Glossary
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2023 UnitedHealthcare Care Provider Administrative Guide
Home Health Care or Home Health Services: Medical care
services provided in the home, often by a visiting nurse,
usually for recovering patients, aged homebound patients or
patients with a chronic disease or disability.
Managed Care: A system designed to better manage the
cost and quality of medical services. Managed care products
not only offer less member liability but also less member
control. Managed care aims to improve accessibility to health
care, reduce cost and improve quality of service. Many
managed care health insurance programs work with Health
Maintenance Organization (HMO) and Preferred Provider
Organization (PPO) boards to promote use of specific health
treatment procedures. Managed care health insurance benefit
plans also educate and work with consumers to improve
overall health by addressing disease prevention. The common
types of managed care products are HMO, PPO and Point of
Service (POS) benefit plans.
Medical Emergency: A medical condition manifesting itself
by acute symptoms of sufficient severity (including severe
pain) that a prudent layperson, who possesses an average
knowledge of health and medicine, could reasonably expect
the absence of immediate medical attention to result in
the following:
• Placing the health of the individual (or, with respect to a
pregnant woman, the health of the woman or her unborn
child) in serious jeopardy
• Serious impairment to bodily functions
• Serious dysfunction of any bodily organ or part
Medically Necessary: To determine medical necessity, we
use generally accepted standards of medical practice, based
on credible scientific evidence published in peer-reviewed
medical literature and generally recognized by the relevant
medical community. We may also use standards based on
physician specialty recommendations, professional standards
of care and other evidence-based, industry-recognized
resources and guidelines, such as InterQual® Care Guidelines.
For Medicare Advantage and Medicaid members, we
use Medicare guidelines, including National Coverage
Determinations and Local Coverage Determinations, to
determine medical necessity of services requested.
If other nationally recognized criteria contradict InterQual,
UnitedHealthcare and delegated medical groups/IPAs follow
the Medicare guidelines for Medicare Advantage members.
Individual criteria is provided to you upon request.
Member: Refers to an individual who has been
determined UnitedHealthcare-eligible and is enrolled
with UnitedHealthcare to receive services pursuant to the
Agreement. Other common industry terms: customer, patient,
beneficiary, insured, enrollee, subscriber, dependent.
National Provider Identification (NPI): NPI is a unique
10-digit identification number issued to health care providers
in the United States by CMS.
Network provider: A professional or institutional health
care provider who has an Agreement with UnitedHealthcare
member’s plan to provide care at a contracted rate. A network
provider agrees to file claims and handle other paperwork for
UnitedHealthcare member. A network provider accepts the
negotiated rate as payment in full for services rendered.
Non-Network Provider: A non-network provider does not
have an Agreement with UnitedHealthcare but is certified to
provide care to UnitedHealthcare members. There are 2 types
of non-network providers: non-participating and participating.
• Non-participating health care provider: A non-
participating health care provider is a UnitedHealthcare-
authorized hospital, institutional provider, physician or
other provider that furnishes medical services (or supplies)
to UnitedHealthcare members but who does not have an
Agreement and does not accept the UnitedHealthcare
allowable charge or file claims for UnitedHealthcare
members. A non-participating health care provider may only
charge up to 15% above the UnitedHealthcare allowable
charge.
• Participating health care provider: A health care provider
who has agreed to file claims for UnitedHealthcare
members, accept payment directly from UnitedHealthcare,
and accept the UnitedHealthcare allowable charge as
payment in full for services received. Non-network providers
may participate on a claim-by-claim basis. Participating
health care providers may seek payment of applicable
copayments, cost-shares and deductibles from the member.
Under the UnitedHealthcare outpatient prospective payment
system, all Medicare participating health care providers and
hospitals must, by law, also participate in UnitedHealthcare
for inpatient and outpatient care.
Nurse Practitioner: A registered nurse who has graduated
from a program that prepares registered nurses for advanced
or extended practice and who is certified as a nurse
practitioner by the American Nursing Association.
Optum: A UnitedHealth Group
TM
health services and
innovation company that designs and implements custom
information technology systems, and offers management
consulting, in the health care industry nationwide. Optum
offers behavioral health care programs including integrated
behavioral and medical programs, depression management,
employee assistance, work/life management, disability
support and pharmacy management programs.
Out-of-Area Care: Care received by a UnitedHealthcare
member when they are outside of their geographic territory.