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Doc#: PCA-1-016466-082920192020 Care Provider Manual Physician, Health Care Professional, Facility and Ancillary Care
Tennessee
Welcome
2 | UnitedHealthcare Community Plan of Tennessee 03.2020 © 2020 UnitedHealthcare
Welcome to the UnitedHealthcare Community Plan
provider manual. This up-to-date reference PDF manual allows you and your sta to nd important information such as how to process a claim and submit prior authorization requests. This manual also includes important phone numbers and websites on the How to Contact Us page. Find operational policy changes and other electronic tools on our website at UHCprovider. com. This provider manual supports TennCare, Tennessee"s Medicaid program. It has been operating under a waiver from CMS since 1994 to oer coverage to the traditional Medicaid-eligible population as well as an expanded population (TennCare Standard). All TennCare members are enrolled into a managed care organization (MCO) within their geographic region.
We entered into a Contractor Risk Agreement (CRA)
for each Grand Region with the State of Tennessee for provision of the TennCare benets. The TennCare program in each Grand Region is governed by its
Contractor Risk Agreement, the TennCare Rules and
Regulations as well as the TennCare Policies. The Division of TennCare website contains links to all governing documents. These include:
Contractor Risk Agreement: tn.gov
TennCare Rules: publications.tnsoles.com
TennCare Policies: tn.gov
We administer the TennCare program as an MCO
in all three geographic regions doing business as
UnitedHealthcare Community Plan. We are a primary
care practitioner (PCP)-driven HMO network focusing on PCPs providing appropriate care to covered persons based on established clinical guidelines. We operate in an integrated model where all physical, behavioral and long-term services and supports health care needs are assessed, coordinated and monitored. We oer our covered individuals and providers programs in medical management, quality improvement, education and development, as well as quality customer service. Some TennCare enrollees are also eligible for enhanced services provided through CHOICES. CHOICES is the
Long-Term Services and Supports (LTSS) program,
which promotes quality and cost-eective care coordination for CHOICES enrollees with chronic, complex health care, social service and custodial needs. The CHOICES program includes both Nursing Facility and Home- and Community-Based (HCBS) care coordination. CHOICES care coordination operates based on our fully integrated model so the physical, behavioral and LTSS care health needs of the CHOICES enrollees are met. You may nd detailed information on the CHOICES program in Chapter 6: Long Term Services and Supports Program (LTSS), and Chapter 7:
Employment and Community First (ECF) CHOICES of
this Manual.
CLICK THE FOLLOWING LINKS TO ACCESS
DIFFERENT MANUALS:
UnitedHealthcare Administrative Guide for
Commercial and Medicare Advantage member
information. Some states may also have Medicare
Advantage information in their Community Plan
manual.
A dierent state Community Plan manual: go
to UHCprovider.com. Click Menu on top left, select Administrative Guides and Manuals, then
Community Plan Care Provider Manuals, select
state.
UnitedHealthcare Dual Complete: For information
about UnitedHealthcare Dual Complete in
Tennessee, go to UHCprovider.com > Menu > Health
Plans by State > Tennessee Medicare Advantage
Health Plans > Tennessee Dual Complete Special
Needs Plans.
March Vision Routine Care provider reference guide: marchvisioncare.com. Ophthalmologists rendering medical services to TennCare enrollees should refer to this manual.
Welcome
Welcome
3 | UnitedHealthcare Community Plan of Tennessee 03.2020 © 2020 UnitedHealthcare
EASILY FIND INFORMATION IN THIS MANUAL USING
THE FOLLOWING STEPS:
1.
Select CTRL+F.
2.
Type in the key word.
3.
Press Enter.
If available, use the binoculars icon on the top right hand side of the PDF to search for information and topics. We greatly appreciate your participation in our program and the care you oer covered persons.
If you have questions about the information or
material in this manual, or about our policies, please call Provider Services.
Important Information about
the Use of This Manual If there is a conict between your Agreement and this care provider manual, use this manual unless your Agreement states you should use it, instead. If there is a conict between your Agreement, this manual and applicable federal and state statutes and regulations and/ or state contracts, applicable federal and state statutes and regulations and/or state contracts will control. UnitedHealthcare Community Plan reserves the right to supplement this manual to help ensure its terms and conditions remain in compliance with relevant federal and state statutes and regulations.
This manual will be amended as policies change.
PARTICIPATION AGREEMENT
In this manual, we refer to your Participation Agreement as Agreement".
The Division of TennCare requires specic language
in TennCare Provider Agreements. As noted in the
Modication Section of your Provider Agreement,
Division of TennCare required language and State of
Tennessee mandates about the TennCare program can
be updated by inclusion in the care provider manual. For ease of your review, certain required language and TennCare program mandates are contained in a document titled TennCare Program Regulatory Appendix Requirements Appendix. The Appendix is at
UHCprovider.com.
The appendix is routinely appended to our TennCare Provider Agreements. The latest version of this Appendix is also appended to this care provider manual. When we amend your Agreement to comply with federal and state regulatory requirements, most of these changes may be made within the body of this care provider manual. However, those regulatory requirements may require us to make changes to condential portions of your
Agreement, such as the
payment provisions. When this type of change is required, we may provide you a separate condential notice of the regulatory changes to your Agreement. If the payment provisions are aected, we will send you a new fee schedule or payment appendix for your records.
If we provide you notice of changes based on this
paragraph, we will limit such changes to those required to comply with the change in regulatory requirements.
Table of Contents
4 | UnitedHealthcare Community Plan of Tennessee 03.2020 © 2020 UnitedHealthcare
Table of Contents
Chapter 1: Introduction5
Chapter 2: Care Provider Standards & Policies15
Chapter 3: Care Provider Oce Procedures and Individual Benets24
Chapter 4: Medical Management34
Chapter 5: Early, Periodic Screening, Diagnosis and Treatment (EPSDT)/Prevention49 Chapter 6: Long Term Services and Supports (LTSS)52 Chapter 7: Employment and Community First (ECF) CHOICES62
Chapter 8: Value-Added Services80
Chapter 9: Mental Health and Substance Use84
Chapter 10: Individual Rights and Responsibilities91
Chapter 11: Medical Records94
Chapter 12: Quality Management (QM) Program and Compliance Information101
Chapter 13: Billing and Submission 108
Chapter 14: Claim Reconsiderations, Appeals and Grievances116 Chapter 15: Care Provider Communications & Outreach126
Chapter 16: Glossary128
Chapter 1: Introduction
5 | UnitedHealthcare Community Plan of Tennessee 03.2020 © 2020 UnitedHealthcare
TennCare is the Tennessee State Medicaid program
TennCare oers traditional Medicaid to eligible
populations (TennCare Medicaid) as well as an expanded population (TennCare Standard). All TennCare individuals are enrolled into an MCO. UnitedHealthcare Plan of the River Valley has entered into a contractor risk agreement (CRA) with the State of Tennessee to provide TennCare benets to qualifying residents. UnitedHealthcare Plan of the River Valley administers the TennCare program as UnitedHealthcare
Community Plan.
UnitedHealthcare Community Plan supports the
Tennessee state goals of increased access, improved health outcomes and reduced costs by oering
Medicaid benets to eligible individuals:
TennCare
TennCare Kids
TennCare Employment and Community First (ECF)
CHOICES
TennCare CHOICES Long-Term Services and
Supports (LTSS) Program
Tennessee has three geographic regions. All TennCare individuals are enrolled in an MCO within their geographic region. DHSS will determine enrollment eligibility.
If you have questions about the information in
this manual or about our policies, go to
UHCprovider.com/tncommunityplan or call
Provider Services at 800-690-1606.
How to Join Our Network
For instructions on joining the
UnitedHealthcare Community Plan provider
network, go to UHCprovider.com/join. There you will nd guidance on our credentialing process, how to sign up for self-service tools and other helpful information.
Chapter 1: Introduction
Our Approach to Health Care
WHOLE PERSON CARE MODEL
The Whole Person Care (WPC) program seeks to
empower covered persons enrolled in Medicaid, care providers and our community to improve care coordination and elevate outcomes. Targeting covered persons with chronic complex conditions who often use health care, the program helps address their needs holistically. WPC examines medical, behavioral and social/environmental concerns to help them get the right care from the right care provider in the right place and at the right time. The program provides interventions to covered persons with complex medical, behavioral, social, pharmacy and specialty needs. This results in better quality of life, improved access to health care and lower expenses.
WPC provides a care management/coordination team
that helps increase their engagement, oers resources to ll gaps in care and develops personalized health goals using evidence-based clinical guidelines. This approach helps improve the health and well-being of the people and communities we serve. WPC provides:
Extended care team including primary care
practitioner (PCP), pharmacist, medical and behavioral director, and peer specialist.
Interventions that engage individuals, connecting
them to needed resources, care and services.
Individualized and multidisciplinary care plan.
Assistance with appointments with PCP and
coordinating appointments. The Clinical Health
Advocate (CHA) refers individuals to an RN,
Behavioral Health Advocate (BHA) or other
specialists as required for complex needs.
Education and support with complex conditions.
Tools for helping individuals engage with care
providers, such as appointment reminders and help with transportation.
Foundation to build relationships with hard-to-
engage individuals.
Chapter 1: Introduction
6 | UnitedHealthcare Community Plan of Tennessee 03.2020 © 2020 UnitedHealthcare
The WPC program goals are to:
Lower avoidable admissions and unnecessary
emergency room (ER) visits, measured outcomes by inpatient (IP) admission and ER rates.
Improve access to PCP and other needed services,
measured by number of PCP visit rates within identied time frames.
Identify and discuss behavioral health needs,
measured by number of behavioral health care provider visits within identied time frames.
Improve access to pharmacy.
Identify and remove social and environmental barriers to care.
Improve health outcomes, measured by improved
Healthcare Eectiveness Data and Information
Set (HEDIS) and Centers for Medicare & Medicaid
Services (CMS) Star Ratings metrics.
Empower covered persons to manage their
complex/chronic illness or problem and care transitions.
Improve coordination of care.
Engage community and care provider networks
to help ensure access to aordable care and the appropriate use of services.
REFERRING YOUR PATIENT
To refer your patient who is a UnitedHealthcare
Community Plan covered person to WPC, call Provider
Services at 800-690-1606.
Compliance
HIPAA mandates National Provider Identier (NPI)
usage in all standard transactions (claims, eligibility, remittance advice, claims status request/response, and authorization request/response) for all health care providers who handle business electronically.
Cultural Competency
Under state and federal law, all TennCare individuals have a right to receive free interpretation and translations as Limited English Prociency (LEP) services. You must:
Implement LEP policies and procedures for
language assistance, interpretation, and translation services to individuals.
Provide similar services to hearing-impaired
individuals. Oer in-person interpreters, sign language or access to telephonic assistance (e.g., the ATT universal line). This is a requirement for any care provider accepting TennCare funds. To access these services, call the TennCare Foreign Language Line at 800-758-1638. We do not reimburse for translation services oered to TennCare individuals in the care provider"s oce setting. Do not bill us or individuals for these services. To help you meet patient needs, we have developed a Cultural Competency Program. Linguistic and cultural barriers can negatively aect access to health care. You must help us meet this obligation for covered persons.
We oer the following support services:
Language Interpretation Line: We provide oral
interpreter services 24 hours a day, seven days a week to individuals free of charge. More than
240 non-English languages and hearing impaired
services are available. If a covered person needs Interpreter Services, we prefer you use a professional interpreter. To access a professional interpreter during regular business hours, contact the TennCare Foreign Language Line.
Cultural materials: We provide simplied materials
for individuals with LEP and who speak languages other than English or Spanish. We also provide materials for visually impaired individuals.
Evidence-Based Clinical
Review Criteria and
Guidelines
UnitedHealthcare Community Plan uses MCG Care
Guidelines (formally Milliman Care Guidelines) for care determinations.
Network Management
Our Network Management Department can help you
with your contract, credentialing and in-network services.
We have network account managers and provider
Chapter 1: Introduction
7 | UnitedHealthcare Community Plan of Tennessee 03.2020 © 2020 UnitedHealthcare advocates who are available for visits, contracting, credentialing and other related issues.
If you need to speak with a network contract
manager about credentialing status or contracting, call Network Management.
Online Resources
UHCprovider.com is your home for care provider
information with access to Electronic Data Interchange (EDI), Link self-service tools, medical policies, news bulletins, and great resources to support administrative tasks including eligibility, claims, claims status and prior authorizations and notications.
SECURE CARE PROVIDER WEBSITE
We provide a secure portal to network care providers, facilities and medical administrative sta called Link at
UHCprovider.com. This website oers an innovative
suite of online health care management tools, including the ability to view all online transactions for covered persons. It can help you save time, improve eciency and reduce errors.
To access Link, the secure care provider
website, go to UHCprovider.com and either sign in or create a user ID for Link. You will receive your user ID and password within 48 hours.
The secure care provider website lets you:
Verify eligibility, including secondary coverage.
Review benets and coverage limit.
Check prior authorization status.
Access remittance advice and review recoveries.
Review your preventive health measure report.
Access the Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) toolset.
Search for CPT codes. Type the CPT code in the
header search box on UHCprovider.com, and the search results will display all documents and/or web pages containing that code.
Find certain web pages more quickly using
direct URLs. You"ll see changes in the way we direct you to specic web pages on our
UHCprovider.com provider portal. You can
access our most used and popular web pages on UHCprovider.com by typing in that page"s direct URL identied by a forward slash in the web address, e.g. UHCprovider.com/claims. When you see that forward slash in our web links, you can copy the direct URL into your web page address bar to quickly access that page.
DIRECT CONNECT
Direct Connect is a free online portal that lets you securely communicate with payers to address errant claims. This portal can replace letters, faxes, phone calls and spreadsheets. It also helps:
Manage overpayments in a controlled process.
Create a transparent view between you and payer.
Avoid duplicate recoupment and returned checks.
Decrease resolution timeframes.
Real-time reporting to track statuses of inventories in resolution process.
Provide control over nancial resolution methods.
All users will access Direct Connect using Link. On-site and online training is available.
Email directconnectsupport@optum.com to
get started with Direct Connect.
Privileges
To help indivudals access appropriate care and
minimize out-of-pocket costs, you must have privileges at applicable network facilities or arrangements with a network provider to admit and provide facility services. This includes full admitting hospital privileges, ambulatory surgery center privileges and/or dialysis center privileges.
Provider Services
Provider Services is your primary contact for when you need help. It is staed with representatives trained for UnitedHealthcare Community Plan. Provider Services works closely with all our departments.
Provider Services can assist you with questions
on Medicaid benets, eligibility, claim decision, forms required to report specic services, billing questions and more.
Chapter 1: Introduction
8 | UnitedHealthcare Community Plan of Tennessee 03.2020 © 2020 UnitedHealthcare
How to Contact Us
TopicContactInformation
Benetstn.gov/tenncare > Members/Applicants >
Covered Services
UHCprovider.com/benets
800-690-1606
Conrm a person"s benets and/or prior
authorization.
Cardiology Prior
Authorization
For prior authorization or a current list of
CPT codes that require prior authorization,
visit UHCprovider.com/cardiology
Click Menu on top left, select Prior
Authorization and Notication, then
Cardiology
800-690-1606
Request prior authorization of the procedures
and services outlined in this manual"s prior authorization requirements.
ClaimsEDI: UHCprovider.com/edi > Companion
Guides
Payer ID 95378
Link: UHCprovider.com/claimslink
Online: UHCprovider.com/claims
quotesdbs_dbs21.pdfusesText_27
[PDF] Welcome to the community - UnitedHealthcare Community Plan