with E/M codes in which time is a factor in determining level of service in accordance with CPT and/or HCPCS guidelines. Physicians or other qualified health care professionals should

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Cell-Free Fetal DNA Testing

Details: Benefit coverage for health services is determined by the member specific benefit plan document and applicable laws that may require coverage for a specific service. The do cumentation requirements outnli ed below are used to assess whether the member meets the clinci al criteria for coverage but do not guarantee coverage of the service requested.

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Global Days Assignment List

Details: The listing of a code does not imply that the service described by the code is a covered or non-covered health service. Benefit coverage for health services is determined by the member specific benefit plandocument and applicable laws that may require coverage for a specific service.

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Speech Language Pathology Services

Details: trained, the services are no longer skilled, therefore custodial, and not a covered health service. Refer to the Coverage Determination Guideline titled Skilled Care and Custodial Care Services. Mandated benefits (federal and state) for Speech and Language Therapy. Examples may include Developmental Delay, autism, cleft palate and/or lip, aphasia.

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Hospital Acquired Conditions Policy, Facility

Details: to health care services provided in a particular case. Further, the policy does not address all issues related to reimbursement for health care services provided to UnitedHealthcare Medicare Advantage enrollees. Other factors affecting reimbursement may supplement, modify or, in …

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Dental Clinical Policies and Coverage Guidelines

Details: A monthly notice of recently approved and/or revised Dental Clinical Policies and Coverage Guidelines is provided below for your review. We publish a new announcement on the first calendar day of every month.. The appearance of a dental service (e.g., procedure or technology) in the Dental Policy Update Bulletin does not imply that UnitedHealthcare provides coverage for the dental service.

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Federal/State Mandated Regulations

Details: the health care service plan and its participating providers or provider groups, and pursuant to Section 1374.14. d. A health care service plan shall not limit the type of setting where services are provided for the patient or by the health care

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Reimbursement Policies for Community Plan UHCprovider.com

Details: Health Insurance Marketplace (Exchanges) - Chapter 4, 2021 Administrative Guides; Individual marketplace vs. small business health options program marketplace - 2021 Administrative Guide; UnitedHealthcare’s participation in Exchanges - 2021 Administrative Guide; What is the health insurance marketplace? - 2021 Administrative Guide

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Bariatric Surgery – Commercial Medical Policy

Details: Listing of a code in this policy does not imply that the service described by the code is a covered or non- covered health service. Benefit coverage for health services is determined by the member specific benefit plan document and applicable laws that may require coverage for a specific service.

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Ophthalmologic Policy: Vascular Endothelial Growth Factor

Details: Veterans Health Administration (USVHA) requires that only USVHA pharmacies may dispense bevacizumab for intravitreal administration to Veterans Administration beneficiaries. The medication must be dispensed directly to the VA ophthalmologist, who will then be responsible for preparing and administering the bevacizumab dose for each patient.

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Outpatient Surgical Procedures – Site of Service

Details: health benefits. The UnitedHealthcare Utilization Review Guidelines are intended to be used in connection with the independent professional medical judgme nt of a qualified health care provider and do not constitute the practice of medicine or medical advice.

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Genitourinary Pathogen Nucleic Acid Detection Panel

Details: Listing of a code in this policy does not imply that the service described by the code is a covered or non- covered health service. Benefit coverage for health services is determined by the member specific benefit plan document and applicable laws that may require coverage for a specific service.

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Lung Cancer Screening with Low Dose Computed …

Details: Listing of a code in this guideline does not imply that the service described by the code is a covered or non-covered health service. Benefit coverage for health services is determined by the member specific benefit plan document and applicable laws that may require coverage for a specific service.

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Prostate: Services and Procedures

Details: information in making health care decisions. Physicians and patients must exercise their independent clinical discretion and judgment in determining care. Each benefit plan contains its own specific provisions for coverage, limitations, and exclusions as stated in the Member’s Evidence of Coverage (EOC)/Summary of Benefits (SB).

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Home Health Services, Home Health Visits and Respite Care

Details: The law does not permit a home health agency (HHA) to furnish a Medicare covered billable visit to a patient under a home health plan of care outside his or her home, except in those limited circumstances where the patient needs to use medical equipment that is too cumbersome to bring to the home. Section 1861(m) of the Act stipulates that home

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2021 Virginia Community Plan Provider Manual

Details: health advocate or other specialists as required for complex needs. • Education and support with complex conditions. • Tools for helping members engage with providers, such as appointment reminders and help with transportation. • Foundation to build trust and relationships with hard-

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