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QUEST Integration Training & Education for Medical Providers

QUEST Integration Training & Education for Medical Providers. Who is UnitedHealthcare?. Introductions In Hawaii since 1992 Medicare and Commercial products QExA program began in February 2009 QUEST program began in July 2012 QUEST Integration program begins January 2015

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QUEST Integration Training & Education for Medical Providers

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  1. QUEST Integration Training & Educationfor Medical Providers

  2. Who is UnitedHealthcare? • Introductions • In Hawaii since 1992 • Medicare and Commercial products • QExA program began in February 2009 • QUEST program began in July 2012 • QUEST Integration program begins January 2015 • Over 180 employees statewide • Office: 1132 Bishop Street in Honolulu, Suite 400 • Future office opening in Hilo in Jan 2015 • 6,500 Medicare Members on Oahu • 41,000+ QUEST Expanded Access members statewide • 14,000+ QUEST members statewide

  3. UnitedHealthcare Community and State: Includes Medicaid, TANF, CHIP, ABD, long term care, Medicare Dual SNP programs UnitedHealthcare Medicare and Retirement: Includes Medicare and retirement plans UnitedHealthcare Employer and Individual: Includes commercial group and individual plans UnitedHealthcare Military and Veterans: Tricare Program OptumHealth: Includes OptumHealth Care Solutions, Optum Behavioral Health, Nurseline OptumInsight: Provides consulting, health information systems and data management OptumRx: pharmacy benefit manager Logisticare: transportation services United Health Group, Inc. and its partners in Hawaii

  4. Important Highlights UnitedHealthcare is accredited by the National Committee for Quality Assurance (NCQA) for its Medicaid programs Local Member/Provider Call Center for Hawaii Medicare and Medicaid programs Local Provider Services Team, lead by Julie Cooper, Director of Network Strategy & Relationship Building Medical Director, Ronald Fujimoto, DO Confidential Property of UnitedHealth Group. Do not distribute or reproduce without express permission of UnitedHealth Group.

  5. Learning Objectives Updates and changes at UHC Overview of QUEST Integration Health Plan Roles and Responsibilities Health Plan Accreditation Our Commitment to you Care/Case Management Model Roles of UHC Support Team Quality Initiatives Disease Management Provider Roles and Responsibilities PCP Role and PCP Assignment EPSDT Access to Care Standards Provider Complaint, Grievance and Appeals Process Regulatory Requirements Credentialing and ReCredentialing Today’s topics will leave you with an understanding of the: • Fraud, Waste and Abuse • Member Rights and Responsibilities • Cultural Competency • Member Grievance and Appeals • Referrals, Notifications and Prior Authorizations • Billing/Claims Submission and • Reimbursements • Balance Billing • Reporting and Record Keeping • Member Medical Records • Reporting and Data Collection • How to Access Program Services • Provider Resources • Clinical Practice Guidelines • External Resources • Provider Websites • UHC Contact information Confidential Property of UnitedHealth Group. Do not distribute or reproduce without express permission of UnitedHealth Group.

  6. UnitedHealthcare Community Plan QUEST Integration Program Coverarea with croppedimage. Do not overlapblue bar. Completely covergray area. Coverarea with croppedimage. Do not overlapblue bar. Completely covergray area. Coverarea with croppedimage. Do not overlapblue bar. Completely covergray area.

  7. Member Enrollment and Eligibility Confidential Property of UnitedHealth Group. Do not distribute or reproduce without express permission of UnitedHealth Group. • Program offered by the State of Hawaii Department of Human Services and administered by the Med-QUEST Division. • The QUEST Integration replaces the QExA program (serving the Medicaid Aged (Age 65 and over), Blind and Disabled (all ages) population in a mandatory managed care system) and the QUEST program (covering qualified individuals who are not aged, blind or disabled) effective 1/1/15. • Enrollment is determined by the DHS • Eligibility status may change from month to month and member may be retro enrolled into or dis-enrolled out of the UHC QUEST Integration program • To ensure timely reimbursement, Providers must check Member eligibility: • When scheduling each appointment • On the day of each appointment • At the time of claim(s) submission • You may check member eligibility (including TPL carrier name) via: • www.unitedhealthcareonline.com • https://hiweb.statemediciad.us/home.asp • Our local Call Center toll free at 1-888-980-8728

  8. Health Plan Roles and Responsibilities Coverarea with croppedimage. Do not overlapblue bar. Completely covergray area. Coverarea with croppedimage. Do not overlapblue bar. Completely covergray area.

  9. Health Plan Roles and Responsibilities • We will comply with all contractual requirements with DHS, which includes the following: • We will not prohibit healthcare professionals, acting within the lawful scope of his or her license or certification under applicable State law, solely on that license or certification from advising their patients about their medical conditions or diseases and the care or treatment required, regardless of whether the care or treatment is a covered benefit or whether or not the services or benefits are provided by United. • We will not discriminate against providers serving high-risk populations or those that specialize in conditions requiring costly treatments. • We will not control, nor direct the rendering of health care services or prohibit a provider from discussing treatment or non-treatment options with members, including any alternative treatment that may be self-administered as well as any information the member needs in order to decide among all relevant treatment options. We will educate and encourage our members to: • Exercise their right to participate in decisions regarding his or her healthcare, including the right to refuse treatment and to express preferences about future treatment • Receive from their providers the full range of medical advice and counseling appropriate for their condition

  10. Health Plan Roles and Responsibilities (Continued) Confidential Property of UnitedHealth Group. Do not distribute or reproduce without express permission of UnitedHealth Group. • We will not include in our network any providers when a person with an ownership or controlling interest in the provider (an owner including the provider himself or herself), or an agent or managing employee of the provider, has been excluded from participation by the Department of Health and Human Services (DHHS), Office of Inspector General (OIG) under Section 1128 of the Social Security Act, or has been excluded by the DHS from participating in the Hawaii Medicaid program. • We will immediately terminate any provider(s) or affiliated provider(s) whose owners, agents, or managing employees are found to be excluded on the State or Federal exclusion list(s). • We will report application denials or terminations to the DHS where individuals were on the exclusions list, including denial of credentialing for fraud-related concerns, as they occur. • We will immediately comply if the DHS requires that it remove a provider from its network if: • The provider fails to meet or violates any State or Federal laws, rules, or regulations; or • The provider’s performance is deemed inadequate by the State based upon accepted community or professional standards.

  11. Health Plan Roles and Responsibilities (Continued) Confidential Property of UnitedHealth Group. Do not distribute or reproduce without express permission of UnitedHealth Group. • We will keep providers informed of any program benefit updates and changes via the following methods. • Special Written Communication • Provider Newsletters/Bulletins • Bi-Annual Provider Education & Training Sessions • One-on-One Training & Education Sessions (at the time of contract execution and as identified by the Health Plan and/or Provider) • Provider Conferences • Provider Portal: www.UHCCommunityPlan.com/health-professionals • We will maintain a Provider and Member Grievance & Appeals Program. • We will maintain an adequate and comprehensive provider network. • We will monitor PCP assignment reports, network reports, grievance and appeals reports and feedback from providers, UHC staff and external partners to determine necessary network adjustments and/or network expansion initiatives. • We will process claims timely and accurately

  12. Provider Network Confidential Property of UnitedHealth Group. Do not distribute or reproduce without express permission of UnitedHealth Group. • Our network consists of health care providers of all types and specialties in the State of Hawaii to include: • Primary Care Physicians • Specialists • Hospitals • Skilled Nursing Facilities • Hospice Providers • Home and Community Based Service (HCBS) providers • Community Care Foster Family Home (CCFFH) • Behavioral Health providers • Transportation Providers • Durable Medical Equipment Network expansion suggestions? Call our local Provider Services Team toll free at 1-888-980-8728

  13. UHC Support Team • Local Member Services Team • Local Provider Relations Team • Local Claim Research Team • Local Utilization Management Team • Acute Care • Home & Community Based Services (HCBS) • Local Care Coordination Team • Service Coordinators (Field and Telephonic) • Clinical Managers • Community Case Management Agencies • Behavioral Health Care Advocates • Service Coordinator Assistants

  14. Quality Initiatives • UHC's Medicaid Quality Improvement (QI) Program encompasses all quality improvement activities within the health plan, including programs / standards that focus on: • Clinical quality and excellence • Access and affordability • Customer service and operational excellence • Hawaii-specific and National Quality Committees • Develop and monitor Quality Management program activities such as Clinical Practice Guidelines. Confidential Property of UnitedHealth Group. Do not distribute or reproduce without express permission of UnitedHealth Group.

  15. Disease Management Confidential Property of UnitedHealth Group. Do not distribute or reproduce without express permission of UnitedHealth Group. • Provide proactive coordination of care for: • Asthma • Congestive Heart Failure (CHF) • Diabetes • Practitioner and member compliance with HbA1C testing and Diabetic Retinal Eye Exams • Obesity • Body Mass Index (BMI) documented during outpatient office visits • Practitioner compliance in documenting height and weight as a baseline in determining the need for interventions for maintaining optimal weight. • Poly-Substance Abuse • Hypertension • High Risk Pregnancy

  16. Provider Roles and Responsibilities Coverarea with croppedimage. Do not overlapblue bar. Completely covergray area. Coverarea with croppedimage. Do not overlapblue bar. Completely covergray area. Coverarea with croppedimage. Do not overlapblue bar. Completely covergray area.

  17. Provider Roles and Responsibilities Confidential Property of UnitedHealth Group. Do not distribute or reproduce without express permission of UnitedHealth Group. • Administrative/Contractual • Comply with all applicable federal, state, and local laws • Comply with the Health Insurance Portability and Accountability Act of 1996 (HIPAA) regulations • Comply with the Medicare and Medicaid Anti-Fraud Act and the State Medicaid Fraud Act • Re-credentialing Requirements (every 3 years) • Provide an updated Provider Disclosure Form (Form in the packet) • At the time of initial credentialing • Upon execution of a provider contract • At the time of recredentialing • Within 35 days after any change in ownership of the disclosing entity information • Upon request from the United or the DHS

  18. Provider Roles and Responsibilities (continued) Confidential Property of UnitedHealth Group. Do not distribute or reproduce without express permission of UnitedHealth Group. • Member-Related • Verify member eligibility • Accept new members for treatment unless a waiver has been obtained from the Plan • Not intentionally segregate members in any way from other persons receiving services, except for health and safety reasons • Deliver services to members without regard to race, color, creed, ancestry, sex, including gender identity or expression, sexual orientation, religion, health status, income status, or physical or mental disability • Offers hours of operation that are no less than the hours of operation offered to commercial members or comparable to hours offered to members under Medicaid fee-for-service, if the provider has no commercial members • Assist members in accessing interpreting and auxiliary services by contacting the Health Plan toll free at 1-888-980-8728 or TTY: 711 (for the hearing impaired) on the availability of these services

  19. Provider Roles and Responsibilities (Continued) • Reporting • Submit claims in a timely and complete manner • Maintain member medical records and other record keeping systems • Report any known or suspected cases of fraud, waste and abuse • Report all cases of suspected child abuse to the Child Protective Services Section of the DHS such as: • Substantial or multiple skin bruising or any other internal bleeding • Any injury to skin causing substantial bleeding • Malnutrition • Failure to thrive • Burn or burns • Poisoning • Fracture of any bone • Subdural hematoma, etc. • Note: To make a report call the Child Protective Services 24 hours at: • Oahu: 808-832-5300 • Neighbor Islands: 1-800-494-3991 • Or, visit: http://humanservices.hawaii.gov/ssd/files/2013/01/MANDATED-REPORTER-HANDBOOK.pdf Confidential Property of UnitedHealth Group. Do not distribute or reproduce without express permission of UnitedHealth Group.

  20. Provider Roles and Responsibilities (Continued) • Report all suspected dependent adult abuse to the Adult Protective Services Section of the DHS such as: • Physical Abuse: non-accidental injury, pain, or impairment such as from hitting, slapping, improper physical restraint or poisoning. • Psychological Abuse: threats, insults, harassment, humiliation, intimidation, or other means that profoundly confuse or frighten the vulnerable adult. • Sexual Abuse: sexual contact or conduct including pornographic photographing without consent. • Financial Exploitation: wrongful taking, withholding, appropriation, or use of the adult’s money, real property, or personal property. • Caregiver Neglect: failure to provide adequate food, shelter, clothing, timely health care, personal hygiene, supervision, protection from abandonment or an assumed, legal or contractual caregiver. • Self-neglect:failure to care for one’s self thereby exposing one’s self to a condition that poses an immediate risk of health or serious physical harm. • Note: To make a report, call the office of Adult Protective Service at 808-832-5115, between 7:45 AM and 4:30 PM (HST), Monday through Friday, except state holidays • Or, visit: http://humanservices.hawaii.gov/ssd/files/2013/01/APS-Guidelines.pdf Confidential Property of UnitedHealth Group. Do not distribute or reproduce without express permission of UnitedHealth Group.

  21. Primary Care Provider (PCP) Role Confidential Property of UnitedHealth Group. Do not distribute or reproduce without express permission of UnitedHealth Group. • PCPs play a central role in the member’s care. Some responsibilities include: • Supervise, coordinate and provide all primary care • Conduct face-to-face initial and ongoing assessments • Collaborate with member’s Service Coordinator or Care Manager • Coordinate and initiate referrals for specialty care (for both in-network and out-of-network) • Coordinate and initiate prior authorization requests for out-of-network providers • When appropriate, enroll, provide appropriate forms or conduct screening for special programs (e.g. VFC program, EPSDT program, etc.) • Follow Timely Access to Care Standards • Follow medical record documentation and maintenance requirements

  22. PCP Assignment Confidential Property of UnitedHealth Group. Do not distribute or reproduce without express permission of UnitedHealth Group. • All Members must select a PCP • Members with QUEST Integration coverage only must select an In-Network PCP within 10 calendar days of their enrollment otherwise they will be auto assigned a PCP • Members with other medical coverage that is primary to QUEST Integration can choose an In-Network or Out-of-Network PCP • Members have 10 calendar days to choose an In-Network PCP • Members who elects to have an Out-of-Network PCP will have a “PCP Not Selected” indicator on their QUEST Integration membership ID (we will work with the provider to join our network) • Members can contact Member Services for assistance with PCP selection or assignment toll free at: 1-888-980-8728 or TTY: 711 for the hearing impaired • Network PCPs are sent a monthly Member Rosters for those members that have chosen a UHC Network PCP

  23. Early Periodic Screening and Diagnostic Testing (EPSDT) • Clearly documenting the following on the EPSDT forms will decrease medical record requests by UHC: • Height, Weight, BMI, BMI% • Immunizations given & status • Blood lead screening • Medicaid ID# • Contact XEROX State Healthcare (formerly ACS) toll free at 808-952-5570 (Oahu) or 1-800-235-4378 for additional EPSDT forms • Instructions regarding EPSDT forms can be found on the back of the form; for more information about the EPSDT can be found in the Med-QUEST Provider Manual, Chapter-5 at: www.med-quest.us • For questions, call Evangeline Apacible-Rivera, RN, EPSDT Coordinator at 808-275-9216 Confidential Property of UnitedHealth Group. Do not distribute or reproduce without express permission of UnitedHealth Group. • Federally mandated program • Provides preventive and comprehensive health services for Medicaid-eligible individuals under age 21 • Primary goal is to offer prevention, early diagnosis and medically necessary treatment of conditions • EPSDT Services include: • Comprehensive EPSDT Screenings from newborn through age 20 • Regular dental services every 6 months from age 12 months through age 20 • Documentation/Reporting • Use DHS EPSDT Exam form 8015 and 8016 • By PCP/other providers • Keep results of screenings or tests in child’s medical record • Forms must be complete and accurate for State reporting, data collection and claims processing • Original signed EPSDT form must be attached to each corresponding claim form to ensure payment • The modifier field in the claim form must have “EP”

  24. Early Periodic Screening and Diagnostic Testing (EPSDT) (continued) *Visits must be approximately a year apart **Center for Medicaid Services (CMS) Confidential Property of UnitedHealth Group. Do not distribute or reproduce without express permission of UnitedHealth Group.

  25. NurseLine and Nurse Chat Services • Available to UnitedHealthcare QUEST Integration Members 24 Hours, 7 days a week • Nurseline can help with minor injuries, common illnesses, self-care tips and treatment options, recert diagnoses and chronic conditions and much more • Members may access the Nurseline by calling toll free at 1-888-980-8728 or TTY: 711 (for the hearing impaired) • Members may access the Nurse Chat at: www.myuhc.com Confidential Property of UnitedHealth Group. Do not distribute or reproduce without express permission of UnitedHealth Group.

  26. Compliance with ADA Confidential Property of UnitedHealth Group. Do not distribute or reproduce without express permission of UnitedHealth Group. Providers must comply with the Americans with Disability Act (ADA) and must assist members in accessing services such as: • Oral interpreter services to ALL individuals with limited English proficiency • Sign language interpreter and TTY/TDD services at no cost to the individuals • Auxiliary Aids • Written translation services is also available to our members • Providers must contact UHCCP by calling toll free at 1-888-980-8728 or TTY: 711 (for the hearing impaired) for assistance in accessing all of the services listed above

  27. Access to Care Standards Confidential Property of UnitedHealth Group. Do not distribute or reproduce without express permission of UnitedHealth Group. • Providers are required to comply with appointment and wait time standards as follows: • Quarterly accessibility member and provider telephone surveys will be conducted to document provider compliance with Contractual and State requirements

  28. Referrals, Notifications and Prior Authorizations

  29. For Non-Emergent (Medical and Behavioral Health) Facility Admissions notify us: At or prior to admission When we are the secondary payer When the primary insurer’s benefits exhaust When a member is retro-enrolled into our plan When the level of care changes, e.g. to sub-acute Notifications for services through the Emergency Room: When the member enters the into the Emergency Room at the time of each episode (regardless of the number of episodes per day) When the member is placed in a Observation status within the ER setting at the time of each episode When the member is admitted into the Hospital (within in 48 hours) Notifications must be faxed to 1-800-267-8328 or online at https://www.unitedhealthcareonline.com Notifications

  30. Referrals Confidential Property of UnitedHealth Group. Do not distribute or reproduce without express permission of UnitedHealth Group. • Referrals to In-Network Providers: • PCP may call or fax a referral directly to an in-network provider (no form required and providers do not have to ask the Plan for permission). • Referrals to Out-of-Network Providers: • PCP must obtain authorization from the Plan for referrals to out-of-network providers. A prior authorization request form must be completed and faxed to 1-800-267-8328. You may also submit an electronic request through our website at: https://www.unitedhealthcareonline.com • No Referrals Required: • For family planning providers or women’s routine and preventive health care services.

  31. Prior Authorization Confidential Property of UnitedHealth Group. Do not distribute or reproduce without express permission of UnitedHealth Group. • Prior Authorizations: • Refer to the Notification and Prior Authorization Quick Reference Guide for a list of services that require notification and/or prior authorization • Request Form must be complete or the form will be returned • Include diagnosis codes, procedure codes and clinical notes • Rendering provider name on the authorization form must match the contracted business name • Follow instructions on the form • An urgent fax should be submitted with a maximum of 3 requests per fax transmission • Prior Authorization Request Form samples are included in today’s packet, for additional assistance call our local Provider Services staff at 1-888-980-8728 • Authorizations must be faxed to 1-800-267-8328 or you may submit a request online at https://www.unitedhealthcareonline.com

  32. Prior Authorization Reminder • Remember that as of June 1, 2013:Prior Authorization is NOT required for incontinence supplies within the threshold (maximum limit) specified in the following table: • Exception:All incontinence supplies for children under the age of three (3) will still require a prior authorization from the Health Plan. Confidential Property of UnitedHealth Group. Do not distribute or reproduce without express permission of UnitedHealth Group.

  33. Off Island and Out-of-State Transportation • All transportation services require a Prior Authorization from UnitedHealthcare. Confidential Property of UnitedHealth Group. Do not distribute or reproduce without express permission of UnitedHealth Group.

  34. Online Prior Authorization Submission Process You may also submit a Referral, Notification and/ or a Prior Authorization request through the provider portal at: https://www.unitedhealthcareonline.com An online tutorial is available for the online submission process (including status) for your use You may also contact Provider Services for assistance on how you may schedule a one-on-one in-service at 1-888-980-8728

  35. Claim Submission and Reimbursement

  36. Claims Submission Confidential Property of UnitedHealth Group. Do not distribute or reproduce without express permission of UnitedHealth Group. • Participating physicians/providers must submit claims on the member’s behalf • Claims filing timeline is one (1) year from the date of service or the receipt date of the primary payer’s EOB • Submitting claims online (1500 Billers Only) • Submit via UnitedHealthcare Online at www.unitedhealthcareonline.com • Free to participating network providers (single submissions only) • To register, providers call 1-866-UHC-FAST (1-866-842-3278) • For batch submissions you can utilize www.eprovidersolutions.com or www.officeally.com • Using a clearing house or provider own Electronic Medical Record System • Submission via Electronic Data Interchange (EDI) using a claims clearinghouse (there may be costs associated, please check with the clearinghouse for details). • Use Payer ID 87726. • Paper Claim • Use a UB04 for facility or hospital claims • Use a CMS 1500 for physician and ancillary claims UnitedHealthcare Community Plan P.O. Box 31362 Salt Lake City, UT 84131-0362

  37. Claims Reconsideration & Corrected Claims Confidential Property of UnitedHealth Group. Do not distribute or reproduce without express permission of UnitedHealth Group. • Claims Reconsideration – when a provider feels that the information on the claim that was denied is correct. • Claims reconsideration requests must be filed within one (1) year from the date of service or sixty (60) days from notice of determination for the claim, whichever is later. • Claims reconsideration requests must be sent to the Provider dispute Unit (PDU) at: UnitedHealthcare Community Plan P.O. Box 31350 Salt Lake City, UT 84131-0350 • Claims reconsideration forms are located online at: http://www.uhccommunityplan.com/health-professionals/hi.html • A copy is also included in today’s packet • Corrected Claims must be sent to: UnitedHealthcare Community Plan P.O. Box 31362 Salt Lake City, UT 84131-0362

  38. Helpful Billing Tips Confidential Property of UnitedHealth Group. Do not distribute or reproduce without express permission of UnitedHealth Group. • CMS 1500 Forms • Provider name on the claim (box 33) must match the contracted business name • Bill for a span of time (max 1 month) • For dual eligible members, bill for gloves on a separate claim • Note correct place of service on claim (box 24b) • UB Forms • Include discharge status code (box 17) • Refer to contract for specific billing requirements • The ‘XX7’ bill type must be included with corrected claims • NDC code information • Required to accompany any claim when billing with HCPCS J codes (340(b) participating entities are exempt from this requirement) • Valid units of measure: F2 = International Unit; GR = Gram; ML = Milliliter; UN = Unit (Each) • Not valid units of measure: MG and CC • Corrected claims • Hard copy corrected claims must have ‘corrected claim’ written at the top of the claim and all changes circled otherwise claim will be denied as a duplicate • Electronic corrected claims may be submitted using bill type XX7

  39. Coordination of Benefits • Providers must conduct appropriate coordination of benefits to ensure accurate primary payer source (e.g. employer group health, Medicare Fee For Service/Managed Care, No-Fault, Worker’s Comp, etc.). QUEST Integration is always the last payer resort. Providers may check member TPL carrier name and other information via the UnitedHealthcareOnline.com. Use the table below as a guide for when to submit a secondary claim to UnitedHealthcare.

  40. Reimbursement • UnitedHealthcare will reimburse for all medically necessary covered services even if the contract between DHS and UHC is no longer in effect providing that all of the following criteria have been met: • The Member was covered at the time of service; • All applicable UHC policies and procedures have been met; and • The claim was filed within the 1-year filing timeline • UnitedHealthcare will recoup or request for a refund from the provider for any services previously paid as a result of: • A Member retro-disenrollment from the UHC QUEST Integration plan • A confirmed fraud, waste and/or abuse case Confidential Property of UnitedHealth Group. Do not distribute or reproduce without express permission of UnitedHealth Group.

  41. Balance Billing of Members Confidential Property of UnitedHealth Group. Do not distribute or reproduce without express permission of UnitedHealth Group. • Provisions of when a provider may or may not bill a Member:

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  43. Inquiries, Grievances and Appeals Confidential Property of UnitedHealth Group. Do not distribute or reproduce without express permission of UnitedHealth Group. Definitions • Inquiry – Is a contact from a provider that questions any specific aspect of a UnitedHealthcare, subcontractor or provider’s operations, activities or behavior but does not express dissatisfaction. • Grievance - An expression of dissatisfaction made by a provider in regard to Benefits & limitations, eligibility and enrollment of a member or provider, member issues or plan issues, availability of health services for a member, delivery of health services or the quality of service. • Appeals (including expedited appeals) -A request for review of an action. Examples include Bundling issues, Fee disputes, Unit disputes, Retro/Denied Authorization Requests.

  44. Provider Inquiries • Providers may contact Provider Services at 1-888-980-8728 with questions related to but are not limited to: • Contracting process • Credentialing/Recredentialing process • Claims process • Referral, Notification, or Authorization process • Status of a claim • Filing a claims reconsideration, grievance or appeal • How to reach a Service Coordinator • How to request for an in-service for new office staff, etc.

  45. Provider Grievances • Grievances related to the decision making or processing of a health plan appeal must be filed within thirty (30) days from UnitedHealthcare’s decision. • All other grievances may be filed at any time after the dissatisfaction occurred and with no timeframe limitation. • Grievances must include the provider’s name, address, telephone number, member name, member ID#, description or explanation of the grievance. • To file a Grievance: • You may call Provider Services toll free at 1-888-980-8728 or, • Send written requests to (no special form required): UnitedHealthcare Community Plan Attention: Appeals Department P.O. Box 2960, Honolulu, HI 96802 • You may also send an electronic request via email to: HI_AG@UHC.com

  46. Provider Appeals • Post Services • Providers have 60 calendar days from the claims reconsideration decision to file an appeal related to but are not limited to bundling issues, fee disputes, unit disputes, retrospective and denied authorization requests • Pre-Service and Concurrent Review Prior Authorization Denials • Must be processed as a member appeal (see Member Appeals Section) • Appeals may be submitted via: • Phone at 1-888-980-8728 • Email at: HI_AG@UHC.com • Mail at: UnitedHealthcare Community Plan, Attention: Appeals Department, P.O. Box 2360, Honolulu, HI 96802 • Expedited Appeal • If waiting up to 30 days to decide an appeal could seriously risk the member’s life or health, including his/her ability to reach, keep or get back to maximum function, Provider must call the Plan to request for an expedited review (see Member Appeals Section)

  47. NEW Local Appeals and Grievances Department

  48. Appeals and Grievances Contact Information

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  50. Assisting Members Confidential Property of UnitedHealth Group. Do not distribute or reproduce without express permission of UnitedHealth Group. • Providers may assist UHCCP QUEST Integration Members in filing and/or representing the member in the following: • Grievances • Standard Appeals • Expedited Appeals (upon determination by UHCCP that taking the time for a standard resolution could seriously jeopardize the member’s life, health or ability to attain, maintain, or regain maximum function) • State Administrative Hearings • An Appointment of Representative (AOR) must be on file with UHCCP in order for a provider to assist a member in filing a Grievance or Standard Appeal and/or for representation in a State Administrative Hearing. • The next two slides provide a summary on the appeals and grievance process. Additional/Detailed information is also provided within Section-14 of the Provider Administrative Guide.

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