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United Healthcare Community Plan of Missouri Overview

Agenda

UnitedHealthcare Community Plan of Missouri

Member Eligibility and Benefits

Personal Care Overview

Notification and Prior Authorization

Claims Management

Care Provider Resources

UnitedHealthcare Community Plan

Overview

Doc#: PCA-1-007978-09142017_09292017 Proprietary information of UnitedHealth Group. Do not distribute or reproduce without express permission of UnitedHealth Group.

Our Mission

Our mission is to help people live healthier lives and to help make the health system work better for everyone. Our Vision

To be the premier health care delivery organization in the eyes of our state partners, providing health plans that meet the unique needs of our Medicaid members as well as our members in other government-sponsored health care programs; to be effective partners with physicians, hospitals and other health care professionals in serving their patients.

Mission and Vision


On May 1, 2017, UnitedHealthcare Community Plan of Missouri covers Medicaid members under the MO HealthNet program. UnitedHealthcare Community Plan serves members in all Missouri counties.

UnitedHealthcare Community Plan of Missouri


Managed Care Eligibility Groups

• UnitedHealthcare Community Plan of Missouri will cover Medicaid members in these eligibility groups. • MO HealthNet for Families • MO HealthNet for Kids • MO HealthNet for Pregnant Women • Transitional MO HealthNet • Children receiving adoption subsidies • Children in care and custody of the state • Children receiving refugee assistance • Children’s Health Insurance Program (CHIP)


Because member eligibility can vary by day, please verify eligibility and benefits before providing services. You can verify eligibility by: •Visiting the MO HealthNet portal at emomed.com. • Using the eligibilityLink app on Link. If you don’t have an Optum ID, go to UHCprovider.com and select “New User” to begin registration.

• Call Provider Services at 866-815-5334 or call the number on the back of the member’s ID card.

Verifying Eligibility and Benefits


Member ID Cards

• Information on the UnitedHealthcare Community Plan member ID card can help you submit claims more efficiently and accurately.

• Be sure to check the member’s ID card at each visit and copy both sides of the ID card for your files.

• You can also view Member ID cards online using the eligibilityLink app on Link.

Personal Care


Personal Care Overview

• Personal care services are medical tasks provided in the individual’s home that are

approved by the state or a physician as necessary to meet a member’s physical needs. This helps the member stay at home and be treated on an outpatient basis rather than be admitted to a hospital or nursing facility.

• “Home” can include members in Residential Care Facilities or Assisted Living

Facilities.

• Personal care services are intended to meet personal, physical requirements that can’t be met by other resources.

• To be covered by the Missouri Title XIX (Medicaid) Program, these services must be provided by a qualified individual who is not a member of the participant’s family.

Source: Manuals.momed.com/collections/collection_per/print.pdf.


Procedure Codes Please use these procedure codes when billing for personal care services.

PROC CODE DESCRIPTION SERVICE UNIT • T1019 Personal Care 15 min. unit

• T1001 Authorized Nurse Visit Per visit • T1019TF Advanced Personal Care 15 min. unit

• T1019U3 Personal Care in RCF/ALF 15 min. unit

• T1019U3TF Advanced Personal Care in RCF/ALF 15 min. unit • T1001U3 Authorized Nurse Visit in RCF/ALF Per visit

• T1028TS Participant Reassessments One per year

The only acceptable place of service (POS) is 12, for home. A licensed Residential Care Facility (RCF)/Assisted Living Facility (ALF) is also considered the participant’s home when providing MO HealthNet personal care; therefore, the POS code for services delivered in an RCF/ALF is 12.


Other Procedure Codes

The following codes are valid only for MO Health Net participants aged 0-20, for services under the Healthy Children and Youth Program.

PROC CODE DESCRIPTION SERVICE UNIT

T1019EP Personal Care 15-min. unit

T1019TFEP Advanced Personal Care 15-min. unit

T1001EP Authorized Nurse Visit Per visit

The only acceptable place of service (POS) is 12, for home. A licensed Residential Care Facility (RCF)/Assisted Living Facility (ALF) is also considered the participant’s home when providing MO HealthNet personal care; therefore, the POS code for services delivered in an RCF/ALF is 12.

Prior Authorization and Notification


Requesting Prior Authorization You can request prior authorization in one of the following ways:

• Use the Prior Authorization and Notification app on Link. Learn more at UHCprovider.com/PAAN.

• Fax a request form to 844-881-4772. • Call 800-366-7304, Monday – Friday, 8 a.m. – 5 p.m. (Exception: state-designated holidays)

• After hours, call 800-366-7304 and follow the prompts for prior authorization requests.

For a list of services requiring prior authorization, please visit UHCCommunityPlan.com > For Health Care Professionals > Missouri > Advanced Notification/Prior Authorization List.

You can find prior authorization request forms at UHCCommunityPlan.com > For Health Care Professionals > Missouri > Provider Forms > Prior Authorization Fax Request Form.


Prior Authorization Response Times

• Please schedule procedures as far in advance as possible.

• Request prior authorization at least 14 calendar days before the planned service date.

• A decision for standard/non-emergency requests will be provided within 36 hours after we receive clinical information.

• Decisions for urgent requests will be rendered within 24 hours.

• If we need additional information, response times may vary for standard/non-emergency requests.

• If you are emergency room staff, requesting a non-emergency service, please call to initiate prior authorization.

• Prior authorization is a medical necessity review, but doesn’t guarantee payment.

Claims Management


Claims Submission

For electronic submission, Payer ID 87726 is the most common primary Payer ID. Check with eSolutions and health plan for a different payer ID.

• Link application – claimsLink

• Clearinghouse of your choice: If you receive 835 Electronic Remittance Advice (ERAs) through a vendor, please ask them to enroll you for the 835 through OptumInsight.

• Connectivity Director

• To find out more, please contact your vendor or call Electronic Data Interchange (EDI) at 800-842-1109.

• To submit paper claims, please send them to: UnitedHealthcare Community Plan of Missouri P.O. Box 5240 Kingston, NY 12402-5240


Submitting a Claims Reconsideration

If you disagree with the outcome of a claim determination, your first step is submitting a claim reconsideration request in one of the following ways:

• Preferred Method: Please submit claims reconsideration requests electronically through your EDI Clearinghouse or using the claimLink application on Link.

• Call Provider Services at 866-815-5334 or call the number on the back of the member’s ID card.

• To submit paper claim reconsideration, please use the Claim Reconsideration Request Form for corrections that require specific instructions. The form is not required for basic corrections or adjustments.

• When correcting or submitting late charges on 837 institution claims, use bill type “xx7, Replacement of Prior Claim.”

• Do not submit corrected or additional information charges using bill type “xx5, Late Charge Claim.”

• Be sure to obtain a tracking number for future reference. This will be an 18 digit number beginning with SF or a PTPCR number from Link.

The Claim Reconsideration Request Form is available at UHCprovider.com > Menu > Claims, Billing and Payments > Submit a Claim Reconsideration.


Submitting a Corrected Paper Claim

• On the Claim Reconsideration Form, check the box #4: Resubmission of a corrected claim.

• Complete the Comments section, clearly stating what data elements have been corrected and why.

• Send the claim and Claim Reconsideration Request Form to the address on the explanation of benefits (EOB) or back of the member ID card.

Doc#: PCA-1-007978-09142017_09292017 Proprietary information of UnitedHealth Group. Do not distribute or reproduce without express permission of UnitedHealth Group. .

You have several options for filing a formal appeal:

• Online: Use the Claims Management or ClaimsLink application on Link.

• Fax: 801-994-1082

• Mail: UnitedHealthcare Grievances and Appeals PO Box 31364 Salt Lake City, UT 84131-0364

Our Provider Advocates are available to assist you in navigating our processes. There is a one year timely filing limit, from the date of the first EOB, to complete all steps in the reconsideration and appeal process.

Filing Appeals


Signing Up for Electronic Payments & Statements (EPS)

With EPS, you receive electronic funds transfers (EFT) for claim payments - and Explanation of Benefits (EOBs) are delivered online. • Lessens administrative costs and simplifies bookkeeping • Reduces reimbursement turnaround time • Funds are available as soon as they are posted to your bank account

Here’s what you’ll need: • Bank account information for direct deposit • Either a voided check or a bank letter to verify bank account information • A copy of your practice’s W-9 form

To receive direct deposit and electronic statements through EPS, please enroll at myservices.optumhealthpaymentservices.com.


Electronic Payments & Statements (EPS)

If you’re already signed up for EPS, you will automatically receive direct deposit and electronic statements through EPS for UnitedHealthcare Community Plan of Missouri.

For more information, please call 866-331-2243.

Or go to UHCprovider > Claims, Billing and Payments > Electronic Pay.ments and Statements.

Resources


Online Community Plan Resources

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UnitedHealthcare Community Plan of Missouri • Helpful care provider resources, including: • Administrative Guide • Reimbursement & Clinical policies • Care Provider bulletins • Practice Matters Newsletter

Visit UHCCommunityPlan.com > For Health Care Professionals > Missouri.


Link

Link is your gateway to UnitedHealthcare’s online tools.

Use Link applications to help simplify daily administrative tasks: • Check member eligibility • Submit a claims reconsideration • Review coordination of benefits

information • View care opportunities for members

To register for Link, sign in to UHCprovider.com using your Optum ID or click “New User” if you do not have an Optum ID.


Network Management Resources

Need to make demographic changes to your office information? Call 877-369-1302.

You can also email the Network Management Team at [email protected].


Provider Relations Support

If you have questions and provide services in the following Missouri counties, email us at [email protected]: Andrew, Atchison, Bates, Buchanan, Caldwell, Clay, Carroll, Cass, Clinton, Daviess, De Kalb, Harrison, Henry, Holt, Gentry, Grundy, Jackson, Johnson, Lafayette, Livingston, Linn, Nodaway, Mercer, Platte, Ray and Worth For all other counties, please email us at [email protected].

mailto:[email protected]

Thank You

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