introduction to unitedhealthcare community plan of virginia · 2 days ago · introduction to...

Introduction to UnitedHealthcare Community

Plan of Virginia

Agenda

• Mission and Vision

• UnitedHealthcare Community Plan of Virginia

• Eligibility and Benefits

• Care Provider Responsibilities

• Notification and Prior Authorization

• Pharmacy Services

• Claims

• Care Provider Resources

• Questions

Proprietary information of UnitedHealth Group. Do not distribute or reproduce without express permission of UnitedHealth Group.


Mission and Vision



Mission and Vision

Our Mission

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. And to be effective partners

with physicians, hospitals and other

health care professionals in serving their

patients.


UnitedHealthcare Community

Plan of Virginia



• Features five community health plans

o UnitedHealthcare Dual Complete® (HMO SNP)*

A Dual Special Needs Plan (DNSP)

o UnitedHealthcare Dual Complete® (Regional PPO SNP)*

DNSP

o Commonwealth Coordinated Care Plus (CCC Plus)

Long Term Services and Supports (LTSS)

o UnitedHealthcare Community Plan of Virginia (Medicaid-

TANF/CHIP/FAMIS)

Medicaid

• Includes locally based resources

• Deploys care providers in the communities of the members we serve

• Promotes core values of integrity, compassion, relationships, innovation and

performance *Our plan will educate members on benefits of alignment and encourage dual members to also enroll in our companion DSNP for

the Medicare portion of their benefits. However, members will continue to have a choice in how they receive their Medicare

benefits.

Plan Overview

Eligibility and Benefits



Virginia Medicaid Regional Map

The effective dates of CCC Plus and Medallion 4.0 members are determined by

the following regions and their open enrollment periods.


Open Enrollment

To assist your members with choices during open enrollment, please visit:

• Medallion: virginiamanagedcare.com/learn/open-enrollment

• CCC Plus: cccplusva.com/enroll


United Healthcare Community Plan of Virginia

Commonwealth Coordinated Care Plus

(CCC Plus)

Medallion 4.0

(TANF/Chip/FAMIS)

• Receives full Medicaid benefits and meets

one of the following categories:

Ages 65 and older

Adult or child with a disability

Resides in a nursing facility

Receives services through CCC Plus

home and community-based waivers,

formerly Assistive Technology (AT) and

Virginia Elderly or Disabled with

Consumer Direction (EDCD)

Receives services through any of three

waivers serving people with

developmental disabilities, also known

as Developmental Disability (DD)

waivers

Lives in Virginia

Children younger than 19

Adults ages 19-64 meeting new income

and other eligibility

Children younger than 21 who are in

foster care or adoption assistance

Individuals younger than 26 who are a

former foster care child

Pregnant women

Some parents and caregivers

United States citizens or lawfully

residing immigrants

Live-in families meeting Family Access

to Medical Insurance Security Plan

(FAMIS) income guidelines


Virginia’s New Health Coverage for Adults

Who is eligible for Medicaid expansion?

• Virginia residents, ages 19-64

• Individuals not already in or eligible for Medicare

• Those who meet income requirements, which vary by household size

Coverage includes doctor, hospital and emergency services as well as preventive

and wellness services such as:

• Annual wellness exams

• Immunizations

• Smoking cessation

• Nutritional counseling

For more information or to help patients with sign-up:

• Online: Visit www.coverva.org

• Phone: Call 855-242-8282


Verifying Member Eligibility and Benefits

Before providing services, please verify member eligibility:

• Online: You can use our eligibilityLink tool on Link to check

eligibility and benefits. To access eligibilityLink, sign in to Link by

going to UHCprovider.com and clicking on the Link button in the

top right corner.

• Phone: Call Provider Services

• Medallion 4.0: 844-284-0146

• CCC Plus: 877-843-4366

• You can also check Medicaid member eligibility on the Department

Medical Assistance Services (DMAS) provider website at

virginiamedicaid.dmas.virginia.gov.


Enrollment and Disenrollment

• The majority of Medicaid enrollees are auto-enrolled into a managed care

organization by the state. o Members have an initial 90-day window to switch health plans as well as an

annual election period.

• Health care providers are permitted to suggest a managed care organization

plan to their patients.

• How can you help? o Educate your patients about open enrollment

o Encourage patients to exercise the right to choose their plan

o Tell your patients about the different managed care organizations

o Have your staff distribute the open enrollment educational materials from

UnitedHealthcare

• For more information, please contact:

o Medallion 4.0: 800-643-2273

o CCC Plus: 844-374-9159


Medallion 4.0 (Medicaid) Benefits

Medallion 4.0 includes comprehensive healthcare and prevention service

benefits such as:

• Preventive and regular medical care

• Prenatal, delivery and postpartum care

• Newborn and pediatric preventative acute treatment

• Immunizations

• Non-emergency Medical Transportation (NEMT)

• Early and Periodic Screening, Diagnosis and Treatment (EPSDT)

• Early Intervention Services

• Addiction and Recovery Treatment Services (ARTS)

• Community Mental Health Rehabilitation Services (CMHRS)

• Chiropractic Services (FAMIS only)


UnitedHealthcare Medallion 4.0 Added Benefits

To help our members focus on improving quality of life and health outcomes,

we offer additional benefits beyond standard Medicaid benefits.

Non-emergent

transportation to

appointments with doctors,

pharmacies and food banks

Rewards program for

attending prenatal and

baby appointments

Baby

Blocks

On My

Way

(OMW)

Eye exam each year and

frames/lenses every two

years

on

Vision

Care

Assistance

for

Asthmatics

Interactive website to

educate and help prepare

young adults for real

world situations

Special mattress covers and

pillowcases that prevent

asthma due to dust mites

Transpor-

tation

Boys &

Girls

Clubs

Payment of Boys & Girls

Clubs of America

registration fees


More Added Benefits

10 meetings each

year with resources

for healthy eating and

weight loss

Weight

Watchers

Answers to health

questions for kids,

teens and parents

Sports

Physical

Extracurricular

sports physical

Kids

Health


CCC Plus Benefits

CCC Plus includes comprehensive healthcare and prevention service benefits

such as:

• Preventive and regular medical care

• Addiction Recovery and Treatment Services (ARTS)

• Community Mental Health Rehabilitation Services (CMHRS)

• Care coordination services

• Early intervention services

• Maternity and high-risk pregnancy care

• Routine eye exams and glasses for children and routine eye exams for

adults

• Telemedicine services


UnitedHealthcare CCC Plus Added Benefits

To help our members focus on improving quality of life and health outcomes,

we offer additional benefits beyond standard Medicaid benefits:

Acute home-delivered

meals Rewards program for

attending prenatal and

baby appointments

Baby

Blocks

Eye exam each year and

frames/lenses every two

years

on

Vision

Care

Alere Quit

for Life

10 meetings each year,

with resources for

healthy eating and

weight loss

Tobacco smoking cessation

program

Meals

Weight

Watchers

Free cellphone program

Adult

Dental

Preventive dental coverage

My

Healthline


Our Care Focus

As part of our coverage for members, UnitedHealthcare Community

Plan of Virginia offers:

• Holistic, integrated case management

• More engaged care coordination across care providers

• Family planning awareness

• Earlier prenatal care and coordinated postpartum care

• Increased behavioral health assessments and depression screens

• Fewer early elective deliveries

• Better foster care transitions

• Support for members who choose to breastfeed

• More support through social media and telehealth channels

• Additional education for members and providers


Vaccines for Children

• Primary care providers are encouraged to

enroll in the Virginia Vaccines for Children

Program (VVFC).

• Primary care providers shouldn’t routinely

refer Medicaid members to local health

departments to receive vaccines.

• Immunizations are covered for children

enrolled in Medicaid.

• We educate parents and guardians about

the importance and coverage of

immunization services.

• We coordinate information regarding

the member’s immunizations.

Care Provider Responsibilities



PCP Responsibilities

• Each member may select a primary

care provider (PCP) at enrollment. If

a member doesn’t, UnitedHealthcare

Community Plan will assign one.

• Multiple members in the same household

may each choose a unique PCP.

• Members may see network care providers

for specialty care without a referral.

• For a list of services that require

notification/prior authorization, go to:

UHCprovider.com > Menu > Health

Plans by State> Virginia > Prior

Authorization and Notification.


Cultural Competency

To help improve overall care for all of our members, please consider

cultural competency and Americans with Disabilities Act (ADA)

requirements:

• Provide scheduling flexibility to accommodate member needs

• Allow for flexible arrival times, due to dependency on transportation

• Accommodate members who physically cannot sit for long periods

• Provide interpreters for members who are hard of hearing or who do not

speak English

• Offer written materials after appointment

• Consider cultural and social differences

• Provide members with reasonable accommodations for effective

communication.


Community Plan Care Provider Manual

Your Community Plan Care Provider Manual is an important resource that

contains additional guidance on responsibilities for you as a network provider.

This manual serves as a supplement to your network participation agreement.

Examples include:

• Medicaid enrollee rights and responsibilities as noted in your Community

Plan Care Provider Manual

• Reporting suspected fraud and abuse

• Care provider privileges and more

Your Community Plan Care Provider Manual is updated annually and will serve

as a useful guide to understand program requirements.

Notification and Prior

Authorization Requirements



Advance Notification

• Advance notification is required for certain planned services.

• Advance notification is required at least 14 calendar days before the

planned service date.

• To help expedite the approval process, please include complete

clinical information with your request.

• You can submit advance notifications at UHCprovider.com > Menu

> Prior Authorization and Notification > Submit a Request for Prior

Authorization and Notification.

To view a list of procedure codes and services requiring services, please

go to UHCprovider.com > Menu > Prior Authorization and Notification

Requirements.


Hospital Admission Notification

• Notification must include all items and services needed for a stay at a

participating hospital, including room and board, nursing care, medical

supplies and all diagnostic and therapeutic services.

• We must be notified of an emergency/urgent admission or after ambulatory

surgery within two business days of the admission.

• Observation does not require notification unless the member’s level of care is

adjusted to inpatient.

To notify us of a hospital admission:

• Online: Visit UHCprovider.com > Menu > Prior Authorization and

Notification > Submit a Request for Prior Authorization and Notification

• Phone: 844-284-0146 for Medallion 4.0 or 877-843-4366 for CCC Plus

• Fax: 844-805-7522 (this fax is for Hospital Admission Notification only)

If notification timeframes are not followed, claims may be denied.


Prior Authorization Requirements

• Prior authorization is required when a member’s benefit document

requires that only medically necessary services are covered.

• A clinical coverage review will use evidence-based clinical guidelines to

determine if the service is medically necessary.

• The care provider or facility requesting prior authorization will receive a

written clinical coverage determination.

• If we determine the information submitted doesn’t meet medical necessity

guidelines, you’ll be offered a peer-to-peer review with the reviewing

UnitedHealthcare physician.


Prior Authorization Timeframes

CCC Plus Medallion 4.0

• We will provide a decision for standard

or non-emergent medical care within

3 business days of receipt of all clinical

information.

• Urgent requests will have a decision

rendered within 72 hours after receipt

of request for service.

• LTSS will have a decision rendered

within 5 business days if all clinical

information is available.

• If we need additional information,

requests may be pended for up to 5

additional business days.

• Please schedule procedures as far in

advance as possible.

• We will provide a decision for standard

or non-emergent medical requests

within 14 calendar days following

receipt of the request for service.

• Urgent requests will have a decision

rendered within 72 hours after receipt

of request for service.

• If we need additional information,

decisions may be extended for up to 14

additional calendar days.


Prior Authorization Requirements for

Radiology/Cardiology

• The same advanced imaging and cardiac procedures requiring advance

notification are the same procedures requiring prior authorization.

• All care providers must obtain authorization before performing select

inpatient, outpatient and office-based procedures.

• Prior authorizations are not required for cardiac or radiology procedures

ordered through an:

o Emergency room treatment visit

o Observation unit

o Urgent care facility

o Inpatient stay

• For specific protocols, visit UHCprovider.com > Menu > Prior

Authorization and Notification > (select Cardiology or Radiology) >

Community Plan

Exception: Electrophysiology

implants like pacemakers, which

require authorization in an inpatient

setting


Prior Authorization Resources

• To view the prior authorization list, visit UHCprovider.com > Menu >

Health Plans by State > Virginia > Community Plan > Prior

Authorization and Notification

• You have two ways to submit prior authorization requests:

o Online: Visit UHCprovider.com/paan

o Phone: 844-284-0146 for Medallion or 877-843-4366 for CCC

Plus weekdays, 8 a.m. – 6 p.m. ET (available 24 hours for

emergencies)

• To check prior authorization status, visit

UHCprovider.com/paan or call 866-889-8054


Clinical Coverage Review Process

If insufficient clinical information is submitted, we’ll contact you for

additional information.

• If you provide the information within the requested timeframe, we’ll

conduct a clinical coverage review to determine medical necessity.

• Without that additional information, the request for authorization may be

denied.

• A clinical denial will be issued if medical necessity criteria is not met for a

prior authorization or precertification request.

• You’ll receive a denial notice with the option to appeal.


Continuity of Care

Members will transition from other plans without any disruption in care.

• Members transitioning to Unitedhealthcare Community Plan of Virginia from

other plans will have a continuity-of-care period that can last up to 30 days.

• During this period, members can continue seeing their current care

providers, even if those care providers have not contracted with the

member’s new health plan.

• To offer a smooth transition, we will honor and reimburse care providers for

existing service authorizations, including out-of-network care providers, for

30 days.

• If the member does not select a new participating care provider within 30

days, we will transition the member to a new provider.


Appeal Process

• Peer-to-Peer Review: You can discuss denial decisions with a physician

reviewer.

• Reconsideration/Appeal: Each denial letter will include the phone number

to request an appeal.

• Timeframes for Appeal Reviews

o Pre-service/outpatient reviews: 30 calendar days from notice of denial

o Inpatient: 30 calendar days from notice of denial or three business

days after discharge, whichever comes first

Pharmacy



Pharmacy

• Our preferred drug list (PDL) is available at UHCprovider.com > Menu

> Pharmacy Program.

• The PDL includes information on preferred drugs, prior authorization criteria

requirements, quantity limits and age limits.

• The drugs listed in the PDL have been reviewed and approved by the

Commonwealth’s DMAS.

• OptumRx oversees pharmacy network contracting and claims processing.

• BriovaRx is our specialty pharmacy provider.

• Online: BriovaRx.com

• Phone: 855-4BRIOVA


Electronic Prescribing

We offer e-prescribing to help you save

time and money and help eliminate

medication confusion.

E-prescribing allows you to:

• Access a member’s medication history

• Check a member’s eligibility

• Access the formulary

• Send real-time electronic prescriptions


Pharmacy Prior Authorization

• Some medications may require prior

authorization.

• If drug therapy must begin before

receiving approval, the dispensing

pharmacist can provide a three-day

emergency supply of medication.

To request pharmacy prior authorization, please contact the

UnitedHealthcare Community Plan Pharmacy Department:

Phone: 800-310-6826

Fax: 866-940-7328

Prior authorization requests are reviewed and notification is sent back

within 24 hours.

Claims



Electronic Claims

• Online: Use the Claim Submission tool on Link. To sign in to Link, go

to UHCprovider.com and click on the Link button in the top right

corner.

• 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.

• For more information, please contact your vendor or call Electronic Data

Interchange (EDI) at 800-842-1109.

Payer ID 87726 is the most common primary Payer ID for this plan.


Paper Claims

Mail claims to:

UnitedHealthcare Community Plan –

Virginia

P.O. Box 5270

Kingston, NY 12402-5240

Our standard timely filing limit is 365 days from

date of service.


Claim Payment Resolution

If you disagree with a claim payment decision, please follow these steps:

1. Submit a reconsideration request:

• Use claimsLink tool on Link

• Submit a paper reconsideration

• Call UnitedHealthcare Community Plan Provider Services line

Be sure to obtain a five-digit tracking number for future reference.

2. If the issue remains unresolved after 30 days, please send your Provider

Advocate the member name, member ID number, date of service and

tracking number or a copy of the claim.

3. Your Provider Advocate will try to determine the cause and resolve

your issue.


Submitting a Claim Reconsideration Request

• Preferred Method: Please submit claim reconsideration requests

electronically using the claimsLink tool on Link. To sign in to Link,

go to UHCprovider.com and click on the Link button in the top

right corner.

• To submit a paper claim reconsideration, please use the Claim

Reconsideration Request Form for corrections that require specific

instructions.

• You don’t need the form for basic corrections or adjustments.

• The Claim Reconsideration Request Form is available at

UHCprovider.com > Menu > Claims, Billing and Payments > Submit a

Corrected Claim, Claim Reconsideration.


Submitting a Corrected Paper Claim

• On the Claim Reconsideration Form, check box 4, "Resubmission of a

corrected claim."

• Complete the comments section and explain which 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.


Electronic Payments and Statements (EPS)

EPS lets you receive electronic funds transfer (EFT) for claim payments and

receive EOBs online.

• Reduces administrative costs and simplifies bookkeeping

• Speeds up reimbursement turnaround time

• Funds are available as soon as they are posted to your bank account

To receive EFT and electronic EOBs through

EPS, please enroll at

myservices.optumhealthpaymentservices.com

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


EPS Resources

If you’re already signed up for EPS, you will automatically receive direct

deposit and electronic statements through EPS for UnitedHealthcare

Community Plan of Virginia.

Phone: Call 877-620-6194

Online: Visit UHCprovider.com > Menu > Claims,

Billing and Payments > Enroll in Electronic Payments

& Statements (EPS)

For more information:

Care Provider Resources



Link Resources

Link is your gateway to UnitedHealthcare’s online tools.

Use Link tools to help simplify daily administrative tasks:

• Check member eligibility

• Submit a claims reconsideration

• Review coordination of benefits information

• View care opportunities for members

To learn more about Link, please visit UHCprovider.com/link.


Online Care Provider Resources

UHCprovider.com

UnitedHealthcare Community Plan of Virginia resources include:

• Care Provider Manual

• Reimbursement updates and clinical policies

• Practice Matters newsletter

• Guidelines on claim submission, prior authorization and member

eligibility

• Network Bulletin newsletter


Provider Advocates

Tidewater

Linda Sweet

Phone: 763-732-6755

Northern /Winchester

Holley Thai

Phone: 571-262-2268

Alexandra Mateo

Phone: 571-262-8958

You can email any advocate at [email protected].

Central

Oasis Sykes

Phone: 804-267-5296

Roanoke/Alleghany

Tiffany Paige

Phone: 612-383-3889

Charlottesville/Western

Jessika DeFelice

Phone: 804-267-5215

Your Provider Advocate can help when you have questions. They are your

single point of contact across all lines of business and benefit plans to help

make your interactions with us easier and more efficient.

Southwest

Amanda Hustad

Phone: 423-845-0173


UHC On Air

UHC On Air offers live and on-demand education and training

videos. Visit UHCprovider.com, sign in to Link and select the

UHC On Air tool.


UHC On Air Channels

Select the UHC News Now channel to watch

national UnitedHealthcare information related to

Medicare, Medicaid and Commercial benefit plans,

programs and services.

Select the Virginia channel to see your local

programming. After selecting your state-specific

channel, you’ll see videos categorized by plan type.


Additional Resources

• Department of Medical Assistance Services: dmas.virginia.gov

• Medallion Provider Registration and Enrollment:

virginiamedicaid.dmas.virginia.gov > Provider Enrollment

Behavioral Health

Phone: 844-284-0146 for Medallion

4.0 or 844-843-4366 for CCC Plus

Hours: Monday – Friday, 8 a.m. to 6 p.m.

Dental: Smiles for Children

Phone: 888-912-3456


Vision: MarchVision

Phone: 855-476-2724


Non-Emergent Transportation:

National Med Trans Network

Reservations: 844-525-1493

Where’s My Ride: 833-215-3885

Hours: Monday – Friday, 8 a.m. to 5p.m.

OptumHealthNurseLine

Phone: 877-543-4293

Hours: Available 24/7


Additional Resources

Ancillary Services

[email protected]

Monday through Friday, 9 a.m. – 5 p.m.

Home and Community Based Services

[email protected]

Monday through Friday, 9 a.m. – 5 p.m.

PT/OT/SLP and Chiropractic

Amber Halford Contract Manager

[email protected]

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