2023
UnitedHealthcare
Care Provider
Administrative Guide for
Commercial and Medicare
Advantage
i
2023 UnitedHealthcare Care Provider Administrative Guide
Welcome to UnitedHealthcare
Welcome to the UnitedHealthcare Care Provider Administrative Guide for Commercial and Medicare Advantage (MA) products.
This guide has important information on topics such as claims and prior authorizations. It also has protocol information for
health care professionals. This guide has useful contact information such as addresses, phone numbers and websites. More
policies and online solutions are available on uhcprovider.com.
• If you are looking for information about Surest, please see the Surest supplement to this guide.
• If you are looking for a Community and State manual, go to uhcprovider.com/guides > Community Plan Care Provider
Manuals By State and select the state.
• If you are a UnitedHealthcare or Optum® participating health care provider or facility with an active Department of Veterans
Affairs Community Care Network (VA CCN) agreement, you can find more information about VA CCN on the Optum VA
Community Care Network UnitedHealthcare Provider Portal at VACommunitycare.com/provider.
You may easily find information in this guide using these steps:
1. Hold keys CTRL+F.
2. Type in the key word.
3. Press Enter.
This 2023 UnitedHealthcare Care Provider Administrative Guide (this “guide”) applies to covered services you provide to our
members or the members of our affiliates
1
through our benefit plans insured by or receiving administrative services from us,
unless otherwise noted.
This guide is effective April 1, 2023, for physicians, health care professionals, facilities and ancillary health care providers
currently participating in our commercial and MA networks. It is effective now for health care providers who join our network
on or after Jan. 1, 2023. This guide is subject to change. We frequently update content in our effort to support our health care
provider networks.
Terms and definitions as used in this guide:
• “Member” or “customer” refers to a person eligible and enrolled to receive coverage from a payer for covered services as
defined or referenced in your Agreement.
• “Commercial” refers to all UnitedHealthcare medical products that are not MA, Medicare Supplement, Medicaid, CHIP,
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 care
professionals, facilities and ancillary providers, except when indicated. All items are applicable to all types of health care
providers subject to this guide.
• “Your Agreement,” “Provider Agreement,” “Agreement” or ”your contract” refers to your Participation Agreement with us.
• “Us,” “we” or “our” refers to UnitedHealthcare on behalf of itself and its other affiliates for those products and services
subject to this guide.
• Any reference to “ID card” includes both a physical or digital card.
MA policies, protocols and information in this guide apply to covered services you provide to UnitedHealthcare MA members,
including Erickson Advantage members and most UnitedHealthcare Dual Complete members, excluding UnitedHealthcare
Medicare Direct members. We indicate if a particular section does not apply to such MA members.
If there is a conflict or inconsistency between a Regulatory Requirements Appendix attached to your Agreement and this guide,
the provisions of the Regulatory Requirements Appendix controls for benefit plans within the scope of that appendix.
If there is inconsistency between the terms of your Agreement and this guide, your Agreement controls. The exception to this
rule is when your Agreement defines a protocol that is specific to one of our affiliates and is inconsistent with a protocol in the
corresponding affiliate supplement to this guide. In that situation, the protocol in the applicable affiliate supplement to this
guide controls.
Per your Agreement, you must comply with protocols. Payment will be denied, in whole or in part, for failure to comply with
a protocol.
1
UnitedHealthcare affiliates offering commercial and Medicare Advantage benefit plans and other services, are outlined in Chapter 1: Introduction.
Quick reference guide
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2023 UnitedHealthcare Care Provider Administrative Guide
Quick reference guide
Join our Network
and Credentialing
If you are interested in joining our network, visit uhcprovider.com/join. To view our credentialing
policies and procedures.
Credentialing application: Check on your application status by emailing [email protected].
Digital Solutions uhcprovider.com: uhcprovider.com is your home for health care provider information with 24/7
access to the UnitedHealthcare Provider Portal, medical policies and news bulletins. The website
offers great resources to support administrative tasks including eligibility, claims, referrals, and prior
authorizations and notifications.
uhcprovider.com/digitalsolutions: Going digital means less paper and more automation, faster
workflow between applications and quicker claims submission process to get you paid faster. Our
three digital solutions, Electronic Data Interchange (EDI), Application Programming Interface (API)
and the UnitedHealthcare Provider Portal, help to make that a reality, and it’s not a one-size-fits-all
approach. There’s flexibility to choose the best approach for your practice, and there’s the ability to
integrate with the practice management systems you use today. This webpage will help you choose the
right solution to fit your practice’s needs.
uhcprovider.com/portal: Our portal allows you to quickly get the answers you need to claims
information like status updates, reconsiderations and appeals. You can also submit prior authorization
requests, check eligibility and benefits information, access items in Document Library (including
virtual card payment statements) and even track your work, all at no cost to you and without having to
make a phone call. To log in, click Sign In in the top right corner of uhcprovider.com.
uhcprovider.com/edi: Submit and receive data using HIPAA Electronic Data Interchange (EDI) X12
transactions for claim submissions, eligibility and benefits, claim status, authorizations, referrals,
hospital admission, discharge and observation stay notifications, and electronic remittance advice.
You can submit single or batch transactions for multiple members and payers without manual data
entry or logging into multiple payer websites.
uhcprovider.com/api: Our Application Programming Interface (API) solutions allow you to access
comprehensive real-time data on a timetable you set. Data can be distributed to your practice
management system, proprietary software or any application you prefer. We have APIs for claim status
and payment, eligibility and benefits, reconsiderations and appeals, documents, and referrals.
Healthcare
Professional
Education and
Training
We provide a full range of training resources including interactive self-paced courses and instructor-
led sessions at uhcprovider.com/training. The training content is organized by categories to make it
easier to find what you need.
Provider Portal
Access and New
User Registration
In order to access the UnitedHealthcare Provider Portal, you’ll need to create a One Healthcare ID.
Visit uhcprovider.com/access.
UnitedHealthcare
Communications
Network News: Find health care provider news and updates for national and state commercial,
Medicare and Medicaid plans at uhcprovider.com/news.
Policy and Protocol Updates: News and updates regarding policy, product or reimbursement
changes are posted online at uhcprovider.com/news. Updates are posted at the beginning of each
month. Sign up to receive notification of these updates by email at uhcprovider.com/subscribe.
Quick reference guide
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2023 UnitedHealthcare Care Provider Administrative Guide
Contact
UnitedHealthcare
Most questions can be answered using one of our online solutions at
uhcprovider.com/digitalsolutions. If you need to speak with someone, we’re here to help. For state-
specific contact information, visit uhcprovider.com > Contact us.
UnitedHealthcare Web Support 1-866-842-3278
providertechsuppor[email protected]
Provider Services 1-877-842-3210
Provider Services (Individual Exchange Plans) 1-888-478-4760
Prior Authorizations 1-877-842-3210
Prior Authorizations (Individual Exchange Plans) 1-888-478-4760
Optum Pay
TM
Helpdesk 1-877-620-6194
Participation Agreement questions: Contact your Network Management representative. To identify
your Network Management representative, go to uhcprovider.com > Contact us > State-specific
health plan and network support and select your state.
Provider Advocate: To find your health care provider advocate, go to uhcprovider.com > Contact us >
State-specific health plan and network support and select your state.
Find a health care
provider
uhcprovider.com > Our network > Find a provider.
• Search for doctors, clinics or facilities by plan type.
• Find dental providers by state, network or location.
• Locate mental health or substance abuse services.
Eligibility Access benefit, coverage and identification card information:
Online: uhcprovider.com/eligibility and click Sign In in the top right corner.
EDI: 270/271 transaction | uhcprovider.com/edi270
For Individual Exchange Plans, call 1-888-478-4760.
Advance
Notification/Prior
Authorization,
Admission
Notification,
Discharge
Notification,
Observation Stay
Notification and
Referrals
To notify us or request prior authorization:
EDI: Transactions 278 and 278N
• Submit prior authorization requests and referrals using EDI 278 transactions. Go to uhcprovider.
com/edi278 for more information.
• Submit hospital admission, discharge and observation stay notifications using EDI 278N
transactions. Go to uhcprovider.com/edi278n for more information.
• Check the status of prior authorization requests and notifications at uhcprovider.com/edi278i.
Online: uhcprovider.com/paan
Use the Prior Authorization and Notification tool in the UnitedHealthcare Provider Portal to:
• Determine if notification or prior authorization is required.
• Complete the notification or prior authorization process.
• Upload medical notes or attachments.
• Check request status.
Information: uhcprovider.com/priorauth (information and advance notification/prior
authorization lists)
Phone: Call Care Coordination at the number on the member’s ID card (self-service available after
hours) and select “Care Notifications.”
Quick reference guide
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2023 UnitedHealthcare Care Provider Administrative Guide
Claims EDI: uhcprovider.com/edi837 View our Claims Payer List to determine the correct payer ID.
Online: uhcprovider.com/claimstool > Click Sign In in the top right corner.
Information: uhcprovider.com/claims (policies, instructions and tips)
Phone: 1-877-842-3210 (follow the prompts for status information)
1-888-478-4760 (Individual Exchange Plans)
Reimbursement Policies:
uhcprovider.com > Resources > Plans, policies, protocols and guides > For Commercial Plans >
Reimbursement Policies for UnitedHealthcare Commercial Plans
uhcprovider.com > Resources >Plans, Policies, protocols and guides > For Exchange Plans >
Reimbursement Policies for UnitedHealthcare Individual Exchange Plans
uhcprovider.com > Resources > Plans, policies, protocols and guides > For Medicare Advantage
Plans> Reimbursement Policies for Medicare Advantage Plans
uhcprovider.com > Resources > Plans, policies, protocols and guides > For Community Plans >
Reimbursement Policies for Community Plan
Reimbursement policies may be referred to in your Agreement as “payment policies.” Refer to the
Medicare Advantage policies for DSNP members.
Claim
Reconsiderations
and Appeals
API: Submit reconsiderations and appeals with attachments using our API solution. Get more
information online at uhcprovider.com/api.
Online: uhcprovider.com. Click Sign In in the top right corner.
Report escalated or unresolved issues to your Provider Advocate by email. Submit an appeal as a
final resolution.
Medical Policies: Get copies of the medical policies and guidelines at uhcprovider.com/policies.
Timely Filing
Guidelines
Refer to your internal contracting contact or Participation Agreement for timely filing information.
Care Provider
or Group
Demographic
Information
Update Forms
Care Provider or Group Demographic Information Update forms:
• uhcprovider.com/mpp > My Practice Profile
• uhcprovider.com/getconnected > Step 3: Verify your demographic and tax ID information
Preferred Lab
Network
uhcprovider.com > Our network > Preferred Lab Network
Specialty
Pharmacy
Program
(Commercial and
Exchange)
Specialty Pharmacy Program provides focused support to help better manage rare and complex
chronic conditions. Find details about the Specialty Pharmacy Program online at uhcprovider.com >
Resources > Drug Lists and Pharmacy > Specialty Pharmacy - Medical Benefit Management
(Provider Administered Drugs).
Commercial medical benefit specialty prior authorizations are managed under the
Specialty Guidance Program (SGP).
Phone: 1-888-397-8129
Email: [email protected]
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2023 UnitedHealthcare Care Provider Administrative Guide
Contents
Welcome to UnitedHealthcare ........................................................i
Quick reference guide ii
Chapter 1: Introduction 1
Manuals and benefit plans referenced in this guide ...................................... 1
Online/interoperability resources and how to contact us .................................5
Online resources and how to contact us ...............................................8
Chapter 2: Provider responsibilities and standards 11
Verifying eligibility, benefits and your network participation status .........................11
Health plan identification (ID) cards ..................................................11
Access standards ................................................................14
Network participating health care provider responsibilities ...............................16
Civil rights .......................................................................16
Confidentiality, Use of Licensed Marks, Publicity .......................................17
Consolidated Appropriations Act, 2021 (CAA) requirements .............................18
Cooperation with quality improvement and patient safety activities ........................19
Demographic changes ............................................................19
Notification of practice or demographic changes (applies to Commercial benefit plans in
California) .......................................................................21
Administrative terminations for inactivity ..............................................22
Member dismissals initiated by a PCP (Medicare Advantage) ............................23
Medicare opt-out .................................................................23
Additional MA requirements ........................................................23
Filing of a lawsuit by a member .....................................................25
Chapter 3: Commercial products 27
Commercial product overview table .................................................27
Benefit plan types ................................................................31
PCP selection ...................................................................31
Consumer-driven health benefit plans ................................................31
Chapter 4: Individual Exchange plans 33
UnitedHealthcare participation in Exchanges ..........................................33
Plan coverage and metal levels .....................................................36
UnitedHealthcare benefit plans for Individual Exchanges ................................38
Understanding your network participation ............................................40
Verifying eligibility and benefits .....................................................41
Plan requirements/features ........................................................41
Patient care coordination and case management ......................................43
Government Inspections and Audits .................................................44
Telemedicine and Virtual Care .....................................................44
Pharmacy .......................................................................45
Specialty services (hearing, vision, dental, transplant, behavioral health, chiropractor, skilled
nursing facility) ...................................................................45
Claims process ..................................................................45
Policies and protocols ............................................................46
Quick reference guide .............................................................46
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2023 UnitedHealthcare Care Provider Administrative Guide
Chapter 5: Medicare products 53
Medicare product overview tables ...................................................54
PCP selection ....................................................................60
Coverage summaries and policy guidelines for MA members ............................60
Special needs plans managed by Optum .............................................61
Medicare supplement benefit plans .................................................63
Free Medicare education for your staff and patients ....................................64
Chapter 6: Referrals 65
Commercial products referrals ......................................................65
Non-participating health care providers (all Commercial plans) ...........................68
Individual exchange referral required plan ............................................69
Medicare Advantage (MA) referral required plans ......................................69
Chapter 7: Medical management 71
Advance notification/prior authorization protocol ......................................71
Advance notification/prior authorization requirements ..................................72
Advance notification/prior authorization list ...........................................73
Facilities: Standard notification requirements* .........................................74
How to submit advance notification/prior authorization, admission notification, discharge
notification and observation stay notification ..........................................77
Updating advance notification or prior authorization requests ............................78
Coverage and utilization management decisions .......................................78
Clinical trials, experimental or investigational services ..................................80
Medical management denials/adverse determinations ..................................81
Pre-service appeals ...............................................................82
MA Part C reopenings .............................................................83
Outpatient cardiology notification/prior authorization protocol ............................84
Outpatient radiology notification/prior authorization protocol .............................91
Medication-assisted treatment ......................................................98
Trauma services .................................................................. 98
Air ambulance licensure ...........................................................99
Chapter 8: Specialty pharmacy and Medicare Advantage pharmacy 100
Commercial pharmacy ...........................................................100
Specialty pharmacy requirements for certain medical benefit specialty medications (commercial
plans – not applicable to UnitedHealthcare West) .....................................100
Medicare Advantage pharmacy ....................................................102
Drug utilization review program ....................................................106
Drug management program ......................................................106
Medication therapy management. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 107
Transition policy .................................................................108
Chapter 9: Specific protocols 109
Non-emergent ambulance ground transportation .....................................109
Interoperability protocol ..........................................................109
Laboratory services protocol ......................................................109
Nursing home and assisted living plans .............................................111
Social determinants of health protocol ..............................................112
Telehealth services protocol .......................................................113
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2023 UnitedHealthcare Care Provider Administrative Guide
Chapter 10: Our claims process 114
Optum Pay™ ...................................................................115
Virtual card payments ............................................................115
Enroll and learn more about Optum Pay .............................................116
Claims and encounter data submissions ............................................116
Risk adjustment data – MA, commercial and exchange ................................118
NPI ...........................................................................119
MA claim processing requirements .................................................119
Claim submission tips ............................................................120
Pass-through billing ..............................................................122
Special reporting requirements for certain claim types .................................122
Overpayments ..................................................................124
Subrogation and COB ............................................................125
Claim correction and resubmission .................................................126
Claim reconsideration and appeals process ..........................................127
Resolving concerns or complaints ..................................................129
Member appeals, grievances or complaints ..........................................130
Medical claim review .............................................................131
Chapter 11: Compensation 132
Reimbursement policies ..........................................................132
Charging members ..............................................................132
Member financial responsibility ....................................................135
Preventive care ..................................................................135
Extrapolation ...................................................................136
Audit services. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 136
Audit failure denials .............................................................137
Notice of Medicare Non-Coverage ..................................................137
Chapter 12: Medical records standards and requirements 138
Chapter 13: Health and disease management 141
Health management programs .....................................................141
Case management ..............................................................141
Commercial health services, wellness and behavioral health programs ...................142
Commercial consumer transparency tools ...........................................143
Medicare Advantage .............................................................143
Commercial and MA behavioral health information ....................................144
Chapter 14: Quality Management program 146
UnitedHealth Premium® program (commercial plans) ..................................147
Star ratings for MA and prescription drug plans .......................................148
Members’ experience of care ......................................................148
Imaging accreditation protocol .....................................................148
Chapter 15: Credentialing and recredentialing 149
Credentialing/profile reporting requirements .........................................149
Health care provider rights related to the credentialing process ..........................150
Credentialing committee decision-making process (non-delegated) ......................150
Monitoring of network providers and health care professionals ..........................151
Chapter 16: Member rights and responsibilities 152
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2023 UnitedHealthcare Care Provider Administrative Guide
Chapter 17: Fraud, Waste and Abuse 154
Medicare compliance expectations and training ......................................154
Exclusion checks ................................................................155
Preclusion list policy .............................................................155
Examples of potentially fraudulent, wasteful or abusive billing ...........................156
Prevention and detection .........................................................156
Corrective action plans ...........................................................157
Beneficiary inducement law .......................................................157
Reporting potential FWA to UnitedHealthcare ........................................157
Chapter 18: Provider communication 158
Email communication ............................................................158
Online resources ................................................................158
All Savers supplement 160
How to contact All Savers .........................................................160
Surest supplement 163
Surest plan resources ........................................................163
Surest health plan ID card. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 164
Our claims process ..............................................................165
Claim reimbursement (adjustments) ................................................165
How to submit your reconsideration or appeal ........................................165
Still have questions? .............................................................165
Capitation and/or Delegation Supplement 166
What is Capitation? ..............................................................166
What is Delegation? ..............................................................166
How to contact us ...............................................................167
Verifying eligibility and effective dates ...............................................167
Commercial eligibility, enrollment, transfers and disenrollment ..........................167
Medicare Advantage (MA) enrollment, eligibility and transfers, and disenrollment ..........172
Authorization guarantee (CA Commercial only) .......................................175
Health care provider responsibilities ................................................175
Delegated credentialing program ...................................................181
Virtual Care Services (Commercial HMO plans – CA only) ..............................183
Referrals and referral contracting ..................................................184
Medical management ............................................................188
Pharmacy ......................................................................197
Facilities .......................................................................198
Claim delegation oversight .......................................................203
Claims disputes and appeals ......................................................213
Contractual and financial responsibilities ............................................216
Customer service requirements between UnitedHealthcare and the delegated entity
(Medicare) .....................................................................221
Capitation reports and payments ...................................................222
CMS premiums and adjustments ...................................................226
Delegate performance management program ........................................229
Appeals and grievances ..........................................................230
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2023 UnitedHealthcare Care Provider Administrative Guide
Empire Plan supplement 231
Referrals .......................................................................231
ID cards .......................................................................231
Prior authorization and notification requirements ......................................232
Online resources and how to contact us .............................................234
Leased Networks 235
Level2 supplement 236
How to contact us ...............................................................236
Health plan ID cards .............................................................237
Claims process .................................................................237
Mid-Atlantic Regional supplement 239
Provider responsibilities ..........................................................240
Referrals .......................................................................242
Prior authorizations ..............................................................242
Claims process .................................................................244
Capitation ......................................................................245
Neighborhood Health Partnership supplement 247
How to contact NHP .............................................................247
Discharge of a member from participating provider’s care ..............................250
Laboratory services ..............................................................250
Referrals .......................................................................251
UM ............................................................................252
Claims reconsiderations and appeals ...............................................253
Capitated health care providers ...................................................253
New Mexico Supplement 254
OneNet PPO/Workers’ Compensation supplement 256
Who to contact ..................................................................257
Bill process .....................................................................258
Referrals .......................................................................263
Provider responsibilities and workflows .............................................264
Medical records standards and requirements ........................................264
Quality management and health management programs ...............................264
Participant rights and responsibilities ...............................................265
Oxford Commercial supplement 266
Oxford Commercial product overview ...............................................266
Oxford commercial products contact information .....................................266
Health care provider responsibilities and standards ...................................270
Referrals ......................................................................275
Utilization management ..........................................................277
Using non-participating health care providers or facilities ...............................279
Radiology and cardiology procedures ...............................................283
Emergencies and Urgent Care .....................................................288
Utilization reviews ...............................................................290
Claims process .................................................................298
Member billing ..................................................................301
Claims recovery, appeals, disputes and grievances ....................................302
Quality assurance ...............................................................307
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2023 UnitedHealthcare Care Provider Administrative Guide
Case management and disease management programs ...............................308
Clinical process definitions ........................................................308
Member rights and responsibilities .................................................311
Medical/clinical and administrative policy updates ....................................311
Oxford Level Funded plans (CT, NJ and NY) 312
Oxford Level Funded product contacts ..............................................312
Our claims process ..............................................................312
How to submit your reconsideration or appeal ........................................313
Preferred Care Network supplement 314
How to contact us ...............................................................314
Confidentiality of Protected Health Information (PHI) ...................................318
Referrals .......................................................................318
Prior authorizations ..............................................................319
Appeal and reconsideration processes ..............................................323
Member rights and responsibilities .................................................324
Documentation and confidentiality of medical records .................................324
Provider reporting responsibilities ..................................................328
Preferred Care Partners supplement 329
About Preferred Care Partners .....................................................329
How to contact us ...............................................................329
Confidentiality of Protected Health Information (PHI) ...................................333
Prior authorizations ..............................................................333
Clinical coverage review ..........................................................335
Appeal and reconsideration processes ..............................................337
Member rights and responsibilities .................................................338
Documentation and confidentiality of medical records .................................339
Case management and disease management program information ......................340
Special needs plans .............................................................341
Health care provider reporting responsibilities ........................................342
River Valley Entities supplement 343
Eligibility .......................................................................343
How to contact River Valley .......................................................344
Reimbursement policies ..........................................................346
Referrals .......................................................................346
Utilization Management (UM) ......................................................347
Claims process .................................................................351
UMR supplement 355
How to contact UMR .............................................................355
Health plan identification cards ....................................................357
Prior authorization and notification requirements ......................................357
Clinical trials, experimental or investigational services .................................358
Pharmacy and specialty pharmacy benefits ..........................................358
Specific protocols ...............................................................358
Our claims process ..............................................................359
Health and disease management ...................................................360
Frequently asked questions .......................................................360
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2023 UnitedHealthcare Care Provider Administrative Guide
UnitedHealthcare FlexWork™ supplement 363
How to contact FlexWork™ ........................................................363
Health plan ID card ..............................................................364
Our claims process ..............................................................364
UnitedHealthcare Level Funded supplement 366
How to contact us ...............................................................366
Our claims process ..............................................................367
UnitedHealthcare West supplement 369
UnitedHealthcare West information regarding our health care provider website ............372
How to contact UnitedHealthcare West resources .....................................372
Health care provider responsibilities ................................................375
Utilization and medical management ................................................379
Hospital notifications .............................................................383
Home delivery pharmacy .........................................................387
Claims process .................................................................388
Health care provider claims appeals and disputes .....................................392
California language assistance program (California commercial plans). . . . . . . . . . . . . . . . . . . . 396
Member complaints and grievances ................................................397
California Quality Improvement Committee ..........................................397
UnitedHealthOne Individual Plans supplement 398
How to contact UnitedHealthOne resources ..........................................398
Claims process .................................................................399
Member complaints and grievances ................................................401
Glossary 404
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2023 UnitedHealthcare Care Provider Administrative Guide
Chapter 1: Introduction
Manuals and benefit plans referenced in this guide
Some benefit plans included under your Agreement may be subject to requirements found in other health care provider guides
or manuals or to the supplements found in the second half of this guide.
This section provides information about some of the most common UnitedHealthcare products. Your Agreement may use
“benefit contract types,” “benefit plan types” or a similar term to refer to our products.
Visit uhcprovider.com/plans for more information
about our products and Individual Exchange
benefit plans offered by state.
If a member presents a health plan ID card with a product name you are not familiar with, use the UnitedHealthcare Provider
Portal > Eligibility to quickly find information on the plan. You may also call us at 1-877-842-3210 or Exchange Provider Services
at 1-888-478-4760.
You are subject to the provisions of additional guides when providing covered services to a member of those benefit plans, as
described in your Agreement and in the following table. We may make changes to health care provider guides, supplements
and manuals that relate to protocol and payment policy changes.
We may change the location of a website, a benefit plan name, branding or the health plan ID card. We inform you of those
changes through one of our health care provider communications resources.
Benefit plans subject to this guide
Plan Name Location of most members
subject to additional guides
Location of plan information
All Savers:
All Savers Insurance Company
All markets All Savers supplement to this
guide
myallsaversconnect.com
Empire Plan All markets outside of NY* and national health
care providers; Primary concentrations in: AZ,
CA, CT, DE, FL, GA, MA, MD, NC, NJ, NV, PA,
SC, TN, TX, VA
Health plan ID card indicates NYSHIP, The
Empire Plan and references UnitedHealthcare
logo on the back
* In the NY markets, there are a limited number
of health care providers with the Empire Plan
specifically added to their UnitedHealthcare
Agreement. Otherwise, we have a separate
health care provider network for Empire Plan
members in NY.
Empire Plan supplement to this
guide
uhcprovider.com
Exchanges AL, AZ, FL, GA, IL, KS, LA, MD, MI, MS, MO, NC,
OH, OK, TN, TX, VA, WA
Chapter 4: Individual Exchange
Plans to this guide.
Chapter 1: Introduction
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2023 UnitedHealthcare Care Provider Administrative Guide
Plan Name Location of most members
subject to additional guides
Location of plan information
MDIPA:
MD Individual Practice
Association, Inc.
DC, DE, MD, VA, WV
Some counties in: Southeastern PA
Mid-Atlantic Regional Supplement
to this guide.
uhcprovider.com
Capitated and/or Delegated
Providers (Commercial and
MA) Supplement
All markets Capitation and/or Delegation
Supplement to this guide.
NHP:
Neighborhood Health
Partnership, Inc.
FL Neighborhood Health Partnership
Supplement to this guide.
uhcprovider.com
OCI:
Optimum Choice Inc.
DC, DE, MD, VA, WV
Some counties in: PA
Mid-Atlantic Regional Supplement
to this guide.
uhcprovider.com
OneNet PPO DC, DE, FL, GA, MD, NC, PA, SC, TN, VA, WV OneNet PPO Supplement to this
guide.
uhcprovider.com
Oxford:
• Oxford Health Plans, LLC
• Oxford Health Insurance, Inc.
• Investors Guaranty Life
Insurance Company, Inc.
• Oxford Health Plans (NY), Inc.
• Oxford Health Plans (NJ), Inc.
• Oxford Health Plans (CT), Inc.
• Oxford Level Funded Plans
(NJ, CT)
CT, NJ, NY (except upstate)
Some counties in: PA.
Oxford Commercial Supplement
to this guide.
For commercial benefits:
uhcprovider.com
For Medicare benefits:
uhcprovider.com
Preferred Care Network
Supplement
FL counties: Broward and Miami-Dade Preferred Care Network
Supplement to this guide.
uhcprovider.com
Preferred Care Partners FL counties: Broward, Miami-Dade and
Palm Beach
Preferred Care Partners
Supplement to this guide.
uhcprovider.com
Chapter 1: Introduction
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2023 UnitedHealthcare Care Provider Administrative Guide
Plan Name Location of most members
subject to additional guides
Location of plan information
River Valley:
• UnitedHealthcare Services
Company of the River
Valley, Inc.
• UnitedHealthcare Plan
of the River Valley, Inc.
• UnitedHealthcare Insurance
Company of the River Valley
Parts of AR, GA, IA, IL, TN, VA, WI
Your UnitedHealthcare contract specifically
references River Valley or John Deere Health
protocols or guides; and
You are located in AR, GA, IA, TN, VA, WI
or these counties in Illinois: Jo Daviess,
Stephenson, Carroll, Ogle, Mercer, Whiteside,
Lee, Rock Island, Henry, Bureau, Putnam,
Henderson, Warren, Knox, Stark, Marshall,
Livingston, Hancock, McDonough, Fulton,
Peoria, Tazewell, Woodford, McLean; and
You are providing services to a River Valley
Commercial member and not a River Valley
Medicare Advantage, Medicaid or CHIP member.
Note: River Valley also offers benefit plans in LA,
NC, OH and SC, but the River Valley Additional
Guide does not apply to those benefit plans.
River Valley Entities Supplement
to this guide.
uhcprovider.com
Sierra or Health Plan of
Nevada:
• Sierra Health and Life
Insurance Co., Inc.
• Health Plan of Nevada, Inc.
• Sierra Healthcare Options,
Inc.
Outside NV only:
The health plan ID card identifies the Sierra or
Health Plan of Nevada members who access the
UnitedHealthcare network outside of Nevada,
and includes the following reference:
UnitedHealthcare Choice Plus Network
Outside Nevada.
Services rendered outside of
Nevada to Sierra or Health Plan of
Nevada members with the ID card
reference described in this row are
subject to your UnitedHealthcare
Agreement and to this guide unless
you are in Arizona or Utah and have
a contract directly with Sierra or
Health Plan of Nevada.
UMR:
• UMR
• UnitedHealthcare Shared
Services (UHSS)
All markets UMR supplement to this guide.
umr.com
UnitedHealthcare Level
Funded
(Previously sold under the
name All Savers® Alternate
Funding)
December 2020: AL, SD, ND, DE
September 2021: All markets
UnitedHealthcare Level Funded
supplement to this guide.
uhcprovider.com
Chapter 1: Introduction
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2023 UnitedHealthcare Care Provider Administrative Guide
Plan Name Location of most members
subject to additional guides
Location of plan information
UnitedHealthcare West:
(Formerly referenced in this
guide as “PacifiCare”)
• UHC of California dba
UnitedHealthcare of California
(hereinafter referred to
as UnitedHealthcare of
California)
• UnitedHealthcare of
Oklahoma, Inc.
• UnitedHealthcare of
Oregon, Inc.
• UnitedHealthcare Benefits of
Texas, Inc.*
* PacifiCare of Arizona,
PacifiCare of Colorado
and PacifiCare of Nevada
are now referenced as
UnitedHealthcare Benefits of
Texas, Inc.
AZ, CA, CO, NV, OR, TX, WA UnitedHealthcare West
Supplement to this guide.
uhcprovider.com
UnitedHealthOne:
• Golden Rule
Insurance Company
Group #705214
• Oxford Health Insurance, Inc.
Group #908410
All markets
New Jersey
UnitedHealthOne Individual Plans
Supplement to this guide.
uhcprovider.com and
myuhone.com
UnitedHealthcare Freedom
Plans
NH, ME, VT uhcprovider.com
Chapter 1: Introduction
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2023 UnitedHealthcare Care Provider Administrative Guide
Benefit plans not subject to this guide
Plan name Location of most
members subject to
additional guides
Additional guide/website
Rocky Mountain Health Plan (RMHP) CO rmhp.org
Sierra:
Sierra Health and Life Insurance Co., Inc.
Sierra Healthcare Options, Inc.
Health Plan of Nevada, Inc.
Health Plan of Nevada Medicaid/
Nevada Check Up
NV Benefit plans for Sierra Health and Life Insurance
Company, Inc.
sierrahealthandlife.com/provider
Benefit plans for Sierra Healthcare Options, Inc:
sierrahealthcareoptions.com
Benefit plans for Health Plan of Nevada, Inc:
healthplanofnevada.com/provider
myhpnmedicaid.com/provider
UnitedHealthcare Community Plan
Medicaid, CHIP and Uninsured
Multiple states UnitedHealthcare Community Plan Physician, Health
Care Professional, Facility and Ancillary Administrative
Guide for Medicaid, CHIP, or Uninsured.
uhcprovider.com/communityplan and
uhcprovider.com
Online/interoperability resources and how to contact us
Going digital means less paper and more automation, faster workflow between applications and a quicker claims submission
process to help you get paid faster. Learn the differences by viewing our Digital Solutions Comparison Guide. You will conduct
business with us electronically. This means using electronic means, where allowed by law, to submit claims and receive
payment, and to submit and accept other documents, including prior authorization requests and decisions, and reconsideration
and appeal requests and decisions. Using electronic transactions is fast, efficient, and supports a paperless work environment.
The UnitedHealthcare Provider Portal has tools such as EDI (uhcprovider.com/edi) and API (uhcprovider.com/api) that
provide maximum efficiency in conducting business electronically.
Application Programming Interface (API)
API is becoming the newest digital method in health care to distribute information to health care professionals and business
partners in a timely and effective manner. API is a common programming interface that interacts between multiple applications.
Our API solutions allow you to electronically receive detailed data on claims status and payment, eligibility and benefits, claim
reconsiderations and appeals (with attachments), referrals and documents. Information returned in batch emulates data in the
UnitedHealthcare Provider Portal and complements EDI transactions, providing a comprehensive suite of services. It requires
technical coordination with your IT department, vendor or clearinghouse. The data is in real time and can be programmed to be
pulled repetitively and transferred to your practice management system or any application you prefer. For more information, visit
uhcprovider.com/api.
Electronic Data Interchange (EDI)
EDI is a self-service resource using your internal practice management or hospital information system to exchange transactions
with us through a clearinghouse.
The benefit of using EDI is it permits health care providers to send batch transactions for multiple members and multiple payers
in lieu of logging into different payer websites to manually request information. This is why EDI is usually health care providers’
first choice for electronic transactions.
• Send and receive information faster.
• Identify submission errors immediately and avoid processing delays.
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2023 UnitedHealthcare Care Provider Administrative Guide
• Exchange information with multiple payers.
• Reduce paper, postal costs and mail time.
• Cut administrative expenses.
The following are EDI transactions available to health care providers:
• Claims (837)
• Eligibility and benefits (270/271)
• Claims status (276/277)
• Referrals and authorizations (278)
• Hospital admission, discharge and observation stay notifications (278N)
• Electronic remittance advice (ERA/835)
Visit uhcprovider.com/edi for more information. Learn how to optimize your use of EDI at uhcprovider.com/optimizeEDI.
Getting started
• If you have a practice management or hospital information system, contact your software vendor for instructions on how to
use EDI in your system.
• Contact clearinghouses to review which electronic transactions can interact with your software system.
Read our Clearinghouse Options page for more information.
Point of Care Assist
TM
When made available by UnitedHealthcare, you will do business with us electronically. Point of Care Assist integrates members’
UnitedHealthcare health data within the Electronic Medical Record (EMR) to provide real-time insights of their care needs,
aligned to their specific member benefits and costs. This makes it easier for you to see potential gaps in care, select labs,
estimate care costs and check prior authorization requirements, including benefit eligibility and coverage details. This helps you
to better serve your patients and achieve better results for your practice. For more information, go to uhcprovider.com/poca.
uhcprovider.com
This public website is available 24/7 and does not require registration to access. You’ll find valuable resources including
administrative and plan-specific policies, protocols and guides, health plans by state, regulatory and practice updates, quality
programs, network news and more. You’ll also find information about our electronic workflow solutions, including Electronic
Data Exchange (EDI), Application Programming Interface (API), and the UnitedHealthcare Provider Portal.
UnitedHealthcare Provider Portal
This secure portal is available at uhcprovider.com. It allows you to access patient information such as eligibility and benefit
information and digital ID cards. You can also perform administrative tasks such as submitting prior authorization requests,
checking claim status, submitting appeal requests, and find copies of PRAs and letters in Document Library. All at no cost to
you and without needing to pick up the phone.
To access the portal, you will need to create or sign in using a One Healthcare ID. To use
the portal:
• If you already have a One Healthcare ID (formerly known as Optum ID), simply go to
uhcprovider.com > Sign In to access the portal.
• If you need to set up an account on the portal, follow these steps to register.
Use the UnitedHealthcare Provider Portal to access information for the following:
• UnitedHealthcare Commercial
• UnitedHealthcare Medicare Advantage
• UnitedHealthcare Community Plan (as contracted by state)
• UnitedHealthcare West
• UnitedHealthcare of the River Valley
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2023 UnitedHealthcare Care Provider Administrative Guide
• UnitedHealthcare Oxford Commercial
• UnitedHealthcare Individual Exchange Plans
Available benefit plan information varies for each of our UnitedHealthcare Provider Portal tools.
Here are the most frequently used tools:
• Eligibility and Benefits — View patient eligibility and benefits information for most benefit plans. For more information, go to
uhcprovider.com/eligibility.
• Claims — Get claims information for many UnitedHealthcare plans, including access letters, remittance advice documents and
reimbursement policies. For more information, go to uhcprovider.com/claims.
• Prior Authorization and Notification — Submit notification and prior authorization requests. For more information, go to
uhcprovider.com/paan.
• Specialty Pharmacy Transactions — Submit notification and prior authorization requests for certain medical injectable drugs
by selecting the Prior Authorization dropdown in the UnitedHealthcare Provider Portal landing page. You will be directed to
Prior Authorization and Notification capability to complete your requests.
• My Practice Profile — View and update
1
your health care provider demographic data that UnitedHealthcare members see for
your practice. For more information, go to uhcprovider.com/mpp.
• Document Library — Access reports and correspondence from many UnitedHealthcare plans for viewing, printing or
download. For more information on the available correspondence, go to uhcprovider.com/documentlibrary.
• Paperless Delivery Options — Eliminate paper mail correspondence. In Document Library, you can set up daily or weekly
email notifications to alert you when we add new letters to your Document Library. With our delivery options, you decide when
and where the emails are sent for each type of correspondence. This tool is available to One Healthcare ID Primary Access
Administrators only.
You can learn more about the portal and access self-paced user guides for many of the
tools and tasks available in the portal.
UnitedHealthcare Web Support:
providertechsuppor[email protected] or 1-866-842-3278, option 1. Monday-Friday, 7 a.m. – 9 p.m. CT.
1
For more instructions, visit uhcprovider.com/training.
Chapter 1: Introduction
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2023 UnitedHealthcare Care Provider Administrative Guide
Online resources and how to contact us
Online resources and how to contact us Where to go
How to Join Our Network For instructions on joining the UnitedHealthcare provider network, go to
uhcprovider.com/join. There you will find guidance on our credentialing
process, how to sign up for online tools and other helpful information.
UnitedHealthcare Provider Website uhcprovider.com
Resources:
• Administrative guides for network health care providers
• Plan-specific policies, protocols and guidelines
• Health plans by state
• News, regulatory and practice updates
• Guidance on common member- and claim-related tasks, including
eligibility and benefit verification, prior authorization and referral
requirements, and claims submissions and payments
• Information on our electronic workflow solutions, including Electronic
Data Interchange (EDI), Application Programming Interface (API) and the
UnitedHealthcare Provider Portal.
Advance Notification, Prior Authorization and
Admission, Discharge and Observation Stay
Notification
(To submit and get status information)
EDI: See EDI transactions and code sets on uhcprovider.com/edi
Online: Go to the UnitedHealthcare Provider Portal: uhcprovider.com >
Sign In to get started.
Information: Go to uhcprovider.com/priorauth and select the specialty
you need.
Phone: 1-877-842-3210 (Provider Service Voice Portal)
1-888-478-4760 (Individual Exchange Plans)
See ID card for specific service contact information.
Air Ambulance Non-Emergency Transport Online: uhcprovider.com/findprovider
Appeal – (Clinical) Urgent Submission
(Commercial members)
(Medicare Advantage – follow the directions in
the customer decision letter)
All Savers, Golden Rule Insurance Company
and UnitedHealthcare Oxford Navigate
Individual
An expedited appeal may be available if the time needed to complete a
standard appeal could seriously jeopardize the member’s life, health or
ability to regain maximum function.
Urgent medical fax: 1-801-994-1083
Urgent pharmacy fax: 1-801-994-1058
Urgent appeal fax: 1-866-654-6323
For Individual Exchanges:
Urgent medical fax: 1-888-808-9123
Application Programming Interface (API) Online: uhcprovider.com/api
Cardiology and Radiology
Notification/Prior Authorization
–Submission and Status
Online: Go to the UnitedHealthcare Provider Portal: uhcprovider.com >
Sign In to get started.
Information: Go to uhcprovider.com/priorauth and select the specialty
you need.
Phone: 1-866-889-8054
Chapter 1: Introduction
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2023 UnitedHealthcare Care Provider Administrative Guide
Online resources and how to contact us Where to go
Chiropractic, Physical Therapy, Occupational
Therapy and Speech Therapy Providers
(Contracted with Optum Physical Health, a
UnitedHealth Group company)
Online: myoptumhealthphysicalhealth.com
Phone: 1-800-873-4575
Claims
(Filing, payments, reconsiderations)
EDI: uhcprovider.com/edi837 Learn more about the types of claims you
can file using EDI and view our claims payer list to identify the correct
payer ID.
Online: Go to UnitedHealthcare Provider Portal: uhcprovider.com > Sign
In to get started.
Information: uhcprovider.com/claims for policies, instructions and tips.
Phone: 1-877-842-3210 (follow the prompts for status information)
1-888-478-4760 (Individual Exchange Plans)
Optum Pay Online: optum.com/optumpay
Help Desk: 1-877-620-6194
Electronic Data Interchange (EDI)
and EDI Support
Online: uhcprovider.com/edi
Help: uhcprovider.com/edicontacts
Phone: 1-800-842-1109 (Monday–Friday, 7 a.m.–9 p.m. CT)
UnitedHealthcare EDI Support
Online: EDI Transaction Support Form
Email: suppor[email protected]
Phone: 1-800-842-1109
UnitedHealthcare Community Plan EDI Support
Online: EDI Transaction Support Form
Email: [email protected]
Phone: 1-800-210-8315
Fraud, Waste and Abuse
(Report potential fraud, waste
or abuse concerns)
Online: uhc.com/fraud, select the “Report a concern” icon.
Phone: 1-844-359-7736
Phone: 1-877-842-3210 (United Voice Portal)
For more information on fraud, waste and abuse prevention efforts, refer
to Chapter 17: Fraud, Waste and Abuse.
Genetic and Molecular Testing Online: Go to the UnitedHealthcare Provider Portal: uhcprovider.com >
Sign In to get started.
Information: Go to uhcprovider.com/priorauth and select the specialty
you need.
Member/Customer Care Online: myuhc.com
Phone: 1-877-842-3210 or the number listed on the back of the ID card
Mental Health and Substance Use Services See ID card for carrier information and contact numbers.
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2023 UnitedHealthcare Care Provider Administrative Guide
Online resources and how to contact us Where to go
Outpatient Injectable Chemotherapy and
Related Cancer Therapies
Online: Go to the UnitedHealthcare Provider Portal: uhcprovider.com >
Sign In to get started.
Information: Go to uhcprovider.com/priorauth and select the specialty
you need.
Phone: 1-888-397-8129
Pharmacy Services Online: professionals.optumrx.com
Phone: 1-800-711-4555
Provider Advocates
For participating hospitals, health care, and
ancillary providers; locate your physician or
hospital advocate
Online: uhcprovider.com > Contact us > State-specific health plan and
network support
Provider Directory uhcprovider.com/findprovider
Radiation Therapy Prior Authorization For members:
Online:
1. Go to the UnitedHealthcare Provider Portal: uhcprovider.com > Sign
In to access the Prior Authorization and Notification tool.
2. Select Radiology, Cardiology, Oncology and Radiation Oncology
Transactions.
3. Select the service type Radiation Oncology
4. Select one of the product types: Commercial, Exchanges, Medicaid,
Medicare, or Oxford.
Phone: 1-888-397-8129 (8 a.m. – 5 p.m. local time Monday-Friday)
Referral Submission and Status
You can determine if a member’s benefit
plan requires a referral when you view their
eligibility profile.
EDI: 278 transaction
API: Referral API details are online at uhcprovider.com/api
Online: Go to the UnitedHealthcare Provider Portal: uhcprovider.com >
Sign In to get started.
Information: uhcprovider.com/referrals
Note: Submitted referrals are effective immediately but may not be
viewable for 48 hours.
Skilled Nursing Facilities
(Free-standing)
Online: uhcprovider.com/skillednursing
Phone: 1-877-842-3210 (Provider Service)
1-888-478-4760 (Individual Exchange Plans)
Subrogation Online: subroreferrals.optum.com
Fax: 1-800-842-8810
Mail: Optum
11000 Optum Circle
MN102-0300
Eden Prairie, MN 55344
Transplant Services See ID card for carrier information and contact numbers.
Vision Services See ID card for carrier information and contact numbers.
11
2023 UnitedHealthcare Care Provider Administrative Guide
Chapter 2:
Provider responsibilities and standards
Verifying eligibility, benefits and your network
participation status
Check the member’s eligibility and benefits prior to providing care. Doing this:
• Helps ensure you submit the claim to the correct payer.
• Allows you to collect copayments.
• Determines if a referral, prior authorization or notification is required.
• Reduces denials for non-coverage.
One of the primary reasons for claims rejection is incomplete or inaccurate eligibility information.
There are 4 easy ways to verify eligibility and benefits as shown in the Online/interoperability resources and how to contact
us section in Chapter 1: Introduction.
Eligibility grace period for Individual Exchange Plan members
When individuals enroll in a health benefit plan through the Health Insurance Marketplace (also known as Individual Exchange),
the plans are required to provide a 3-month grace period before terminating coverage. The grace period applies to those who
receive federal subsidy assistance in the form of an advanced premium tax credit and who have paid at least 1 full month’s
premium within the benefit year. Additionally, for individuals who do not receive federal subsidy assistance, plans are required
to provide a grace period consistent with state law (typically 30 or 31 calendar days) before terminating coverage.
You can verify if the member is within the grace period when you verify eligibility.
Refer to the Chapter 4: Individual Exchange Plans for more information.
Understanding your network participation status
Your network status is not returned on 270/271 transactions. Know your status prior to submitting 270 transactions. As our
product portfolio evolves and new products are introduced, it is important for you to confirm your network status for the medical
or pharmacy benefit plan (and tier status for commercial tiered benefit plans) while checking eligibility and benefits in the
UnitedHealthcare Provider Portal or by calling us at 1-877-842-3210 or 1-888-478-4760 (Individual Exchange Plans). If you
are not participating in the member’s benefit plan or are outside the network service area for the benefit plan, the member may
have higher costs or no coverage.
Commercial only
For more information about tiered benefit plans, visit uhcprovider.com/plans > Select your state > Commercial >
UnitedHealthcare Tiered Benefit Plans.
Health plan identification (ID) cards
We are moving towards eliminating physical ID cards, and members may not have one if not required by law. Use the Eligibility
and Benefits tool in the UnitedHealthcare Provider Portal to see a digital version of the ID card. You’ll also be able to access
member-specific information around plan benefits and requirements. Sample member ID cards are for illustration only; actual
information varies depending on payer, plan and other requirements.
Chapter 2: Provider responsibilities and standards
12
2023 UnitedHealthcare Care Provider Administrative Guide
View and download current ID cards for most
members using the Eligibility and Benefits tool in the
UnitedHealthcare Provider Portal. You can also view
member eligibility and benefits through an API solution.
You may download and keep a copy of both sides of the health plan ID card for your records. Possession of a physical ID card
is not proof of eligibility.
Commercial health plan ID card legend
Front Back
Member ID: Group Number:
Member:
Office: $99
Referrals Required
UrgCare: $99
Rx Bin:
610279
Rx PCN:
9999
Rx Grp:
UHEALTH
UnitedHealthcare Navigate
Underwritten by UnitedHealthcare Insurance Company
DOI-0508
ER: $99
Payer ID 87726
Copays:
999999999 999999
Customer Name Line 1
PCP:
FIRSTNAME LASTNAME
PCP Phone: (999) 999-9999
Spec: $99
MEMBER SMITH
Customer Name Line 2
INN: $99999/$99999 $99999/$99999
Tier 1: $99999/$99999 $99999/$99999
OON: $99999/$99999 $99999/$99999
Coins 99%
Ded IND/FAM OOPM IND/FAM
Ded IND/FAM
OOPM IND/FAM
$99999/$99999
$99999/$99999
$99999/$99999
$99999/$99999
INN:
OON:
Printed: 10/17/21
Members: We're here to help. Check benets, view claims, nd
a doctor, ask a question and more.
Web:
myuhc.com
Phone:
Providers:
UHCprovider.com 877-842-3210 or
Medical Claims:
555-555-5555
Pharmacy Claims: OptumRx PO Box 650540 Dallas, TX 75265-0540
Pharmacists:
888-290-5416
PO Box 740825, Atlanta GA 30374-0825
1. UnitedHealthcare brand: This includes UnitedHealthcare, All Savers, UnitedHealthcare Level Funded, UnitedHealthcare
Oxford Level Funded, Golden Rule, UnitedHealthcare Oxford, UnitedHealthOne, UMR and UnitedHealthcare Shared
Services (UHSS), UnitedHealthcare Freedom Plans.
2. Member Plan Identifier: This is a customized field to describe the member’s benefit plan (i.e., Individual Exchange, Tiered
Benefits, ACO).
3. Payer ID: Indicates claim can be submitted electronically using the number shown on card. Contact your vendor or
clearinghouse to set up payer in your system, if necessary.
4. PCP name and phone number: Included for benefit plans that have PCP selection requirements. For Individual Exchange
Members “PCP required” is listed in place of the PCP name and number. This section may also include Laboratory (LAB),
Preferred Lab Network (PLN) and Radiology (RAD) participant codes.
5. Copay information: If this area is blank, the member is not required to make a copay at the time of service.
6. Benefit plan name: identifies the applicable benefit plan name.
7. Referral requirements identifier: Identifies plans with referral requirements. Requires PCP to send electronic referrals.
8. For members section: Lists benefit plan contact information and, if applicable, referrals and notifications information.
9. For providers section: Includes the prescription plan name.
1
5
3
4
2
9
6
8
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Chapter 2: Provider responsibilities and standards
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2023 UnitedHealthcare Care Provider Administrative Guide
Medicare Advantage (MA) member ID card legend
Front Back
1. Benefit plan name: Identifies the applicable benefit plan name.
2. Dental benefits: Included if routine dental benefits are part of the benefit plan and/or if the member purchased an
optional supplemental dental benefit rider.
3. Prescription information: If the benefit plan includes Part D prescription drug coverage, the Rx BIN, PCN and Group
code are visible. If Part D coverage is not included, this area lists information for Medicare Part B Drugs.
4. Plan ID number: Identifies the plan ID number that corresponds to Centers for Medicare & Medicaid Services (CMS)
filings.
5. PCP: Included for benefit plans that require a PCP selection.
6. Referrals required: Identifies benefit plans with referral requirements. Refer to the Medicare Advantage (MA) Referral
Required Plans section in Chapter 6: Referrals for more detailed information.
7. Copay information: Select plans do not list copay information or may have a variance.
8. For members: Lists benefit plan contact information for the member.
9. For providers: Lists benefit plan contact information for the health care provider.
10. Plan Year: The year (1/1-12/31) during which plan benefits apply.
11a. Network Logo: If the Medicare National Network logo is present, the member has access to the national network.
11b. UnitedHealth Passport Logo: If the UnitedHealth Passport logo is present, the member’s plan has the Passport travel
benefit.
12. Payer ID: Indicates claim can be submitted electronically using the number shown on card. Contact your vendor or
clearinghouse to set up payer in your system, if necessary.
13. S3 Bar code, logo, card number and security code: S3 technology allows UnitedHealthcare to direct members to
approved products for in-store purchase.
1
2
3
4
5
6
7
8
12
10
11a
9
13
11b
Chapter 2: Provider responsibilities and standards
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2023 UnitedHealthcare Care Provider Administrative Guide
Medicare Advantage (MA) Group Retiree member ID card legend
Front Back
1. UnitedHealthcare brand: Present on a UnitedHealthcare ID card.
2. Network Logo: If the UnitedHealth Passport logo is present, the member’s plan has the Passport travel benefit.
3. Group name: Identifies the name of the employer group.
4. PCP: Included for benefit plans that require a PCP selection.
5. Prescription information: If the benefit plan includes Part D prescription drug coverage, the Rx Bin, PCN and Group code
are visible. If Part D coverage is not included, this area lists information for Medicare Part B Drugs.
6. Copay information: Includes PCP, specialist and ER copays.
7. Plan ID number: Identifies the plan ID number that corresponds to Centers for Medicare & Medicaid Services (CMS)
filings.
8. Benefit plan name: Identifies the applicable benefit plan name.
9. For members: Lists benefit plan contact information for the member.
10. For providers: Lists benefit plan contact information for the health care provider.
Access standards
Covering physician
As a PCP, you must arrange for 24 hours a day, 7 days per week coverage of our members. If you are arranging a substitute
health care provider, use those who are in-network with the member’s benefit plan.
You must alert us if the covering health care provider is not in your medical group practice to prevent claim payment issues.
Use modifiers for substitute physician (Q5), covering physician (CP) and locum tenens (Q6) when billing services as a covering
physician. Collect the copay at the time of service.
To find the most current directory of our network physicians and health care professionals, go to
uhcprovider.com/findprovider.
2
3
4
5
6
7
8
9
10
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Chapter 2: Provider responsibilities and standards
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2023 UnitedHealthcare Care Provider Administrative Guide
Appointment standards
We have appointment standards for access and after-hours care to help ensure timely access to care for members. We use
these to measure performance annually. Our standards are shown in the following table.
Type of service Standard
Preventive care Within 30 calendar days
Regular/routine care appointment Within 30 calendar days
Urgent care appointment Same day
Emergency care Immediate
After-hours care 24 hours/7 days a week for PCPs
These are general UnitedHealthcare guidelines. State or federal regulations may require standards that are more stringent.
Contact your Network Management representative for help determining your state or federal regulations.
After-hours phone message instructions
If a member calls your office after hours, we ask that you provide emergency instructions, whether a person or a recording
answers. Tell callers with an emergency to do one of the following:
• Hang up and dial 911 or local equivalent.
• Go to the nearest emergency room.
When it is not an emergency, but the caller cannot wait until the next business day, advise them to do one of the following:
• Go to a network urgent care center.
• Stay on the line to connect to the physician on call.
• Leave a name and number with your answering service (if applicable) for a physician or qualified health care professional to
call back within specified time frames.
• Call an alternative phone or pager number to contact you or the physician on call.
Timely access to non-emergency health care services (applies to Commercial in California)
• The timeliness standards require licensed health care providers to offer members appointments that meet the California time
frames. The applicable waiting time for a particular appointment may be extended if the referring or treating licensed health
care provider, or the health professional providing triage or screening services, as applicable, is:
– Acting within the scope of their practice and consistent with professionally recognized standards of practice.
– Has determined and noted in the relevant record that a longer waiting time will not have a detrimental impact on the
member’s health.
• Licensed staff must triage or screen services by phone 24 hours a day, 7 days a week. Unlicensed staff shall not use the
answers to those questions in an attempt to assess, evaluate, advise or make any decision regarding the condition of a
member or determine when a member needs to be seen by a licensed medical professional.
• UnitedHealthcare of California managed care members and covered persons under UnitedHealthcare benefit plans have
access to free triage and screening services 24 hours a day, 7 days a week by calling the Optum NurseLine number on the
back of their ID card. If a member is unable to obtain a timely referral to an appropriate health care provider, refer to the Out-
of-Network Provider Referrals (Commercial HMO and Medicare Advantage) section for further details. If still unable to
obtain a timely referral to a health care provider after following these steps, contact the following:
– For members with Department of Managed Healthcare regulated plans: 1-888-466-2219
– For members with California Department of Insurance regulated plans: 1-800-927-4357
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Telehealth services
Under certain benefit plans, we provide coverage for telehealth services regardless of whether the member is located at a CMS-
designated originating site. For more information on telehealth services, see the Telehealth services protocol in Chapter 9:
Specific protocols.
Provider privileges
You must have privileges at participating facilities or an arrangement with another participating health care provider to admit
and offer facility services. This helps our members have access to appropriate care and lower their out-of-pocket costs.
Cultural competency
Provide services in a culturally competent manner. This includes members with limited English proficiency, those with diverse
backgrounds and/or disabilities. For more information, go to uhcprovider.com > Resources > Resource Library > Patient Health
and Safety Resources > Cultural Competency
Translation/interpretation/auxiliary aide services
You must provide language services and auxiliary aides, including, but not limited to, sign language interpreters to members as
required, to provide members with an equal opportunity to access and participate in all health care services.
If the member requests translation/interpretation/auxiliary aide services, you must promptly arrange these services at no cost to
the member.
Members have the right to a certified medical interpreter or sign language interpreter to accurately translate health information.
Friends and family of members with limited English proficiency, or members who are deaf or hard of hearing, may arrange
interpretation services only after you have explained our standard methods offered, and the member refuses. Document the
refusal of professional interpretation services in the member’s medical record.
Any materials you have a member sign, and any alternative check-in procedures (like a kiosk), must be accessible to an
individual with a disability.
If you provide Virtual Visits, these services must be accessible to individuals with disabilities. Post your Virtual Visits procedures
for members who are deaf or hard of hearing so they receive them prior to the Virtual Visit.
Network participating health care provider responsibilities
Primary care providers (PCP)
As a PCP, you are responsible to provide medically necessary primary care services. You are the coordinator of our members’
total health care needs. You are responsible for seeing all members on your panel who need assistance, even if the member has
never been in for an office visit. Some benefit plans require PCPs to submit electronic referrals for the member to see another
network physician. Go to Chapter 6: Referrals for detailed information on referral requirements.
Civil rights
Non-discrimination
You must not discriminate against any patient with regard to quality of service or accessibility of services because they are our
member. You must not discriminate against any patient on the basis of any of the following:
• Type of health insurance
• Race
• Ethnicity
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• Color
• National origin
• Religion
• Sex or gender
• Age
• Mental or physical disability or medical condition
• Sexual orientation
• Gender identity
• Claims experience
• Medical history
• Genetic information
• Type of payment
You must maintain policies and procedures to demonstrate you do not discriminate in the delivery of services and must provide
treatment for any members who need your service.
Complying with laws and regulations for individuals with disabilities
You must comply with applicable laws which include, but are not limited to, the Americans with Disabilities Act (ADA) and
Section 504 or 508 of the Rehabilitation Act.
Participating health care providers must have practice policies showing they accept any patient in need of the health care
they provide. The organization and its health care providers must make public declarations (i.e., through posters or mission
statements) of their commitment to non-discriminatory behavior in conducting business with all members. These documents
should explain that this expectation applies to all personnel, clinical and non-clinical, in their dealings with each member.
In this regard, you must undertake new construction and renovations, as well as barrier reductions required to achieve program
accessibility, following the established accessibility standards of the ADA guidelines. For complete details go to ADA.gov >
Featured Topics > A Guide to Disability Rights Laws.
We may request any of the following ADA-related descriptions of:
• Accessibility to your office or facility.
• The methods you or your staff use to communicate with members with disabilities. This may also include any electronic
communications.
• The training your staff receives to learn and implement these guidelines.
Care for members who are deaf or hard of hearing
You must provide a sign language interpreter if a member requests one. You must also have written office procedures for taking
phone calls or providing Virtual Visits to members who are deaf or hard of hearing.
Confidentiality, Use of Licensed Marks, Publicity
Consolidated Appropriations Act, 2021 (CAA) Prohibition on Gag Clauses
Your participation agreement may include a confidentiality provision that describes information that neither party may disclose
to a member, other health care provider or other third party except as required by an agency of the government, court order
or other third party. You agree the CAA constitutes such a requirement by an agency of the government, and nothing in your
participation agreement will be interpreted to supersede or conflict with the CAA. Specifically, your participation agreement will
not be interpreted to directly or indirectly restrict us (as a health insurance issuer offering group and individual health insurance
coverage) or a group health plan from:
1. Providing provider-specific cost or quality of care information to referring health care providers or current and potential
members.
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2. Electronically accessing de-identified claims and encounter information for each member in the plan or coverage,
upon request and consistent with the privacy regulations related to section 264(c) of the Health Insurance Portability
and Accountability Act (HIPAA), the amendments made by the Genetic Information Nondiscrimination Act of 2008 and
American with Disabilities Act of 1990. This includes, on a per claim basis, the following:
a. Financial information
b. Provider information
c. Service codes
d. Any other data included in claim or encounter transactions.
3. Sharing information with a business associate as defined in section 160.103 of title 45, Code of Federal Regulations (or
successor regulations), consistent with HIPAA, the amendments made by the Genetic Information Nondiscrimination Act of
2008 and the Americans with Disabilities Act of 1990.
Use of Licensed Marks, Publicity
Except as required by applicable law or as provided herein, you will not have any right to use the names, logos, trademarks,
trade names or other marks of United (c