2019 care provider manual · • role of network dental providers 94 • primary care physicians...

Doc#: PCA-1-016511-02032020_02102020

2019 Care Provider ManualPhysician, Health Care Professional, Facility and Ancillary Provider

New Jersey

2 UnitedHealthcare Community Plan New Jersey 2019 UHCprovider.com/njcommunityplan © 2019 UnitedHealthcare

Welcome

Welcome to the UnitedHealthcare Community Plan care provider manual. This complete and up-to-date reference PDF (manual/guide) allows you and your staff to find important information such as processing a claim and prior authorization. This manual also includes important phone numbers and websites on the How to Contact Us page. Operational policy changes and other electronic tools are ready on our website at UHCprovider.com.

Click the following links to access different manuals:

• UnitedHealthcare Administrative Guide for Commercial and Medicare Advantage member information visit UHCprovider.com > Menu > Administrative Guides and Manuals. Some states may also have Medicare Advantage information in their Community Plan manual.

• A different Community Plan manual-go to UHCCommunityPlan.com, click For Health Care Professionals at the top of the screen. Select the desired state.

• To locate the online version of this manual, visit UHCprovider.com > Menu > Health Plans by State > Choose Your State: New Jersey > Go to UHCCommunityPlan.com > Provider Administrative Manual.

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 “Find” binoculars icon on the top right hand side of the PDF.

If you have any questions about the information or material in this manual or about any of our policies, please call Provider Services at 888-362-3368.

We greatly appreciate your participation in our program and the care you offer our members.

Important Information about the use of this manualIn the event of a conflict between your agreement and this care provider manual, the manual controls unless the agreement dictates otherwise. In the event of a conflict 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.

We amend the manual as policies change.

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https://www.uhcprovider.com/guides

http://UHCprovider.com

http://www.uhccommunityplan.com/

https://www.uhcprovider.com/en/health-plans-by-state/new-jersey-health-plans/nj-comm-plan-home.html?cid=none


Preface

The UnitedHealthcare Community Plan of New Jersey (UHCCPNJ or UHCCP) Care Provider Manual for Physicians, Health Care Professionals, Facility and Ancillary Providers is designed as a comprehensive reference source for the information you and your staff need to conduct your interactions and transactions with us in the quickest and most efficient manner possible.

Our goal is to help ensure our members have convenient access to high-quality care provided according to the most current and efficacious treatment protocols available. We are committed to working with and supporting you and your staff to achieve the best possible health outcomes for our members.

Operational policy changes and additional electronic tools, are available on our website at UHCprovider.com/njcommunityplan.

If you have any questions about the information or material in this administrative guide or about any of our policies or procedures, please contact Provider Services at 888-362-3368.



• How to Contact Us 10

• Chapter 1: UnitedHealthcare Community Plan Products 13• NJ FamilyCare 13

• UnitedHealthcare Dual Complete ONE (Medicare) 14

• Chapter 2: Covered and Non-Covered Services 15• How Benefits Vary Under UnitedHealthcare 15

• Benefits for Division of Developmental Disabilities (DDD) Clients 15

• Dual Eligibles (Medicare/Medicaid) 15

• Interpreter Services 15

• Benefits Under UnitedHealthcare Community Plan Products 16

• Benefits for UnitedHealthcare Products 16

• NJ FamilyCare Benefits 16

• 2019 UnitedHealthcare Dual Complete ONE Benefits 18

• Chapter 3: Prior Authorization 19• Responsibility for Requesting Prior Authorization 19

• Determination of Medical Necessity 19

• Criteria and Guidelines 20

• Provider’s Responsibility to Verify Prior Authorization 21

• Continuity of Care When Provider Leaves Network 21

• Authorization of Care for New Members 21

• Referrals to Non-Participating Care Providers 21

• Assure Required Services are Furnished 21

• Methods to Identify Those at Risk Who Should be Referred for a Comprehensive Needs Assessment 22

• Methods and Guidelines of Determining Specific Needs of Referred Individuals 22

• Allow for Continuation of Existing Relationships With Non-par Care Providers 22

• Referrals to Special Care Facilities for Highly Specialized Care 22

• Standing Referrals for Long-Term Specialty Care 22

• Responding to Crisis Situations After Hours for Enrollees With Special Needs 22

• Provision for Dental Services for Enrollees With Developmental Disabilities 22

• Prior Authorization Forms 23

• Hysterectomy Procedures and Consent Form 23

• Sterilization Procedures and Consent Form 23

• Chapter 4: Referrals 24• Primary Care Provider – The Entry Point to Health Care Services 24

Table of Contents


• Referral Guidelines 24

• Services Not Requiring a Referral (Self-Referral Services) 24

• PCP Referrals 24

• Standing Referral to a Specialist 24

• Special Needs 24

• Elective Admissions and Same Day Surgery 25

• OptumRx Medication Prior Authorization 25

• Referrals to Nonparticipating Care Providers 26

• PCPs Acting as Specialists 26

• Second Opinions 26

• Chapter 5: Claims Policies and Procedures 27• Our Claims Process 27

• Electronic Claims Submission 27

• Paper Claims Submission 27

• Complete Claims 27

• National Provider Identifier (NPI) 28

• How do I submit an NPI, TIN and Taxonomy on a Claim? 29

• Claim Adjustments 30

• Claim Reconsideration and Appeal Timelines 32

• Coding Standards 34

• Capitated Primary Care Provider and EPSDT Encounters 34

• Early and Periodic Screening, Diagnostic and Treatment (EPSDT) 34

• EPSDT Guide for EPSDT Visit Codes For Children 0-21 Years 34

• Encounter Data 35

• Coordination of Benefits 35

• Subrogation and Tort Policy 36

• How to Change Provider Information 37

• Newborn Claims for Outpatient Visits 37

• Fraud, Waste, and Abuse 37

• Chapter 6: Hospitals and Hospitalization 39• General Requirements 39

• Elective Admissions and Same Day Surgery 39

• Emergency Admissions 39

• Care in the Emergency Room 39

• Maternity Care and Obstetrical Admissions 40


• Newborn Admissions 40

• Enrollment of Newborns 41

• Concurrent Review 41

• Inpatient Concurrent Review: Clinical Information 41

• Discharge Planning and Continuing Care 41

• Chapter 7: UnitedHealthcare Person Centered Care Model (PCCM) 42• Standing Referral to a Specialist 43

• New Jersey Early Intervention Services 43

• Chapter 8: Pharmacy 45• Pharmacy Benefit Management 45

• Member ID Cards for Prescription Benefit 45

• Dual Complete ONE 45

• Prescription Drug Coverage 45

• Prescriptions Requiring Prior Authorization 45

• Pharmacy Network 46

• Generic Drugs 46

• Outpatient Injectable Chemotherapy Drugs 46

• Pharmacy Benefit Exclusion 46

• Supply Limit for Opioids 46

• Chapter 9: NJ Behavioral Health 47• Optum Behavioral Health Expansion of Covered Health Benefits — Effective October 1, 2018 47

• Screening for Behavioral Health Problems 47

• Behavioral Health Services for UnitedHealthcare Members 47

• Role of the Behavioral Health Unit 47

• Behavioral Health Emergencies 48

• Referrals for Behavioral Health Services for NJ FamilyCare DDD, & MLTSS and UnitedHealthcare Dual Complete ONE (Medicare) Members 48

• Authorization for Continuation of Outpatient Behavioral Health Services for NJ FamilyCare DDD & MLTSS and UnitedHealthcare Dual Complete ONE (Medicare) Members 48

• Behavioral Health Guidelines and Standards 48

• Behavioral Health Toolkit for the Primary Care Provider (PCP) 49

• Pharmacy Lock-In Program 49

• Chapter 10: Enrollees With Special Needs 50• Assure Required Services are Furnished 50

• Methods to Identify Those at Risk Who Should be Referred for a Comprehensive Needs Assessment 50

• Allow for Continuation of Existing Relationships With Non-Par Providers 50


• Referrals to Special Care Facilities for Highly Specialized Care 50

• Standing Referrals for Long-Term Specialty Care 50

• Responding to Crisis Situations After Hours for Members With Special Needs 50

• Provision for Dental Services for Enrollees With Developmental Disabilities 50

• Children With Special Health Care Needs 51

• Refer Special Needs Members to Behavioral Health Providers 51

• Office-Based Addictions Treatment (OBAT) Attestation 52

• Chapter 11: Member Information 53• Member ID Cards 53

• UnitedHealthcare NJ FamilyCare and Dual Complete ONE Member ID Cards 54

• Eligibility Information 54

• PCP Selection 54

• Member-Initiated Transfers 54

• PCP-Initiated Transfers 55

• PCP Member Roster 55

• Capitation Report 55

• Member’s Cultural and Linguistic Needs 55

• Cultural Competency 55

• Member Rights and Responsibilities 55

• NJ FamilyCare Enrollee Grievance Process 59

• UnitedHealthcare Dual Complete ONE – SNP Member Grievance/Appeal Process 60

• Continuity of Care 61

• Chapter 12: Participating Provider Responsibilities 62• General Requirements 62

• Provider Office Standard 63

• Timeliness Standards for Appointment Scheduling 63

• Allowable Office Waiting Times 65

• Compliance With American Disabilities Act (ADA) 65

• Medical Record Documentation Standards 66

• UnitedHealthcare Community Plan of New Jersey Medical Record Review Tool and Addendum 67

• Provider Facility Questionnaire 68

• Medical Record Audit Tool 69

• Advance Directives 71

• Chapter 13: Primary Care Providers Standards & Policies 72• Role of the Primary Care Provider (PCP) 72


• Responsibilities of the PCP 72

• Panel Roster 73

• Assignment to PCP Panel Roster 74

• PCP as Specialist 74

• Vaccines for Children Program (VFC) Program 74

• Pediatric Primary Care Medical Record and Charting Standards 77

• Nurse Practitioners and Physician Assistants in PCP Office 77

• 24-Hour, 7-Days-a-Week Coverage 77


• Chapter 14: Specialist Providers Standards & Policies 79• Responsibilities of Specialist Providers 79

• Specialists as PCPs 79

• 24 Hours, Seven Days a Week Coverage 79


• Chapter 15: Preventive Health & Clinical Practice Guidelines 81• Preventive Health Care 81

• Clinical Practice Guidelines for Chronic Conditions 81

• Lead Screening 81

• Newborn Screening Program 81

• Mammogram and Prostate Cancer Screenings 81

• Current Protocols 81

• Chapter 16: Utilization Management Appeals 82• Medicaid Managed Care Rules Amended – Effective July 1, 2017 82

• Overview of Utilization Management (UM) Appeals 82

• Types of Internal UM Appeals 82

• Internal UM Appeals for Medicaid and NJ FamilyCare 82

• Expedited Appeals for NJ FamilyCare 83

• External Appeal Process for Medicaid and NJ FamilyCare 83

• UnitedHealthcare Dual Complete ONE (Medicare) Appeals 84

• Appeals of Pharmacy Denials 86

• Chapter 17: Quality Management Program 88• Overview 88


• The Quality Management Approach 88

• Monitoring and Improving Quality of Care 88

• Quality Concerns and Corrective Actions 88

• Sanctions for Quality Concerns 89

• Termination and Appeal Process 89

• Reinstatement in the UnitedHealthcare Provider Network 93

• Provider Participation in Quality Management 93

• Chapter 18: Dental 94• Purpose/Scope 94

• Role of Network Dental Providers 94

• Primary Care Physicians and Dental Treatment 94

• Prior Authorization 95

• Specialist Referral Process 95

• Administration of Medical or Dental Services 95

• Additional Dental Services 95

• Dental Services Provided in an Operating Room 95

• Individuals Younger Than Age 21 97

• Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) 97

• NJ Smiles 97

• American Academy of Pediatrics (AAP) Oral Health Risk Assessment Tool 98

• Chapter 19: Managed Long Term Services and Support (MLTSS) 99• Introduction 99

• MLTSS Eligibility and Enrollment 99

• MLTSS Benefits/MLTSS Services 99

• PDN Services 100

• Cost-Effectiveness of Services 100

• Provider Responsibility 100

• Prior Authorization 101

• Background Check Requirements 101

• MLTSS Provider Critical Incident Reporting 101

• MLTSS Claims 102

• Provider Credentialing/Verification 102

• Chapter 20: Glossary 106


How to Contact Us

Who are you contacting Service Area How to Contact Here you can:

UnitedHealthcare Community Plan of New Jersey (UHCCPNJ) for Health Care Professionals, Facility and Ancillary Providers

Provider Resources for UHCCPNJ

UHCprovider.com/njcommunityplan

• Stay up-to-date with UnitedHealthcare Community Plan’s latest provider bulletins

• Read about new programs and educational articles in the newsletters

• Reference the most current payment policies• Find useful forms

Provider Services and Care Management

Provider Services: 888-362-3368 Monday through Friday, 6 a.m. to 6 p.m. EST

Care Management:• NJ FamilyCare/Medicaid:

888-362-3368• MTSS NJ FamilyCare/

Medicaid: 888-702-2168• Dual Complete ONE:

888-362-3368

• Inquire about whether a service may require prior authorization

• Confirm a patient‘s eligibility• Ask about covered benefits• Check claim status• Notify us of the procedures and services that

require prior authorization, as outlined in the prior authorization section of this guide

Special Needs and Care Management Referral

Phone 877-704-8871 • Refer high-risk members to the Care Management program

MLTSS (Managed Long Term Services and Supports) Provider Services

Phone 888-702-2168 • Inquire about the MLTSS program

PCA, Medical Day Care, and MLTSS Services

Phone 800-262-0305 Fax 855-489-1553

• Notify us of all personal care services and/or medical day care that require prior authorization

Monday – Friday 6:00 a.m. – 6:00 p.m. EST





UnitedHealthcare Networks

UHC Provider UHCprovider.com • Review a patient‘s eligibility and plan benefits• Submit claims, claim reconsiderations and prior

authorizations • Check claims status • Download the most recent patient panel roster

(for Primary Care Physicians)• Find tools and training to enhance your practice

UnitedHealthcare ONLINE Help Desk

Phone 866-842-3278For more contact information visit UHCprovider.com > Contact Us

• Report any technical problems • Receive assistance on how to use the website• Ask questions related to transaction results,

data displayed or claims submitted through UHCprovider.com

Electronic Data Interchange (EDI)

Phone 800-210-8315Select option 1

• EDI Support Services provides support for all electronic transactions involving claims, electronic remittances and eligibility. Please call us for assistance with any of these transactions.

OptumRx Pharmacy Services Phone 800-866-0931 • Inquire about whether a prescription drug may require prior authorization

• Ask if a prescription drug is covered under a member’s plan

• Check claim status

Optum Behavioral Health

Behavioral Health Services

Phone 888-362-3368 • Inquire about whether a service may require prior authorization

• Check claim status

eviCore Radiology Prior Authorization

Phone 866-889-8054or Fax 866-889-8061UHCprovider.com

• Submit prior authorizations • Inquire about prior authorizations needed

for MRIs, MRAs, CTs, PETs through eviCore National

MARCH Vision Care Vision Services Phone 844-686-2724marchvisioncare.com


• Confirm a patient‘s eligibility• Ask about covered benefits• Check claim status

How to Contact Us

http://UHCProvider.com


http://www.UHCprovider.com


http://marchvisioncare.com



Dental Benefits Provider (DBP)

Dental Services Phone 800-508-4881uhcproviders.com


• Confirm a patient‘s eligibility• Ask about covered benefits• Check claim status

How to Contact Us

http://uhcproviders.com


Chapter 1: UnitedHealthcare Community Plan Products

Product OverviewIn New Jersey, UnitedHealthcare Community Plan offers the following insurance coverage plans:

• NJ FamilyCare

• UnitedHealthcare Dual Complete ONE (Medicare)

NJ FamilyCareNJ FamilyCare, a state and federally funded program, offers free or low-cost health insurance for uninsured children, pregnant women, parents/caretaker relatives, and single adults/childless couples who live in New Jersey. The program is available to families who do not have or cannot afford employer-funded or private insurance.

Who is Eligible?Eligible NJ FamilyCare members must live in New Jersey. Lawful permanent residents or those in a qualified immigrant status may be eligible if they have been in the country for at least five years; children may be eligible regardless of their date of entry into the United States. Eligibility is based on family size and income only. Assets are not counted. For income eligibility levels, visit njfamilycare.org > Income Eligibility and Cost. *Source: njfamilycare.org

What does it cost?For many families, it costs nothing; no monthly premiums or copayments. For families with higher incomes, there is a sliding scale for small copayments and monthly premiums may be required. For more information, visit njfamilycare.org > Income Eligibility and Cost.

What does it cover?NJ FamilyCare has fourdifferent plans (A, B, C & D). Enrollment in the plan is based on the family‘s income and household size. Please see Section 2: Covered and Non-Covered Services for a detailed list of services covered under each plan. If applicable, premiums and copays associated with each plan will be identified on the member‘s UnitedHealthcare Community Plan ID card.

Are there any restrictions?Applicants will be eligible for NJ FamilyCare only if they have been uninsured for a period of three months or more. However, there are exceptions to this rule; such as if they lose their insurance because their place of work went out of business or they were laid off. Depending on income, other exceptions may apply for families privately paying for health insurance or for COBRA benefits. Pre-existing conditions do not affect eligibility.

Certain NJ FamilyCare members are also eligible to receive enhanced services provided through the Managed Long Term Services and Supports (MLTSS) program.

MLTSS is a program that applies solely to individuals who meet MLTSS eligibility requirements and encompasses the NJ Family Care Plan A benefit package, Home and Community Based Services (“HCBS”) and institutionalization for long term care in a nursing facility or special care nursing facility. It is a program that works to promote quality and cost-effective coordination of care for members with chronic, complex healthcare, social service and custodial needs.

The MLTSS program includes both Nursing Facility and HCBS care coordination. MLTSS care coordination operates in accordance with our member centric model so that the physical, behavioral and long term services and supports health care needs of the MLTSS members are met. Detailed information on the MLTSS program is outlined in Chapter 19.

UnitedHealthcare Dual Complete ONE (Medicare)UnitedHealthcare Dual Complete ONE is a Dual Special Needs Plan (FIDE SNP) for people with Medicare Parts A & B and full Medicaid eligibility under Title XIX. UnitedHealthcare Dual Complete ONE offers qualified individuals all of the benefits of Medicaid and Medicare; plus, extra services at no additional costs. A few examples include:

http://www.njfamilycare.org/income.aspx

http://www.njfamilycare.org/default.aspx

http://www.njfamilycare.org/income.aspx


• Transportation (24 round trips or 48 one-way routine medical trips) for visits to any health care appointment, including trips to the pharmacy at no additional cost to the member

• Benefit credits to choose from over 150 health care products from a UHCCP Personal Health Care Catalog. Credits can be used to order vitamins, bandages, aspirin, blood pressure monitors, digital thermometers, bath safety items and much more at no cost to the member

• (PERS) Personal Emergency Response System – emergency response services through an electronic monitoring system 24 hours a day, seven days a week

• NurseLineSM – Members can speak with a registered nurse (RN) 24 hours a day, 7 days a week

Chapter 1: UnitedHealthcare Community Plan Products


Chapter 2: Covered and Non-Covered Services

How Benefits Vary Under UnitedHealthcareFrom the care provider‘s perspective, the list of covered services is important in developing treatment plans and in obtaining prior authorization when necessary. For services that must obtain prior authorization, refer to the Benefits for UnitedHealthcare NJ FamilyCare and UnitedHealthcare Dual Complete ONE section which includes Prior Authorization for Contracted Providers charts in this section. Members are encouraged to utilize their Primary Care Provider (PCP) or Primary Care Dentist (PCD) as a knowledge resource for health questions and information.

Both PCPs and PCDs possess knowledge to provide members with appropriate referrals to specialists. This includes knowledge of overlapping fields of expertise such as orthopedics/neurosurgery for back problems and oral surgery/otolaryngology (ear, nose, and throat doctors) for tumors of the mouth or broken facial bones.

Benefits for Division of Developmental Disabilities (DDD) ClientsThe benefits for DDD clients are displayed separately on the following pages because of the differences in how benefits aremanaged for DDD clients in contrast to other NJ FamilyCare members.

Dual Eligibles (Medicare/Medicaid)In New Jersey, an individual who is dually eligible for Medicare and full Medicaid may enroll in UnitedHealthcare Dual Complete ONE Dual Special Needs Plan (FIDE SNP). To be enrolled in this Plan, the individual must have Medicare Parts A and B and full Medicaid eligibility under Title XIX. In 2019, UnitedHealthcare Dual Complete ONE, also known as HMO SNP, services members in Atlantic, Bergen, Burlington, Camden, Cumberland, Essex, Gloucester, Hudson, Hunterdon, Mercer, Middlesex, Monmouth, Morris, Ocean, Passaic, Salem, Somerset, Sussex, and Union counties.

Plan Features • The plan integrates all available Medicaid and Medicare

managed care benefits across acute, primary, behavioral health and long-term care.

• Single Claim Submission: Submit the claim once using the Medicare ID and we will coordinate collections from different payer sources, such as Medicare and Medicaid.

• Offers preventive services at no cost to our members.

• Reimbursement is based on the member’s existing Community Plan network agreement.

• Members receive a single ID card, which provides both the Medicare and Medicaid ID numbers.

UnitedHealthcare coordinates both the Medicare and Medicaid benefits for Dual Complete ONE members. The UnitedHealthcare NJ FamilyCare plan supplements the UnitedHealthcare Dual Complete ONE Medicare benefit package. To have a full picture of the covered benefits for members, first review the chart displaying UnitedHealthcare Dual Complete ONE benefits found in the plan’s Evidence of Coverage. In the Evidence of Coverage, Chapter 4 of the Evidence of Coverage outlines covered Medicare services, services where both Medicare and Medicaid are covered, and services not covered.

Interpreter ServicesUnitedHealthcare provides members with access to interpreter services including the deaf or hard of hearing or those who have need of interpreter services due to language barriers.

Language services can be accessed via UnitedHealthcare‘s contract with a telephone language service or can be provided via in-person assistance.

Call the Member Helpline at 800-941-4647 or Provider Services at 888-362-3368 for additional information or to arrange for services.

Family members, especially children, should not be used as interpreters in assessments, therapy or other situations where impartiality is critical.

https://www.uhccommunityplan.com/assets/plandocuments/2019/eoc/en/2019-NJ-EOC-H3113-005-EN.pdf


NJ FamilyCare Benefits 2019 Summary of BenefitsBenefit information is available starting on page 32 in the Member Handbook. The Member Handbook can be found by visiting UHCCommunityPlan.com/NJ > NJ FamilyCare > Member Handbook (under Member Information).

Prior authorization is indicated where required. If you have any questions about whether a service may require prior authorization, call Provider Services at 888-362-3368.

Medical policies and coverage determination guidelines can be found at UHCprovider.com > Menu > Health Plans by State > Choose Your State: New Jersey > Medicaid (Community Plan) View Offered Plan Information > Bulletins and Newsletters > Medical Policy Update Bulletins > Policies and Protocols.

The following services are not covered by UnitedHealthcare for clients of NJ FamilyCare A, B and C programs:

• Services not medically necessary

• Cosmetic surgery, except when medically necessary and with prior approval

• Experimental organ transplants and investigational services

• Infertility treatment services

• Rest cures, personal comfort, convenience items and custodial care

• Respite Care

• Services involving the use of equipment in facilities, the purchase, rental or construction of which has not been approved by applicable laws of the State of New Jersey and regulations issued pursuant thereto

• All claims arising directly from services provided by or in institutions owned or operated by the federal government such as Veterans Administration hospitals

• Services provided in an inpatient psychiatric institution, that is not an acute care hospital, to individuals under 65 years of age and over 21 years of age

• Services provided to all persons without charge

• Services and items provided without charge through

programs of other public or voluntary agencies (for example, New Jersey Department of Health, New Jersey Heart Association, First Aid Rescue Squad and so forth) shall be utilized to the fullest extent possible

• Services or items furnished for any sickness or injury occurring while the covered person is on active duty in the military

• Services provided outside the United States and territories

• Services or items furnished for any condition or accidental injury arising out of and in the course of employment for which any benefits are available under the provisions of any workers‘ compensation law, temporary disability benefits law, occupational disease law, or similar legislation, whether or not the NJ FamilyCare beneficiary claims or receives benefits there under and whether or not any recovery is obtained from a third-party for resulting damages

• That part of any benefit which is covered or payable under any health, accident, or other insurance policy (including any benefits payable under the New Jersey no-fault automobile insurance laws), any other private or governmental health benefit system, or through any similarly third-party liability, which also includes the provision of the Unsatisfied Claim and Judgment Fund

• Any service or items furnished for which the care provider does not normally charge

• Services furnished by an immediate relative or member of the NJ FamilyCare beneficiary‘s household

• Services billed for which corresponding health care records do not adequately and legibly reflect the requirements of the procedure code utilized by the billing provider

• Services or items reimbursed based upon submission of a cost study when there are no acceptable records or other evidence to substantiate either the costs allegedly incurred or beneficiary income available to offset those costs. In the absence of financial records, a care provider may substantiate costs or available income by means of other evidence acceptable to the Division

NJ Family Care D ExclusionsThe following services are not covered by UnitedHealthcare for clients enrolled in NJ FamilyCare D program:

• Non-medically necessary services


https://www.uhccommunityplan.com/content/dam/uhccp/plandocuments/handbook/en/NJ-MemberHandbook-En.pdf



• Intermediate Care Facilities/Intellectual Disability

• Private duty nursing unless authorized by the contractor

• Personal Care Assistant Services

• Medical Day Care Services

• Chiropractic Services

• Orthotic devices

• Dental services for members age 19 or older

• Residential treatment center psychiatric programs

• Religious non-medical institutions care and services

• EPSDT except for well-child care including immunizations and lead screening and treatments

• Transportation Services including non-emergency ambulance, invalid coach and lower mode transportation

• Hearing Aid Services except for children under 16 years old

• Blood and Blood Plasma, except administration of blood, processing of blood, processing fees and fees related to autologous blood donations are covered

• Cosmetic Surgery

• Custodial Care

• Special Remedial and Educational Services

• Experimental and Investigational Services

• Medical Supplies, except diabetic supplies

• Infertility Services

• Rehabilitative Services for Substance Use

• Weight reduction programs or dietary supplements, except surgical operations, procedures or treatment of obesity when approved by the contractor

• Acupuncture and acupuncture therapy, except when performed as a form of anesthesia in connection with covered surgery

• Recreational Therapy

• Sleep Therapy

• Court-ordered services

• Thermograms and thermography

• Biofeedback

• Radial keratotomy

• Respite Care

• Nursing facility services

• Audiology services, except for children under 16 years

Cost-Sharing for Dual Eligible MembersYou are not to bill, charge, collect a deposit from, seek compensation, remuneration or reimbursement from, or have any recourse against any UnitedHealthcare Dual Complete ONE member who is eligible for both Medicare and NJ FamilyCare. You shall submit one claim to UnitedHealthcare Dual Complete ONE for all covered services.

You are not to balance bill members.



2019 UnitedHealthcare Dual Complete ONE BenefitsPeople who qualify for Medicare and Medicaid are known as dual eligibles. Members who are a dual eligible receive benefits under both the federal Medicare program and Medicaid. UnitedHealthcare Dual Complete® ONE (HMO SNP) members must have full Medicaid benefits and meet other requirements. The Medical Benefits Chart on the following pages lists the services UnitedHealthcare Dual Complete® ONE (HMO SNP) covers.

For a full list of benefits covered under UnitedHealthcare Dual Complete® ONE (HMO SNP), please visit UHCCommunityplan.com/nj > UnitedHealthcare Dual Complete® ONE (HMO SNP) H3113-005 > Downloadable Resources. Refer to Chapter 4, Benefits Chart: (what is covered). For a summary of benefits, go to UHCCommunityplan.com/nj > UnitedHealthcare Dual Complete® ONE (HMO SNP) H3113-005 > Summary of Benefits.

You will see this apple next to the preventive services in the benefits chart.

Note: Non-Contracted care providers always require prior authorization for all Dual Complete ONE covered services.

We regularly review new procedures, devices and drugs to determine whether or not they are safe and effective for members. New procedures and technology that are safe and effective are eligible to become covered services. If the technology becomes a covered service, it will be subject to all other terms and conditions of the plan, including medical necessity.

In determining whether to cover a service, we use proprietary technology guidelines to review new devices, procedures and drugs, including those related to behavioral/mental health. When clinical necessity requires a rapid determination of the safe and effective use of a new technology or new application of an existing technology for an individual member, one of our medical directors makes a medical necessity determination based on individual member medical documentation, review of published scientific evidence, and, when appropriate, relevant specialty or professional opinion from an individual who has expertise in the technology.


https://www.uhccommunityplan.com/nj

https://www.uhccommunityplan.com/nj/medicare/2019/dual-complete-hmo-snp-one

https://www.uhccommunityplan.com/content/dam/uhccp/plandocuments/2019/eoc/en/2019-NJ-EOC-H3113-005-EN.pdf


http://www.UHCCommunityPlan.com/nj

http://www.UHCCommunityPlan.com/nj

https://www.uhccommunityplan.com/content/dam/communityplan/plandocuments/2018/sob/en/2018-NJ-SOB-H3115-005-EN.pdf


Chapter 3: Prior Authorization

Responsibility for Requesting Prior AuthorizationThe PCP or specialist referring a patient for an elective admission or same day surgery is responsible for contacting UnitedHealthcare for prior authorization. UnitedHealthcare recommends calling at least five days, but not later than 48 hours, in advance of the admission or surgery. Requests for prior authorization are prioritized according to level of medical exigency. Certain cases are reviewed under emergency guidelines.

For prior authorizations, you should call the appropriate number listed below. If faxing, use the UnitedHealthcare forms.

For Long-Term Care Services (Personal Care Services and Adult/Pediatric Medical Day Care Services), you should call or fax the LTC Intake Prior Authorization Form to the number indicated below.

Prior Authorization 24 hrs / 7 days a week

Online Phone

Medical/Surgical UHCprovider.com/paan

866-604-3267

Maternity/Newborn UHCprovider.com/paan

866-604-3267

Behavioral Health 888-362-3368

LTC (PCA/MDC) 800-262-0305

Fax: 855-853-4011 or 855-489-1553

OptumRx Prior Authorization 800-711-4555 (Mon–Fri, 9:00 a.m. – 9:00 p.m.)

The following information is required:

• Patient‘s Name and UnitedHealthcare ID number• PCP‘s name and UnitedHealthcare Provider ID number• Attending MD‘s name and UnitedHealthcare Provider ID

number• Facility name• Expected date of admission or service• Diagnosis(es) or reason for treatment• Planned procedures, services, or medications• Other insurance information for Coordination of benefits (COB)

Once the Service Center receives the complete information to review the request according to MCG Care Guidelines (guidelines are not applicable to LTC Services), the Service Center makes a determination.

If approved, UnitedHealthcare assigns an authorization number to the elective admission or same day surgery and enters the authorization number into UnitedHealthcare‘s information system. UnitedHealthcare then informs the requesting physician‘s office of the authorization number. This authorization number references the admission or procedure.

Determination of Medical NecessityMedically necessary services or supplies are those services required to identify and treat a member‘s illness or injury and which, as determined by the Medical Director, are:

• Appropriate and necessary for the diagnosis, prevention, quantification, cure or treatment of the member‘s medical condition, illness, disease, or injury;

• Appropriate with regard to standards of UnitedHealthcare and good medical practice as recommended and accepted by the medical community;

• Not solely for the convenience of the care provider, the member, or the member‘s family; and

• The most appropriate supply or level of service which can be safely provided to the member.

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When specifically applied to an inpatient, it further means that the member‘s medical symptoms or conditions require that the member cannot be treated as an outpatient.

Criteria and GuidelinesUnitedHealthcare uses MCG Care Guidelines for determinations of appropriateness of care.

UnitedHealthcare has written policies and procedures specifying responsibilities and qualifications of staff that authorize admissions, services, procedures, or extensions of stay. UnitedHealthcare makes determinations on a timely basis, as required by the exigencies of the situation.

The Care Manager can authorize, but not deny, an admission, service, procedure, or extension of stay. If the Care Manageris unable to determine by chart documentation, documentation from the facility utilization review department, or discussion with the PCP or attending physician, the need for admission, surgical or diagnostic procedure, or continued stay, the case is referred to a Medical Director or a Physician Advisor under the direction of a Medical Director.

If, after reviewing all documentation of clinical information, a Medical Director/Physician Advisor determines that the admission, service, procedure, or extension of stay isreasonable, the Care Manager notifies the care provider by phone or fax, assigns an authorization number, and sets the next review date.

If a Medical Director/Physician Advisor makes a determination to deny or limit an admission, service, procedure, or extension of stay, UnitedHealthcare notifies the facility‘s utilization review department, which is responsible for notifying the attending physician. UnitedHealthcare informs the facility of a Medical Director/Physician Advisor‘s name and contact information.The attending physician or designee may contact a Medical Director/Physician Advisor to have the decision reconsidered, based on medical information. A Medical Director/Physician Advisor is available immediately in urgent or emergency cases and on a timely basis for all other cases.

If, after discussion with the attending physician or designee, a Medical Director/Physician Advisor determines the admission, service, procedure, or extension of stay is reasonable, a Medical Director/Physician Advisor notifies the Care Manager , who notifies the facility‘s utilization review department by phone or fax.

UnitedHealthcare will not retroactively deny reimbursementfor a covered service provided to a member by a care provider who relied upon the written or oral authorization of UnitedHealthcare prior to providing the service to the member, except in cases where there was material misrepresentation or fraud. Prior authorization for an inpatient stay does not mean authorization for continued inpatient stays. After giving prior authorization for an admission, service, or procedure, UnitedHealthcare conducts concurrent review to determine whether the stay continues to meet MCG Care Guidelines for determinations of appropriateness of care. UnitedHealthcare approves or denies continuation of the stay in accordance with the criteria and guidelines described in this section.

In the case of a denial, UnitedHealthcare notifies the facility by phone or fax within one working day, followed by writtennotification from the UnitedHealthcare UM Appeals Department within 15 working days. You may request a copy of the clinical criteria used to make the determination by calling 888-362-3368.

The PCP, specialist, attending physician, or the facility may appeal any adverse decision, according to the procedures in Section Utilization Management Appeals.

Affirmative Statement about IncentivesUnitedHealthcare Community Plan affirms that UM decision-making is based only on the appropriateness of care and services and the existence of coverage. UnitedHealthcare Community Plan does not specifically reward care providers or other individuals for issuing denials of coverage of care. Financial incentives for UM decision-makers do not encourage decisions that result in under-utilization.

Access to UnitedHealthcare Community Plan Staff MembersThe UM staff is available at least eight hours a day, during normal business hours, for inbound calls regarding UM issues.The staff can receive inbound communication regarding UM issues after normal business hours. Staff members can send outbound communication regarding UM inquiries during normal business hours, unless otherwise agreed upon. Staff members identify themselves by name, title and organization name when making calls about UM issues. If you have any questions about the UM process, please call Provider Services at 888-362-3368.



Provider’s Responsibility to Verify Prior AuthorizationAll physicians, facilities, and agencies providing services that require prior authorization should call the Prior Authorization Department at 888-362-3368 in advance of performing the procedure or providing service(s) to verify that UnitedHealthcare has issued an authorization number.

Continuity of Care When Provider Leaves NetworkUpon termination by care provider or UnitedHealthcare of the provider agreement for any reason, other thanUnitedHealthcare‘s insolvency, the care provider shall continue to furnish covered services to members and UnitedHealthcare shall continue to compensate care provider in accordance with the provisions of the provider agreement:

• For any member who is registered as an inpatient of the care provider as of the date of termination, coverage shall continue until the member is transferred or discharged from the care provider.

• If care provider is a health care professional, for any member under the provider’s care who, at the time of termination of the provider agreement, is a registered bed patient at a hospital or other institution, coverage shall continue until such member‘s discharge therefrom.

• Where it is medically necessary for the member to continue treatment with the care provider, coverage shall continue for up to four months.

• In cases of the pregnancy of a member, medical necessity shall be deemed to have been demonstrated and coverage by provider shall continue to postpartum evaluation of a member, up to six weeks after delivery.

• In cases of post-operative care, coverage by the care provider shall continue for up to six months.

• In cases of oncological treatment, coverage by the care provider shall continue for up to one year.

• In cases of psychiatric treatment, coverage by the care provider shall continue for up to one year.

• In the case of a hospital care provider whose contract is not renewed or terminated by either party, the care provider and UnitedHealthcare agree to continue to abide by the terms of the most current contract for a period of four months from the contract termination

date, or some other mutually agreed upon date. UnitedHealthcare members must be permitted to continue to receive non-emergency services from the hospital during the four-month period.

Emergency services will continue to be available to UnitedHealthcare members after the four-month period expires.

The determination as to the medical necessity of a member‘s continued treatment with the care provider shall be subject to appeal.

UnitedHealthcare shall not be required to continue coverageby the care provider if the reason for termination was: (i) that the care provider is an imminent danger to members or public health, safety, and welfare; (ii) a determination of fraud; or (iii) the care provider is subject to disciplinary action by the State Board of Medical Examiners.

Authorization of Care for New MembersUnitedHealthcare will honor plans of care (including prescriptions, DME, medical supplies, prosthetic and orthotic appliances, and any other ongoing services) initiated prior to a new member‘s enrollment until the PCP evaluates the member and establishes a new plan of care.

Referrals to Non-Participating Care ProvidersAll referrals to non-participating care providers must receive prior authorization from UnitedHealthcare.

If you need to verify a care provider‘s participation with UnitedHealthcare, call 888-DOC-DENT (888-362-3368).

Assure Required Services are FurnishedEnrollees with Special Needs: Are those individuals with complex/chronic medical conditions requiring specialized health care services, including persons with physical, mental, substance use, and for developmental disabilities, including such people who are homeless.



Standing Referrals for Long-Term Specialty CareUnitedHealthcare Community Plan realizes that some care exceeds the capabilities of the Primary Care Provider (PCP) therefore, UnitedHealthcare Community Plan allows qualified specialists who meet the credentialing criteria of the plan to serve as the overall coordinator of all medically necessary care for members with complex conditions.

Responding to Crisis Situations After Hours for Enrollees With Special NeedsAll medical emergencies should be handled by contacting 911. Members or care providers may reach their Personal Care Manager directly by phone during normal business hours. After hours messages may be left on the automated voice messaging system.

The Special Needs Hot Line 877-704-8871 X5260 is also available for messages; these messages will be returned in one business day.

Provision for Dental Services for Members with Developmental DisabilitiesUnitedHealthcare will provide access for comprehensive,quality dental services for the special needs member. Emphasis will be placed on providing coordinated care and managed dental services with the goal of decreasing the member susceptibility to caries and periodontal disease.

Program Goals:• Improve special needs members‘ access to quality

comprehensive dental care through a network of care providers with expertise with developmental disabilities.

• Coordination of access and delivery with Primary Care Provider(s) linkages and community based organizations.

• Creation of dental management services and expanded benefits for comprehensive dental care within the framework of comprehensive total treatment planning and preventive care delivery.

Methods to Identify Those at Risk Who Should be Referred For a Comprehensive Needs AssessmentMembers with Special Needs are identified in the following ways:

• State Enrollment File

• Call Center

• Care Providers

• Member/guardian

• Utilization reports

• Census reports

• Pharmacy

• Plan Selection Form (PSFs)

Methods and Guidelines of Determining Specific Needs of Referred Individuals

Members who are designated as having special needs should be referred to Care Management for a Comprehensive Health Status Assessment by calling 1-877-704-8871.

A plan of care will be developed in conjunction with the care provider, the member, and/or the member‘s family/guardian.

Allow for Continuation of Existing Relationships With Non-par Care ProvidersAdditionally, UnitedHealthcare Community Plan provides for specialty care, diagnostic, and interventional strategies, as well as long term management of medical conditions, and continuation of out of network care providers when considered to be in the best medical interest of the member.

Referrals to Special Care Facilities for Highly Specialized CareUnitedHealthcare provides access to specialty centers for diagnosis and treatment of rare disorders.



Objectives:• The dental care management coordinator will monitor

linkages with care managers, community based organizations and the Primary Care Provider to emphasize preventive education.

• Quality utilization management and improvement of the program using national and internally developed benchmark standards will be monitored by the Chief Dental Officer.

• Provider directories will identify dentists that meet the treatment requirements of the special needs member.

• The special needs dental coordinator will assist members with special needs in all aspects of dental treatment.

Requirements:

• The provider network includes dentists that offer expertise in the dental management of enrollees with developmental disabilities. In addition to the covered services offered by UnitedHealthcare, special needs enrollees have the following benefit of increased frequency of visits based on the dental risk assessment. The standard allows up to four visits annually without prior authorization. All other quality utilization management and improvement benchmark standards are in effect. Emphasis is placed on establishing linkages with the Primary Care Provider, care manager, and community organizations.

• Informed Consent is required from all patients with developmental disabilities or authorized legal representative/guardian before all surgical cases are treated in the operating room.

• The care manager of an enrollee shall coordinate authorizations for dental required hospitalizations in conjunction with the UnitedHealthcare dental consultant team.

• The special needs program will be reviewed, audited and monitored using the utilization management and quality improvement measures established by UnitedHealthcare.

Prior Authorization FormsForms are avilable online for you to use when faxing. They are available at UHCprovider.com > Menu > Health Plans by State > Choose Your State: New Jersey > Provider Forms.

Hysterectomy Procedures and Consent FormsFederally prescribed documentation regulations for hysterectomies are extremely rigid. Specific Medicaid requirements must be met and documented on the Hysterectomy Receipt of Information Form (FD-189). Any claim (hospital, operating physician, anesthesiologist, clinic, etc) involving hysterectomy procedures must have a properly completed FD-189 attached when submitted for payment. Hysterectomy claims are hard copy restricted; electronic billing is not permitted.

A Hysterectomy Consent Form and instructions for the form’s proper completion can be found on UHCprovider.com/njcommunityplan > Provider Forms and References > Provider Forms > Hysterectomy Consent Form with Instructions.

Sterilization Procedures and Consent FormsFederally prescribed documentation regulations for sterilization procedures are extremely rigid. Specific Medicaid requirements must be met and documented on the Consent Form prior to the sterilization of an individual. The Consent Form is a replica of the form contained in the Federal Regulations and must be utilized by providers when submitting claims for sterilization procedures. Any claim (hospital, operating physician, anesthesiologist, clinic, etc) involved in a sterilization procedure must have a properly completed Consent Form attached when it is submitted for payment. Sterilization claims are hard copy restricted; electronic billing is not permitted.

A Sterilization Consent Form and instructions for the form’s proper completion can be found on UHCprovider.com/njcommunityplan > Provider Forms and References > Provider Forms > Sterilization Consent Form with Instructions.



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Chapter 4: Referrals

Primary Care Provider – The Entry Point to Health Care ServicesThe Primary Care Provider (PCP) is the physician care manager for all members on the PCP‘s roster. The PCP‘s roleis to help ensure that members receive the most appropriate care, at the most appropriate time, at the most appropriate level of care during an episode of illness or injury.

The PCP is the member‘s point of entry into the delivery system, except for services allowing self- referral, emergencies, and out-of-area urgent care. UnitedHealthcare expects PCPsto communicate with specialists in writing (e.g., prescription or letter) the reason for the referral and to note this in the patient‘s medical record.

UnitedHealthcare expects specialists to communicate to the PCP via consultation report significant findings andrecommendations for continuing care. A specialist may refer the patient directly to another specialist.

Referral GuidelinesWritten referrals from the PCP using prescription form or letterhead are recommended for most care delivered by other care providers. The guidelines for referrals are as follows:

• Refer only to UnitedHealthcare participating laboratories.

• Refer only to UnitedHealthcare participating specialists. Referrals to non-participating specialists require prior authorization (needs to be called in by the PCP).

• Initial referrals should be limited to 1–2 visits. Subsequent referrals are usually up to 3 visits.

• For chronic dialysis, referrals will be valid for six months. Referrals are not required for out-of-area dialysis for ESRD.

• Referrals should indicate all services requested including frequency and duration of each service.

Services Not Requiring a Referral (Self-Referral Services)Please refer to the Summary of Benefits member grid. Benefit information is on page 32 in the Member Handbook

on UHCCommunityPlan.com/nj > NJFamilyCare > View Plan Details > Member Handbook (English).

PCP ReferralsPCPs can issue referrals by completing a prescriptionor written note on the PCP‘s letterhead. In addition to clearly noting that the patient is a UnitedHealthcare member, include the following information:

• Member Name, Address, Date of Birth

• PCP Name, UnitedHealthcare Provider ID Number, and Telephone Number

• Specialist/Ancillary Provider Name, UnitedHealthcare Provider ID Number, Address, and Telephone Number

• The PCP should record the referral in the member‘s medical record and give the prescription or letter to the member to take to the specialist at the time of the appointment.

Standing Referral to a SpecialistUnitedHealthcare has a provision for allowing for standing referrals when ongoing, long-term specialty care is required. The referring care provider is required to consult theUnitedHealthcare medical director and specialist to determine if the standing referral is appropriate. Approval of the referral is pursuant to a treatment plan approved by UnitedHealthcare in consultation with the primary care provider, the specialist, the care manager, and the member (or authorized person).

The standing referral may be limited to a specific number of visits or the period during which visits are authorized.

Special NeedsUnitedHealthcare has a provision to allow enrollees with special needs that require highly complex, specialized health care services over a prolonged period of time, to be referred to a physician specialist (where available) in lieu of a traditionalPCP. The referral to a physician specialist may be made when the member‘s condition is at a level of complexity that is difficult for a traditional PCP to manage.

The physician specialist is required to be specially credentialed demonstrating they have the clinical skills, capacity,

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accessibility, and availability to help ensure the member receives all necessary specialty care related to their special need. The physician specialist is also contractually obligated to assume the responsibility for the member‘s overall health care coordination which includes all routine preventive care and health maintenance services.

For further information care providers may contact UnitedHealthcare Special Needs and Care Management Hot Line at 1-877-704-8871.

Elective Admissions and Same Day SurgeryThe PCP or specialist referring a patient for an elective admission or same day surgery is responsible for contacting UnitedHealthcare for prior authorization. UnitedHealthcare recommends that information should be submitted no less than 5 business days prior to the expected date of service.Consideration will be given for less notice on a case by case basis. Notification to UnitedHealthcare may be made by phone, iExchange or mail. Requests for prior authorization are prioritized according to level of medical exigency. Certain cases are reviewed under emergency guidelines.

The prior authorization process can move promptly and efficiently by phone if physicians help ensure that

• A clinical person, familiar with medical terminology, calls UnitedHealthcare

• The caller is prepared in advance with all the necessary information (see list below)


Online Phone


866-604-3267

Maternity/Newborn UHCprovider.com/paan

866-604-3267


The following information is required to receive authorization for an admission or procedure:

• Patient‘s name and UnitedHealthcare ID number

• Referring Physician and UnitedHealthcare Provider ID number

• Physician referred to and UnitedHealthcare Provider ID number

• Facility name

• Expected date of admission or service

• Diagnosis(es) Code(s)

• Planned procedure(s)

• Procedure code(s)

• Type of service (e.g., outpatient, inpatient admission, home care, DME)

• Other insurance information for Coordination of benefits (COB)

The Service Center will contact the physician if there are questions or more information is needed. Once the Service Center receives the complete information to review the request according to MCG Care Guidelines, the Service Center makes a determination.

If approved, UnitedHealthcare assigns an authorization number to the elective admission or same day surgery and enters the authorization number into UnitedHealthcare‘s information system. UnitedHealthcare then informs the requesting physician‘s office of the authorization number . This authorization number references the admission or procedure.

OptumRx Medication Prior AuthorizationOptumRx Prior Authorization

Phone 800-310-6826 (Mon–Fri, 9:00 a.m. – 9:00 p.m.)

Fax 866-940-7328

For a list of Pharmacy Prior Authorization Forms, visit UHCprovider.com/njcommunityplan > Pharmacy Resources and Physician Administered Drugs.

UnitedHealthcare provides clients with a 72-hour supply of medication, whether on or off the formulary, while awaiting a prior authorization determination.

Existing UnitedHealthcare members may continue taking a medication that has been removed from the formulary for as long as that member is enrolled in UnitedHealthcare (unless the medication has been deemed unsafe) with valid medical







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reasoning from the member‘s prescribing care provider, and with the member‘s consultation and agreement. A member may change his or her medication to a medication that is on UnitedHealthcare‘s formulary only if the prescribing care provider and member agree to that change. Members new to therapy will be required to use a medication on the formulary.

Referrals to Nonparticipating Care ProvidersA participating physician must initiate requests for referrals to nonparticipating care providers. Care providers should not ask members to contact UnitedHealthcare to initiate requests for nonparticipating care provider referrals. Members may initiate requests for services allowing self-referrals.

If the PCP has difficulty locating a participating care provider, the Service Center can assist the PCP. Call 888-362-3368.

PCPs Acting as SpecialistsIf a physician is credentialed as a specialist as well as a PCP, the physician can accept referrals from other PCPs. If the PCP wants to provide specialty services to members on his or her own panel, the PCP can contact a Medical Director to discuss arrangements for providing these services.

The PCP should call 888-362-3368 and explain what he/she wants to do with his/her patients and ask to speak with a Medical Director.

Second OpinionsUnitedHealthcare does not require a second opinion for any specific services or procedures. However, all UnitedHealthcare members are entitled to a second opinion from a UnitedHealthcare participating care provider prior to initiating any recommended treatment plan or undergoing any surgical procedure. The member must have seen his/her PCP, or a participating specialist to whom the PCP referred the member, for initial evaluation or treatment prior to requesting a second opinion consultation.

Normally, the PCP, upon the request of the member, will initiate a referral to the second opinion physician.

If the UnitedHealthcare network does not include specialists in the specialty needed, the PCP should call 888-DOC-DENT (888-362-3368) to request authorization for a second opinion by an out-of-plan specialist.

UnitedHealthcare will contact the PCP and specialist within 72 hours with referral information, including the authorization number.

The member and his/her family, after considering the recommendation of the second opinion physician and evaluation of alternatives, will make the final decision regarding the course of treatment.



Chapter 5: Claims Policies and Procedures

Our Claims ProcessTo be paid promptly for the services you provide, please follow these procedures:

• Claims must be submitted within 180 days from date of service/date of discharge.

• After we receive your claim, if we request additional information in order to process your claim, you must submit this additional information within 90 days.

• If Coordination of Benefits (COB) is involved where UnitedHealthcare is considered a secondary payer, COB of claims should be submitted within 60 days from the date of the primary insurer’s Explanation of Benefits (EOB) or 180 days from the dates of service, whichever is later.

• You must submit corrected claims within 365 days from the date of service.

• In cases where a corrected claim will need to be submitted, you must submit it within 365 days from the date of service.

• Register for UHCprovider.com, our free website for network physicians and health care professionals. At UHCprovider.com you can check eligibility, claims status, and adjustment requests – and submit claims electronically, for faster claims payment. To register, follow the instructions on UHCprovider.com.

• Once you‘ve registered, review the patient‘s eligibility on the web site at UHCprovider.com. To check patient eligibility by phone, call Provider Services at 888-362-3368.

• Notify us of planned procedures and services on our notification list.

• Prepare a complete and accurate claim form.

Electronic Claims Submission

• Submit the claim online at UHCprovider.com OR

• Submit via Emdeon or another clearinghouse vendor – If you currently use Emdeon or another vendor to submit claims electronically, be sure to use the correct UnitedHealthcare electronic payer ID to submit claims to us.

Payer ID – 86047Plan Description – UnitedHealthcare Community Plan

For more information, contact your vendor or the UnitedHealthcare EDI Support Group at (800) 210-8315. To become a registered user of Emdeon, call (800) 845-6592.

Paper Claims SubmissionIn the event that a care provider is unable to submit medical, professional or facility claims electronically, or is submittinga claim requiring invoice documentation, or as a contingency when the electronic system is not available, paper claims may be submitted to the following address:

UnitedHealthcare Community PlanP.O. Box 5250Kingston, NY 12402-5250

• Medicare claims must be separated from all other claims. Refer to section on Coordination of Benefit for more instructions.

• Claims sent to the wrong lock box will be denied.

• Do not send claims to UnitedHealthcare of New Jersey offices

• Do not send claims to any New Jersey PO Box.

Complete ClaimsWhether you use an electronic or a paper form, complete a CMS 1500 (formerly HCFA 1500) or UB-04 (formerly UB-92) form. A complete claim includes the following information; additional information may be required for certain types of services or based on particular circumstances or state requirements.

• Patient‘s name, sex, date of birth and relationship to subscriber

• Member ID Number

This must be the member identification number as it appears on the member‘s UnitedHealthcare ID card. For UnitedHealthcare Dual Complete ONE (Medicare) claims, use the UHC Medicare ID number on the member’s ID card. Do not use the member‘s Medicare ID from his/her Medicare card or Medicaid number (if dually eligible on Medicare/Medicaid).







• Subscriber‘s name, address and ID number

• Subscriber‘s group name and group number

• Name, signature, remit to address and phone number of physician or care provider performing the service, as in your contract document

• National Provider Identifier (NPI) number

• Physician‘s or provider‘s federal tax ID number

• Date of service(s), place of service(s) and number of services (units) rendered

• Current CPT-4 and HCPCS procedure codes with modifiers where appropriate

• Current ICD-10 diagnostic codes by specific code to the highest level of specificity (e.g. 493. 1)

• Referring physician‘s name (if applicable)

• Charges per service and total charges

• Information about other insurance coverage, including job- related, auto or accident information, if available

• Attach operative notes for claims submitted with modifiers 22, 62, 66 or any other team surgery modifiers as well as CPT 99360 (physician standby)

• Attach an anesthesia report for claims submitted with a 23, QS, G8 or G9 modifier

• Attach a detailed description of the procedure or service provided for claims submitted with unlisted medical or surgical CPT or ― other revenue codes as well as experimental or reconstructive services

• For hysterectomy and sterilization procedures, you must submit paper claims with the appropriate Consent Form attached (see Chapter 3: Prior Authorization)

• Purchase price for DME rental claims exceeding $500

• If you need to correct and re-submit a claim, submit a new CMS 1500 or UB-04 indicating the correction being made. Hand corrected claim re-submissions will not be accepted.

Additional information needed for a complete UB-04 form:

• Date and hour of admission and discharge as well as patient status-at-discharge code

• Type of bill code

• Type of admission (e.g. emergency, urgent, elective, newborn)

• Current revenue code and description

• Current principal diagnosis code (highest level of specificity e.g. 493. 1) with the applicable Present on Admission (POA) indicator on hospital inpatient claims

• Present on Admission (POA) indicator on hospital inpatient claims.

• Current other diagnosis codes, if applicable (highest level of specificity e.g. 493. 1), with the applicable Present on Admission (POA) indicator on hospital inpatient claims.

• Attending physician ID

• Bill all outpatient surgeries with the appropriate revenue and CPT code if reimbursed according to ambulatory surgery groupings

• Provide specific CPT and appropriate revenue code (e.g. laboratory, radiology, diagnostic or therapeutic) for services reimbursed based on a contractual fee maximum

• Attach an itemized list of services or complete box 45 for physical, occupational or speech therapy services (revenue code 420-449) submitted on a UB-04

• Submit claims according to any special billing instructions that may be indicated in your agreement (or letter of contract)

• If patient is seen in the ER and the inpatient admission is denied or not authorized, when submitting the claim, be sure to add the revenue codes of 450-459 for the ER services rendered. This will help ensure that Claims pays the ER portion as required by law.

If you have questions about submitting claims to us, please contact Provider Services at 888-362-3368.

National Provider Identifier (NPI)The Health Insurance Portability and Accountability Act (HIPAA), federal Medicare regulations, and many state Medicaid agencies mandate the adoption and use of a standardized National Provider Identifier (NPI) for all health care professionals. In compliance with HIPAA, all covered health care providers and organizations must obtain an NPI for identification purposes in standard electronic transactions

To avoid payment delays or denials, please include a valid NPI on all Medicare and Medicaid claims submitted to UnitedHealthcare for processing.



A valid NPI is required for all covered claims. It is important that in addition to the NPI you continue to submit your Tax Identification Number (TIN) on all electronic and paper professional medical claims. Please continue to submit complete claims to comply with complete claim billingrequirements as published in the UnitedHealthcare New Jersey Provider Manual. The NPI information that you report to us now and on all future claims is essential in allowing us to efficiently process claims. View How to Submit NPI, TIN and Taxonomy on Paper and Electronic Claims for more information.

To help ensure effective and efficient processing of transactions, companion documents should also be referenced. These documents include company-specific details for Electronic Data Interchange transactions. These companion documents contain only supplementary instructions for the ASC X12 implementation guides, and they do not replace or modifythe implementation guides, but should be used in conjunction with them.

For more information, please visit wpc-edi.com.

A covered health care provider is any provider who transmits health information in electronic form in connection with a transaction for which standards have been adopted. These covered health care providers must obtain an NPI and use this number in all HIPAA transactions, in accordance with the instructions in the Implementation Guides.

How Do I Submit an NPI, TIN and Taxonomy on a Claim?UnitedHealthcare is able to accept NPI on the UB-04 and CMS 1500 (08-05) paper and HIPAA 837 professional andinstitutional claim submissions. It is important that all electronic and paper claims include the TIN in addition to the NPI. In addition, we are requesting the billing provider NUCC taxonomy code be submitted on institutional claims.

Any changes to our NPI policy will be preceded with communications to physicians, health care professionals, organizations and trading partners. Such communications will express when we will reserve the right to no longer accept HIPAA transactions which do not contain a valid NPI in the fields specified by our HIPAA-adopted implementation guides.

The information below identifies the location for NPI, TIN and Taxonomy on paper and electronic claims in accordance with HIPAA NPI compliance effective May 23, 2008:

HIPAA 837P (Professional) Claim Transaction (for enumerated providers)Billing Provider Identifier Location

• Primary Identifier NPI Loop 2010AA, NM109 / NM108=X

• Secondary Identifier TIN Loop 2010AA, REF02 (REF01=EI or SY)

• Pay-To Provider

• Primary Identifier NPI Loop 2010AB, NM109 (NM108=XX)

• Secondary identifier TIN Loop 2010AB, REF02 (REF01=EI or SY)

• Referring Physician

• Primary Identifier NPI Loop 2310A, NM109 (NM108=XX

• Rendering Physician

• Primary Identifier NPI Loop 2310B, NM109 (NM108=XX HIPAA 837I (Institutional) Claim Transaction (for enumerated providers)Billing Provider Identifier Location

• Primary Identifier NPI Loop 2010AA, NM109 (NM108=XX

• Secondary Identifier TIN Loop 2010AA, REF02 (REF01=EI or SY)

• Taxonomy NUCC Code Loop 2000A, PRV03 (PRV01=BI)

• Pay-To Provider

• Primary Identifier NPI Loop 2010AB, NM109 (NM108=XX)

• Secondary identifier TIN Loop 2010AB, REF02 (REF01=EI or SY)

• Taxonomy NUCC Code Loop 2000A, PRV03 (PRV01=PT)

• Attending Physician

• Primary Identifier NPI Loop 2310A, NM109 (NM108=XX

• Taxonomy NUCC Code Loop 2310A, PRV03


http://wpc-edi.com


Refer to the Implementation Guides at wpc-edi.com for additional 837I/P rules regarding the above identifiers. Taxonomy is mutually exclusive.

As of March 6, 2013, UnitedHealthcare will reject 837I and 837P electronic claims that contain a P.O. Box address in the 2010AA Billing Provider Loop. You should make any necessary adjustments in your system to avoid an increase in claim rejections.

If you need to submit a P.O. Box or lockbox address, the 2010AB Pay-to Address Loop should be used instead. This change is due to the ASC X12 Health Care Claim: Professional (837) implementation guide (005010X222A1) and the Institutional (837) implementation guide (005010X223A2), which specify that the 2010A Billing Provider Loop must contain a street address.

If you have any questions about this information, please contact our EDI Support Team at (800) 842-1109.

CMS 1500 (08-05) Professional Claim Form (for enumerated providers)Billing Provider NPI Field 33a Billing Provider TIN Field 25 Referring Provider NPI Field 17b Rendering Provider NPI Field 24jService Facility Location NPI Field 32a

Important: Make sure that your claim software supports the revised 1500 claim form (08-05). Reference the 1500 Reference Instruction Manual at nucc.org for specific details on completing this form.

UB-04 Paper Institutional Claim Form (for enumerated providers)Billing Provider NPI Locator 56 Billing Provider TIN Locator 05Billing Provider Taxonomy Code Locator 81 Attending Provider NPI Locator 76 Operating Provider NPI Locator 77Other Provider NPI Locator 78-79

See definitions in the UB-04 Data Specification Manual available at nubc.org.

Claim AdjustmentsIf you believe you were underpaid, you may submit an adjustment request at UHCprovider.com or call the Provider Services Line at 866-362-3368. If you or our staff identifies a claim where you were overpaid, we ask that you send us the overpayment within 30 calendar days from the date of your identification of the overpayment of our request.If your payment is not received by that time, we may apply the overpayment against future claim payments.

We typically make claim adjustments without requesting additional information from the network physician. You will see the adjustment on the Explanation of Benefits (EOB) orProvider Remittance Advice (PRA). When additional or correct information is needed, we will ask you to provide it. If you disagree with a claim adjustment, you can appeal the determination as described in the following processes:

1. PROVIDER CLAIM PAYMENT APPEAL PROCESSESClaim payment disputes are disputes that do not require any action by the UnitedHealthcare member. The claim payment appeal process is a procedure to resolve billing, payment, and other administrative disputes between the health care provider and UnitedHealthcare. There are two types of claim payment appeals: Informal and Formal.

A. Informal Claim Appeals Informal claim payment appeals are claim resubmissions

in order to revise a previously submitted claim and obtain payment. Care providers seeking an informal claim appeal can choose to send a written appeal to the Appeals & Grievances address listed below prior to or concurrent with seeking a formal appeal.

UnitedHealthcare Community Plan Attn: Appeals P.O. Box 31364 Salt Lake City, UT 84131-0364

Supporting documents should be included for the following:

1. Claim previously denied for – Additional Information to process claim

2. Claim is being resubmitted as a – Corrected Claim

3. Claim is being resubmitted with – Prior Notification and/or Prior Authorization information


http://wpc-edi.com

http://nucc.org

http://nubc.org




4. Claim is being resubmitted because it was a – Bundled Claim

5. Previously denied/closed as – Exceeds Timely Filing

EXPLANATION OF REASONS FOR REQUESTING CLAIM RESUBMISSION:

1. Previously denied/closed for “Additional Information” Please attach a copy of all information requested and

include the following information on the first page of the request:

• Patient name

• Patient’s address

• Patient member ID number

• Provider name and address

• Reference number

Add the additional information requested. Examples include:

• Medical notes

• Anesthesia time units

• Current Procedural Technology (CPT) or Healthcare Common Procedure Coding System (HCPCS) codes (missing, illegible, or deleted)

• Date of service

• Description of service

• Diagnosis code where the primary code is missing, illegible or is the wrong number of digits

• Physician name

• Patient name

• Place of service (POS) code

• Provider’s Tax Identification Number (TIN)

• Semi-private room rate

• Accident information

2. Resubmission of a “Corrected Claim” Health Care Financing Administration (HCFA): Consistent

with Health Insurance Portability and Accountability Act (HIPAA) requirements, submit corrected claims in their entirety. If a claim needs correction, please follow these guidelines:

• Make the necessary changes in your practice management system, so the corrections print on the amended claim.

• Attach the corrected claim (even line items that were previously paid correctly). Any partially-corrected request will be denied. Enter the words, “Corrected Claim” in the comments field on the claim form. Your practice management system help desk or your software vendor can provide specific instructions on where to enter this information in your system. If you do not have this feature, stamp or write “Corrected Claim” on the CMS 1500 form. Changes must be made in your practice management system and then printed on the claim form. You may not write on the claim itself.

• The resubmitted claim is compared to the original claim and all charges for that date of service. The care provider and patient must be present on the claim, or we will send a letter advising that all charges for that day are required for resubmission.

• Complete the resubmission form as instructed and mark the box on Line 4 for Corrected Claims. Continue to the Comments section and list the specific changes made and rationale or other supporting information.

UB04: UB Type of Bill should be used to identify the type of bill submitted as follows:

– XX5 Late Charges– XX7 Corrected Claim– XX8 Void/Cancel previous claim

3. Resubmission of “Prior Notification/Prior Authorization Information”

If you receive a claim denial for no prior authorization required, submit a prior authorization number and other documents that support your request. If you spoke to a customer service representative and were told that notification was not required, please submit the date, time and reference number of that call and the name of the representative handling the call. Please also advise if the service was performed on an emergency basis and therefore notification was not possible. You can send a written appeal with the supporting documentation to the Appeals & Grievances address listed below

UnitedHealthcare Community Plan Attn: Appeals P.O. Box 31364 Salt Lake City, UT 84131-0364

4. Resubmission of a “Bundled Claim” Review your claim for appropriate code billing, including

modifiers. If the claim needs to be corrected, please submit a corrected claim. If a bundled claim is not paid



correctly, or is denied, submit a detailed explanation including any pertinent information on why you believe the claim determination is incorrect.

5. Previously denied/closed as “Exceeds Timely Filing” Timely Filing is the time limit for filing claims; claims are

considered timely when submitted by care providers within 180 days of the date of service. For a non-network care provider, the benefit plan would decide the timely filing limits. When timely filing denials are upheld, it is usually due to incomplete or invalid documentation submitted with claim reconsideration requests.

If you disagree with the outcome of the claim determination or reconsideration as it relates to timely filing, you can send a written appeal with the supporting documentation to the Appeals & Grievances address listed below.

UnitedHealthcare Community PlanAttn: AppealsP.O. Box 31364 Salt Lake City, UT 84131-0364

Submission requirements for electronic claims:• Submit an electronic data interchange (EDI) acceptance

report. This must show that UnitedHealthcare or one of its affiliates received, accepted and/or acknowledged the claim submission.

• A submission report alone is not considered proof of timely filing for electronic claims. It must be accompanied by an acceptance report.

– The acceptance report must indicate the claim was either “accepted,” “received” and/or “acknowledged” within the timely filing period

Submission requirements for paper claims:• Submit a screen shot from your accounting software that

shows the date the claim was submitted. The screen shot must show the:

– Correct patient name

– Correct date of service

– Submission date of claim that is within the timely filing period

Provide any additional information that supports your request.

Claim Reconsideration and Appeal TimelinesNJ FamilyCareRequests from all care providers regardless of participation status for claim dispute/reconsideration must be submitted within 90 days from the receipt of the EOB/PRA. Requests for all other appeal types must be submitted within 90 days from receipt of response or determination from UnitedHealthcare.

Dual Complete ONE (FIDE SNP)Participating FIDE SNP (Dual Complete ONE) providers have ninety (90) days in which to file 1st level claim dispute/reconsideration from receipt of PRA/EOB, and sixty (60 days) from receipt of response or determination from UnitedHealthcare to file all other appeals.

Non-participating FIDE SNP (Dual Complete ONE) providers have 120 days in which to file a first level claim dispute/reconsideration from receipt of PRA/EOB, and 60 days from receipt of response or determination from UnitedHealthcare to file all other appeals.

Grievances can be filed at anytime.

UHCCPNJ will provide a response within 10 days of acknowledgement of the claim dispute/reconsideration, appeal, or grievance. UHCCPNJ will provide a resolution to the care provider within thirty (30) calendar days.

Note: The sixty (60) day limit may be extended for good cause. Include in your written request the reason why you could not file within the 60 day timeframe.

Claim Reconsiderations can be submitted online atUHCprovider.com or by callingthe Provider Service Center at 888-362-3368.

Or in writing to the following address:

UnitedHealthcare Community PlanAttn: Appeals & Grievance DepartmentP.O. Box 31364Salt Lake City, UT 84131-0364



Please note that clinical information will not be reviewed for appeals based on medical necessity, experimental orinvestigational services through the informal claim payment appeal process.

If you are dissatisfied with the claim reconsideration payment appeal outcome and would like to submit a formal claim payment appeal, the formal appeal must be done within 90 days of the most recent adverse determination on a claim or claim appeal PRA for NJ FamilyCare. For Dual Complete ONE, the formal appeal must be done within 60 days of the most recent adverse determination on a claim or claim appeal. Please be advised that you do not receive an additional 90 days from the date of the decision of the informal claim payment appeal.

Formal Claim AppealsA formal claim appeal must be submitted to UnitedHealthcare utilizing the New Jersey Department of Banking and Insurance approved form – Health Care Provider Application to Appeal a Claims Determination (HCAPPA), located under the – Provider Forms Tab at UHCprovider.com > Menu > Health Plans by State > Choose Your State: New Jersey > Go to UHCCommunityPlan.com > Provider Forms.

If the Provider submits a claim payment appeal using this formwithin 90 days of the most recent adverse determinationon a claim or claim appeal, and UnitedHealthcare Community Plan of New Jersey upholds the claim payment denial, the provider has the right to file an external Claims Arbitrationvia MAXIMUS at the address listed below. Include a copy of the claim in question, and submit all supporting documentation,if applicable, within 90 days of the most recent adverse determination on a claim or claim appeal to:

New Jersey Provider Appeals MAXIMUS, Inc.3750 Monroe Avenue, Suite 705Pittsford, NY 14534

You can also submit the request online at:njpicpa.maximus.com.

If you do not submit the claim payment appeal on a HCAPPA Form, you do not have the right to a Claims Arbitration case.

Claim appeals based on UnitedHealthcare‘s adverse determination regarding medical necessity, experimental or investigational services should be processed under the

Utilization Management (UM) appeal process within 60 days from receipt of the original UM denial letter.

According to New Jersey Administrative Code 11:24-8.4, any care provider appealing on behalf of a member must have the member’s written consent in order to request a Utilization Management (UM) appeal. To proceed with a Stage 1 Utilization Management Appeal, include a copy of the original UM denial letter, the member‘s written consent, a copy of the medical record, and any additional information which supports the need for medical necessity on the denied date(s) of services.

Utilization Management Appeals should be mailed to the following address:

UnitedHealthcare Community Plan Attention: UM Appeals CoordinatorP.O. Box 31364Salt Lake City, UT 84131-0364

To help ensure all required medical information is reviewed with your appeal, it is important to send the necessary medical records with the initial appeal request. The appeal process will start in the absence of necessary medical records.

Note: If a care provider submits a UM appeal on behalf of a member with clinical information and without member written consent, the appeal will be considered a provider service appeal. Although clinical information may be reviewed formedical necessity, the care provider appealing on behalf of a member is not entitled to a Stage II UM appeal nor the New Jersey Department of Banking and Insurance arbitration process.

See Chapter 16: Utilization Management Appeals for additional information.

Provider GrievancesIf you have a grievance, you may call the Provider Service Center at 888-362-3368 and speak to a Customer Center Professional (CCP). Hours of operation are 8 a.m. to 6 p.m. ET, Monday through Friday. If we are not able to resolve your inquiry during the initial call, a written response will be sent to you within 30 days of your call. Written provider grievances will receive a written response back to the care provider within 30 days of receipt.



https://www.uhccommunityplan.com/health-professionals/nj/provider-forms.html

https://njpicpa.maximus.com/njportal/



Coding StandardsUnitedHealthcare uses the most recent versions of the following codes:

• Current Procedural Terminology, 4th edition (CPT-4)

• Health Care Financing Administration Common Procedure Coding System (HCPCS)

• International Classification of Diseases, 9th revision, Clinical Modifications (ICD-10-CM)

Submittal of claims without the most current set of codes will result in delayed payment or denial.

The U.S. Department of Health and Human Services (DHHS) and the American Medical Association (AMA) annually publish industry standard codes that are essential for prompt and accurate payment of care provider claims. All care providers are encouraged to obtain the most current version of CPT-4, HCPCS,and ICD-10-CM codes. Each new version becomes effective on January 1 of the current year and expires on December 31.

You must use codes for data items with a schedule of codes. No narratives are accepted for data items where codes are available.

You must state ICD-10-CM codes to the highest level of specificity stated in the current version. You must add whatever modifier is stated in the current version. Do not rely on the index, which only lists family of codes and not the highest level of specificity. Claims lacking codes with the highest level of specificity are denied.

Capitated Primary Care Provider and EPSDT EncountersPCPs must report all encounters, especially Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) encounters and those covered by capitated payment.

Early and Periodic Screening, Diagnosis & Treatment (EPSDT)Early and Periodic Screening, Diagnostic and Treatment (EPSDT) is a Title XIX mandated program that covers screening and diagnostic services to determine physical and

mental defects in enrollees under the age of 21, and health care, treatment, and other measures to correct or ameliorate any defects and chronic conditions discovered, pursuant to Federal Regulations found in TITLE XIX of the Social Security Act.UnitedHealthcare monitors pediatric preventive care according to the EPSDT guidelines and the American Academy of Pediatrics Recommendations for Preventive Care. In addition, UnitedHealthcare makes incentive payments to PCPs for providing EPSDT services.

All well-child visits and immunizations must be documented on CMS 1500 claim forms and only ONE date of service should be recorded on each form. To help ensure appropriate incentive payments, PCPs must record their NPI and tax ID numbers on the claim forms.

UnitedHealthcare reimburses for the administration of immunizations included under the VFC Program. To help ensure payment, PCPs must submit appropriate CPT 4 Codes for the vaccines given, as well as the administration code.

EPSDT Guide For EPSDT Visit Codes For Children 0–21 Years

EPSDT VISIT CODES

Age and Status CPT4 Code

Normal Newborn Care 99432

New Patient (Under One Year) 99381

New Patient (Ages 1–4 Years) 99382

New Patient (Ages 5–11) 99383

New Patient (Ages 12–17) 99384

New Patient (Ages 18–21) 99385 EP

Established Patient (Under One Year) 99391

Established Patient (Ages 1–4 Years) 99392



Established Patient (Ages 18–21 Years) 99395 EP


IMMUNIZATION & LEAD SCREENING

Description CPT4 Code

Lead Screening 83655-91

HPV 90649

Hep A-Adult 90632

Hep-A Ped/Adol 90633

Hep A-Hep B (Adult) 90636

Hib PRP-OMP 90647

Hib PRP-T 90648

Flu (Split Virus) 90655




Flu (Intranasal) 90660

Pneumococcal Conjugate – 7 valent 90669

Pneumococcal Conjugate – 13 valent 90670

Rotavirus – 3 Dose Series 90680

Rotavirus – 2 Dose Series 90681

DTaP 90700

MMR 90707

MMRV 90710

E-IPV 90713

Td 90714

Tdap 90715

Varicella 90716

Tetanus & Diphtheria (Td) for seven y/o or older

90718

Diptheria, tetanus, acellular pertussis and Hemophilus influenza B vaccine (DTaP-Hib)

90721

DTaP/HepB/IPV 90723

Pneumococcal (Polysaccharide) 90732

Meningococcal 90734

Hep B - Adol 90743

Hep B 90744

IMMUNIZATION & LEAD SCREENING

Hep B- Adult 90746

Hep B/Hib PRP-OMP 90748

DTaP/Hib/IPV 90698

DTaP-IPV 90696

Administration Codes* 90465, 90466, 90471, 90472, 90467, 90468,90473, 90474

ICD-10 Diagnosis Codes** Z76.1, Z76.2, Z00.129, Z00.121

* Administrative codes should not be submitted to UnitedHealthcare for EPSDT visits.

** Denotes primary diagnosis whenever well-child care and immunizations are rendered.

Encounter DataUnitedHealthcare is contractually obligated to submit accurate, detailed, and complete encounter information to Centers for Medicare and Medicaid (CMS) and the NJ Department of Human Services (DHS). Consequently, UnitedHealthcare participating care providers are required to submit accurate, detailed, and complete encounter information to UnitedHealthcare.

Claims submission constitutes the care provider‘s certification of the submitted data.

Coordination of BenefitsCoordination of benefits (COB) is used when a member is covered by more than one insurance policy. By coordinating benefit payments, the member receives the maximum benefit allowable under each plan.

The most common COB issue among UnitedHealthcare members arises with persons who have traditional Medicare Fee-for-Service (FFS) and are enrolled in NJ FamilyCare.

In New Jersey, an individual who is dually eligible for Medicare and Medicaid may be enrolled in one of the following combinations:



• Enrolled in UnitedHealthcare Dual Complete ONE Special Needs Plan (FIDE SNP) and NJ FamilyCare

• Enrolled in traditional Medicare and NJ FamilyCare

• Enrolled in a Medicare Advantage plan and NJFamilyCare

For members who have both Medicare and Medicaid, Medicare is always primary and should be billed first. You should bill either traditional Medicare, the member’s Medicare Advantage plan, or UnitedHealthcare Dual Complete ONE (FIDE SNP), depending on the member‘s coverage for Medicare.

If the member is enrolled in UnitedHealthcare Dual Complete ONE (Medicare), then submit the Medicare claim to UnitedHealthcare. Because both the primary and secondary payers are UnitedHealthcare, UnitedHealthcare will coordinate the benefits through automatic claim adjudication.

If the member is enrolled in either traditional Medicare or a Medicare Advantage plan and UnitedHealthcare Medicaid is secondary, then first submit the claim to either traditional Medicare or the Medicare Advantage plan, depending on the member’s primary coverage plan. Then the secondary claim must be submitted on paper with the Medicare EOB attached to UnitedHealthcare.

The only exception is for a working Medicare beneficiary who has health coverage through his or her employer, in which case the commercial insurance is primary. However, members inthis category are rarely enrolled in the UnitedHealthcare Dual Complete ONE Program.

If COB is involved, then attach evidence of payment from the first payer (traditional Medicare, Medicare Advantage or Commercial insurance) when billing UnitedHealthcare as the second payer. Coordination of Benefits (COB) of claims should be submitted within 60 days from the date of primary insurer’s Explanation of Benefits (EOB) or 180 days from the dates of service, whichever is later.

In New Jersey, some individuals in the Aged, Blind, and Disabled (ABD) category, including Division of Developmental Disabilities (DDD) clients, may be enrolled in UnitedHealthcare and also have commercial health insurance coverage as a dependent through a parent or guardian‘s health plan.In these cases, the commercial plan is primary and must be billed first.

Unless UnitedHealthcare has given prior authorization for services that require prior authorization, UnitedHealthcare shall not be liable for payment if the other payer refuses payment due to a determination that the services provided were not medically necessary. If UnitedHealthcare givesprior authorization for services for UnitedHealthcare members and another payer denies the authorized services, UnitedHealthcare will pay according to the terms of its contractual agreement with the care provider.

With respect to Medicaid/NJ FamilyCare members, the care provider shall maintain and make available to UnitedHealthcare records reflecting collection of benefits by the care provider and amounts paid directly to Medicaid/NJ FamilyCare members by other payers. UnitedHealthcare shall maintain or have immediate access to records concerning collection of benefits.

UnitedHealthcare members should NEVER receive a bill or a balance bill for covered services. Sending bills or balance bills to UnitedHealthcare members for covered services is a violation of your Participating Provider Agreement with UnitedHealthcare and violates New Jersey law and regulation. Instruct office staff to ask for appropriate documentation of a patient‘s insurance coverage and accurately maintain this information in all billing systems.

If your office has not received payment for covered services provided to a UnitedHealthcare member, call 888-DOC-DENT (888-362-3368).

Subrogation and Tort PolicyTo the extent permitted by applicable law, you shall cooperate with subrogation procedures in instances where the member is covered by automobile insurance or worker‘s compensation.

In the event that UnitedHealthcare is notified of a legal action being taken by, or on behalf of, a member in connection with an illness or injury, UnitedHealthcare may contact you to make available information related to the services provided in connection with the illness or injury.

With respect to Medicaid/NJ FamilyCare members, you shall maintain and make available to UnitedHealthcare records reflecting collection of benefits by the provider and amounts paid directly to Medicaid/NJ FamilyCare members by other payers. UnitedHealthcare shall maintain or have immediate access to records concerning collection of benefits



All care providers are required to notify UnitedHealthcare when a UnitedHealthcare member is present with an illness or injury that is related to an automobile accident or employment. Notification can be made on a standard claim form.

You are required to notify UnitedHealthcare if you become aware of any litigation on behalf of the member resulting from the member‘s injuries. You should call 888-DOC-DENT (888-362-3368).

How to Change Provider InformationTo notify UnitedHealthcare of any provider changes, complete and fax the Provider Information Update Form which can be found on UHCProvider.com > Menu > Demographics and Profiles.

Newborn Claims for Outpatient VisitsThere may be newborn outpatient visits in the 60 days before a Medicaid/NJ FamilyCare number is assigned to the newborn. If no member identification number has been issued for the newborn, report the following information on the electronic claim or the CMS 1500 form for services eligible for reimbursement:

• the mother‘s identification number in Section 1

• the newborn‘s name in Section 2

• the newborn‘s date of birth in Section 3

• the mother‘s name in Section 4

Fraud, Waste, and AbuseThere is no single definition of “fraud” in the health care industry. Generally speaking, fraud as a legal concept involves an intentional misrepresentation of a material fact made to induce detrimental reliance by another. A misrepresentation can entail an affirmative false statement or the omission ofa material fact. Moreover, fraud can be both intentional (knowing), reckless, or negligent. Intentional or knowing fraud can include both misrepresentations made to deceive and induce reliance, and those made with the knowledge thatthey are substantially likely to induce reliance. Federal and state statutes and regulations variously define fraud (e.g., 42 C.F.R. § 455.2 defines fraud as “an intentional deception or misrepresentation made by a person with the knowledge that the deception could result in some unauthorized benefit to himself or some other person.”). For the purposes of this

Program, PSMG construes health care fraud liberally in its broadest sense.

“Waste and abuse” in the context of health care claims are generally broader concepts than fraud. They include over- utilization of services and care provider and member practices inconsistent with sound fiscal, business, or medical practices that cause unnecessary costs or fail to meet professionally recognized health care standards.

Some typical general categorical examples of care provider health care fraud, waste and abuse include:

• Billing for services/goods never provided

• Billing for services/goods not medically necessary

• Billing for services/goods not covered (e.g., experimental services) and/or for services to ineligible members

• Duplicative billing for the same services/goods

• Billing without adequate supporting documentation

• Billing for more costly/complex services/goods than those actually provided (“upcoding”)

• Billing separately services/goods required to be billed collectively (“unbundling”)

• Improper modifications of billing code

• Billings by fictitious, sanctioned, and/or unqualified provider

• Excessive fees charged for services/goods

• Poor quality services that are tantamount to no services provided

• Care provider/member identity theft

• Care provider waiver of patient copayments

• Misrepresentations in cost reports

• Unlawful referrals of patients to related care providers

Some examples of member/beneficiary health care fraud, waste and abuse include:

• Selling/loaning member identification information

• Intentional receipt of unnecessary/excessive services/goods

• Unlawful sales of prescriptions and/or prescription medications

• Misrepresentations to establish program/plan eligibility (e.g., non-disclosure of income/assets)




Medical Record RequestsFraud, Waste & Abuse may request copies of medical records from you in connection with our utilization management/care management, quality assurance and improvement processes, claims payment and other administrative obligations, including reviewing your compliance with the terms and provisions of your agreement with us, and with appropriate billing practice.

If we request medical records, you will provide copies of those records free of charge unless your participation agreement provides otherwise. Records shall be submitted in accordance with the method established by the requestor. These records must be maintained and protected for confidentiality for six years or longer if required by applicable statutes or regulations. In the event that provider fails to comply, actions including, but not limited to, interruption of payment and contract termination may be taken by UnitedHealthcare Community Plan.

Reporting Fraud, Waste, and AbuseIf you suspect a care provider or member has committed fraud, waste, or abuse, you have a responsibility and a right to report it. When you report a situation that you believe is fraud, waste or abuse you are doing your part to protect patients, save money for the health care system and prevent personal loss for others. Taking action and making a report is an important first step. After your report is made, UnitedHealthcare Community Plan works to detect, correct and prevent fraud, waste and abuse in the health care system.

Reports of suspected fraud, waste or abuse can be made in several ways by contacting UnitedHealthcare directly. You can report to UnitedHealthcare Community Plan:

• Online: uhc.com/fraud, or

• Phone: 844-359-7736.

For care provider-related matters (e.g. doctor, dentist, hospital, etc) please furnish the following:

• Name, address and phone number of provider

• NPI or Tax ID of the provider

• Type of care provider (physician, physical therapist, pharmacist, etc.)

• Names and phone numbers of others who can aid in the investigation

• Dates of events

• Specific details about the suspected fraud or abuse


For member-related matters (beneficiary/recipient) please furnish the following:

• The person‘s name, date of birth, Social Security number, ID number

• The person‘s address

• Specific details about the suspected fraud, waste, or abuse.

https://www.uhc.com/fraud


General RequirementsThe standards, policies and procedures described in this section of the manual apply to participating hospitals unless they specifically address another type of provider, e.g.Primary Care Providers (PCPs). For additional information about the Utilization Management process, see Section Prior Authorization of Services.

Elective Admissions and Same Day SurgeryThe PCP or specialist referring a patient for an elective admission or same day surgery is responsible for contacting UnitedHealthcare for prior authorization. UnitedHealthcare recommends calling at least five days, but not later than 48 hours, in advance of the admission or surgery. Requests for prior authorization are prioritized according to level of medical exigency. Certain cases are reviewed under emergency guidelines.

Nurses in the Service Center can authorize admissions and procedures, but may not deny authorization. All cases that do not meet MCG Care Guidelines or are clinically questionable are referred to a Medical Director or Physician Advisor who renders a medical necessity determination.

Once the Service Center receives the complete information to review the request according to MCG Care Guidelines, the Service Center makes a determination.

If approved, UnitedHealthcare assigns an authorization number to the elective admission or same day surgery and enters the authorization number into UnitedHealthcare‘s electronic clinical documentation system. UnitedHealthcare then informs the requesting physician‘s office of the authorization number. This authorization number references the admission or procedure.

The hospital learns of requests for elective admissions or same day surgeries from several sources: the PCP, specialist, or attending physician. UnitedHealthcare recommends that the hospital contact the appropriate unit listed below in advanceof performing the procedure or providing service(s) to verify that UnitedHealthcare has issued an authorization number for the procedure or service. The authorization is valid only if the patient is a UnitedHealthcare member on the date of service.


Online Phone


866-604-3267


Pharmacy Prior Authorization800-310-6826 (Mon–Fri, 9:00 a.m. – 9:00 p.m.)UnitedHealthcare provides clients with a five day supply of medication, whether on or off the formulary, while awaiting a prior authorization determination.

Admissions are subject to concurrent review for medical necessity of continued stays after the initial authorization.

The PCP, specialist, attending physician, or facility may appeal any adverse decision made by UnitedHealthcare. Procedures for filing an appeal are in Chapter 16: Utilization Management Appeals. (Dispensing the five-day day supply of medication is at the discretion of the dispensing pharmacy.)

Emergency AdmissionsPrior authorization is not required for emergency services. Emergency care should be rendered at once, with notification by the hospital of any admission to the Provider Service Center at 888-DOC-DENT (888-362-3368) within 24 hours or by 5:00 PM the next business day.

Nurses in the Health Services Department review emergency admissions within one working day of notification. UnitedHealthcare uses MCG Care Guidelines for determinations of appropriateness of care.

Care in the Emergency RoomUnitedHealthcare members who present at an emergency room should be screened to determine whether a medical emergency exists. Prior authorization is not required for the medical screening. UnitedHealthcare provides coverage for these services without regard to the emergency care provider‘s contractual relationship with UnitedHealthcare.

Chapter 6: Hospitals and Hospitalization




Emergency services, i.e. inpatient and outpatient services furnished by a qualified care provider necessary to treat an emergency medical condition, are covered both within and outside of UnitedHealthcare‘s service area.

An emergency medical condition is defined as a medical condition manifesting itself by acute symptoms of sufficient severity, including severe pain, such that a prudent layperson who possesses an average knowledge of health and medicine, could reasonably expect in the absence of immediate medical attention to result in:

• Placing the health of the individual afflicted with such condition in serious jeopardy (or, with respect to a pregnant woman, the health of the woman or her unborn child);

• Serious impairment to the individual‘s bodily functions; or

• Serious dysfunction of any bodily organ or part.

Maternity Care and Obstetrical AdmissionsMaternity CarePregnant UnitedHealthcare members should receive care from UnitedHealthcare participating care providers only.

UnitedHealthcare considers exceptions to this policy if 1) the woman was in her second trimester of pregnancy when she became an UnitedHealthcare member, and 2) if she has an established relationship with a non-participating obstetrician.UnitedHealthcare must approve all out-of-plan maternity care. You should call 888-362-3368 to obtain approval.

You should notify UnitedHealthcare immediately of a member‘s confirmed pregnancy to help ensure appropriate follow-up and coordination by the UnitedHealthcare Maternal Care Manager.

You can call 888-362-3368 or fax a prior authorization form to 800-766-2597.

The following information must be provided to UnitedHealthcare within one business day of the visit when the pregnancy is confirmed:

• Patient‘s name and UnitedHealthcare ID number

• Obstetrician‘s name, phone number, and UnitedHealthcare ID number

• Facility name

• Expected date of confinement (EDC)

• Planned vaginal or cesarean delivery

• Any concomitant diagnoses that could affect pregnancy or delivery

• Obstetrical risk factors

• Gravida

• Parity

• Number of living children

• Previous care for this pregnancy

An UnitedHealthcare member does not need a referral from her PCP for prenatal care provided by participating obstetricians.An obstetrician does not need approval from the member‘sPCP for prenatal testing or obstetrical procedures. Obstetricians may give the pregnant member a written prescription to present at any of the UnitedHealthcare participating radiology and imaging facilities listed in the provider directory. Perinatal home care services are available for UnitedHealthcare memberswhen medically necessary. In addition, UnitedHealthcare has community-based outreach and social service support programs specific to the needs of pregnant women. The UnitedHealthcare Maternal Care Manager can assist obstetricians and PCPs with referrals to these services.

Obstetrical AdmissionsUnitedHealthcare considers all full-term maternity admissions to be scheduled admissions. Obstetricians and PCPs are expected to notify UnitedHealthcare as soon as a pregnancy is confirmed.

Newborn AdmissionsThe hospital must notify UnitedHealthcare at888-362-3368 prior to or upon the mother‘s discharge, if the baby stays in the hospital afterthe mother is discharged.

The Health Services Department conducts concurrent review of the newborn‘s extended stay. The hospital should make available the following information:

• Date of birth

• Birth weight

• Gender

• Any congenital defect

• Name of attending neonatologist



Enrollment of Newborns Participating hospitals can facilitate the enrollment of newborns in Medicaid/NJ FamilyCare by advising each new mother covered by Medicaid/NJ FamilyCare to report the birth of her baby to her Medical Assistance Customer Center (MACC). Once reported, the MACC will have the baby enrolled in Medicaid/NJ FamilyCare and accreted to the Medicaid/NJ FamilyCare eligibility file and subsequently to UnitedHealthcare’s enrollment file.

If the mother does not report the birth of her baby to the MACC, UnitedHealthcare must wait 60 days before notifying the state of the baby‘s birth. The state then notifies the appropriate MACC to have the baby enrolled in Medicaid/NJ FamilyCare and accreted to the Medicaid/NJ FamilyCare eligibility file and subsequently to UnitedHealthcare’s enrollment file. This process can take several weeks.

Concurrent ReviewUnitedHealthcare performs concurrent review on all hospitalizations for the duration of the stay based on contractual arrangements with the hospital. UnitedHealthcare performs the reviews telephonically or on site whenever possible.

UnitedHealthcare uses MCG Care Guidelines for determinations of appropriateness of care. We also use ASAM patient placement criteria and the Level of Care Index (LOCI) for SUD services.

The Care Manager may certify extension of the length ofstay, but may not deny any portion of the stay. Only a Medical Director or Physician Advisor can deny an extension of the length of stay.

If a Medical Director or Physician Advisor determines that the extended stay is not justified, UnitedHealthcare will notify the facility of its decision.

The PCP, attending physician, or the facility may appeal any adverse decision, according to the procedures in Chapter 16 Utilization Management Appeals.

Inpatient Concurrent Review: Clinical InformationYour cooperation is required with all UnitedHealthcare requests for information, documents or discussions related to

concurrent review and discharge planning including: primary and secondary diagnosis, clinical information, treatment plan, admission order, patient status, discharge planning needs, barriers to discharge and discharge date. When available, provide clinical information by access to Electronic Medical Records (EMR).

Your cooperation is required with all UnitedHealthcare requests from the interdisciplinary care coordination team and/or medical director to support requirements to engage our members directly face-to-face or by phone.

You must return/respond to inquiries from our interdisciplinary care coordination team and/or medical director. You must provide all requested and complete clinical information and/or documents as required within four hours of receipt of our request if it is received before 1 p.m. local time, or make best efforts to provide requested information within the same business day if the request is received after 1 p.m. local time (but no later than 12 p.m. local time the next business day).

UnitedHealthcare uses MCG (formally Milliman Care Guidelines), CMS guidelines, or other nationally recognized guidelines to assist clinicians in making informed decisions in many health care settings. UnitedHealthcare Community Plan uses ASAM patient placement criteria and the LOCI for SUD services. This includes acute and sub-acute medical, long term acute care, acute rehabilitation, skilled nursing facilities, home health care and ambulatory facilities.

Discharge Planning and Continuing CareThe Care Manager contacts the PCP, attending physician, member, Hospital Discharge Planner and member‘s family to assess needs and develop a plan for continuing care beyond discharge, if medically necessary.

UnitedHealthcare Care Managers manage each patient across the continuum of care. The Care Managers work with the member, family members, physicians, hospital dischargeplanners, rehabilitation facilities, and home care agencies. They evaluate the appropriate use of benefits, oversee the transition of patients between levels of care, and refer to community- based services as needed.



Chapter 7: UnitedHealthcare Person Centered Care Model (PCCM)

UnitedHealthcare’s Person Centered Care Model (PCCM) is a holistic, person-centered, continuum of care model with a particular focus on care coordination for those most vulnerable and most likely to need assistance. We implement our model of care (MOC) by helping all beneficiaries with access to appropriate, timely and affordable care through their Medicare and Medicaid benefits and by empowering beneficiaries or their authorized representatives to make decisions regarding their care.

Our model understands beneficiaries’ chronic or disabling condition(s) and medications, age appropriate preventive are needs and the implications for lifestyle, quality of life goals on care and future health care decision making. For those who qualify, our model supports access to in home services that help modify or delay functional decline and promote the beneficiaries’ desired level of independence and quality of life.The MOC includes beneficiary engagement, risk assessment and stratification, comprehensive assessment, promotion of an identified primary care home, an interdisciplinary plan of care, deployment of clinical programs based on individual needs and evidence-based interventions, coordination of care and services, beneficiary education in self-care, ongoing monitoring and evaluation from prevention reminders to end of life support.

The Special Needs Plan (SNP) -specific target population includes individuals who are dually-eligible for Medicare and Medicaid that are enrolled in the UnitedHealthcare Dual Special Needs Plan (DSNP). Enrollment in the SNP product is voluntary and provides the membership specialized services based on the population needs. The MOC for DSNP has been designed to meet the needs of the membership by employing condition specific interventions to drive improvements in health outcomes.

The “high utilizing” beneficiaries, and often their care-givers, have multiple conditions and represent a smaller number of the base population, but are significant drivers of cost. The focus is on members with the highest overall medical expense, with the addition of members identified via the Significant Episode Cluster Activity (SECA) report (Inpatient and ER Visit Clusters). There are additional criteria to consider when risk stratifying and prioritizing members for care coordination, such as: Impact Pro™, a predictive modeling tool, is used to identify those members with increased care needs based on claims data and identified care opportunities.

Appropriate identification and risk stratification of the member is one of the most important critical success factors in achieving optimal clinical outcomes; it is the foundation of a successful program. Because early identification and intervention are critical for high-risk vulnerable members, our protocols focus on identifying members for enrollment into the integrated programs.

We gather data about each member during a variety of member touch points (e.g., new member welcome call), using a variety of assessment instruments (e.g., health risk assessment tool) and through various data analyses (e.g., integrated claims, pharmacy data and lab data). We analyze this data to:

• Identify members with high utilization of health care services.

• Identify members with a history of frequent or inappropriate ER use or repeat inpatient admissions.

• Identify members with abnormal utilization patterns.

• Identify members with significant illness burden reflected in predictive modeling scores.

• Identify members with high-risk pregnancies.

• Assign an overall “future risk score” for each member representing the degree to which case management has the opportunity to have an impact on the member’s health status and clinical outcomes.

• Provide clinical (medical and behavioral health) insights into why an individual is at risk, predict future expenditures and the probability of one or more hospitalizations and identify gaps in evidence-based care.

We continuously identify and stratify members for engagement in high-risk case management. Each month we analyze integrated medical and behavioral data to identify gaps in care, changes in health status, follow up or care opportunities and changes in the member’s health risk categories. Using this analysis and other methods, such as automated alerts (e.g., admits, discharges or transfers) and reminders in our electronic record or through referral by a member, family, PCP or our UM and clinical staff, we monitor member progress and identify members that may benefit from high-risk case management.


Standing Referral to a SpecialistUnitedHealthcare has a provision for allowing for standing referrals when on-going, long-term specialty care is required. The referring provider is required to consult theUnitedHealthcare medical director and specialist to determine if the standing referral is appropriate. Approval of the referral is pursuant to a treatment plan approved by UnitedHealthcare in consultation with the primary care provider, the specialist, the care manager, and the member (or authorized person).The standing referral may be limited to a specific number of visits or the period during which visits are authorized.

New Jersey Early Intervention ServicesNew Jersey Department Of Health Special Child, Adult and Early Interventions Services County Case Management Units

Atlantic County SCHS-Case Management Unit Atlantic County Special Services School District 4805 Nawakwa Blvd.Mays Landing, NJ 08330 PHONE: (609) 909-9269FAX: (609) 476-4362

Bergen County SCHS-Case Management UnitBergen County Dept. of Human Services One Bergen County PlazaHackensack, NJ 07601-4895PHONE: (201) 634-2621FAX: (201) 336-7199

Burlington County SCHS-Case Management UnitVirtua Community Nursing Services 15 Pioneer Blvd.Westampton, NJ 08060-0287PHONE: (609) 914-8550 Ext. 42837FAX: (609) 914-8552

Camden County SCHS-Case Management UnitCamden County Division of HealthDiPiero Center - 512 Lakeland Road, Ste. 401 Blackwood, NJ 08012-0009PHONE: (856) 374-6021 or (800) 999-9045FAX: (856) 374-9734

Cape May County SCHS-Case Management UnitCape May Dept. of Health6 Moore Rd. DN 601 Crest Haven Complex Cape May Court House, NJ 08210-3067 PHONE: (609) 465-6841FAX: (609) 463-0511

Cumberland County SCHS-Case Management UnitCumberland County Dept. of Health 309 Buck StreetMillville, NJ 08332PHONE:(856) 327-7602 Ext. 7132

Essex County SCHS-Case Management UnitSpecial Child Health Services50 South Clinton Street, Suite 4301 East Orange, NJ 07018PHONE: (973) 395-8836 -or- (973) 395-8837FAX: (973) 395-8897

Gloucester County SCHS-Case Management UnitGloucester County Dept. of Health, Senior & Disability Services204 E. Holly Avenue Sewell, NJ 08080PHONE: (856) 218-4111FAX: (856) 218-4125

Hudson County SCHS-Case Management UnitJersey City Medical Center 953 Garfield AvenueJersey City, NJ 07304-3199

Hunterdon County SCHS-Case Management UnitHunterdon Medical Center 2100 Wescott DriveFlemington, NJ 08822-9238PHONE: (908) 788-6399FAX: (908) 788-6581 Mercer County SCHS-Case Management UnitSpecial Child Health Services 1068 Old Trenton Road Hamilton, NJ 08690PHONE: (609) 588-8460FAX: (609) 631-6592



Middlesex County SCHS-Case Management UnitMiddlesex County Office of Health Services 75 Bayard St., Administration Bldg. 5th Floor New Brunswick, NJ 08901PHONE: (732) 745-3187FAX: (732) 745-2568

Monmouth County SCHS-Case Management UnitSpecial Child Health Services/Early Intervention Monmouth County176 Riverside Avenue Red Bank, NJ 07701 PHONE: (732) 224-6950FAX: (732) 747-4404

Morris County SCHS-Case Management UnitMorristown Medical Center 100 Madison Avenue, Box 99Morristown, NJ 07962-1956PHONE: (973) 971-4155FAX: (973) 290-7358

Ocean County SCHS-Case Management UnitOcean County Health Department 175 Sunset AvenueP.O. Box 2191Toms River, NJ 08754-2191 PHONE: (732) 341-9700 ext. 7602FAX: (732) 678-0037

Passaic County SCHS-Case Management UnitCatholic Family and Community Services 775 Valley RoadClifton, NJ 07013PHONE: (973) 523-6778FAX: (973) 523-7715

Salem County SCHS-Case Management UnitSalem County Department of Health 110 5th Street, Suite 400Salem, NJ 08079-1911PHONE: (856) 935-7510 ext. 8305FAX: (856) 935-8483 Somerset County SCHS-Case Management Unit Somerset Handicapped Children’s Treatment Center 377 Union AvenueBridgewater, NJ 08807-0824PHONE: (908) 725-2366FAX: (908) 725-3945

Sussex County SCHS-Case Management UnitSpecial Child Health Services 201 Wheatsworth RoadHamburg, NJ 07419PHONE: (973) 948-5239FAX: (973) 948-2270

Union County SCHS-Case Management Unit313 South Avenue, Suite 102Fanwood, NJ 07023PHONE: (908) 889-0950 ext. 2544FAX: (908) 889-7535

Warren County SCHS-Case Management UnitWarren County Health Department Special Child Health Services162 East Washington Avenue Washington, NJ 07882-2196



Chapter 8: Pharmacy

Pharmacy Benefit ManagementNJ FamilyCare members receive their outpatient prescription drugs through UnitedHealthcare, with the following exception:

• Methadone used for substance use maintenance — cost and administration

• Generically equivalent drug products of the above

Member ID Cards for Prescription BenefitAll UnitedHealthcare members must use their UnitedHealthcare member ID card to obtain covered prescription drugs.

Dual Complete ONEUnitedHealthcare Dual Complete ONE members have a List of Covered Drugs (Formulary). It tells which Part D prescription drugs are covered under the Part D benefit included in UnitedHealthcare Dual Complete® ONE (HMO SNP). The drugs on this list are selected by the plan with the help of a team of doctors and pharmacists. The list must meet requirements set by Medicare and Medicaid. Medicare has approved the UnitedHealthcare Dual Complete® ONE (HMO SNP) Drug List.

In addition to the drugs covered by Part D, some prescription drugs are covered under Medicaid benefits. The Drug List says which drugs are covered under Medicaid.

The Drug List also says if there are any rules that restrict coverage for drugs. Formularies can be found here.

Prescription Drug CoverageCoverage for outpatient prescription drugs varies by UnitedHealthcare product:

Prescription Drug Coverage

UnitedHealthcare Product

Outpatient Prescription Benefit

NJ FamilyCare A NJ FamilyCare B

Prescription and over-the-counter drugs covered by the Medicaid program

No cap. No copayments.

NJ FamilyCare C Prescription and over-the-counter drugs covered by the Medicaid program.

No cap.

$1 copay for generic drugs

$5 copay for brand name drugs

NJ FamilyCare D Prescription drugs covered. No cap

$5 copay for brand and generic drugs. If greater than a 34-day supply of a prescription drug, $10 copay applies. Most over-the-counter drugs excluded.

UnitedHealthcare Dual Complete ONE

Prescriptions covered by Medicare Parts B and D and additional Medicaid only drug coverage.Dual Complete ONE members have no cost share.

For details regarding drugs covered underthe UnitedHealthcare pharmacy benefit and the list of drugs that require prior authorization, providers can go to UHCprovider.com/njcommunityplan > Pharmacy Resources and Physician Administered Drugs.

Prescriptions Requiring Prior Authorization

For Pharmacy Prior Authorization, including injectable drugs, call 800-310-6826 or fax the prior authorization request to 866-940-7328.

http://www.uhccommunityplan.com/content/communityplan/homepage/nj/medicare/2016/dual-complete-hmo-snp-one/lookup-tools.html#view-drug





You should consult the UnitedHealthcare Drug Formulary to identify the drugs that require prior authorization to verify if prior authorization is necessary.

For a copy of the current UHCCPNJ Preferred Drug List (PDL) and PDL updates for NJFamilyCare and Dual Complete ONE, visit UHCprovider.com/njcommunityplan > Pharmacy Resources and Physician Administered Drugs > Prescription Drug Lists/Formulary Lists, Drug Search and Updates

You should receive prior authorization before giving an UnitedHealthcare member a prescription for a medication that requires prior authorization.

UnitedHealthcare makes prior authorization determinations within 24 hours of receiving all the necessary information. The member is entitled to a five day supply of medication while awaiting the prior authorization determination (dispensing the five-day day supply of medication is at the discretion of the dispensing pharmacy).

Pharmacy NetworkMost chain pharmacies and many independent pharmacies fill prescriptions for UnitedHealthcare members.

To locate a pharmacy that is convenient for a member, please visit our website at UHCprovider.com > Find Dr.

Generic DrugsGeneric drugs are provided when available as required by State mandatory generic substitution regulations. Genericdrugs are approved by the Food and Drug Administration (FDA) to be equivalent to their brand name counterparts. If a generic drug is available, a brand name drug will not be provided tothe member. However, a physician can provide information that documents why a brand name drug is medically necessary through a prior authorization. Exception: No generic substitutions will be made for mental health/substance use prescriptions written by psychiatrists or mental health/ substance use providers.

Physicians submitting a request for prior authorization for brand-name drugs should contact the Pharmacy Prior Authorization service at 800-310-6826 to present the information supporting the medical necessity of the brand drug.

Outpatient Injectable Chemotherapy DrugsEffective January 1, 2017, prior authorization will be required for outpatient injectable chemotherapy drugs when billed for a cancer diagnosis.

Pharmacy Benefit ExclusionCertain drugs are not covered by the pharmacy benefit. Drugs that are not covered include:

• Drugs that are used for weight loss or appetite suppression

• Drugs that are used for cosmetic purposes

• Drugs used to treat infertility

• Drugs used to stimulate hair growth or prevent hair loss

• Investigational and experimental drugs, unless a Medical Director gives prior authorization

• DESI drugs

Existing UnitedHealthcare members may continue taking a medication that has been removed from the formulary for as long as that member is enrolled in UnitedHealthcare (unless the medication has been deemed unsafe) with valid medical reasoning from the member‘s prescribing care provider, and with the member‘s consultation and agreement. A member may change his or her medication to a medication that is on UnitedHealthcare‘s formulary only if the prescribing provider and member agree to that change. Members new to therapy will be required to use a medication on the formulary, unless otherwise authorized.

Supply Limit for Opioids UnitedHealthcare Community Plan implemented a 90 morphine equivalent doses (MED) supply limit for the long-acting opioid class. We updated prior authorization criteria to match the CDC’s recommendations for the treatment of chronic non-cancer pain. Prior authorization will apply to all long-acting opioids. The CDC guidelines on long-acting opioids are available online at cdc.gov > More CDC Topics > Injury, Violence & Safety > Prescription Drug Overdose > CDC Guideline for Prescribing Opioids for Chronic Pain. For more information, access our website at liveandworkwell.comFor short-acting opioids, we implemented a supply limit of seven days and less than 50 MED per day for patients new to opioid therapy. For patients age 19 or younger, there is a supply limit of three days. Requests for opiods beyond these limits require prior authorization. For more information on this change, please call 888-362-3368.

Chapter 8: Pharmacy



http://cdc.gov

www.liveandworkwell.com


Chapter 9: NJ Behavioral Health

Optum Behavioral Health Expansion of Covered Health Benefits — Effective October 1, 2018Effective 10/1/2018, there will be an expansion of the covered Behavioral Health benefits available to certain members enrolled in UnitedHealthcare Community Plan of New Jersey (UHCCPNJ). This will align behavioral health benefit coverage for:

• UHCCPNJ FamilyCare beneficiaries Medicaid Long term services (MLTSS);

• Division of Developmentally Disabled (DDD);

• Fully Integrated Dual Eligible Specialty Needs Plans (FIDE SNP)

For the above 3 plans, all SUD services will be covered under UHCCPNJ Behavioral Health benefit services, regardless of age including:

• Hospital Based Inpatient Services

• SUD Intensive Outpatient Services (IOP)

• SUD Partial Care

• SUD Residential Services

• Ambulatory Withdrawal Management

• Medication Assisted Treatment (MAT)

***Still Covered under Fee-For-Service (FFS)

• Targeted Case Management

• Programs in Assertive Community Treatment (PACT)

• Behavioral Health Homes (BHH)

• Community Support Services

Additional Benefits effective 10/1/18 for all UHCCPNJ FamilyCare members include:

Acute Inpatient Hospital Coverage

• All admissions to a general acute hospital (including admissions to a psychiatric unit) will be the responsibility of the MCO for ALL MCO enrolled individuals. This is NOT limited to MLTSS/DDD/FIDE SNP.

Effective for Dates of Service October 1, 2018 and after, all claim submissions for the above services should be submitted directly to UHCCPNJ.

Screening for Behavioral Health ProblemsPrimary Care Providers (PCPs) are required to screen UnitedHealthcare members for behavioral health problems, using the Screening Tool for Substance Use and Mental Health found at the end of this section. PCPs should file the completed screening tool in the patient‘s medical record. In addition, please refer to the section titled “Behavioral Health Toolkit for the PCP” found in this section to assist the PCP in referring members for behavioral health services.

Behavioral Health Services for UnitedHealthcare MembersNJ FamilyCare MLTSS & DDD, and UnitedHealthcare Dual Complete ONE (FIDE SNP) members must use UnitedHealthcare participating care providers listed in the provider directory. UnitedHealthcare Dual Complete ONE (Medicare) members receive mental health and substance use services through UnitedHealthcare. Dual Complete ONE members get their Medicare covered mental health and substance use services through UnitedHealthcare. Medicaid covered mental health and substance use services should be submitted to NJ Medicaid FFS unless MLTSS or DDD, wherein the claims would then be submitted to UnitedHealthcare. Please refer to Chapter 2: Covered and Non-Covered Services under Behavioral Health to see what behavioral health Medicaid services are covered and which are fee-for-servce (FFS).

Role of the Behavioral Health UnitUnitedHealthcare‘s Behavioral Health Unit is an important resource to all care providers when members experience mental health or substance use problems.

Call Provider Services at 888-362-3368 6:00 a.m. – 6:00 p.m. ET, weekdays


The Behavioral Health Unit:• Responsible for member emergencies and requests for

inpatient behavioral health admissions 24 hours, seven days a week

• Fully supports primary care providers with assessment and referrals to mental health and chemical dependence services

• Provides behavioral health care management

• Reviews, monitors, and authorizes behavioral health care

• Responsible for provider relations for behavioral health providers

• Staffed by professionals with extensive experience in mental health and chemical dependence services

Behavioral Health EmergenciesIf you believe the member is having a psychiatric emergency, then call 911 or direct the member to the designated county screening center or nearest hospital emergency room.

If you are unsure about the member‘s mental status, call the UnitedHealthcare Behavioral Health Unit at 888-DOCDENT (888-362-3368).

Referrals for Behavioral Health Services for NJ FamilyCare DDD, MLTSS and UnitedHealthcare Dual Complete ONE (Medicare) MembersPCPs and behavioral health care providers can call the Behavioral Health Unit at 888-362-3368. Document behavioral health referrals or requests in the patient‘s medical record.

An eligible behavioral health member who is DDD, MLTSS, or Dual Complete ONE (FIDE SNP) can self-refer to a participating behavioral health care provider for the first outpatient visit at a participating care provider. The Behavioral Health Unit generally approves a maximum of six initial outpatient visits to allow for full clinical evaluation. The initial treatment assessment must include a full psychosocial history, a mental status examination, and M.D. psychiatric evaluation. The assessment and development of a comprehensive treatment plan must be developed within the first 30 days of treatment.

For non-NJ FamilyCare DDD, MLTSS and UnitedHealthcare Dual Complete ONE (Medicare) members, providers can call 888-362-3368 in order to be provided with and/or transferred to the correct phone number at the New Jersey Division of Medical Assistance and Health Services (DMAHS).

Authorization for Continuation of Outpatient Behavioral Health Services for NJ FamilyCare DDD, MLTSS and UnitedHealthcare Dual Complete ONE (Medicare) MembersBehavioral health care providers can call 888-362-3368 to submit their requests for continued treatment to the Behavioral Health Unit. You can utilize either the UnitedHealthcare Behavioral Health Treatment Plan Form or your own treatment plan form, as long as the form covers all the elements in the UnitedHealthcare form. The Behavioral Health Unit evaluates the treatment plan for quality assurance. The Behavioral Health Unit forwards the treatment plan review to the member‘s PCP to assure coordination of care.UnitedHealthcare authorizes outpatient treatment for a three to six month period depending on treatment intensity.

Behavioral Health Guidelines and StandardsUnitedHealthcare utilizes the following diagnostic assessment tools and placement criteria guidelines, consistent with current standards of care:

• DSM-IV (Diagnostic and Statistical Manual of Mental Disorders), 4th edition

• ASAM PPC-2 (American Society of Addiction Medicine)

UnitedHealthcare uses MCG Care Guidelines for appropriateness of care and discharge reviews for mental health services and ASAM patient placement criteria and LOCI for SUD services.

Behavioral health care providers may not refer patients to another provider without notifying the Behavioral Health Unit and obtaining prior authorization.

UnitedHealthcare expects behavioral health care providers to comply with Timeliness Standards for Appointment Scheduling found in Chapter 12: Participating Provider Responsibilities.




Care providers referring members for behavioral health services need to provide a copy of the medical consultation and diagnostic results to the MH/SA care provider. Care providers must notify an enrollee‘s mental health/substance use provider of the findings of his/her physical examination and laboratory/radiological tests within 24 hours of receipt for urgent cases and within five business days in non-urgent cases. Notification should be made by phone with follow-up in writing when feasible for services that are managed by UHCCP and those that are managed by Medicaid FFS.

Documentation is required when notifying a member‘sMH/SA provider of the findings of his/her physical examination and laboratory/radiological tests within 24 hours of receipt for urgent cases and within five business days in non-urgent cases. Notification should be made by phone with follow-up in writing when feasible.

Behavioral Health Toolkit for the Primary Care Provider (PCP)Purpose: This toolkit was created to assist the PCP in identifying Integrated Care Program (ICP) members who may be in need of behavioral health services, to supply both the PCP and Integrated Care Program member with helpful resources links containing important information about common behavioral health conditions and their treatment, and to assist the PCP in obtaining consultation and/or referral services for Integrated Care Program members with behavioral health conditions.

Clinical Practice Guidelines (CPGs): The followinglinks will enable the PCP to access CPGs for the commonly seen behavioral health conditions.

For CPGs pertaining to Bipolar Disorder, Schizophrenia, Depression, Substance Use Disorders, go to psych.org.

Screening Tool for PCPsDepression (Pfizer Patient Health Questionnaire aka PHQ-9): phqscreeners.com

In those situations where a member screens positive for a behavioral health condition, or you otherwise suspect the presence of a behavioral health condition needing further assessment and/or treatment, please refer the member as appropriate to a UnitedHealthcare behavioral health care provider.

For assistance in identifying a behavioral health provider please contact the UnitedHealthcare Physician Helpline: 888-362-3368.

For care provider and member related resources for Behavioral Health conditions affecting adults follow this link (Substance Abuse and Mental Health Services Administration): samhsa.gov/, or (National Alliance on Mental Illness): nami.org/

Pharmacy Lock-In ProgramIf you suspect that a member is misusing or abusing the prescription benefit by obtaining prescriptions from multiple providers or requesting controlled substances for questionableindications, call the UnitedHealthcare Fraud and Abuse Hotline at 1-877-401-9430. In addition, episodes of stolen prescription pads and suspected forged prescriptions should be reported to UnitedHealthcare.

UnitedHealthcare will investigate the issues and take the appropriate action, which will include, but is not limited to, reporting the member to the State, enrolling the member in the pharmacy lock-in program, and informing the pharmacy network of the activity. The pharmacy lock-in program restricts a member to a single pharmacy for obtaining prescriptions.

https://www.psychiatry.org/

http://www.phqscreeners.com/

https://www.samhsa.gov/

http://nami.org/


Chapter 10: Enrollees with Special Needs

Assure Required Services are FurnishedEnrollees with special needs: Are those individuals with complex/chronic medical conditions requiring specialized health care services, including persons with physical, mental, or substance use and for developmental disabilities, including such people who are homeless.

Methods to Identify Those at Risk Who Should be Referred for a Comprehensive Needs AssessmentMembers with special needs are identified in the following ways:

1. State Enrollment File

2. Call Center

3. Providers

4. Member/guardian

5. Utilization reports

6. Census reports

7. Pharmacy

8. Plan Selection Form (PSFs)

Members who are designated as having special needs should be referred to Care Management for a Comprehensive Health Status Assessment by calling 877-704-8871. A plan of care will be developed in conjunction with the care provider, the member, and/or the member’s family/guardian.

Allow for Continuation of Existing Relationships With Non-Par ProvidersAdditionally, we will provide for specialty care, diagnostic, and interventional strategies, as well as long term management of medical conditions, as well as continuation of out of network providers when considered to be in the best medical interest of the member.

Referrals to Special Care Facilities for Highly Specialized CareWe will provide access to specialty centers for diagnosis and treatment of rare disorders.

Standing Referrals for Long-Term Specialty CareUnitedHealthcare Community Plan realizes that some care exceeds the capabilities of the Primary Care Provider (PCP) therefore, UnitedHealthcare Community Plan allows qualified specialists who meet the credentialing criteria of the plan to serve as the overall coordinator of all medical necessary care for members with complex conditions.

Responding to Crisis Situations After Hours for Members With Special NeedsAll medical emergencies should be handled by contacting 911. Members or care providers may reach their Personal Care Manager directly by phone during normal business hours.After hours messages may be left on the automated voice messaging system.

The Special Needs Hot Line 877-704-8871 is also available for messages; these messages will be returned in one business day.

Provision for Dental Services for Enrollees with Developmental DisabilitiesUnitedHealthcare will provide access for comprehensive,quality dental services for the special needs enrollee. Emphasis is placed on providing coordinated care for managed dental services with the goal of decreasing the member susceptibility to caries and periodontal disease.

Program Goals:• Improve special needs members’ access to quality

comprehensive dental care through a network of providers with expertise with developmental disabilities.


• Coordination of access and delivery with Primary Care Provider(s) linkages and community based organizations.

• Creation of dental management services and expanded benefits for comprehensive dental care within the framework of comprehensive total treatment planning and preventive care delivery.

Objectives:

• The dental care management coordinator will monitor linkages with care managers, community based organizations and the Primary Care Provider to emphasize preventive education.

• Quality utilization management and improvement of the program using national and internally developed benchmark standards will be monitored by the Chief Dental Officer.

• Provider directories will identify dentists that meet the treatment requirements of the special needs member.

• The special needs dental coordinator will assist members with special needs in all aspects of dental treatment.

Requirements:• The provider network includes dentists that offer

expertise in the dental management of enrollees with developmental disabilities. In addition to the covered services offered by UnitedHealthcare, special needs enrollees have the following benefit of increased frequency of visits based on the dental risk assessment. The standard allows up to four visits annually without prior authorization. All other quality utilization management and improvement benchmark standards are in effect. Emphasis is placed on establishing linkages with the Primary Care Provider, care manager, and community organizations.

• Informed Consent is required from all patients with developmental disabilities or authorized legal representative/guardian before all surgical cases are treated in the operating room.

• The care manager of a member shall coordinate authorizations for dental required hospitalizations in conjunction with the UnitedHealthcare dental consultant team.

• The special needs program will be reviewed audited and monitored using the utilization management

and quality improvement measures established by UnitedHealthcare.

• Dentists Management Fee – Providers are paid a dental management fee for initial and follow up dental visits, which may require up to 50 minutes for a comprehensive assessment.

Dental services shall be made available every three months to child or adult special needs members when medically necessary.

Children With Special Health Care NeedsYou are expected to support efforts for well child care, health promotion, disease prevention, and specialty care for children with special health care needs.

UnitedHealthcare Community Plan provides for Well Child Care, health promotion, disease prevention, specialty care, diagnostic and intervention strategies, home therapies, and on-going ancillary services as well as the long-term management of ongoing medical complications. Additionally, all continuation of existing relationships with out-of-network providers, when considered to be in the best medical interest of the member will be evaluated for appropriateness.

Children who are designated as having special needs should be referred to Care Management for a Comprehensive Health Status Assessment by calling 877-704-8871.

A plan of care (IHCP) will be developed in conjunction with the provider, the member, and/or the member’s family/guardian.

Refer Special Needs Members to Behavioral Health ProvidersTo refer a member with special needs to a Behavioral Health provider, visit myuhc.com > Find Medical and Mental Health Providers and Facilities > Mental Health Directory, or call Provider Services at 888-362-3368 to help assist you find a Behavioral Health Provider for your patient.


https://www.myuhc.com/member/prewelcome.do?currentLanguageFromPreCheck=en


Office Based Addictions Treatment (OBAT) AttestationOffice Based Addictions Treatment (OBAT) is the use of medications in combination with navigator services to coordinate counseling and behavioral therapies to treat both Substance Use Disorder (SUD) & Opioid Use Disorder (OUD). These providers are registered with the Drug Enforcement Administration (DEA) to prescribe OUD treatment medication. Increasing PCPs participation in substance use disorder (SUD) treatment, particularly MAT, offers an opportunity to improve access and to expand integration of care within NJ FamilyCare. The majority of NJ FamilyCare beneficiaries are covered by a Medicaid managed care organization (MCO) and receive their primary care through contracted provider practices. Until now, many PCPs have not participated in the treatment of substance use-related disorders (beyond referral) because of perceived barriers to providing treatment, a perceived lack of reimbursement, and/or a lack of experience/knowledge treating these conditions. These barriers include prior authorization requirements and discerning what is covered by the MCO and/or the State. NJ FamilyCare has designed the OBAT program to support providers by increasing rates, removing prior authorization requirements, allowing PCPs to bill the managed care plan for this SUD service when the beneficiary is covered by managed care and offering clinical guidance and support.

For more information about the OBAT program, please refer to the State of New Jersey Department of Human Services Division of Medical Assistance & Health Services Newsletter Volume 29 No. 06 dated March 2019 by visiting njmmis.com > Recent Newsletters > Volume 29 No. 06 - Subject: Office Based Addictions Treatment (OBAT) and Elimination of Prior Authorization for Medication Assisted Treatment (MAT) for All MAT Providers, Effective: January 1, 2019

For a copy of the OBAT form, please visit UHCprovider.com/njcommunityplan > Provider Forms and References > Provider Forms > Medication-Assisted Treatment (MAT) and Office Based Addictions Treatment (OBAT) Questionnaire.


https://www.njmmis.com/documentDownload.aspx?fileType=RecentNewsLetters




Health Plan (80840) 911-86047-08Member ID: Group Number: Member:

PCP Name:DOUGLAS GETWELLPCP Phone: (201)792-3022

See reverse for dental/vision benefitsDOI -0501

Payer ID:

Rx Bin: 610494Rx Grp: AMNJRx PCN: 4343

NJ FamilyCare AUnderwritten by AmeriChoice of New Jersey, Inc.

000300076 NJFAMCAR

REISSUE ENGLISH 86047

03115 9071674 0000 0000133 0000133 290 5 111 03115 9071674 0000 0000133 0000133 290 5 111

RUN_DATE 20181003 18:26:56DATA_SEQ_NO 0000001CLIENT_NUMBER 003115UHG_TYPE DIG1SHRTDOC_ID DOC_SEQ_ID 0000133NAME ENGLISH ,REISSUEMAILSET_NUMBER 0000133CUSTCSP_KEY1 000300076000300076_KEY0 CARD1CUSTCSP_KEY2 NJFAMCARCUSTCSP_KEY3 REISSUECUSTCSP_KEY4 HCAC/MedicalCUSTCSP_KEY5 00CUSTCSP_KEY6 20051101CUSTCSP_KEY7 000300076~00CARD1CUSTCSP_KEY8 000300076CUSTCSP_KEY9 000300076~00CARD1

Printed: 10/02/18

If you are not sure if your problem is an emergency, call your PCP first. No prior authorization is required for emergencies. To verify benefits or to find a provider, visit the website www.myuhc.com/communityplan or call.

Member Services/Dental\Vision: 1-800-941-4647 TDD/TTY 711

In an emergency go to nearest emergency room or call 911.For Providers: UHCprovider.com 1-888-362-3368Medical Claims: PO Box 5250, Kingston, NY, 12402-5250

Pharmacy Claims: OptumRX, PO Box 29044, Hot Springs, AR 71903For Pharmacists: 1-877-305-8952

Shipper ID: 00000000 Insert #1 Insert #2 Shipping Method: DIRECT Insert #3 Insert #4 CARRIER: USPS Insert #5 Insert #6 Address: Insert #7 Insert #8 REISSUE ENGLISH Insert #9 Insert #10 124 ANY STREET Insert #11 Insert #12 ANYTOWN, NJ 99999-9999

Cycle Date: 20181017PDF Date: Wed Oct 03, 2018 @ 18:26:56MaxMover: Y

Mailing/Meter Date: UHG JOB ID: 8310 GRP: NJFAMCAR PV: 0012 RC: 0015 MKT: 77777MT: 00 SA: 00 OI: 97 FORM: K2H000 CPAY: DALE BROWN: NO LETTER NM: LETTER2 DIVISION : C10 CARD TYPE: CATEMPLATE: NEW FAMILY/IND : STD IND : STANDARD : STANDARD

Health Plan (80840) 911-86047-08Member ID: Group Number: Member:

PCP Name:DOUGLAS GETWELLPCP Phone: (201)792-3022

See reverse for dental/vision benefitsDOI -0501

Payer ID:

Rx Bin: 610494Rx Grp: AMNJRx PCN: 4343

NJ FamilyCare AUnderwritten by AmeriChoice of New Jersey, Inc.

000300076 NJFAMCAR


03115 9071674 0000 0000133 0000133 290 5 111 03115 9071674 0000 0000133 0000133 290 5 111

RUN_DATE 20181003 18:26:56DATA_SEQ_NO 0000001CLIENT_NUMBER 003115UHG_TYPE DIG1SHRTDOC_ID DOC_SEQ_ID 0000133NAME ENGLISH ,REISSUEMAILSET_NUMBER 0000133CUSTCSP_KEY1 000300076000300076_KEY0 CARD1CUSTCSP_KEY2 NJFAMCARCUSTCSP_KEY3 REISSUECUSTCSP_KEY4 HCAC/MedicalCUSTCSP_KEY5 00CUSTCSP_KEY6 20051101CUSTCSP_KEY7 000300076~00CARD1CUSTCSP_KEY8 000300076CUSTCSP_KEY9 000300076~00CARD1

Printed: 10/02/18

If you are not sure if your problem is an emergency, call your PCP first. No prior authorization is required for emergencies. To verify benefits or to find a provider, visit the website www.myuhc.com/communityplan or call.

Member Services/Dental\Vision: 1-800-941-4647 TDD/TTY 711

In an emergency go to nearest emergency room or call 911.For Providers: UHCprovider.com 1-888-362-3368Medical Claims: PO Box 5250, Kingston, NY, 12402-5250

Pharmacy Claims: OptumRX, PO Box 29044, Hot Springs, AR 71903For Pharmacists: 1-877-305-8952


Cycle Date: 20181017PDF Date: Wed Oct 03, 2018 @ 18:26:56MaxMover: Y

Mailing/Meter Date: UHG JOB ID: 8310 GRP: NJFAMCAR PV: 0012 RC: 0015 MKT: 77777MT: 00 SA: 00 OI: 97 FORM: K2H000 CPAY: DALE BROWN: NO LETTER NM: LETTER2 DIVISION : C10 CARD TYPE: CATEMPLATE: NEW FAMILY/IND : STD IND : STANDARD : STANDARD

Chapter 11: Member Information

Member ID CardsUnitedHealthcare issues a member identification (ID) card to each member enrolled in the plan. Even when more than one member of a family enrolls, UnitedHealthcare issues a separate ID card to each family member.

All member ID cards display the UnitedHealthcare logo and the UnitedHealthcare toll-free Member Services number. The member ID card also displays:

• The member‘s Primary Care Provider‘s (PCP‘s) name and telephone number

• The member‘s name and UnitedHealthcare ID number

• Co-payment requirements for members if applicable.

The back of the member ID card has the following information:

• Instructions for members on how to access care

• Instructions for providers on how to verify eligibility and obtain prior authorization

• Mailing address for claims

• Pharmacy Help Desk phone number for pharmacy claim issues

• A statement allowing release of medical information (NJ FamilyCare card only)

The member should present his or her member ID card whenever seeking UnitedHealthcare covered services. See Member ID Cards for Prescription Benefits. No member should be denied services because of failure to have a member ID card at the time of service.

You can call 888-362-3368 to verify eligibility. If you believe that an incorrect PCP name is listed on the member’s ID card, you should call 888-362-3368 to verify the member‘s eligibility and to confirm the PCP‘s name.

UnitedHealthcare NJ FamilyCare and Dual Complete ONE Member ID CardsPLEASE NOTE:Claims AddressP.O. Box 5250Kingston, NY 12402-5250

NJ FamilyCare A



UnitedHealthcare Dual Complete ONE Member ID Card

The UnitedHealthcare Dual Complete ONE member ID card contains both the Medicare and Medicaid IDs. Claims should be submitted using the Medicare ID.

Eligibility InformationThe provider is responsible for checking the member‘s eligibility at the time of service. This includes eligibility with UnitedHealthcare, assignment to you as a PCP, or (ifyou are a specialist), assignment to the PCP who initiated a referral to you.

To verify a member‘s enrollment in UnitedHealthcare and the member‘s PCP, providers can:

• Call 888-DOC-DENT (888-362-3368), or

• Check the current PCP Member Roster for appropriate UnitedHealthcare product

• Check UHCprovider.com to verify member eligibility including secondary coverage

For UnitedHealthcare Dual Complete ONE (Medicare) members, use the member‘s Medicare number to determine eligibility. To verify a member‘s enrollment in NJ FamilyCare, you can call the NJ Hotline at 800-676-6562:

• UnitedHealthcare is identified as – 082II

• NJ FamilyCare members use the Medicaid ID number (CIN)

Note: The NJ Hotline does not have the member’s PCP on file.

PCP SelectionEvery member enrolling in UnitedHealthcare is required to select a participating PCP. Members may change their PCP at any time, although UnitedHealthcare encourages members to select a PCP they intend to remain with for an extended period of time.

If a new member does not select a PCP, UnitedHealthcare will assign the member to a PCP, based on geographic location. The member may change this selection later for any reason.

Except for clients of the Division of Youth and Family Services (DYFS), reselection or reassignment of PCP for any cause may be limited, at UnitedHealthcare‘s discretion, to two times a year, except for reasonable cause.

Member-Initiated TransfersA member may change his or her PCP by calling Member Services number listed on the back of their ID card.

Member requests for PCP changes will become effective immediately. Capitated providers‘ payments will be prorated and paid retroactively based on the day of the month the change occurred.

UnitedHealthcare Dual Complete ONE (Medicare) member requests for PCP changes can be effective within 24 hours. It typically takes one to two weeks for the member to receive a new ID card.

UnitedHealthcare monitors the member transfer rates foreach PCP and PCP site by recording the member‘s reason for requesting the transfer. The Quality Management Department investigates quality-related transfer requests.

Health Plan (80840) 911-86047-08UHC Medicare ID: Group Number: Member:

UHC Medicaid ID:PCP Name:DOUGLAS GETWELLPCP Phone: (973)595-0600

Dental Benefits Included H3113 PBP# 005

Payer ID:

Rx Bin: 610097Rx Grp: MPDACUNJRx PCN: 8500

UnitedHealthcare Dual Complete ONE(HMO SNP)

000300108

999999910420

NJDUALCM


Copay: No Copays

03115 9103974 0000 0000002 0000002 311 4 116 03115 9103974 0000 0000002 0000002 311 4 116

RUN_DATE 20181023 16:15:05DATA_SEQ_NO 0000001CLIENT_NUMBER 003115UHG_TYPE DIG1SHRTDOC_ID DOC_SEQ_ID 0000002NAME ENGLISH ,REISSUEMAILSET_NUMBER 0000002CUSTCSP_KEY1 000300108000300108_KEY0 CARD1CUSTCSP_KEY2 NJDUALCMCUSTCSP_KEY3 REISSUECUSTCSP_KEY4 HCAC/MedicalCUSTCSP_KEY5 00CUSTCSP_KEY6 20120201CUSTCSP_KEY7 000300108~00CARD1CUSTCSP_KEY8 000300108CUSTCSP_KEY9 000300108~00CARD1

In an emergency go to nearest emergency room or call 911. Printed: 10/22/18

Preauthorization not required for emergency careCustomer Service Hours: 8am-8pm: 7 Days Oct-Mar; M-F Apr-SeptFor MembersWebsite: www.UHCCommunityPlan.comFor Customer Service/Dental: 1-800-514-4911 TTY 711

NurseLine: 1-877-440-9407 TTY 711Behavioral Health: 1-800-514-4911 TTY 711Dental: 1-800-514-4911 TTY 711

For Providers: UHCprovider.com 1-888-362-3368For Dental Providers: www.uhcproviders.com 1-800-508-4881Medical Claims: PO Box 5250, Kingston, NY 12402-5250

Pharmacy Claims:OptumRX, PO Box 29045, Hot Springs, AR 71903For Pharmacists: 1-877-889-6510 *Medicare ID must be used to submit Rx claims


Cycle Date: 20181107PDF Date: Tue Oct 23, 2018 @ 16:15:05MaxMover: Y

Mailing/Meter Date: UHG JOB ID: 8370 GRP: NJDUALCM PV: 0012 RC: 0002 MKT: 77777MT: 00 SA: 00 OI: 98 FORM: K2H000 CPAY: DALE BROWN: NO LETTER NM: LETTER2 DIVISION : C20 CARD TYPE: CZTEMPLATE: NEW FAMILY/IND : STD IND : STANDARD : STANDARD

Health Plan (80840) 911-86047-08UHC Medicare ID: Group Number: Member:

UHC Medicaid ID:PCP Name:DOUGLAS GETWELLPCP Phone: (973)595-0600

Dental Benefits Included H3113 PBP# 005

Payer ID:

Rx Bin: 610097Rx Grp: MPDACUNJRx PCN: 8500

UnitedHealthcare Dual Complete ONE(HMO SNP)

000300108

999999910420

NJDUALCM


Copay: No Copays

03115 9103974 0000 0000002 0000002 311 4 116 03115 9103974 0000 0000002 0000002 311 4 116

RUN_DATE 20181023 16:15:05DATA_SEQ_NO 0000001CLIENT_NUMBER 003115UHG_TYPE DIG1SHRTDOC_ID DOC_SEQ_ID 0000002NAME ENGLISH ,REISSUEMAILSET_NUMBER 0000002CUSTCSP_KEY1 000300108000300108_KEY0 CARD1CUSTCSP_KEY2 NJDUALCMCUSTCSP_KEY3 REISSUECUSTCSP_KEY4 HCAC/MedicalCUSTCSP_KEY5 00CUSTCSP_KEY6 20120201CUSTCSP_KEY7 000300108~00CARD1CUSTCSP_KEY8 000300108CUSTCSP_KEY9 000300108~00CARD1

In an emergency go to nearest emergency room or call 911. Printed: 10/22/18

Preauthorization not required for emergency careCustomer Service Hours: 8am-8pm: 7 Days Oct-Mar; M-F Apr-SeptFor MembersWebsite: www.UHCCommunityPlan.comFor Customer Service/Dental: 1-800-514-4911 TTY 711

NurseLine: 1-877-440-9407 TTY 711Behavioral Health: 1-800-514-4911 TTY 711Dental: 1-800-514-4911 TTY 711

For Providers: UHCprovider.com 1-888-362-3368For Dental Providers: www.uhcproviders.com 1-800-508-4881Medical Claims: PO Box 5250, Kingston, NY 12402-5250

Pharmacy Claims:OptumRX, PO Box 29045, Hot Springs, AR 71903For Pharmacists: 1-877-889-6510 *Medicare ID must be used to submit Rx claims


Cycle Date: 20181107

PDF Date: Tue Oct 23, 2018 @ 16:15:05

MaxMover: Y

Mailing/Meter Date: UHG JOB ID: 8370 GRP: NJDUALCM PV: 0012 RC: 0002 MKT: 77777MT: 00 SA: 00 OI: 98 FORM: K2H000 CPAY:

DALE BROWN: NO LETTER NM: LETTER2 DIVISION : C20 CARD TYPE: CZ

TEMPLATE: NEW FAMILY/IND : STD IND : STANDARD : STANDARD



pertinent member information. This report may not match the PCP member roster exactly because the capitation reportand the member roster are produced on different days. If the member appears on the monthly roster, UnitedHealthcare expects the provider to render services to the member, even if the member is not on the capitation report.

Member’s Cultural and Linguistic NeedsUnitedHealthcare offers providers tools to support the member‘s cultural and linguistic needs. Tools available to the provider include:

• Call 771 for TDD/TTY services

• 24-hour interpreter access through telephone language services

• Professional interpreters when needed

• List of agencies / interpreters that are available to provide interpreter services

• The care provider must provide documentation when these services are required.

Cultural Competency To learn more about the understanding, appreciation, acceptance of and respect for cultural differences and similarities within, among and between groups and the sensitivity to how these differences influence relationships with enrollees, visit UHCProvider.com > Menu > Health Plans by State > Choose Your State: New Jersey > Go to UHCCommunityPlan.com > Cultural Competency Library.

Member Rights and ResponsibilitiesUnitedHealthcare members have certain rights and responsibilities concerning their health care. Regardless of a patient’s illness or medical treatment, they cannot be refused treatment. A PCP may refer a patient to a specialist for treatment that he or she cannot provide.

Members have the right to:

1. Be treated with respect, dignity and privacy by UnitedHealthcare and its providers.

2. Be told about any illness they have.

3. Be told of any care or treatment that their PCP feels should be done before anything is done, even if


PCP-Initiated TransfersA PCP may wish to transfer a member due to an inability to establish or maintain a professional relationship. To initiate a transfer of the member, the PCP must send a request in writing to the Medical Director identifying the member and describing the circumstances supporting the request. The request should not be made unless interventions have been attempted and documented. These interventions should include contact between the PCP‘s office and UnitedHealthcare to provide education to the member concerning his/her rights and responsibilities.

A PCP may not request a change because of the patient‘s physical condition, degree of illness, or amount of services required, unless the PCP can justify that he or she is unable to deliver quality care to the member. If the Medical Directorapproves the transfer, the PCP is obligated to provide services to the member for 30 days beginning with the date of the letter. For more information, providers should contact their provider relations representative.

UnitedHealthcare trends PCP-initiated transfer requests to help ensure that PCPs are not inappropriately removing patients from their panels. UnitedHealthcare will notify the member about the transfer.

PCP Member RosterUnitedHealthcare sends PCP member rosters to PCPs each month. The roster lists both the UnitedHealthcare Medicaid members and the UnitedHealthcare Dual Complete ONE members in the PCP‘s panel. The roster includes the member’s name, UnitedHealthcare member ID number, address, phone number, date of birth, gender, the date of enrollment and a 4-digit rate code associated with the member‘s category(e.g., 0142 = AFDC Male 2–20 years, 0711 = SSI Aged with Medicare). In addition, it identifies the member’s line of business as either: C10, which is UnitedHealthcare Medicaid or C20, which is UnitedHealthcare Dual Complete ONE. At the end of the roster is a statistical summary profiling the PCP‘s members by line of business.

Capitation ReportUnitedHealthcare sends a capitation report to PCPs with the monthly capitation checks. It contains the list of members on the PCP‘s panel, the capitation amount per member and other



UnitedHealthcare does not cover it. This includes the right to get accurate, easy to understand information to help patients make good choices about their treatment.

4. Refuse treatment as far as the law allows and to knowwhat the outcome may be.

5. Expect doctors to keep patient records and anythingsaid private. No information will be released to anyonewithout the patient’s consent, unless required by law.

6. Request a current directory of providers in theUnitedHealthcare network to choose their own PCP.

7. Get needed medical services within a reasonable lengthof time.

8. Make a grievance or an appeal to UnitedHealthcare andto get a reply in a timely manner.

9. Receive information about UnitedHealthcare, itsservices, its practitioners and providers, memberrights and responsibilities, and to be informed ofUnitedHealthcare rules and any changes that are made.

10. Make suggestions regarding UnitedHealthcare policiesand procedures, including their rights and responsibilitiesand the member rights and responsibilities policy.

11. Talk about medical records with their PCP and get acomplete copy of those records.

12. Be informed of all FFS benefits the patient is eligiblefor and of all medical services made available byUnitedHealthcare.

13. Have an authorized representative of their choice tomake medical determinations for them.

14. Ask for a second opinion about any medical care that thepatient’s PCP advises them to have.

15. Know how UnitedHealthcare decides whether a serviceis covered and/or is medically necessary.

16. A translator, if needed, when they talk to us or one of ourproviders.

17. Participate in all decisions about their health care andthe development of any plan of care designed for them.

18. Speak to providers in private and have their medicalrecords kept private.

19. Be free from harm, including unnecessary physicalrestraints or isolation, excessive medication, physical ormental abuse or neglect.

20. Be free of hazardous procedures.

21. Be free from balance billing.

22. Have services provided that promote a meaningfulquality of life and independence, including living in theirown home or another community setting as long as itis medically and socially feasible, and the right to thepreservation and support of their natural support system.

23. Obtain information about our providers that includesthe provider’s education, residency completed, boardcertification and recertification. To get this information,members can call our Member Services Department at800-941-4647, TTY: 711.

Additional rights for MLTSS members:

1. To request and receive information on choice of servicesavailable;

2. Have access to and choice of qualified service providers;

3. Be informed of their rights prior to receiving chosen andapproved services;

4. Receive services without regard to race, religion, color,creed, gender, national origin, political beliefs, sexualorientation, marital status, or disability;

5. Have access to appropriate services that support theirhealth and welfare;

6. To assume risk after being fully informed and able tounderstand the risks and consequences of the decisionsmade;

7. To make decisions concerning their care needs;

8. Participate in the development of and changes to theirPlan of Care;

9. Request changes in services at any time, including add,increase, decrease or discontinue;

10. Request and receive from their Care Manager a list ofnames and duties of any person(s) assigned to provideservices under their Plan of Care;

11. Receive support and direction from their Care Managerto resolve concerns about their care needs and/orgrievances about services or providers;

12. Be informed of and receive in writing facility specificresident rights upon admission to an institutional orresidential settings;

13. Be informed of all the covered/required services themember is entitled to, required by and/or offered by theinstitutional or residential setting, and any charges notcovered by the managed care plan while in the facility;



14. Not to be transferred or discharged out of a facility except for medical necessity; to protect their physical welfare and safety or the welfare and safety of other residents; or because of failure, after reasonable and appropriate notice of non-payment to the facility from available income as reported on the statement of available income for FFS payment.

15. Have their health plan protect and promote their ability to exercise all rights identified in this document.

16. Have all rights and responsibilities outlined here forwarded to their authorized representative or court appointed legal guardian.

Members have the responsibility to:

• supply information that the organization or practitioners need in order to provide care.

• follow plans and instructions for care that you have agreed to with your practitioner.

• understand your health problems and participate in developing mutually agreed upon treatment goals.

NJ FamilyCare: New Jersey HMO Consumer Bill of RightsIn addition to the rights members have as part of UnitedHealthcare that are explained on the previous page, they have some other rights as a member of a health plan in New Jersey.

Members additionally have the right to:

• obtain a current directory of doctors in the UnitedHealthcare network.

• have a choice of specialists following a referral.

• be referred to specialists who are experienced in treating disabilities if the member has a chronic disability.

• have access to a primary care provider or a back-up 24 hours a day, 365 days a year.

• call 911 in a potentially life-threatening situation without prior approval from UnitedHealthcare.

• coverage of certain preventive care, including childhood immunizations, lead screening, certain cancer screening, testing for glaucoma, cholesterol and blood glucose levels.

• change PCPs without having to wait more than two weeks.

• sue UnitedHealthcare for losses if you or a covered family member sustains serious injury or death that you believe is the result of a denial or delay of approval of medically necessary covered services.

• have UnitedHealthcare pay for your medical screening exam in the emergency room to determine if an emergency medical condition exists.

• have the right to receive up to one year and no less than four months (depending on your condition) of continued coverage—if it is medically necessary—from a doctor who has been terminated by UnitedHealthcare. In the cases of pregnancy, the time frame is up to six weeks after delivery. Coverage will not be continued if UnitedHealthcare‘s Medical Director judges that the doctor would be a danger to your health, safety and welfare, or if the doctor committed fraud or breach of contract or is the subject of disciplinary action by the State Board of Medical Examiners.

• have a doctor make the decision to deny or limit your coverage.

• know gag rules. Your doctors are free to discuss all medical treatment options, even if they are not covered services.

• know how UnitedHealthcare pays providers so you know if there are any financial incentive or disincentives tied to medical decisions.

• appeal a decision to deny or limit coverage, first with UnitedHealthcare and then through a independent organization for a filing fee

• know that you or your doctor cannot be penalized for filing a grievance or appeal.

• be notified of any changes in benefits, services, or our provider network.

• not to be charged any doctors fees above/beyond what UnitedHealthcare or FFS pays the provider.

• receive an explanation, in terms you can understand, of your complete medical condition from any of your providers.

• choose a PCP within the limits of the covered benefits.

• be provided with information about UnitedHealthcare’s policies and procedures, rights and responsibilities, products, services, providers and appeal procedures.

• file a grievance or an appeal to us or the State Department of Banking and Insurance or the Division



of Medical Assistance and Health Services. You have the right to receive an answer to those grievances within a reasonable period of time. Those who have NJ FamilyCare A and NJ FamilyCare ABP have a right to the Medicaid Fair Hearing process.

UnitedHealthcare Dual Complete ONE Member Rights and ResponsibilitiesDual Complete ONE members have similar rights and responsibilities. Below is the list of CMS approved Rights & Responsibilities for the Dual Complete ONE plan.

Dual Complete ONE members have the right to:

• receive information about the organization, its services, its practitioners and providers and member rights and responsibilities. We must provide information in a way that works for the member (in languages other than English, in Braille, in large print, or other alternate formats etc.)

• be treated with respect and recognition of their dignity and right to privacy. We must treat them with fairness and respect at all times

• timely access to their covered services and drugs

• protection of the privacy of their personal health information

• to ask to restrict uses or disclosures of their information for treatment, payment, or health care operations. Members also have the right to ask to restrict disclosures to family members or to others who are involved in health care or payment for health care.

• get information about their coverage and costs as a member of UnitedHealthcare that is easy to understand. This includes getting information about which medical services are covered and not covered by UnitedHealthcare Dual Complete, what the member must pay, and what to do if they have a concern or grievance.

• ask to receive confidential communications of information in a different manner or at a different place (for example, by sending information to a P.O. Box instead of home address).

• to file a complaint (called a grievance) about the quality of care they receive, waiting times at the doctor‘s office and the physical conditions of the doctor‘s office. Members also have the right to complain about getting medical care or payment for care they have received

(called a request for reconsideration or appeal). Members have the right to have us be fair in examining and addressing all grievances, and to not discriminate against them if they complain. You have the right to get information about the grievances and appeals that members have filed against UnitedHealthcare.

• see and obtain a copy of certain health information we maintain about the member such as claims and case or medical management records.

• get medical services, including timely access to plan providers and all services covered by UnitedHealthcare Dual Complete ONE.

• choose a qualified provider who is part of UnitedHealthcare Dual Complete ONE timely access to their Primary Care Provider (PCP) and referrals to specialists when medically necessary

• get emergency care when and where they need it. We will pay for emergency services without giving our approval in advance if the member, acting as a prudent person believes that he/she has a medical condition that requires emergency treatment.

• receive urgently needed services when traveling outside of the UnitedHealthcare Dual Complete ONE service area. Also, while the member is inside the service area, he/she has the right to receive urgently needed care from providers who are not part of UnitedHealthcare Dual Complete ONE if unusual circumstances keep him/her from getting care from their PCP or other plan provider.

• ask to amend certain health information we maintain about the member such as claims and case or medical management records, if the member believes the health information about him/her is wrong or incomplete.

• receive an accounting of certain disclosures of their information made by us during the six years prior to their request.

• receive information about the plan, its network of providers, and covered services.

• participate with practitioners in making decisions about health care. We must support the member’s right to make decisions about his/her care and a candid discussion of appropriate or medically necessary treatment options for his/her conditions, regardless of cost or benefit coverage.



• know their treatment options and participate in decisions about their health care.

• get full information from their doctors and other health care providers when they go for medical care.

• participate fully in decisions about their health care;

– know about all choices

– know about the risks

– the right to say “no.”

– receive an explanation if denied coverage for care

• give instructions about what is to be done if the member is not able to make medical decisions for him/herself

– give someone the legal authority to make medical decisions if he/she ever becomes unable to make decisions

– give doctors written instructions about how he/she wants them to handle the member’s medical care if he/she becomes unable to make decisions

• voice grievances or appeals about the organization or the care it provides.

• make grievances and to ask us to reconsider decisions we have made.

• get a summary of information about the appeals and grievances that other members have filed against our plan in the past.

• be treated fairly, whether asking for a coverage decision, making an appeal, or making a grievance.

• a paper copy of this notice (Explanation of Benefits).

Dual Complete ONE members have the responsibility to:

• get familiar with covered services and the rules they must follow to get these covered services

• tell us if they have any other health insurance coverage or prescription drug coverage in addition to our plan

• tell their doctor and other health care providers that they are enrolled in our plan

• help their doctors and other providers help them by giving them information, asking questions and following through on their care.

– learn as much as they are able to about their health problems and give their doctors the information they need about them and their health.

– make sure their doctors know all of the drugs they are

taking, including over-the-counter drugs, vitamins, and supplements.

– be sure to ask, if they have any questions,.

• be considerate.

– respect the rights of other patients

– act in a way that helps the smooth running of their doctor’s office, hospitals, and other offices

• pay what they owe.

– pay the full cost, if they get any medical services or drugs that are not covered by our plan or by other insurance they may have

– make an appeal if they disagree with our decision to deny coverage for a service or drug

• tell us if they move

• call Customer Service for help if they have questions or concerns.

For a complete details of the Dual Complete ONE member Rights & Responsibilities, see Chapter 7 of the Evidence of Coverage located here.

NJ FamilyCare Enrollee Grievance Process(FOR UM APPEALS, REFER TO CHAPTER 16)

Grievance – any complaint that is submitted in writing or that is orally communicated.

Members are advised of their rights regarding the appeal & grievance process during the New Member Orientation process and are also advised on how they can contact UnitedHealthcare to file a grievance. This information is included in the Member Handbook. A grievance is a problem that cannot be resolved immediately to the member’s satisfaction. The member, or care provider acting on the member’s behalf and with the member’s consent, may file a grievance in writing or orally through the UnitedHealthcare Customer Service Center. No member/care provider will ever be penalized for filing a grievance with UnitedHealthcare and members who need assistance with the UnitedHealthcare grievance process can be referred to the State’s Health Benefits Coordinator.




Member grievances are immediately logged into an electronic tracking system for monitoring purposes. At the time of initial contact, members are informed that information related to their grievance is confidential and will be safeguarded from inappropriate public disclosure.

After five business days, the member will receive a letter acknowledging the grievance in the member‘s primary language.

UnitedHealthcare will look into the member’s grievance and respond in writing within 30 calendar days. If UnitedHealthcare‘s response is not satisfactory to the member, the member has the right to file an appeal, within 90 days of the date of the denial letter, by contacting the Member Service Center at 800-941-4647 or TTY/TDD at 711 and a Customer Service Representative will provide the member with information necessary to file an appeal. If the member has additional information that is pertinent to the case, the member may present that information with the appeal.

NJ FamilyCare A enrollees or ABP who are not satisfied with UnitedHealthcare‘s decision may access the State‘s Medicaid Fair Hearing process. Contact the UnitedHealthcare Customer Service Center to determine if the member is entitled to access this process. Eligible members must ask for a Medicaid Fair Hearing with the New Jersey Department of Human Services, Division of Medical Assistance and Health Services by writing to the following address within 20 calendar days of the date of the grievance decision letter:

Fair Hearing SectionDivision of Medical Assistance and Health ServicesP.O. Box 712Trenton, NJ 08625-0712

If the member‘s grievance is about a medical issue, a Medical Director or Physician will make the decision on the matter.

UnitedHealthcare Dual Complete ONE – SNP Member Grievance/Appeal Process(FOR UM APPEALS, REFER TO CHAPTER 16)

Appeal – a type of complaint made when requesting UnitedHealthcare to reconsider or change a decision made about what services are covered for the member or what will be paid for a service.

Grievance – a type of complaint made about UnitedHealthcare or one of the UnitedHealthcare providers including a complaint about quality of care.

A grievance may be filed orally through communication with the UnitedHealthcare Customer Service Center orUnitedHealthcare staff or in writing to UnitedHealthcare or any government agency. All verbal grievances will be documented.

The Appeals and Grievances Coordinator will: review the grievance for appropriate classification; log it within 24 hours of receipt; initiate a hard copy file; send out an acknowledgment letter within five business days of receipt; route the grievance to other departments for investigation, if necessary; resolve the issues; and send out the resolution letter within 30 calendar days of case completion.

If the case involves a determination by UnitedHealthcare to deny payment or the provision of a health care service and the member believes that UnitedHealthcare should pay for or provide the services, the issue is classified as an appeal.

If the issue is identified as an appeal, the Appeals and Grievances Coordinator will: review the appeal for appropriate classification; determine if authorized representative written statement is needed; log it within 24 hours of receipt; initiate a hard copy file; send out an acknowledgment letter within five business days of receipt; route the appeal to other departments for investigation, if necessary; resolve the issues; and send out the resolution letter within 30 calendar days of case completion.

Clinical issues and claims appeals will be handled by the Medical Director and the Claims department as appropriate.The member may seek an expedited appeal in which the member is notified of UnitedHealthcare‘s decision within 72 hours. The member is informed of the decision by telephone as soon as possible and within two business days of verbal notification, a written notification is sent. Throughout the grievance and appeal process, the member may request an extension of up to 14 calendar days or if UnitedHealthcare finds that additional information is necessary and the delay is in the interest of the member (i.e., to perform further diagnostic tests or obtain the opinion of a specialist).No member/provider will ever be penalized for filing a grievance/appeal with UnitedHealthcare. Member grievances/ appeals are immediately logged into an electronic tracking system for monitoring purposes. At the time of initial contact, members are informed that information related to their



grievance/appeal is confidential and will be safeguarded from inappropriate public disclosure.

UnitedHealthcare treats all grievances confidentially and will maintain complete records of all grievances and theirresolutions. Forms and instructions will be made available for special needs members who require the grievance form in other languages.

UnitedHealthcare Dual Complete ONE is specifically targeted to those individuals who have both Medicaid and Medicare. These members who‘ve chosen both UnitedHealthcare plans are considered to be dually enrolled. This means that they may also utilize the Medicaid grievance process to address problems that they may have experienced with the Medicaid program.

A grievance is a problem that cannot be resolved immediately to the member’s satisfaction. The member or provider acting on the member’s behalf and with the member’s consent may file a grievance in writing or orally through the UnitedHealthcare Customer Service Center. No member/provider will ever be penalized for filing a grievance with UnitedHealthcare and members who need assistance with the UnitedHealthcare grievance process can be referred to the State’s Health Benefits Coordinator.

Member grievances are immediately logged into an electronic tracking system for monitoring purposes. At the time of initial contact, members are informed that information related to their grievance is confidential and will be safeguarded from inappropriate public disclosure.

After five business days, the member will receive a letter acknowledging the grievance in the member‘s primary language.UnitedHealthcare will look into the member’s grievance and respond in writing within 30 calendar days. If UnitedHealthcare‘s response is not satisfactory to the member, the member has the right to file an appeal, within 90 days of the date of the grievance decision letter, by contacting the Member Service Center at 800-941-4647 or TTY/TDD at 711 for NJ FamilyCare or UnitedHealthcare Dual Complete ONE at 800-514-4911and a Customer Service Representative will provide the member with documentation necessary to file an appeal.

If the member has additional information that is pertinent to the case, the member may present that information with the appeal. The member will receive an acknowledgment letter within 10 business days and a determination letter within 20 calendar days.

NJ FamilyCare A enrollees and ABP who are not satisfied with UnitedHealthcare‘s decision may access the State‘s Medicaid Fair Hearing process. (Contact the UnitedHealthcare Customer Service Center to determine if the member is entitled to access this process). Eligible members must ask for a Medicaid Fair Hearing with the New Jersey Department of Human Services, Division of Medical Assistance and Health Services by writing to the following address within 20 calendar days of the date of the grievance decision:


If the member‘s grievance is about a medical issue, a Medical Director or Physician will make the decision on the matter.

Continuity of CareUpon termination by provider or UnitedHealthcare of the provider agreement for any reason, other than UnitedHealthcare‘s insolvency, the healthcare provider shall continue to furnish covered services to members and UnitedHealthcare shall continue to compensate provider in accordance with the provisions of the provider agreement. The determination as to the medical necessity of a member‘s continued treatment with a dental provider shall be subject to review. UnitedHealthcare shall not be required to continue coverage by any healthcare provider if the reason for termination was: (i) that provider is an imminent danger to members or public health, safety, and welfare; (ii) adetermination of fraud; or (iii) provider is subject to disciplinary action by the State Board of Medical Examiners.



Chapter 12: Participating Provider Responsibilities

General RequirementsIn contracting with UnitedHealthcare, all providers (physicians, other health professionals, hospitals, facilities, and agencies) agree to:

• The provider/practitioner will not restrict the number of office hours that they offer members. The hours of operation offered to UnitedHealthcare Community Plan members may not be less than those offered to commercial members.

• NEVER bill or balance bill UnitedHealthcare members for covered services. Sending bills or balance bills to UnitedHealthcare members for covered services is a violation of your Participating Provider Agreement with UnitedHealthcare and violates New Jersey law and regulation. Instruct office staff to ask for appropriate documentation of a patient’s insurance coverage and accurately maintain this information in all billing systems.

• Not discriminate against an enrollee or attempt to disenroll for filing a complaint or grievance/appeal against the Health Plan.

If your office has not received payment for covered services provided to an UnitedHealthcare member, call 888-DOC-DENT (888-362-3368).

• Advise patients of services not covered by their UnitedHealthcare plan and their financial obligation for those services prior to rendering the service.

• Collect copayments as indicated on the member’s card for NJ FamilyCare Plan C and D members.

• Bill other insurance carriers which are primary for NJ FamilyCare prior to billing UnitedHealthcare.

• Offer access to office visits on a timely basis, in conformance with the standards outlined in Chapter 11 Timeliness Standards for Appointment Scheduling.

• Maintain medical records according to UnitedHealthcare Medical Records Documentation Standards contained in this manual and maintain patient confidentiality.

• Maintain all licenses and certifications required to practice and render services without any encumbrances, limitations, or restrictions and provide copies of such licenses and certifications to UnitedHealthcare for

verification and (re)credentialing purposes.

• Transfer medical records upon request. Copies of members‘ medical records must be provided to members upon request at no charge.

• Provide covered benefits in a manner consistent with professionally recognized standards of health care and in accordance with standards established by UnitedHealthcare.

• Respect the rights of UnitedHealthcare members, including honoring enrollees’ beliefs, sensitivity to cultural diversity, and fostering respect for enrollee cultural background.

• Notify UnitedHealthcare of any change in office location, office hours, or additional office location at least 30 days prior to the date when services will be rendered at the new location(s). This change may generate a new provider ID number to be used when billing for a new site.

• Notify UnitedHealthcare promptly of any changes in the information originally submitted in the application to participate in UnitedHealthcare.

• Submit to UnitedHealthcare all data necessary to characterize the content and purpose of each member encounter. The submission of a claim or encounter information by a provider is the provider’s certification that the data are accurate, complete, and truthful.

• Never employ or contract with individuals who are excluded from participation in any federal health care program or with entities that employ or contract with such individuals.

• Health care providers are required by law to keep information about their patients private and confidential.

Conduct criminal background checks of all employees and/ or agents who provide direct care to enrollees as required by federal and State law.

• Help ensure that all individuals and entities the provider hires or contracts with to provide services to UnitedHealthcare Dual Complete ONE members comply with Medicare regulations and requirements.

• Upon discharge from an inpatient hospitalization, the hospital staff will give Medicare members the Notice


of Discharge and Medicare Appeal Rights (NODMAR) letter. The hospital must also send a copy of the signed NODMAR to UnitedHealthcare Dual Complete ONE.

• Comply with:

– Title VI of the Civil Rights Act of 1964, as implemented by regulations at 45 C.F.R. Part 84

– The Age Discrimination Act of 1975, as implemented by regulations at 45 C.F.R. Part 91

– The Rehabilitation Act of 1973

– The Americans with Disabilities Act

– The informed consent procedures for Hysterectomy and Sterilization specified in 42 CFR, Par 441, sub-part F, and 18 NYCRR Section 505.13.

– Copies of the consent forms are located in this manual.

– Other laws applicable to recipients of federal funds

– Standards set forth by the UnitedHealthcare Compliance program

– All other applicable laws and rules

– Critical Incident Reporting in accordance with applicable requirements

• Cooperate with and participate in UnitedHealthcare Quality Management and Utilization

• Management Programs.

• Compliance with Critical Incident Reporting

Provider Office StandardUnitedHealthcare requires a clean and structurally sound office that meets applicable Occupational Safety and Health Administration (OSHA) and Americans with Disabilities (ADA) standards.

Provider Relations Representatives conduct periodic site visits to help ensure that each PCP office meets ADA standards.

If a PCP is planning to relocate an office, a Provider Relations Representative must perform a site visit before care can be rendered at the new location.

Timeliness Standards for Appointment SchedulingProviders shall comply with the following appointment availability standards:

Emergency CareImmediately upon the member‘s presentation at a service delivery site

Primary CarePCPs and providers of primary care should arrange appointments for:

• Urgent care within 24 hours of request

• Non-urgent ―sick visit within 72 hours of request, as clinically indicated

• Routine care within 28 days of request

• Preventive care within four weeks of request

• Initial office visit for ABD elderly and disabled enrollees shall be contacted within 45 days of enrollment and offered an appointment according to the needs of the enrollee

• Initial office visit for an enrollee identified with special needs shall be contacted within 10 days of enrollment and offered an expedited appointment.

• Well child care within three months of enrollment

• Baseline physicals for new adult enrollees within 180 days of enrollment

• Baseline physicals for new children enrollees within 90 days of enrollment

• Baseline physicals for adult clients of DDD within 90 days of enrollment

• Routine physicals for school, sports, camp or work within four weeks of request

Specialty CareSpecialists and specialty clinics should arrange appointments for:


• Non-urgent care within four weeks of request, as clinically indicated



Behavioral Health (Mental Health and Substance Use)Behavioral and MLTSS health providers should arrange appointments for DDD members for:

• Emergency care (dangerous to self or others) immediately upon presentation

• Urgent problems within 24 hours of member‘s request

• Non-urgent problems within 10 days of member‘s request

Prenatal and Postpartum CareProviders of prenatal care should arrange appointments for the initial prenatal visit:

• Positive pregnancy test – within three weeks of request

• Identification of high risk – within three days of identification of high risk

• First or second trimester – within seven days of request

• Third trimester – within three days of request

• Postpartum – between 21–56 days after delivery Dental CareDental providers should arrange appointments for:

• Emergency treatment – no later than 48 hours, or earlier as condition warrants

• Urgent care within three days of request

• Elective or routine care within 30 days of request

• The provider shall establish and maintain policies and procedures for emergency dental services for all enrollees.

• Within the provider‘s Enrollment/Service Area, the provider will help ensure that:

– Members shall have access to emergency dental services on a (24) hour, seven day a week basis.

– The provider shall bear full responsibility for the provision of emergency dental services, and shall assure the availability of a back-up provider in the event that an on-call provider is unavailable.

• Outside the provider’s service area, the care provider shall ensure that:

– Members shall be able to seek emergency dental services from any licensed dental provider without the need for prior authorization from the provider while outside the Service Area (including out-of-state services covered by the Medicaid program).

Lab and RadiologyProviders should arrange appointments for:

• Routine appointments within three weeks of request


Random Surveys for Appointment SchedulingOn quarterly bases, providers are chosen at random to be surveyed for the access standards that are required by all providers. The provider office is called and the surveyor asks the front desk personnel questions in relation to the access standards. The surveyors do identify themselves as a “surveyor” that is contracted by the Health Plan. Questions are asked from the view of the member.

This information should be shared with the office staff so they are aware and prepared to answer the questions correctly.

The following are samples of the questions that are asked at the time of the survey:

PCP Adult:

• Urgent symptoms e.g. high fever presented to be seen within 24 hours

• Non urgent symptoms e.g. back hurting to be seen within 72 hours.

• Appointment for a physical to be seen within 28 days.

• New member appointment within 180 calendar days.

• Disabled/special needs member within 90 calendar days.

• General complaints e.g. allergies, joint stiffness for routine care within 28 days.

PCP Pediatrics:

• Urgent symptoms e.g. ear pain and high fever to be seen within 24 hours.

• Non urgent symptoms e.g. back hurting to be seen within 72 hours.

• Appointment for a physical to be seen within 28 days.

• New member appointment within 90 calendar days.

• Disabled/special needs member within 90 calendar days.

• General complaints e.g. allergies, joint stiffness for routine care within 28 days.



Ob/Gyn:

• Established patient with positive pregnancy test to be seen within 3 weeks.

• 6 months pregnant to be seen within 7 calendar days.

• Established patient 8 months pregnant to be seen within 3 calendar days.

• New patient 8 months pregnant to be seen within 3 calendar days.

• Seen by another Ob-Gyn provider and is 8 months pregnant to be seen within 3 calendar days.

• Established patient and is 5 months pregnant with light spotting/no pain to be seen within 3 calendar days.

Specialist Providers:

• Urgent referral within 24 hours.

• Consult referral from PCP within 4 weeks.

Dental Providers:

• Minor tooth symptom to be seen within 3 calendar days.

• Severe tooth pain to be seen within 48 hours.

• Routine checkup to be seen within 30 calendar days.

After Hours:

• Pediatric and Adult PCPs, Ob-Gyn and Dental providers are called in the evening separate from the above access questions to determine if office is following after hour standards.

Providers surveyed are notified if they fail the survey and are expected to develop an action plan to remedy the standards. Providers are then re-surveyed within 90 days after notification.

Allowable Office Waiting TimesMembers with appointments should not be made to wait longer than 45 minutes. The maximum number of intermediate/limited patient encounters should be four per hour.

Compliance with American Disabilities Act (ADA)What is a Disability According to the ADA?The ADA has created opportunities to ensure that persons with a disability are provided access. The ADA defines disability as:

• a physical or mental impairment that substantially limits a major life activity, such as walking, seeing, hearing, learning, breathing, caring for oneself or working.

The ADA protects three classes of people with disabilities:

a. Those who have a disability;

b. Those who have a record of having a disability; and

c. Those who are regarded as having a disability, whether or not they actually have one, if they are being perceived as having one results in discrimination.

The Supreme Court has held that a disability should be considered in its corrected state; thus, if vision can be corrected with glasses, it is at that point it would be evaluated.

What can be done to accommodate the requirements of ADA?Here are some things that can be evaluated and corrected:

• Grading; parking lots; walkways; ramps; entrances; doors and doorways; stairs; floors; rest rooms; water fountains and elevators. These items should be looked at from the viewpoint of the blind, hearing impaired, persons who use canes, walkers or wheelchairs.

• Access to areas where services are provided; public restrooms access; entrance access and other areas is required. Rooms should be spacious to accommodate a wheelchair or walker.

• Doorways, hallways and restrooms also need to be wider. Ideally, doorways will be 3 feet wide. Items that may impact the pathway of the blind, cane, walker or wheelchair user should not be kept in the hallways.

• Restrooms should include light switches that are within the reach of a wheelchair user, usually 28-31 inches high. Minimum restroom size before fixtures is 10x10, grab bar should be near the toilet and wheelchair user should be able to roll under the wash bin. Single level water faucet controls are easier for someone who has arm weakness or a higher level of paralysis.

• Ramps should be designed to be 42 inches in width, with a minimum of 5x5 turning radius at the platform. The grade of the ramp should be one foot long for each one inch of height to be reached.

• Vinyl, wood or tightly woven carpet, with no foam layer underneath, flooring make it easier for the wheelchair user.



What are the Benefits?This is a win-win for you and our member, your patient. It makes access available to a member to attain medical care. It sets a tone for you and your office to the disabled community, and there are tax credits and deductions available under the IRS code (see sections 44 and 190) for removal of barriers in accordance to ADA requirements.

Useful Website: adachecklist.org

Medical Record Documentation StandardsAll participating medical, dental, behavioral and MLTSS UnitedHealthcare practitioners are required to maintain medical records in a complete and orderly fashion which promotes efficient and quality patient care. Participating practitioners are subject to UnitedHealthcare‘s periodic quality review of medical and service records to determine compliance to the following medical record keeping requirements.

Confidentiality of RecordsOffice policies and procedures exist for the following

• Confidentiality of the patient medical record

• Initial and periodic training of office staff concerning medical record confidentiality

• Release of information

• Provider transfers to ensure medical records are transferred in timely and confidential manner

• Record retention

• Availability of medical record when housed in a different office location (as applicable)

Record OrganizationAn office policy exists that addresses a process to respond to and provide medical records upon request of patients to include a provision to provide copies.

Medical records are maintained in a current, detailed, organized and comprehensive manner. Organization should include evidence of:

• Identifiable order to the chart assembly

• Papers are fastened in the chart

• Each patient has a separate medical record

Medical records are:

• Filed in a manner for easy retrieval

• Readily available to the treating practitioner where the member generally receives care

Medical records are:

• Stored in a manner that ensures protection of confidentiality

• Released only to entities as designated consistent with federal requirements.

• Kept in a secure area accessible only to authorized personnel

Procedural Elements• Medical records are legible*

• All entries are identified as to author and date

• Patient name/identification number is located on each page the record or electronic file is in

• Linguistic or cultural needs are documented

• Medical records contain demographic data that includes name, identification numbers, date of birth, gender, address, phone number(s), employer, contact information, marital status and an indication whether the patient‘s first language is something other than English

• Mechanism for monitoring and handling missed appointments is evident

• Adults 18 years and older, emancipated minors and minors with children are asked about their Advanced Directive status and are given information regarding advance directives.

• Informed consents for hysterectomy and sterilization

• A problem list includes a list of all significant illnesses and active medical conditions

• A medication list includes prescribed and over the counter medications and is reviewed annually

• Documentation of the presence or absence of allergies or adverse reactions is clearly documented

HistoryAn initial history (for patients seen three or more times) and physical is present to include:

• Medical and surgical history


https://www.adachecklist.org/doc/fullchecklist/ada-checklist.pdf


• A family history that minimally includes pertinent medical history of parents and/or siblings

• A social history that minimally includes pertinent information such as occupation, living situations, education, smoking, ETOH, and/or substance use/ history beginning at age 12

• Current and history of immunizations of children, adolescents and adults or documentation of member refusal

Screenings of/for:

• Recommended preventive health screenings/tests including dental care and family planning services (notation of the discussion and referral when appropriate, patients 18 and older and emancipated minors).

• Depression

• High-risk behaviors such as drug, alcohol and tobacco use; and if present, advise to quit

• Medicare patients for functional and cognitive status assessment and pain

• Adolescents on depression, substance use, tobacco use, sexual activity, exercise and nutrition and counseling as appropriate

Problem Evaluation and ManagementDocumentation for each visit includes:

• Appropriate vital signs (Measurement of height, weight, and BMI annually)

• Chief complaint

• Physical assessment

• Diagnosis

• Treatment planTracking and referral of age and gender appropriate preventive health services consistent with Preventive Health Guidelines

Documentation of all elements of age appropriate federal Early, Periodic, Screening, Diagnosis and Treatment (EPSDT)

Clinical decisions and safety support tools are in place to help ensure evidence based care, such as flow sheet

Treatment plans are consistent with evidence-based care and with findings/diagnosis

• Timeframe for follow-up visit as appropriate

• Appropriate use of referrals/consults, studies, tests

X-rays, labs consultation reports are included in the medical record with evidence of practitioner review

There is evidence of practitioner follow-up of abnormal resultsUnresolved issues from a previous visit are followed up on the subsequent visit There is evidence of continuity and coordination of care between primary and secondary practitioners including behavior health providers

Education, including lifestyle counseling is documented

Patient input and/or understanding of treatment plan and options is documented

Copies of hospital discharge summaries, home health care reports, emergency room care, physical or other therapies, as ordered by the practitioner are documented.

Medical Record Documentation ReviewThe following chart is used annually by UnitedHealthcare Community Plan during provider audit visits to review samples of medical records from provider offices. It is included for reference purposes only to help you and your practice align with these requirements.




Confidentiality & Record Organization & Office Procedures Yes No N/A1. Do you have an electronic record system?

If no electronic record system, please answer the following:a. Is there an identified order to the chart assembly?b. Are pages fastened in the medical record?c. Does each patient have a separate medical record?d. Is the chart legible?

2. Staff are trained in medical record confidentiality

3. The office uses a Release of Information form that requires patient signature

4. There is a policy for timely transfer of medical records to other locations/providers

5. Medical records are stored in an organized fashion for easy retrieval

6. Medical records are available to the treating practitioner where the member generally receives care

7. Medical records are released to ntities as desgnated consisten with federal regulations

8. Records are stored in a secure location only accessible by authorized personnel

9. There is a mechanism to monitor and handle missed appointments

10. Is there a policy for medical record retention?

Does the office provide: Yes No N/A1. ADA/Handicap parking?

2. Working elevator if office is not located at street level? (Note: If office is located at street level, you may select N/A)

3. Office that is wheelchair accessible?

4. Exam rooms that are wheechair accessible?

Will this office provide care for a patient who: Yes No N/A1. Has been diagnosed with HIV/AIDS?

2. Is aged (elderly)? (Note: If this is a pediatric only office, please indicate N/A)

3. Is developmentally disabled (mentally challenged, cerebral palsy, etc.)?

Provider Facility Questionnaire

Provider Name: Provider ID#: Provider Specialty: Review Date:



Provider Name: Provider ID:Reviewer Name: Review Date:

AUDIT CRITERIA (Found in the Provider Administrative Manual - Chapter 12)

Member Name:Member ID:

YES NO N/AProcedural Elements1 The medical record is legible2 All entries are signed and dated3 Patient name/identification number is located on each page of the record4 Medical records contain patient demographic information

5Medical record identifies primary language spoken and any cultural or religious preferences if applicable

6

Adults 18 and older, emancipated minors, and minors with children have an executed advance directive documented in a prominent part of the medical record. IF NONE, then adults 18 and older, emancipated minors, and minors with children are given information about advance directives and documented.

7 A problem list includes significant illnesses and active medical conditions8 A medication list includes prescribed and over-the-counter medications and is reviewed annually9 The presence or absence of allergies or adverse reactions is clearly displayed

History1 Medical and surgical history is present

2For members (birth to 18 years) documentation of prenatal care, birth and operations of childhood (if applicable)

3 The family history is present and includes pertinent history of parents and/or siblings

4The social history minimally includes pertinent information such as occupation, living situation, etc.

Preventive Services1 Evidence of current age appropriate immunizations (both adults and pediatrics)2 Annual comprehensive physical (or more often fo newborns)

3Documentation o mental & physical development for children and/or cognitive functioning for adults

4 Evidence of depression/mental health screening (12 years or older)5 A problem list includes significant illnesses and active medical conditions6 A medication list includes prescribed and over-the-counter medications and is reviewed annually

7Evidence of screening for high-risk behaviors such as drug, alcohol, tobacco use, sexual activity, exercise and nutrition counseling (12 years and older) (if applicable)

8Documentation of screening for smoking with encouragement to stop (12 years and older) (if applicable)

9Documentation of alcohol and substance use with referral for counseling (12 years and older) (if applicable)

10 Evidence of tracking and referral of age and gender appropriate preventive health services

Medical Record Audit Tool


Provider Name: Provider ID:Reviewer Name: Review Date:

AUDIT CRITERIA (Found in the Provider Administrative Manual - Chapter 12)

Member Name:Member ID:

YES NO N/A

11Use of flow sheets or tools to promote adherence to Clinical Practice Guidelines/Preventive Screenings

12Dental referral/education/visit for adults or any child greater than 1 year or after first tooth eruption

13

Documentation of all elements of age appropriate Federal Early, Periodic, Screening, Daignosis and Treatment (EPSDT) for children under age 21: (if applicable) *Comprehensive health and development history, physical exam, immunizations, lab testing including lead screening, vision/hearing screening

Problem Evaluation and Management1 Adult BMI done annually (ages 18-74)2 Child/adolescent BMI done annually (ages 3-17)

3If there is BMI documentation, is there documentation of cousneling for nutrition & physical activity (age 3-17)

4 Appropriate vital signs done at each visit5 Chief complint listed at each visit6 Physical assessment done at each visit7 Diagnosis listed at each visit8 Treatment plan for each visit

Treatment Plans - Are consistent with evidence-based care and with findings/diagnosis:1 Appropriate use of referrals, consults, studies and tests

2X-rays, labs, consulation reports are documented in the medical record and reviewed by provider (if applicable)

3 Timeframe for follow-up visit as appropriate4 Follow-up of all abnormal diagnostic tests, procedures, x-rays, consultation reports (if applicable)5 Unresolved issues from the first visit are followed up on the subsequent visit (if applicable)6 There is evidence of coordination of care with behavior health as applicable (if applicable)7 Education, including counseling is documented

8Copies of hospital discharge summaries, home health care reports, emergency room care, physical or other



Advance DirectivesMembers have the right to make health care decisions for themselves, including the right to accept or refuse treatment and to execute an advance directive. An advance directive is a written instruction, such as a living will or a durable power of attorney for health care that is recognized under state law and relates to the provision of health care when an individual is incapacitated. There may be several types of advance directives available to a member. You must comply with state law requirements regarding advance directives in the state(s) in which you practice.

Members are not required to have an advance directive and you cannot condition the provision of care or otherwise discriminate against a member based on whether or not themember has executed an advance directive. You should document in a member‘s medical record whether or not the member has executed an advance directive. If a member does have an advance directive, a copy of it should be maintained in the member‘s medical record. The member (or the member‘s designee) should keep the original. You should not send a copy of a member‘s advance directive to UnitedHealthcare.

If a member has a grievance about non-compliance with an advance directive requirement, the member may file a grievance with the UnitedHealthcare Medical Director, theUnitedHealthcare Physician Reviewer, and/or the state survey and certification agency.



Chapter 13: Primary Care Providers Standards & Policies

Role of the Primary Care Provider (PCP)The PCP plays a vital role as a physician care manager in the UnitedHealthcare system by improving health care delivery in four critical areas—access, coordination, continuity and prevention. The role of the PCP shall apply for both NJ FamilyCare members as well as UnitedHealthcare Dual Complete ONE members unless it is specified that the standard is applies only to a specific plan.

The PCP is responsible for the provision of initial andbasic care to members who have selected the PCP, makes referrals for specialty and ancillary care, and coordinates all care delivered to members. The PCP must provide24-hour/seven day coverage and backup coverage when he or she is not available.

The PCP is the point of entry into the delivery system, except for services allowing self-referral, emergencies, and out-of-area urgent care. UnitedHealthcare expects PCPs to communicate with specialists the reason for the referral by use of a prescription or letter and to note this in the patient‘s medical record.

UnitedHealthcare expects a specialist to communicate to the PCP significant findings and recommendations for continuing care. A specialist may refer the patient directly to another specialist.

UnitedHealthcare works with members and providers to help ensure that all participants understand, support and benefit from the PCP care management system.

Responsibilities of the PCPIn addition to the requirements applicable to all providers, the responsibilities of the PCP include:

• Offer access to office visits on a timely basis, in conformance with the standards outlined in Chapter 12 - Timeliness Standards for Appointment Scheduling.

• Conduct a baseline examination during the member‘s first appointment. This should occur within 90 days of enrollment for children and DDD clients, and within 180 days for adult NJ FamilyCare members. The PCP should attempt to schedule this appointment if the new member fails to do so.

• Treat general health care needs of members listed on the PCP‘s panel roster.

• Provide all EPSDT services to and NJ FamilyCare members under 21 years.

• Screen all children ages (6) six months to (6) six years for lead toxicity according to guidelines.

• Screen UnitedHealthcare members for behavioral health problems, using the Screening Tool for Substance Use and Mental Health. File the completed screening tool in the patient‘s medical record.

• Refer to participating specialists for health problems not managed by the PCP. The PCP completes a referral form or prescription and assists the member in making an appointment.

• Refer members, as appropriate, to county care managers for Special Child, Adult, and Early Intervention Services.

• Laboratory/Radiology Notification

– For urgent or emergent cases, notification to enrollee within 24 hours of receipt of results. Arranging an appointment to discuss the laboratory and/or radiology results is acceptable.

– Notification to member of Rapid strep test results within 24 hours of the test.

– For Routine Results (non-urgent or non-emergent) notification to enrollee within 10 business days of receipt of the results.

• Refer women aged 35–39 for a baseline mammogram and women aged 40 and over for an annual mammogram.

• Refer men aged 65–75 to prostate cancer screening every two years.

• Document the reason for a specialist referral and the outcome of the specialist intervention in the member‘s medical record.

• Coordinate each member‘s overall course of care.

• Be available personally to accept UnitedHealthcare members at each office location at least 20 hours a week

• Refer members to Primary Care Dental providers (PCDs) using the DENTAL link in myuhc.com

http://www.myuhc.com



• Pediatric members shall be referred to a dentist by the age of 1 or soon after the eruption of the first tooth.

• Be available to members by telephone 24 hours a day, seven days a week, or have arrangements for telephone coverage by another UnitedHealthcare participating PCP. There are acceptable telephone standards.

• Respond to after-hour patient calls within 30–45 minutes for non-emergent symptomatic conditions and within 15 minutes for emergency situations.

• Identify and reschedule broken and no-show appointments.

• Document procedures for monitoring patients‘ missed appointments as well as outreach attempts to reschedule missed appointments.

– When missed appointments and referrals for problems are identified through EPSDT exams, the provider is required to document procedures for monitoring patients‘ missed appointments and outreach attempts. Documentation of reasonable outreach includes a minimum of (3) three attempts to reach the member, one of which MUST be by written notification. Providers may also attempt to reach the member by telephone, use of MEDM System provided by the State, contact with the Medical Assistance Customer Center (MACC), DDD, or DYFS/DCF regional offices.

• Triage for medical and dental conditions and special behavioral needs for non-compliant individuals who are mentally deficient

• Educate members about appropriate use of emergency services.

• Discuss available treatment options and alternative courses of care with members.

• Refer services requiring prior authorization to the Service Center, Behavioral Health Unit, or Pharmacy as appropriate.

• UnitedHealthcare recommends calling at least (5) five days, but not later than 48 hours, in advance of the admission or surgery. The PCP may appeal any adverse decision made by UnitedHealthcare. Procedures for filing an appeal are in Chapter 16 - Utilization Management Appeals.

• Inform UnitedHealthcare Care Management at 888-DOC-DENT (888-362-3368) of any member showing signs of End Stage Renal Disease.

• Inform UnitedHealthcare Care Management at 888-DOC-DENT (888-362-3368) of any member who requires a referral to a Medicare-certified hospice

• Admit UnitedHealthcare members to the hospital when necessary and coordinate the medical care of the member while hospitalized.

• Assist the UnitedHealthcare Care Manager in assessing a patient‘s needs and developing a plan for continuing care beyond discharge, if medically necessary.

• Respect the advance directives of the patient and document in a prominent place in the medical record whether or not a member has executed an advance directive form.

• Provide covered benefits in a manner consistent with professionally recognized standards of health care and in accordance with standards established by UnitedHealthcare.

• Transfer medical records upon request. Copies of members‘ medical records must be provided to members upon request at no charge.

• Maintain staff privileges at a minimum of one UnitedHealthcare participating hospital.

• Report infectious diseases, lead toxicity and other conditions as required by state and local laws and regulations.

Panel RosterPCPs may print a monthly Primary Care Provider Panel Roster by visiting UHCprovider.com/reports > Capitation, Claim, Quality, Roster and Profile Reports- UnitedHealthcare > Learn more about UnitedHealthcare Reports.

The PCP Panel Roster provides a list of UnitedHealthcare Community Plan members currently assigned to the provider.

Females have direct access (without a referral or authorization) to any OB/GYNs, midwives, physician assistants, or nurse practitioners for women’s health care services and any non-women’s health care issues discovered and treated in the course of receiving women’s health care services. This includes access to ancillary services ordered by women’s health care providers (lab, radiology, etc.) in the same way these services would be ordered by a PCP.

https://www.uhcprovider.com/en/reports-quality-programs.html?CID=none


UnitedHealthcare Community Plan works with members and care providers to help ensure that all participants understand, support, and benefit from the primary care case management system. The coverage shall include availability of 24 hours, seven days per week. During non-office hours, access by telephone to a live voice (i.e., an answering service, physician on-call, hospital switchboard, PCP’s nurse triage) which will immediately page an on-call medical professional so referrals can be made for non-emergency services or information can be given about accessing services or managing medical problems. Recorded messages are not acceptable.

Assignment to PCP Panel RosterOnce a member has been assigned to a PCP, panel rosters can be viewed electronically on the UnitedHealthcare Provider Portal at UHCprovider.com. The portal requires a unique user name and password combination to gain access.

Go to UHCprovider.com/reports > Capitation, Claim, Quality, Roster and Profile Reports- UnitedHealthcare > Learn more about UnitedHealthcare Reports.

PCP as a SpecialistIf a physician is credentialed as a specialist as well as a PCP, the physician can accept referrals from members whose PCP is a different physician. If the PCP wants to provide specialtyservices to members on his or her own panel, UnitedHealthcare must give prior authorization for the specialty services in order for the physician to receive payment.

The PCP should call 888-DOC-DENT (888-362-3368).

Vaccines for Children (VFC) ProgramState of New Jersey Vaccines for Children (VFC)The Vaccines for Children (VFC) program is a federally funded program that began in 1994. Each state operates the vaccine supply and distribution to providers.

New Jersey‘s VFC program became fully operational in January 1999. There are currently over 2,000 providers who areenrolled in the NJ VFC program.

The program was created to address the disparity between insured children and children with no insurance or children from certain groups. The groups include children enrolled in Medicaid or Medicaid Managed Care, NJ FamilyCare A.

The program supplies vaccines for these designated groupsat no cost to all public and private care providers who agree to administer the vaccine. Providers will be reimbursed for the administration of the vaccine for NJ FamilyCare Plan A.

Vaccines offered through the VFC program can only be given to children with health insurance when their health insurance does not cover the cost of VFC vaccines and the vaccines are received at a Federally Qualified Health Center (FQHC).

Claims reimbursement for vaccines and administration of vaccines for NJ FamilyCare members B, C, & D should be submitted directly to UnitedHealthcare.

UnitedHealthcare Community Plan of New Jersey (UHCCPNJ) requires all physicians who see children between the ages of 0 to 19 to be enrolled in the VFC program. Because enrollment in the VFC program is independent of your participation with UnitedHealthcare, it requires separate enrollment (see below for instructions.) UnitedHealthcare will reimburse all care providers $11.50 for each administered vaccine. You must submit on a CMS 1500 billing form the vaccine CPT code, as well as the administration code to obtain the payment.

Benefits of VFC program and how to enroll Several benefits include:

• Eliminates out of pocket expenses for parents and enrolled providers.

• Children need not be referred to public health centers for vaccination, keeping children within their medical home

• Provides a ready inventory of vaccines for VFC enrollees.

Enrollment is easy, go the following website: njiis.nj.gov. All the forms are readily available to become enrolled. For more information about the VFC program call 609-826-4862 or send an emailto [email protected]



http://UHCprovider.com/reports

https://njiis.nj.gov/core/web/index.html

mailto:VFC%40doh.state.nj.us?subject=


We reimburse for the administration of the VFC program for all Medicaid plan types B, C, and D. The State of New Jersey’s VFC program provides vaccines for Medicaid plan A.

If you are enrolled in VFC and disenroll from the program, notify us by mailing and dated letter to:

UnitedHealthcare Community Plan of New JerseyAttn: Provider RelationsP.O. Box 2040Edison, NJ 08818-2040

CPT codes that are currently approved under the NJ State VFC Program are listed on page below:

CPT Code Vaccine ID

90632 Hepatitis A Vaccine Adult (2 dose schedule)

90633 Hepatitis A Vaccine Ped/Adol (2 dose schedule)

90636 Hepatitis A-Hepatitis B Vaccine Adult

90647 Hepatitis A-Hepatitis B Vaccine Adult

90648 Hemophilus b Conjugate Vaccine (Tetanus Toxoid Conjugate)

90649 Human Papilloma Virus Vaccine (HPV4) (3 dose schedule)

90650 Human Papilloma Virus Vaccine (HPV2) (3 dose schedule)

90670 Pneumococcal 13-valent Conjugate

90680 Rotavirus (RV5) (3 doses schedule)

90681 Rotavirus (RV1) (2 dose schedule)

90696 Diphtheria and Tetanus Toxoids and Acellular Pertussis Adsorbed and Inactivated Poliovirus Vaccine (DTaP-IPV)

90698 Diphtheria and Tetanus Toxoids and Acellular Pertussis Adsorbed, Inactivated Poliovirus and Haemophilus b Conjugate (Tetanus Toxoid Conjugate) (DTaP/Hib/IPV)

CPT Code Vaccine ID

90700 Diphtheria and Tetanus Toxoids and Acellular Pertussis (DTaP)

90707 Measles, Mumps & Rubella Vaccine (MMR)

90710 Measles, Mumps,Rubella & Varicella Vaccine (MMRV)

90713 Poliovirus Vaccine Inactivated (IPV)

90714 Tetanus and Diphtheria Toxoids Adsorbed (Td)

90715 Tetanus Toxoid, Reduced Diphtheria Toxoid and Acellular Pertussis Vaccine, Adsorbed (Tdap)

90716 Varicella Virus Vaccine Live (Var)

90723 Diphtheria and Tetanus Toxoids and Acellular Pertussis Adsorbed, Hepatitis B (Recombinant) and Inactivated Poliovirus Vaccine (DTaP/HepB/IPV)

90732 Pneumococcal Vaccine, polyvalent

90734 Meningococcal (Groups A, C, Y and W-135) Polysaccharide Diphtheria Toxoid Conjugate Vaccine) (MCV4)

90736 Zoster Vaccine Live - Adult

90743 Hepatitis B Vaccine (Recombinant) - Adol (2 dose schedule)

90744 Hepatitis B Vaccine (Recombinant) - Ped/Adol (3 dose schedule)

90746 Hepatitis B Vaccine (Recombinant) - Adult (3 dose schedule)

90748 Haemophilus b Conjugate (Meningococcal Protein Conjugate) and Hepatitis B (Recombinant)



VFC Program influenza vaccine choices are:

Manufacturer Brand name Description Age

GSK Fluarix-Quad 0.5mL single dose syringe, 10 pack; P-free 36 months+

GSK FluLaval-Quad 0.5mL single dose syringe, 10 pack; p-free 6 months+

Sanofi Fluzone-Quad 0.5mL single dose syringe, 10 pack; P-free 36 months+

Sanofi Fluzone-Quad 5mL multi-dose vial, One 10-dose vial 6 months+

Sanofi Fluzone-Quad 0.25mL single dose syringe, 10 pack; Pfree 6 months+

Seqirus Flucelvax-Quad 0.5mL single dose syringe, 10 pack; P-free 4 years+

317 Program influenza vaccine choices are:

Manufacturer Brand name Description Age

GSK Fluarix-Quad 0.5ml single dose syringe, 10 pack; P-free 19 years+

Seqirus Flucelvax 5ml multi-dose vial, One 10-dose vial 19 years+

The VFC program is pleased to offer FluLavalÒ GSK, as an additional influenza vaccine for children six months+. On November 18, 2016, the Food and Drug Administration approved an extension of the age range of quadrivalent FluLaval (inactivated influenza vaccine) to include children six through 35 months of age. The Flulaval dosage is 0.5 mL, regardless of the age of the child.

As with all vaccine orders: open flu vaccine shipments immediately, check the temperature monitor reading, inspect the vaccine, compare the vaccine received to the packing list, and store at appropriate temperatures. If vaccines have been compromised, if temperature monitors are out-of-range, or if the order received is not accurate, providers should immediately notify McKesson Specialty Customer Care dedicated vaccine viability telephone line at 877-TEMP123 (877-836-7123).



Pediatric Primary Care Medical Records and Charting StandardsPediatric charting must include:

• Flow chart for immunizations

• Growth and development chart

• Documentation of compliance with EPSDT guidelines (for NJ FamilyCare members under age 21 years)

Nurse Practitioners and Physician Assistants in PCP OfficeUnitedHealthcare supports the use of certified nurse practitioners and physician assistants to increase accessto and availability of services. The use of nurse practitioners and physician assistants does not, however, in any way relieve the PCP of his or her contractual obligations for member access and availability.

PCPs may employ nurse practitioners and physician assistants to see UnitedHealthcare members, subject to their scope of practice limitations under New Jersey State law.

24-Hour, Seven-Days-a-Week CoveragePCPs must be available to members by telephone 24 hours a day, seven days a week, or have arrangements for telephone coverage by another UnitedHealthcare participating PCP.A Medical Director must approve coverage arrangements that vary from this requirement. PCPs are expected to respond to after-hour patient calls within 30–45 minutes for non-emergent symptomatic conditions and within 15 minutes for crisis situations.

UnitedHealthcare tracks and follows up on all instances of PCP unavailability. UnitedHealthcare also conducts periodic access surveys to help ensure that all access and availability standards are met. PCPs are required to participate in all activities related to these surveys.

We conduct an annual PCP after-hours availability audit. We contact care providers after business hours or on weekends to determine their availability and telephone coverage.

The following are examples of acceptable and unacceptable responses as defined by UnitedHealthcare Community Plan of New Jersey per State requirements:

Acceptable telephone coverage will be based on the following criteria:

1. Telephone is answered by PCP, office staff, answering service or voice mail.

2. The answering service either:

• Connects the caller directly to the care provider;

• Contacts the PCP on behalf of the caller and the care provider returns the call; or

• Provides a telephone number where the PCP/covering provider can be reached.

3. The answering machine message provides a telephone number to contact the care provider who is responsible for maintaining PCP coverage.

4. The answering machine instructs the caller to dial 911 for life-threatening emergencies at the beginning of the call, or to go to the emergency room if an emergency exists, especially if the emergency is trauma related.

Unacceptable Care Provider Responses1. Office/Answering service hangs up.

2. The care provider’s answering machine message:

– Instructs the caller to go to the emergency room for non- emergent situations.

– Instructs the caller to leave a message for the care provider for any urgent situation.

3. There is no answer.

4. The caller is placed on hold for longer than five minutes.

5. The telephone lines are persistently busy despite multiple attempts to contact the care provider.

Timeliness Standards for Appointment SchedulingEmergency CareImmediately upon the member‘s presentation at a service delivery site

Primary CarePCPs and providers of primary care should arrange appointments for:


• Non-urgent ―sick visit within 72 hours of request, as clinically indicated



• Routine, preventive care within 14 days of request

• Preventive care within four weeks of request

• Initial office visit for ABD elderly and disabled members shall be contacted within 45 days of enrollment and offered an appointment according to the needs of the member

• Initial office visit for an enrollee identified with special needs shall be contacted within 10 days of enrollment and offered an expedited appointment.

• Well child care within three months of enrollment

• Baseline physicals for new adult enrollees within 180 days of enrollment

• Baseline physicals for new children enrollees within 90 days of enrollment

• Baseline physicals for adult clients of DDD within 90 days of enrollment

• Routine physicals for school, sports, camp or work within four weeks of request



Chapter 14: Specialist Providers Standards & Policies

Responsibilities of Specialist ProvidersIn addition to the requirements applicable to all providers, the responsibilities of specialist physicians include:

• Offer access to office visits on a timely basis, in conformance with the standards outlined in Chapter 12 - Timeliness Standards for Appointment Scheduling.

• Provide specialty care medical services to UnitedHealthcare members referred by the member‘s Primary Care Provider (PCP) or who self-refer (for services not requiring a referral)

• Refer services requiring prior authorization to the Prior Authorization Department, Behavioral Health Unit, or Pharmacy as appropriate. UnitedHealthcare recommends calling at least five days, but not later than 48 hours, in advance of the admission or surgery. A physician may appeal any adverse decision made by UnitedHealthcare. Procedures for filing an appeal are in Chapter 15 Utilization Management Appeals.

• Provide the PCP copies of all medical information, reports, and discharge summaries resulting from the specialist‘s care

• Communicate in writing to the PCP all findings and recommendations for continuing patient care and note them in the patient‘s medical record

• Maintain staff privileges at a minimum of one UnitedHealthcare participating hospital

• Report infectious diseases, lead toxicity and other conditions as required by state and local laws and regulations

Specialists as PCPsIf a member has a life-threatening or degenerative and disabling condition or disease that requires prolonged specialized care, UnitedHealthcare may authorize the member‘s specialist to also serve as the PCP. In these cases, a Medical Director must approve a treatment plan, in consultation with the PCP, the specialist, and the member (or the member‘s designee). UnitedHealthcare will approve only specialists who are participating in UnitedHealthcare‘s network, unless no qualified specialist can be identified in the UnitedHealthcare network.

24 Hours, Seven Days a Week Coverage Obstetricians must be available to members by telephone 24 hours a day, seven days a week, or have arrangements for telephone coverage by another UnitedHealthcare participating obstetrician.

A Medical Director must approve coverage arrangements that vary from this requirement. PCPs and obstetricians are expected to respond to after-hour patient calls within 30–45 minutes for non-emergent symptomatic conditions and within 15 minutes for crisis situations.

We track and follow up on all instances of unavailability. We conduct periodic access surveys to help ensure all standards are being met. PCPs and obstetricians are required to participate.

We conduct an annual PCP after-hours availability audit. We contact care providers after business hours or on weekends to determine their availability and telephone coverage.

The following are examples of acceptable and unacceptable responses as defined by UnitedHealthcare Community Plan of New Jersey per State requirements:

Acceptable Care Provider Telephone Responses Acceptable telephone coverage will be based on the following criteria:

1. Your telephone is answered by PCP, office staff, answering service or voice mail permitting immediate contact.

2. The answering service you use either:

– Connects the caller directly to the care provider;

– Contacts the PCP on behalf of the caller and the provider returns the call; or

– Provides a telephone number where the PCP or covering provider can be reached.

3. Your answering machine message provides a telephone number to contact the care provider who is responsible for maintaining PCP coverage.

4. Your answering machine instructs the caller to dial 911


for life-threatening emergencies at the beginning of the call, or to go to the emergency room if an emergency exists, especially if the emergency is trauma related.

Unacceptable Care Provider Responses1. Office/Answering service hangs up.2. The care provider’s answering machine message:

– Instructs the caller to go to the emergency room for non-emergent situations.

– Instructs the caller to leave a message for the care provider for any urgent situation.

3. There is no answer.4. The caller is placed on hold for longer than five minutes.5. The telephone lines are persistently busy despite multiple

attempts to contact the care provider.

Timeliness Standards for Appointment SchedulingProviders shall comply with the following appointment availability standards:

Emergency CareImmediately upon the member‘s presentation at a service delivery site

Specialty CareSpecialists and specialty clinics should arrange appointments for:


• Non-urgent care within four weeks of request, as clinically indicated

Prenatal and Postpartum CareProviders of prenatal care should arrange appointments for the initial prenatal visit:

• Positive pregnancy test – within three weeks of request

• Identification of high risk – within three days of identification of high risk

• First or second trimester – within seven days of request

• Third trimester – within three days of request

• Postpartum – between 21-56 days after delivery

Chapter 14: Specialist Providers Standards & Policies


Chapter 15: Preventive Health & Clinical Practice Guidelines

Preventive Health CareUnitedHealthcare‘s goal is to partner with providers to help ensure that members receive preventive care. UnitedHealthcare endorses and monitors the practice of preventive health standards recommended by recognized medical and professional organizations. UnitedHealthcare monitors the provision of these services through chart reviews and analysis of encounter data.

Preventive health care standards and guidelines are available at UHCprovider.com > Policies and Protocols > Clinical Guidelines > Preventive Services - Clinical Guideline

Clinical Practice Guidelines for Chronic ConditionsUnitedHealthcare strongly supports evidence-based medicine and we have identified sources that have received national recognition both from the government and the health care community. We have vetted these sources within UnitedHealth Group and our own network advisory committees. Providers are encouraged to visit the following websites for clinical practice guidelines as they are intended as an important resource to support and guide your clinical decision-making.

The complete Clinical Practice Guidelines (CPGs) are available at UHCprovider.com/njcommunityplan > Current Policies and Clinical Guidelines > View Clinical Practice Guidelines.

Lead ScreeningUnitedHealthcare has implemented a program to screen for the presence of lead toxicity in children. The screening consists of a verbal risk assessment and blood lead testing.

Providers are encouraged to check the Centers for Disease Control and Prevention (CDC) website at cdc.gov/nceh/lead for additional information on lead screening.

UnitedHealthcare supports and supplements the PCP‘s screening with outreach to parents and caregivers and a Lead Care Management Program for children with blood lead level

of 10 micrograms per deciliter. This program also applies to members of the same household who are between 6 months and 6 years of age.

Newborn Screening ProgramUnitedHealthcare will refer all newborns who test positive on the expanded Newborn Screening Program set forth by the Department of Health (DOH) for confirmatory lab tests and treatment of rare conditions. These newborns will be referred to care management for further assessment, intervention and care coordination.

Mammogram and Prostate Cancer ScreeningsThe State of New Jersey requires an annual mammography for women aged 40 and over, and screening for prostate cancer for men between 65 to 75 years of age every two years. UnitedHealthcare supports access to, and utilization of, mammography through education of members and by encouraging self-referral to mammogram screenings and prostate cancer screenings.

Current ProtocolsProviders must assure the use of the most current diagnosis and treatment protocols and standard established by the DHSS and medical community. Providers are expected to follow evidence-based treatment guidelines for treatment and diagnosis where available. Such guidelines are available from professional societies (e.g., American College of Cardiology,American College of Physicians), government funded agencies (e.g., National Institutes of Health, US Preventive Services Task Force, National Guideline Clearinghouse). These organizations can all be located by a simple internet search engine query. In addition, diagnosis and treatment guidelines and protocols for many common conditions impacting our members are located on our website.

https://www.uhcprovider.com/en/policies-protocols/clinical-guidelines.html

https://www.uhcprovider.com/en/health-plans-by-state/new-jersey-health-plans/nj-comm-plan-home/nj-cp-policies.html

https://www.uhcprovider.com/en/health-plans-by-state/new-jersey-health-plans/nj-comm-plan-home/nj-cp-policies.html

https://www.cdc.gov/nceh/lead/


Chapter 16: Utilization Management Appeals

Medicaid Managed Care Rules Amended — Effective July 1, 2017Please be advised that effective July 1, 2017 CMS has amended the Medicaid Managed Care rules surrounding the Utilization Management (UM) appeal process. There are considerable revisions to the UM appeal process with regard to timeframes and continuation of benefits. Further, CMS has eliminated the Stage 2 formal Internal Appeal process. Please find the overview of the new process below.

Overview of Utilization Management (UM) AppealsUnitedHealthcare operates an Internal Appeals process to review appeals by members (or a member‘s designee) who are dissatisfied with UnitedHealthcare‘s Utilization Management decisions. In New Jersey, UnitedHealthcare members also have the right to an External Appeal once the Internal Appeal process has been exhausted in most situations. Some UnitedHealthcare clients also have a right to request a Medicaid Fair Hearing with the State of New Jersey at the end of the Internal Appeal process if the outcome of the Internal Appeal is not in their favor.

Types of Internal UM AppealsThere are two types of internal UM appeals:

1. Medical Decision Appeals. These appeals contest UnitedHealthcare‘s determination of medical necessity. (See Chapter 3 - Determination of Medical Necessity.) Viewed as an ― adverse determination‖ by a provider or member, this is a determination by a Medical Director or Physician Advisor that an admission, extension of stay, level of care (e.g., emergency vs. triage, acute vs. subacute), or other health care service, based on review of the information available to UnitedHealthcare, is not medically necessary or is considered experimental or investigational.

2. UM Administrative Appeals. These are appeals which are not related to a covered benefit, other insurance is primary, member is not eligible and late notification of an authorization request.

Appeals of claims regarding any other denial reason or alleged inappropriate type or level of payment are addressed in Section 5 - Claims Policies and Procedures.

Appeals of sanctions against a provider for quality concerns are addressed in Chapter 17: Quality Management Program.

Internal UM Appeals for NJ FamilyCareAny member, or a member‘s designee, who is dissatisfied with any aspect of UnitedHealthcare‘s Utilization Management (UM) decision has a right to file a UM appeal. A provider may file on behalf of a member but must have the member‘s written consent.

An Internal Appeal can be initiated as follows:

• A call from the member (or member‘s designee) to the Member Helpline (1-800-941-4647) where the call is recorded and forwarded to the UM Appeals Coordinator

• A call from the health care provider on behalf of the member (or member’s designee) to the UM Appeals Department (1-888-362-3368)

• A written request for appeal from the member (or member‘s designee) or health care provider on behalf of the member.

• If you call first, you must follow-up your phone request by writing to UnitedHealthcare Community Plan at Appeals and Grievances, P.O. Box 31364, Salt Lake City, UT 84131.

• If you call to request an expedited, or fast appeal, you do not have to follow-up your phone call with a written request.

All medical decision and UM administrative appeals must be received by UnitedHealthcare no later than 60 days from the date that UnitedHealthcare first notified the member or provider of the adverse determination. The appeal should contain the following information:

• Member name and UnitedHealthcare member identification (ID) number

• Provider name and UnitedHealthcare provider number

• Provider‘s address and phone number

• Requested procedure or service

• Date of denial (if known)


• Diagnosis and medical justification for the procedure or service

• A copy of the original denial letter

• The provider will also need a copy of the member‘s consent if the provider is appealing on behalf of the member on file in the provider’s office

Mail or fax the appeal to:

UnitedHealthcare Community Plan Attention: UM Appeals Coordinator P.O. Box 31364Salt Lake City, UT 84131Fax: 1-973-565-5269

Internal UM Appeal Process A member, or provider acting on behalf of a member (with member consent), who is dissatisfied with any UM determination shall have the opportunity to discuss and appeal that determination with the UnitedHealthcare Medical Director, Physician Advisor or physician designee who rendered the determination.

All Internal Appeals shall be concluded as soon as possible after receipt by UnitedHealthcare in accordance with the medical exigencies of the case. UnitedHealthcare will review the decision within thirty (30) calendar days. If it is a decision about urgent or emergency care, (including all situations in which the client is confined as an inpatient), UnitedHealthcare will expedite the review and review the decision within 72 hours. (See this Section under - Expedited Appeal for Medicaid and NJ FamilyCare.) UnitedHealthcare will notify the member, or provider acting on behalf of the member, in writing of the Internal Appeal decision. The appeal is rendered based on the clinical information provided at the time of the appeal and compliance with time frames will be maintained.

Expedited Appeals for Medicaid and NJ FamilyCareAn appeal is to be expedited if the determination is regarding urgent or emergency care, an admission, availability of care, continued stay, health care services for which the claimant received emergency services but has not been discharged from a facility; or appeals wherein the UnitedHealthcare determines (based on a member’s request) or the provider demonstrates (while making the request on the enrollee’s behalf or in supporting

the enrollee’s request) that expedited resolution is medically necessary, because taking the time for a standard resolution could seriously jeopardize the enrollee’s life, physical or mental health, or ability to attain, maintain, or regain maximum function.UnitedHealthcare will render a decision on the expedited appeal within 72 hours of receipt of all information necessary to conduct such an appeal and provide a written notification at the same time to all appealing parties.

To facilitate the expedited resolution of an appeal, UnitedHealthcare will encourage the health care provider to work collaboratively, including, but not limited to, sharing information via telephone or fax.

Expedited appeals that do not result in a resolution satisfactory to the appealing party may be further appealed through the External Appeal process.

External Appeal Process for NJ FamilyCare A UnitedHealthcare Medicaid or NJ FamilyCare member, and any provider acting on behalf of a member, with the member‘s consent, who is dissatisfied with the results of the Internal Appeal process, has the right to pursue his/her appeal to an independent utilization review organization when advised in the Internal Appeal determination notice and in accordance with the procedures set forth in an External Appeal described in this section. The right to an External Appeal is contingent on the completion of the internal review.

To initiate an External Appeal, a member and/or provider with member consent shall within sixty (60) days from the receipt of the written determination of the Internal Appeal, file a written request with the New Jersey Department of Banking and Insurance. The request shall be filed on the forms automatically provided to the member with the Internal Appeal determination. The fee specified and a general release executed by the member for all medical records pertinent to the appeal needs to be included.

Requests are mailed to:

NJ Department of Banking and Insurance Consumer Protection ServicesOffice of Managed CareP.O. Box 329Trenton, New Jersey 08625-0329



You can also call their toll-free telephone number at 1-888-393-1062 to ask for an IURO appeal and for assistance.

The fee for filing the appeal is $25 for a provider acting on behalf of a member with consent.

Upon receipt of the appeal, the Department will assign the appeal to an IURO in accordance with regulations for review. Additionally, upon receipt of the request for appeal from the Department, the IURO will conduct a preliminary review of the appeal and accept it for processing if it determines that:

1. The individual was or is a member of the HMO;

2. The service which is the subject of the grievance or appeal reasonably appears to be a covered service under the benefits provided by contract to the member

3. The member has fully complied with the Internal Appeals.

4. The member or provider has provided all information required by the IURO and the Department to make the preliminary determination including the appeal form and a copy of any information provided by UnitedHealthcare regarding its decision to deny, reduce, or terminate the covered service, and a fully executed release to obtain any necessary medical records from UnitedHealthcare and any other relevant health care provider.

The IURO completes its review and issues its recommended decision as soon as possible in accordance with the medical exigencies of the case which unless under certain circumstances will not exceed 45 business days from the receipt of all documentation necessary to complete the review. If the appeal involves care for an urgent or emergency case, the IURO shall complete its review within no more than 48 hours following its receipt of the appeal. The IURO‘s decision shall be binding upon UnitedHealthcare

If the provider or the member needs assistance regarding the External Appeal process, he or she should call the UnitedHealthcare Grievance & Appeals Center at 1-888-456-0218. Visit our Web site at UHCProvider.com > Menu > Health Plans by State >Choose Your State: New Jersey > Medicaid Community Plan for more information on filing External Appeals and for the Member Consent and UM Appeal Form.

Please Note: Although a member has 60 days to file an appeal to the IURO, if they are receiving these services and want their services to continue automatically during the IURO appeal, they must request their appeal on or before the final day of the previously approved authorization, or within 10 calendar days of the written determination of the Internal Appeal, whichever is later. If the member does not request their appeal within this timeframe, the services will not continue during the appeal.

Fair Hearing Rights for Medicaid/NJ FamilyCare A and ABPThe New Jersey State Fair Hearing process is available to New Jersey Medicaid/NJ FamilyCare A and ABP members who are not satisfied with an UnitedHealthcare decision. A member, or individual acting on behalf of the member with the member‘s consent, has a right to request a Medicaid Fair Hearing by writing to:


This request must be made within 120 days of the written determination of the Internal Appeal.

Please Note: If the member is currently receiving these services and want their services to continue during the Medicaid Fair Hearing process, they must ask that the services continue while the Fair Hearing is taking place.

For further information, call the New Jersey Managed Care Hotline at 800-356-1561. They will direct you to the Medicaid Fair Hearing office.

UnitedHealthcare Dual Complete ONE (Medicare) AppealsThere are no federal regulations requiring health plans to have a provider appeal process. However, any UnitedHealthcare provider who is dissatisfied with any aspect of UnitedHealthcare‘s administrative or utilization management decisions may file an Informal Dispute Resolution (IDR) appeal. This is a contractually agreed upon process. The IDR appeal request must be filed within 30 days of receipt of the written adverse determination.



https://www.uhcprovider.com/en/health-plans-by-state/new-jersey-health-plans/nj-comm-plan-home.html

https://www.uhcprovider.com/en/health-plans-by-state/new-jersey-health-plans/nj-comm-plan-home.html


Representing a Member in the Medicare Standard Appeals ProcessA provider may file a standard appeal on behalf of a UnitedHealthcare Dual Complete ONE (Medicare) member, with written or verbal permission of the member.

For written permission for the provider to represent the member’s appeal verbally without the member present, both the provider and member must sign a statement authorizing the provider to act on behalf of the member. We encourage members and providers to use the CMS approved representative statement to help ensure all required information is received. Members may obtain a copy of the representative CMS approved representative statement by calling the toll-free number on the back of their member ID card or 800-514-4911. The member must sign the statement and will also need to obtain the signature of their provider on the statement as well. The member should then mail or fax the signed statement back to the address or fax number listed on the form for UHCCP to note in the member’s file for the provider to be able to contact Member Services. The member should also provide a copy of the signed CMS approved representative statement to their provider for records keeping. After the signed CMS approved representative statement has been received from the member, providers may then call to file a grievance or appeal on behalf of a member by contacting the plan using the toll-free number on the back of the member’s ID card without their presence. Members may call to verify UHCCP’s receipt of the CMS approved representative statement by calling the toll-free number on the back of their member ID card or 800-514-4911.

If no CMS approved representative statement is obtained, the provider may also directly send a written appeal in the form of a letter and any supporting documentation to UHCCP. The letter should include both the signatures of the member and provider, the member‘s name and the member’s ID number.

Mail or fax the appeal to:

UnitedHealthcare Dual Complete ONE Attention: UM Appeals CoordinatorP.O. Box 31364 Salt Lake City, UT 84131Fax: 973-565-5269

Providers may also appeal verbally on behalf of a member with the member’s verbal consent, and without a signed CMS approved representative statement. Members can contact

Member Services directly by calling the toll-free number on the back of their member ID card or 800-514-4911. Both the member and provider must be present via the phone conversation at the same time during the call with Member Services. The discussion can be related to the appeal, or any other member-related issue that the member wishes to discuss.

The Medicare process allows the member to appeal an adverse determination regarding 1) health care services the member believes should be covered by Medicare and UnitedHealthcare and 2) any payments that the member must remit and 3) determinations that deny a service or payment partially or in total.

Notices of adverse determinations are sent to the member, PCP and attending physician (if different from the PCP). The notification includes the clinical rationale behind the adverse determination, instructions on how to access the clinical review criteria, instructions on how the member or authorized representative may initiate an appeal and any additional information needed.

The member, and /or provider with member‘s consent, has 60 days to file from the date of initial adverse determination. The member‘s or provider‘s request may include information or documents to support the member‘s position. UnitedHealthcare will acknowledge the appeal within five days.

UnitedHealthcare will respond in: 30 calendar days of an appeal of a service denial. 60 calendar days for appeal of a claim denial.

If UnitedHealthcare upholds the denial, wholly or partially, the file is immediately forwarded to a CMS Center for Health Care Dispute Resolution (CHDR) contractor for final review and decision

If the enrollee is dissatisfied with the CMS reconsideration determination, (s)he may request a hearing before an Administrative Law Judge (ALJ). A hearing will be held if the amount in controversy exceeds $100. The request for ahearing must be filed within 60 days of the date of the notice of reconsideration.

Any party to the Administrative Law Judge hearing may request a Departmental Appeals Board (DAB) of the Social Security Administration to review the ALJ decision or dismissal. The DAB may also independently review an ALJ decision without such a request.



Finally, a party to the appeal may request judicial review ofan appeals case through Federal Court if the DAB denies the party‘s request for review, or affirms the ALJ‘s decision and the amount in dispute is $1000 or more. This step is considered binding unless additional information to support the case ofany party to the appeal is compelling enough to require are-examination of the case. A revised reconsideration made by the health plan, an ALJ or the DAB may be reopened 12 months after issuance of the initial notice of reconsideration or, after four years for just cause.

Medicare 72-Hour Expedited Appeal ProcessIf waiting up to 30 days for a standard appeal could seriously harm the member‘s life, health, or ability to regain maximum function, the member, or member‘s representative, can request a 72-hour appeal. If the physician representing the member asks UnitedHealthcare Dual Complete ONE (Medicare) for a72-hour appeal or supports the request for a 72-hour appeal, UnitedHealthcare must grant the request. All appeals must specifically state that the member, member‘s designee, or provider on behalf of the member (with the member‘s consent)― wants an expedited appeal, fast appeal or 72-hour appeal, or that the appealing party ― believes that the member‘s health could be seriously harmed by waiting 30 days for a normal appeal. There are several options for initiating a 72-hour appeal:

• Call 800-514-4911 or 800-421-1220 (TTY/TDD for the hearing impaired). UnitedHealthcare Dual Complete ONE (Medicare) will document the oral request.

• Send the written appeal request to: UnitedHealthcare Dual Complete ONE Attention: UM Appeals Coordinator P.O. Box 31364 Salt Lake City, UT 84131

• Fax the written appeal request to 1-973-565-5269

If the member is in a hospital or a nursing facility, the member, or member‘s designee, may request that the facility fax the written appeal to UnitedHealthcareDual Complete ONE (Medicare) at 1-973-565-5269.

Note: The 72-hour review time will not begin until UnitedHealthcare receives the appeal.

UnitedHealthcare will decide the appeal and notify the appealing parties of the decision within 72 hours of receipt of the appeal. If the appeal is denied, UnitedHealthcare will

forward the appeal and all supporting documentation to theMaximus Center for Health Dispute Resolution (CHDR) for an independent review and decision.

Medicare 14-Day ExtensionAn extension of up to 14 calendar days is permitted for a 72-hour appeal, if the extension of time benefits themember. (For example, if the member needs time to provide UnitedHealthcare with additional information or if additional diagnostic tests need to be completed.)

If the appeal is denied, UnitedHealthcare will forward the appeal and supporting documentation to the Maximus Center for Health Dispute Resolution (CHDR) for an independent review and decision.

In the case of a hospital or skilled nursing facility (SNF) appealing a discharge recommendation, the member or his/her designee, must contact Quality Insights of Pennsylvania and request an expedited review appealing the identified discharge date. The member or his/her designee must contact Quality Insights no later than noon on the first working day after the member is provided a written notice stating that they are being discharged from the facility. All requests for QIO review must be submitted to:

Quality Insights of Pennsylvania 2601 Market Place Street, Suite 320Harrisburg, PA 17110

Toll-free: 877-346-6180

Quality Insights will review the information concerning the discharge. If the outcome of the QIO review determines thata hospital or SNF discharge was appropriate, the member will not be held responsible for paying the hospital charges until noon of the calendar day after the Quality Insights review. If Quality Insights concurs with the member, the plan will continue to cover the hospital or SNF stay as medically appropriate. If the outcome of the review determines that the hospital or SNF discharge as premature, UnitedHealthcare is responsible for paying for the denied days.

Appeals of Pharmacy DenialsAny member, a member‘s designee or provider on behalf of a member (with the member‘s consent) who is dissatisfied with any aspect of UnitedHealthcare‘s pharmaceutical decisions or operations has a right to file a UM Appeal.



A pharmaceutical appeal should include the following information:

• Patient name and UnitedHealthcare member ID number

• Provider name and UnitedHealthcare provider number

• DEA/CDS number and license number

• Address and phone number

• Requested prescription

• Date of denial (if known)

• Diagnosis and medical justification for the prescription

• A copy of the original denial letter

• A copy of the member‘s consent if the provider is appealing on behalf of the member

A member‘s physician is generally contacted when a member initiates a pharmaceutical medical appeal. The Medicaid and Medicare Appeal processes described above will be followed in the event of a pharmaceutical appeal.

A member may request prior authorization for a medication not included on the Plan formulary in an effort to obtaincoverage for the medication. In this scenario, while awaiting a prior authorization determination, UnitedHealthcare provides clients with a 72-hour supply of medication, whether those prescriptions are included on the formulary or not. Existing UnitedHealthcare members may continue taking a medication that has been removed from the formulary for as long as that member is enrolled in UnitedHealthcare (unless the medication has been deemed unsafe) with valid medical reasoning from the member‘s prescribing provider, and with the member‘s consultation and agreement. A member may change his or her medication to a medication that is on UnitedHealthcare‘s formulary only if the prescribing provider and member agree to that change. Members new to therapy will be required to use a medication on the formulary.



Chapter 17: Quality Management Program

OverviewUnitedHealthcare is committed to its mission of improving the quality of members‘ lives by elevating their health status. To achieve this goal, UnitedHealthcare has implemented a systematic, inter-departmental, organization-wide approach to quality improvement.

The purpose of the UnitedHealthcare Quality Management (QM) Program is to assure the delivery of quality and cost- effective care to all members. UnitedHealthcare achieves this by working with providers in a program of continuous quality improvement that identifies opportunities for improvement and makes changes as necessary.

The UnitedHealthcare Board of Directors has overall responsibility for the QM program. Responsibility for the broad range of activities associated with the quality program has been delegated to the Chief Medical Office . A Quality Management Committee, composed of participating providers and senior staff, directs the QM process. Members are considered essential partners in the delivery of quality care, and member satisfaction is a key measurementof quality.

All providers and practitioners are required to participate in and cooperate with the UnitedHealthcare Quality Management program. The UnitedHealthcare Quality Management program is allowed to use practitioner and provider performance data to conduct quality activities.

Providers interested in learning more about any of the QM processes or initiatives should contact their Provider Services Representative or Provider Services at 888-DOC-DENT (888-362-3368).

The Quality Management ApproachThe QM process consists of three basic components:

• Customer knowledge and involvement—understanding our customers and their involvement in the delivery of quality services

• A focus on the evaluation of health care delivery systems and processes

• The use of qualitative and quantitative analyses to identify and reduce variations in care

Monitoring and Improving Quality of CareThe UnitedHealthcare QM Program comprises a comprehensive set of activities to help ensure that providers deliver accessible, appropriate, high quality health care in a timely manner. Processes used to monitor and improve quality include the following:

• A thorough and rigorous initial credentialing process which includes verification of a provider‘s credentials, accessing the National Practitioner Data Bank and state agencies, on-site reviews of medical record documentation practices, and on-site review of provider facilities

• A recredentialing process performed every three years to help ensure that the circumstances under which the provider was originally credentialed have not changed and that there is documented evidence of the provision of quality care.

• Ongoing audits of PCP and obstetrical practices to assess availability and accessibility of:

– After-hours coverage by medical professionals

– Appointments for urgent and routine care

• Tracking and trending of member grievances

• On-site chart audits of certain types of providers, including behavioral health providers, to help ensure that providers are in compliance with the Medical Record Documentation Standards

• Annual HEDIS and chart audits

• Annual member satisfaction surveys

• Evaluation of providers‘ actions to improve the quality of care and service

• Distribution of profiles to certain participating providers contrasting individual utilization patterns to other similar participating physicians

Quality Concerns and Corrective ActionsAll confirmed quality issues are subject to corrective action, including provider sanctions, as appropriate. The QM staff review monitoring activities for potential quality concerns on an ongoing basis and refer potential quality concerns to aUnitedHealthcare medical director. When a quality concern is identified, the QM staff notifies the appropriate provider (s) and


requests a response, along with any supporting documentation, within a specified period of time. A second opinion by a specialist may be requested, if deemed appropriate. Upon receipt of a response, a medical director assigns a severitylevel as follows:

0 – No quality issue identified; no adverse member outcome

1 – Quality issue identified; appears to have not contributed any harm or damage to the member

2 – Quality issue identified; appears to have contributed to non-permanent harm or damage to the member

3 – Quality issue identified; appears to have contributed to permanent harm or damage to the member (not recoverable), including death

If a quality concern is confirmed, the issue is presented to the Provider Advisory Committee (PAC) for peer review. The PAC will make a final determination regarding the quality concern, assign the final severity level, and make recommendations for further action to be taken by UnitedHealthcare. The Medical Director notifies the appropriate provider(s) of the decision in writing through certified mail. The letter includes a description of the quality concern and detailed action plan.

Sanctions for Quality ConcernsIn addition to the corrective action plan, UnitedHealthcare may impose provider sanctions, depending upon the severity level and frequency of the provider‘s confirmed quality problems and/or failure of the provider to implement the corrective action steps required by UnitedHealthcare.

The care provider‘s failure to implement the corrective action plan within 60 days may result in a 30-day closure of the care provider‘s panel to new members or other pertinent actions. Failure to implement the corrective action within the time period specified by UnitedHealthcare may result in issuance of a Notice of Termination.

As part of the corrective action and based on the frequency and severity of the identified quality issue, a Medical Director may require the provider to obtain additional education, including:

• CME courses pertaining to the identified problem

• Medical literature reading

• Charting conferences

• Self-examination courses

The care provider is given a specified period to complete the appropriate educational plan. Failure to do so may result in the issuance of a Notice of Termination.

Failure to comply with sanctions noted above could result in UnitedHealthcare notifying the appropriate federal, state, and licensing authorities of the care provider‘s actions.

Termination and Appeal ProcessUnitedHealthcare may terminate a care provider‘s participation in the network for failure to comply with certain contractual obligations or Quality Management requirements. Depending on the circumstances, termination may be immediate or allow for an appeals process.

UnitedHealthcare may not suspend or terminate a provider solely because the care provider:

• Acted as an advocate for a member in seeking appropriate, medically necessary health care services

• Filed a or appeal as permitted under the provider‘s agreement with UnitedHealthcare or any applicable law or regulation

• Expressed disagreement with UnitedHealthcare‘s decision to deny or limit benefits to a member or because provider assists such member to seek reconsideration of UnitedHealthcare‘s decision, or because provider discusses with a current, former, or prospective patient any aspect of such patient‘s medical condition, any proposed treatments, or treatment alternatives, whether or not covered by UnitedHealthcare, policy provisions of UnitedHealthcare, or provider‘s personal recommendation regarding selection of a health plan based on provider‘s personal knowledge of the health needs of such patient

• Engaged in medical communications, either explicit or implied, with a patient about medically necessary treatment options, or because provider practiced provider‘s profession in providing the most appropriate treatment required by provider‘s patients, and provided informed consent within the guidelines of the law, including possible positive and negative outcomes of the various treatment modalities



Immediate TerminationUnitedHealthcare may immediately terminate a provider‘s participation in the network if one of the following events occurs:

• The care provider fails to maintain any of the licenses, certifications or accreditations required by the provider‘ agreement with UnitedHealthcare or by the Medicare and Medicaid programs

• The care provider is indicted, arrested for, or convicted of a felony or any criminal charge related to the practice of their profession

• The care provider becomes insolvent or voluntarily or involuntarily files for bankruptcy, assignment for the benefit of creditors, appointment of a receiver, or similar relief

• UnitedHealthcare determines that immediate termination of the provider‘s agreement with UnitedHealthcare is in the best medical interest of the members

• A state licensing board or other agency has made a determination that limits, impairs, or otherwise encumbers the care provider‘s ability to practice their profession

• The Centers for Medicare and Medicaid Services determines that the provider has not satisfactorily performed his/her obligations under the care provider‘s agreement with UnitedHealthcare

• There has been a determination of fraud against the care provider

• The care provider is terminated or suspended by the State of New Jersey Medicaid Program or the federal Medicare Program

In case of immediate termination, UnitedHealthcare will notify the care provider in the most expeditious manner and by certified letter.

Termination for Failure to Comply With Quality Management RequirementsThe Quality Management Committee, based upon recommendations made by the Provider Affairs Subcommittee, may suspend or terminate any health care provider‘s participation in the network.

UnitedHealthcare may initiate termination proceedings regarding a provider‘s network participation for several reasons, including failure to implement and comply with his/


her corrective action plan, refusal to make medical records available for examination, failure to submit recredentialing information, or failure to comply with and participate in the quality management program. In the case of termination for failure to comply with Quality Management requirements,a Medical Director will send the provider a certified letter notifying him/her of the intent to terminate his/her network participation privileges.

Notice of Proposed ActionThe notice of proposed action will contain the following information:

• Notification that a professional review action has been recommended against the provider

• The reasons for the proposed action and any supplemental materials.

• Notification that the provider may request a hearing within 10 business days from receipt of the notice; failure to request the hearing will make the termination notice final

Notice of Hearing• After receipt of a provider‘s request for hearing, a notice

of hearing together with any supplemental materials will be served upon the provider.

• If a provider requests a hearing within 10 business days, UnitedHealthcare will notify the provider of the place, time and date of the hearing. The date of the hearing will be no later than 30 days after the request for a hearing, unless otherwise agreed to by the provider and UnitedHealthcare.

• UnitedHealthcare will include a list of the witnesses (if any) expected to testify at the hearing on behalf of the Quality Management Committee.

Time of Filing a Response• At least five business days prior to the hearing, the

provider must file a written response to the Termination Notice.

• It must be filed with UnitedHealthcare to the person and address identified in the Termination Notice, and a copy served upon each attorney of record and upon each party not represented by an attorney.

• It must be in writing, the original being signed by the provider or their representative. The care provider‘s response must contain the provider‘s address, telephone number and, if made by an attorney or if the care


provider will make use of an attorney, the name and post office address and telephone number of the attorney .

• It must contain a separate and specific response to each and every particular of the Termination Notice or a denial of any knowledge or information thereof sufficient to form a belief

• Any allegation in the Termination Notice which is not denied, will be deemed admitted.

• If the care provider fails to respond to the Termination Notice, the Termination Notice will be deemed final

Hearings:Appearances

• All parties to the proceeding may be present and must be allowed to present testimony in person or by counsel and call and question witnesses.

• If a respondent fails to appear at the duly noted time and place of the hearing and the hearing is not adjourned, irrespective of whether a response to the Termination Notice has been filed, the hearing must proceed on the evidence in support of the Termination Notice. Upon application, the hearing panel for good cause shown may reopen the proceeding, upon equitable terms and conditions.

• Prior to an order after hearing, a default entered upon a provider‘s failure to appear may be reopened, for good cause shown, upon written application to the hearing panel.

Conducting Hearing

• The hearing will be held before a committee appointed by a Medical Director, consisting of at least three members, a majority of whom will be the provider‘s peers in the same discipline and the same or similar specialty.

• UnitedHealthcare may where a specific panel member is not available to participate in the hearing, prior to the commencement or completion of a hearing, substitute one panel member for another. The hearing must continue upon the record of the proceeding.

Form and Content of ProofThe hearing panel, in conducting the hearing, should use any procedures consonant with fairness to elicit evidence concerning the issues before the panel. The following guidelines must govern:

• This is not an adversarial proceeding, but rather one of inquiry and clarification protected by the peer review privilege and thus confidential

• All witnesses will be sworn in at the commencement of the proceeding.

• With the permission of the hearing panel, parties will be allowed to ask clarifying questions throughout the testimony of any particular witness, thus saving hearing time and avoiding confusion on a particular subject of testimony.

• Hearsay evidence is fully admissible.

• The care provider will present evidence, testimonial and documentary first, followed by the evidence, testimonial and documentary, of UnitedHealthcare.

• UnitedHealthcare‘s representative will prepare a binder of evidentiary exhibits to be shared with the hearing panel at the time of the hearing; a copy of the binder will be sent to the provider or his/her representative prior to the hearing.

• Documentary evidence may be admitted without testamentary foundation, where reasonable.

• Witness information need not be introduced in the form of question and answer testimony.

• Information from witnesses may be introduced in the form of affidavits

• The parties have the right to call and question witnesses.

• A stenographic record will be taken of the proceedings.

• Written stipulations may be introduced in evidence if signed by the person sought to be bound thereby or by that person‘s attorney-at-law. Oral stipulations may be made on the record.

• Where reasonable and convenient, the hearing panel may permit the testimony of a witness to be taken by telephone, subject to the following conditions:

– A person within the hearing room can testify that the voice of the witness is recognized, or identity can otherwise be established;

– The hearing panel, reporter and respective attorneys can hear the questions and answers;

– The witness is placed under oath and testifies that he, or she is not being coached by any other person.



Powers of the Hearing PanelThe hearing panel has the following powers to control the presentation of the evidence and the conduct of the hearing:

• To fully control the procedure of the hearing, subject to these rules, and to rule upon all motions and objections, and to issue a final determination affirming, modifying or reversing the Notice of Termination in whole or in part including but not limited to:

– Uphold the suspension or termination

– Reinstate the provider

– Reinstate the provider subject to conditions set forth by UnitedHealthcare, which may include a corrective action plan

• To refuse to consider objections which unnecessarily prolong the presentation of the evidence;

• To foreclose the presentation of evidence that is cumulative, argumentative, or beyond the scope of the case;

• To place evidence in the record without an offer by a party;

• To call and to question witnesses;

• To have oaths administered by a notary public or stenographic reporter who is also a notary;

• To exclude non-party witnesses who have not yet testified from the hearing room;

• To direct the production of documents and other evidentiary matter;

• To propose stipulations of fact for the parties‘ consideration;

• To issue interim or tentative findings of fact at any point during the hearing process;

• To issue questions delimiting the issues for hearing;

• To direct further hearing sessions for the taking of additional evidence or for other purposes, upon the hearing panel‘s own finding that the record is incomplete or fails to provide the basis for an informed decision;

• To amend the Termination Notice to conform to the proof.

Hearing RecordThe record of the hearing may be taken by shorthand reporting, tape recording, or other reasonable method. The method chosen must be within the discretion and direction of UnitedHealthcare.

HearingsHearings will be confidential in support of the peer review privilege which governs this proceeding. The hearing panel may exclude from the hearing room or from further participation in the proceeding any person who engages in improper conductat the hearing. The hearing must be conducted with dignity and respect.

SettlementsWhere the parties agree to a settlement during the course of the hearing, they shall so stipulate on the record and the hearing will be closed on that basis.

Oral Arguments and BriefsThe hearing panel may permit the parties or their attorneys, to argue orally within such time limits as the panel may determine. The parties are free to file pre-hearing or post-hearing letter briefs or memorandum. Any such letter brief or memorandum must be filed in triplicate for distribution to the hearing panel members, with proof of service upon all counsel in the proceeding and parties appearing without counsel.

Continuations, Adjournments and Substitutions of Hearing Panel MembersUnitedHealthcare may postpone a scheduled hearing, or continue a hearing from day to day or adjourn it to a later date or to a different place, by announcement thereof at the hearing or by appropriate notice to all parties.

Time frames for Hearing Panel OrderThe hearing panel shall render a decision on the proposed action in a timely manner. Such decision shall include reinstatement of the provider by UnitedHealthcare, provisional reinstatement subject to conditions set forth byUnitedHealthcare or termination of the care provider. Such decision shall be provided in writing to the care provider. A decision by the hearing panel to terminate a provider shall be effective not less than 30 days after the receipt by the provider of the hearing panel‘s decision. Notwithstanding the termination of a provider for cause or pursuant to a hearing, the provider shall continue to participate in the plan on an ongoing course of treatment for a transition period of up to 90 days, and post-partum care, subject to provider agreement.

In no event shall termination be effective earlier than 60 days from the receipt of the notice of termination.



Reinstatement in the UnitedHealthcare Provider NetworkIf a care provider has been suspended or terminated because of quality of care issues, they will not be eligible for reinstatement in the UnitedHealthcare network until they have developed and implemented an improvement action plan acceptable to UnitedHealthcare.

If a care provider has been suspended or terminated because they have been suspended or terminated from a government-sponsored health care program, they will not be eligible for reinstatement in the UnitedHealthcare network until they are eligible for participation in the government-sponsored health care program from which they were suspended or terminated.

Expired contracts are not terminations. Non-renewals for lapsed contracts also do not constitute terminations. For contracts without expiration dates, non-renewal on January 1st after the contract has been in effect for a year or more shall not constitute a termination.

Provider Participation in Quality ManagementUnitedHealthcare has a Quality Management Committee (QMC) through which participating providers give UnitedHealthcare advice and expert counsel in medical policy, quality management, and quality improvement. A Medical Director chairs the QMC, which meets on a regular basis and has oversight responsibility for issues affecting health services delivery. The QMC is composed of participating providersand UnitedHealthcare management staff and reports its recommendations and actions to the UnitedHealthcare Board of Directors.

The Quality Management Committee has five standing subcommittees:

• Provider Affairs Advisory Committee reviews and recommends action on topics concerning credentialing and recredentialing of providers and facilities, peer review activities, and performance of all participating providers.

• Community Advisory Committee provides an avenue for member and consumer advocate involvement in the overall quality program including member education, satisfaction and customer service.


• Health Care Quality Utilization Management Subcommittee reviews statistics on utilization, provides feedback on Utilization Management and Care Management policies and procedures, and makes recommendations on clinical standards and protocols for medical care.

• Dental Affairs Advisory Committee reviews all policies and procedures related to the clinical management and utilization of dental services. This subcommittee also oversees peer review and credentialing related to the dental network.

• Service Quality Improvement Subcommittee reviews timely tracking, trending and resolution of member administrative grievances. This subcommittee oversees member and practitioner intervention for quality improvement activities as needed.

The UnitedHealthcare Medical Technology Assessment Committee (MTAC) is a corporate-wide committee that periodically assesses new technology for potential inclusion in UnitedHealthcare‘s benefits packages. The committee reports to the QMC at least on a quarterly basis.


Chapter 18: Dental

The following text is from our New Jersey Dental Care Provider Manual. Read the full manual on uhcproviders.com.

Purpose/ScopeThe following guidelines are based on NJ FamilyCare provisions for medically necessary dental services for eligible United Healthcare Community Plan (UHCCP) members. UHC Dual Complete ONE members receive Medicare covered dental benefits through their Medicare enrollment and Medicaid benefits through their NJ FamilyCare A enrollment.

All Medicaid/NJ FamilyCare Members: Plans A, B, C, D, ABP, MLTSS and FIDE SNP (dual eligible Medicare/Medicaid) have the same comprehensive dental benefits which include diagnostic, preventive, restorative, endodontic, periodontal, prosthetic, oral and maxillofacial surgery and other adjunctive general services. Some procedures require prior authorization with documentation of handicapping malocclusion or medical necessity. Orthodontic services are age restricted and only approved with adequate documentation of medical necessity.Dental services are not limited to emergency services. Dental emergency services are a covered benefit which do not require prior authorization. Members that contact you for non-traumatic dental emergencies should be referred to their dentist or to Member Services for assistance for locating a dentist. Member Services can be reached at 800-941-4647 or TTY 711.

Role of Network Dental ProvidersNetwork general dentists and specialty care dentists are involved in a critical role in the dental delivery system, helping ensure that members receive appropriate access, prevention, continuity of care and treatment services. For this reason, all dentists must be available to UHCCP members 24 hours a day, seven days-a-week, and are responsible for assisting in the coordination of dental treatment services. Members have open access to network providers.

Comprehensive dental care services may be provided in the dentist‘s office, a health care facility or hospital-based practice. The dentist is reimbursed on a fee-for-service basis and agrees to maintain standards set forth in the Participating Provider Agreement. Well-maintained dental records provide documentation of care.

Dental providers shall conduct a comprehensive examination during the member’s initial appointment. All dental diagnoses should be documented by the treating dentist. Comprehensive oral evaluations shall be conducted during a member’s initial non-emergency appointment.

The primary care dentist (PCD) should communicate a diagnosis and proposed treatment to the PCP and work together to achieve optimal dental health for our members.

If the member needs specialty care, the PCD can recommend a network specialty dentist. Or the member can self-select a specialist from our provider directory, by visiting myuhc.com/communityplan > Find a Doctor > Select a state to find a plan: New Jersey > Select a Medicaid plan in New Jersey > Scroll down to Looking for Dental Providers > Choose a Dental Provider Directory. Or they may call Member Services at 800-941-4647.

Primary Care Physicians and Dental TreatmentDental screening by the PCP in this context means, at a minimum, observation of tooth eruption, occlusion pattern, presence of caries, or oral infection.

A. A referral to a dentist by one year of age or soon after the eruption of the first primary tooth is mandatory. At a minimum, a dental visit twice a year with follow-up during well-child visits helps ensure that all needed dental preventive and treatment services are provided thereafter through the age of 20.

B. A referral to a dental specialist or dentist that provides dental treatment to patients with special needs shall be allowed when a PCD requires a consultation for services by that specialty provider.

C. The NJ Smiles Program allows non-dental providers to provide dental risk assessment, fluoride varnish application and dental referral for children younger than 6 years.

Primary medical providers or PCPs may refer a member to a general dentist or dental specialist. For a list of general

https://uhcpwp.wonderboxsystem.com/PWP/Landing


Chapter 18: Dental

dentists and dental specialists, PCPs may visit myuhc.com/communityplan > Find a Doctor > Select a state to find a plan: New Jersey > Select a Medicaid plan in New Jersey > Scroll down to Looking for Dental Providers > Choose a Dental Provider Directory. Or call Provider Services at 888-362-3368. General dentists and pediatric dentists that treat patients younger than 6 years may also be found in the provider listing at myuhc.com/communityplan.

Prior AuthorizationPrior authorizations from dental providers can be submitted by calling 800-508-48881 or submission via the provider web portal at uhcproviders.com. Prior authorizations can also be mailed to: UnitedHealthcare DentalP.O. Box 2073 Milwaukee, WI 53201

Dental providers can reference the UnitedHealthcare Community Plan Dental Provider Manual for NJ FamilyCare found on uhcproviders.com for more information. For medical/surgical prior authorizations, please reference Chapter 3: Prior Authorization of this medical manual.

Specialist Referral ProcessIf a member needs specialty care, any PCP or dentist may recommend a network specialty dentist, or the member can self-select a participating network specialist. Referrals must be made to qualified specialists who are participating within the provider network. No written referrals are needed for specialty dental care.

For administrative services or a list of participating network specialists go to our website at uhcprovider.com or contact Provider Services at 800-508-4881.

All dental specialists are either New Jersey board-eligible or board-certified for that specialty and have a valid specialty permit. A dentist with certification in the following specialties must have, or have confirmation of application submission of, valid DEA and CDS certificates:

• Endodontics

• Oral surgery/OMFS

• Periodontics

• Prosthodontics

Administration of Medical or Dental ServicesUnitedHealthcare understands that there are services that can be provided by either a dentist or physician. The plan accepts prior authorization and payment requests from either qualified participating physicians or qualified participating oral surgeons and prosthodontists for procedures that may be considered either medical or dental. These include maxillofacial prosthetics and surgical procedures for fractured jaw or removal of cysts. Make physician requests through the physician portal, UHCprovider.com.

Make physician requests through the physician portal using medical codes. Send dentist requests through the dental portal using dental codes. The followingmedical services can be performed by either provider type, within the scope of their license:

• Repair of cleft palate

• Cysts removal

• Fractured jaw

• Oral and maxillofacial surgery

• Anesthesia services

Non-dentists do not perform extractions including impacted teeth; thus, these services (dental codes in the D7000 series) should be treated under the member’s dental benefit.

Additional Dental ServicesIn the event oral hygiene instruction needs to be provided to members or their family to assist the patient in maintaining oral health, or specialized hygiene equipment is needed for members, an authorization must be requested. Providers should use the appropriate miscellaneous procedure code (i.e., D1999) for the authorization request. The request should include a narrative indicating the patient’s medical necessity for these services or products. The requests will be reviewed by board-certified dental consultants who will make determinations based on the information presented and the patient’s medical necessity. UnitedHealthcare Care Managers are available to design and implement dental management plans to better oversee patient oral health.

Dental Services Provided in an Operating RoomIn the event that dental services must be provided in an

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Chapter 18: Dental

operating room (OR) setting or ambulatory surgery center due to patient medical necessity, a prior authorization must be obtained. This includes members with special health care needs and children younger than 5 years old. The treating dental provider should submit an authorization to use the Operating Room under CDT Code D9999. The authorization request should include the name of the facility. The request should also include an explanation of why an operating room is necessary. For step-by-step instructions for the prior authorization process of dental services provided in a operating room or ambulatory surgery center, please refer to the UnitedHealthcare Community Plan Dental Provider Manual for NJ FamilyCare on uhcproviders.com.

Individuals Younger Than Age 21EPSDT is New Jersey FamilyCare’s comprehensive child health program. The program’s focus is on prevention, early diagnosis and treatment of medical conditions. EPSDT is a mandatory service required to be provided under a state’s Medicaid program.

Early and Periodic Screening, Diagnostic, and Treatment (EPSDT)Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) is a Title XIX mandated program that covers screening and diagnostic services to determine physical and mental defects in enrollees younger than age 21. It covers health care, treatment, and other measures to correct or ameliorate any defects and chronic conditions discovered, pursuant to Federal Regulations found in Title XIX of the Social Security Act.

All Medicaid covered beneficiaries younger than age 21, including those receiving Managed Long Term Services and Supports (MTLSS), shall be entitled to receive any medically necessary service. This includes physician and hospital services, home care services (including personal care and private duty nursing), medical equipment and supplies, rehabilitative services, vision care, hearing services, dental care and any other type of remedial care recognized under state law or specified by the Secretary of the Department of Health and Human Services.

The need for these services shall be based upon medical necessity and shall not be limited in volume, scope or duration, regardless of established state plan or regulatory limitations. While approval for these services is determined by medical necessity, the volume, scope and duration of approved services may take the availability of other medically appropriate, cost

effective alternatives into consideration. When a Medicaid-covered beneficiary younger than age 21 requires a medically necessary service that is not listed in the state plan, the beneficiary or their legally responsible representative should contact their health plan by calling the number on their health plan member identification card so this service can be appropriately delivered and coordinated.

The EPSDT benefit provides comprehensive and preventive health care services for children younger than age 21 who are enrolled in Medicaid. EPSDT is key to ensuring that children and adolescents receive appropriate preventive, dental, mental health, and developmental, and specialty services.

NJ SmilesWe will allow non-dental providers to provide dental risk assessment, fluoride varnish application and dental referral for children through 6 years old.

• Fluoride varnish may be applied by non-dental providers who have proof of training for this service. Primary care physicians (pediatricians or physicians seeing pediatric enrollees), physician assistants and nurse practitioners can receive this training.

• Fluoride varnish application will be combined with risk assessment and referral to a dentist that treats children younger than age 6 and will be linked to well-child visits for children through 6 years old.

• These three services will be reimbursed as an all-inclusive service billed using a CPT code and can be provided up to four times a year. This frequency does not affect the frequency of this service by the dentist.

• UHCCP provides training to all PCPs on the requirement of referral to a dentist for a dental visit by 12 months of age.

• UHCCP notifies PCPs and PCDs on their referral process and required communications between these provider groups.

• UHCCP provides training to all PCDs and PCPs on prescribing fluoride supplements (based on access & use to fluoridated public water) and their responsibility in counseling parents and guardians of young children on oral health and age appropriate oral habits and safety to include what dental emergencies are and use of the emergency room for dental services.

• The caries risk assessment service shall also be allowed by the PCD and is billed using a CDT procedure code. The reimbursement will be the same regardless of the determined risk level. The risk assessment must be provided at least once per year in conjunction with an



oral evaluation service by a PCD and is linked to the provider not the member. It may be provided a second time with prior authorization and documentation of medical necessity.

To better enable the referral process, a complete listing of UnitedHealthcare dental providers who treat members younger than 6 years can be found on on myuhc.com/communityplan > Find a Doctor > Select a state to find a plan: New Jersey > Select a Medicaid plan in New Jersey > Scroll down to Looking for Dental Providers > Choose a Dental Provider Directory.

American Academy of Pediatrics (AAP) Oral Health Risk Assessment ToolThe American Academy of Pediatrics (AAP) Oral Health Risk Assessment Tool is for the use of PCPs. Developed by the American Academy of Pediatrics (AAP) and endorsed by the National Interprofessional Initiative on Oral Health, the Oral Health Risk Assessment (OHRA) Tool is easy to incorporate into any practice. The tool helps medical providers to understand the risk factors, protective factors, and clinical findings that demonstrate risk of dental caries in young children.

To download copies of the following dental assessment forms from the American Dental Association (ADA) and the American Academy of Pediatrics (AAP), please visit the following links:

• American Academy of Pediatrics (AAP) Oral Health Risk Assessment Tool - aap.org

• American Dental Association (ADA) Caries Risk Assessment Form - ada.org

• American Dental Association (ADA) Caries Risk Assessment Form older than 6 - ada.org

• NJ Orthodontic Assessment Tool for Comprehensive Treatment HLD (NJ-Mod3) - state.nj.us/humanservices/dmahs/home > Provider Newsletters & Alerts > November 2019 Newsletter Volume 29, Number 16. Find instructions at this link.

For copies of these forms, check the UnitedHealthcare Community Plan Dental Provider Manual for NJ FamilyCare Dental at uhcproviders.com.


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http://ada.org

http://ada.org

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Sticky Note

Provision for Dental Services for Members with Developmental Disabilities UnitedHealthcare will provide access for comprehensive, quality dental services for the special needs member. Emphasis will be placed on providing coordinated care and managed dental services with the goal of decreasing the member susceptibility to caries and periodontal disease. Program Goals: • Improve special needs members‘ access to quality comprehensive dental care through a network of care providers with expertise with developmental disabilities. • Coordination of access and delivery with Primary Care Provider(s) linkages and community based organizations. • Creation of dental management services and expanded benefits for comprehensive dental care within the framework of comprehensive total treatment planning and preventive care delivery. Methods to Identify Those at Risk Who Should be Referred For a Comprehensive Needs Assessment Members with Special Needs are identified in the following ways: • State Enrollment File • Call Center • Care Providers • Member/guardian • Utilization reports • Census reports • Pharmacy • Plan Selection Form (PSFs) Methods and Guidelines of Determining Specific Needs of Referred Individuals Members who are designated as having special needs should be referred to Care Management for a Comprehensive Health Status Assessment by calling 1-877-704-8871. A plan of care will be developed in conjunction with the care provider, the member, and/or the member‘s family/guardian. Allow for Continuation of Existing Relationships With Non-par Care Providers Additionally, UnitedHealthcare Community Plan provides for specialty care, diagnostic, and interventional strategies, as well as long term management of medical conditions, and continuation of out of network care providers when considered to be in the best medical interest of the member. Referrals to Special Care Facilities for Highly Specialized Care UnitedHealthcare provides access to specialty centers for diagnosis and treatment of rare disorders. Chapter 3: Prior Authorization 23 UnitedHealthcare Community Plan New Jersey 2019 UHCprovider.com/njcommunityplan © 2019 UnitedHealthcare Objectives: • The dental care management coordinator will monitor linkages with care managers, community based organizations and the Primary Care Provider to emphasize preventive education. • Quality utilization management and improvement of the program using national and internally developed benchmark standards will be monitored by the Chief Dental Officer. • Provider directories will identify dentists that meet the treatment requirements of the special needs member. • The special needs dental coordinator will assist members with special needs in all aspects of dental treatment. Requirements: • The provider network includes dentists that offer expertise in the dental management of enrollees with developmental disabilities. In addition to the covered services offered by UnitedHealthcare, special needs enrollees have the following benefit of increased frequency of visits based on the dental risk assessment. The standard allows up to four visits annually without prior authorization. All other quality utilization management and improvement benchmark standards are in effect. Emphasis is placed on establishing linkages with the Primary Care Provider, care manager, and community organizations. • Informed Consent is required from all patients with developmental disabilities or authorized legal representative/guardian before all surgical cases are treated in the operating room. • The care manager of an enrollee shall coordinate authorizations for dental required hospitalizations in conjunction with the UnitedHealthcare dental consultant team. • The special needs program will be reviewed, audited and monitored using the utilization management and quality improvement measures established by UnitedHealthcare.


Chapter 19: Managed Long Term Services & Support (MLTSS)

IntroductionThe New Jersey Managed Long Term Services and Supports (MLTSS) program is member-centric and facilitates collaboration between members and their health care teams that promote self-management, active decision- making, and participation in health care interventions and outcomes. MLTSS provides an integrated standard and consistent approach to meeting the healthcare needs of the MLTSS population and fully coordinates physical and behavioral health services.

MLTSS:1. Provides a single point of contact for the member

creating a seamless integrated healthcare experience

2. Addresses members’ values, goals of care and needs through a member centric, multidisciplinary care management approach using comprehensive interventions

3. Collaborates with members, providers, family, caregivers, and community (stakeholders) and resources

4. Individualizes each members’ economic, psychosocial, cultural, health literacy and environmental circumstances

5. Helps ensure the highest quality of care that addresses preventive health, member safety, health care disparities, and the appropriate use of healthcare services

These goals can be accomplished through the systematic process of assessing, planning, coordinating, implementing, and evaluating a member’s care using care coordination.Fully integrated care coordination helps ensure that the recipient’s acute/ chronic physical health care, behavioral health care, and MLTSS/HCBS are provided in a seamless, cohesive, and collaborative manner reducing waste, duplication, and redundancy in services.

MLTSS Eligibility and EnrollmentMLTSS Eligible PopulationEffective July 1, 2014, all individuals who are at the nursing home level of care now receive their Medicaid benefits through a Managed Care Organization. Members in a community setting are already members and will have had their home and community services managed for the first time beginning July

1, 2014. Eligibility is dependent on state approval of the results of the member’s in person assessment using the NJ Choice Tool. New custodial Medicaid/NJ FamilyCare nursing facility residents will also enroll in a Managed Care Organization. Existing residents as of 7/1/2014 will remain in fee-for-service Medicaid.

MLTSS Benefits/MLTSS ServicesMLTSS members receive the same benefits as all other UHCCP members. For a complete listing of NJ FamilyCare benefits, refer to “Section 2, Benefits” in this Manual. Additionally, the following long term servicesand supports are available to MLTSS members when the services have been determined necessary and have been approved by UHCCP:

• Adult Family Care

• Assisted Living Services (ALR, CPCH)

• Assisted Living Program - (ALP)

• TBI Behavioral Management (Group and Individual)

• Chore Services

• Cognitive Therapy (Group and Individual)

• Community Residential Services (CRS)

• Community Transition Services

• Home Based Supportive Care

• Home-Delivered Meals

• Medical Day Services

• Medication Dispensing Device: SET UP

• Medication Dispensing Device: Monthly Monitoring

• Non-Medical Transportation

• Nursing Facility Services (Custodial)

• Occupational Therapy (Group and Individual)

• Personal Emergency Response System (PERS): SET UP

• Personal Emergency Response System (PERS): Monitoring

• Physical Therapy (Group and Individual)

• Private Duty Nursing (Adult)

• Residential Modifications



• Respite (Daily and Hourly)

• Social Adult Day Care

• Specialized Medical Equipment and Supplies

• Speech, Language and Hearing Therapy (Group and Individual)

• Structured Day Program

• Vehicle Modification

Members who receive MLTSS get their behavioralhealth, mental health and substance use services from UnitedHealthcare. In addition to mental health and substance use services, UnitedHealthcare will also coordinate the following services that are not covered in MLTSS:

• Targeted Case Management

• PACT

• Statewide Clinical Outreach Program for the Elderly (SCOPE)

• Self-help centers

• Supportive housing

• Peer recovery support services

• Behavioral services covered by other sources (TPL)

The MLTSS member’s Care Manager will evaluate service needs and develop the member‘s individualized Plan of Care. HCBS services are determined based on the needsassessment and the assessment of natural supports. The Care Manager will collaborate and communicate the individual plan of care with the member’s physician.

PDN ServicesGuidelines on Limitation, Duration and Location of PDNA. The following requirements shall apply to PDN services:

1. Private duty nursing shall be provided for eligible UHCCP members in the community only and not in hospital inpatient or nursing facility settings.

2. UHCCP shall determine and approve the total PDN hours for reimbursement, in accordance with

3. N.J.A.C. 10:60-5.2(b). A maximum of 16 hours of private duty nursing services may be provided in any 24-hour period.

4. The determination of the total PDN hours approved, up

to the maximum 16 hours per 24-hour period, shall take into account alternative sources of PDN care available to the caregiver, such as medical day care or a school program.

Cost-Effectiveness of ServicesMLTSS members will most often receive the most cost effective placement which will typically be in a community setting.UHCCP care managers evaluate the cost effectiveness of the plan of care for all MLTSS members. If the cost of placement is not cost effective, the care manager will initiate anInter-Disciplinary Team (IDT) meeting to discuss the service options, review and revise the plan of care to include provisions to safeguard the member’s health and safety and shall execute a risk management agreement if necessary. When the IDT does not result in a plan of care that is agreeable to both the member and UHCCP, an MLTSS Case Conference Review is initiated. Upon the conclusion of the Case Conference a plan of care is established. If the member is not in agreement with the plan of care, s/he may follow the grievance and appeals process found in the Member Handbookl.

Provider ResponsibilityCompliance with Critical Incident Reporting

Every care provider and subcontractor must follow the Critical Incident reporting and related requirements. They also must do criminal background checks on all employees who provide direct care to enrollees in our MLTSS program.

Here are examples of Critical Incidents (must occur in a NF/SCNF, inpatient behavioral health, home and community-based long-term care service delivery setting, community alternative residential setting, adult day care centers, other HCBS provider sites or a member’s home):

• Unexpected death of a member

• Missing person or unable to contact

• Suspected or evidenced physical or mental abuse (including seclusion and restrains, both physical and chemical)

• Theft with law enforcement involvement

• Law enforcement contact

• Severe injury or fall resulting in the need for medical treatment


• Medical or psychiatric emergency, including suicide attempt

• Medication error

• Inappropriate or unprofessional conduct by a provider/ agency resulting in serious consequences involving the member

• Sexual abuse and/or suspected sexual abuse

• Neglect/Mistreatment, including self-neglect, and/or suspected abuse and neglect

• Incident likely to result in media attention

• Exploitation including financial theft, destruction of property

• Failure of member’s back-up plan

• Elopement/Wandering from home or facility

• Eviction/Loss of home

• Facility closure, with direct impact to member’s health and welfare

• Cancellation of utilities

• Natural disaster, with direct impact to member’s health and welfare

We require you to follow the mandatory training and reporting requirements listed in your MLTSS Contract and those applicable to Adult Protective Services, Office of Institutionalized Elderly, Department of Health, the Department of Children and Families and the Division of Disability Services.

Contracted MLTSS providers are required to report critical incidents to UnitedHealthcare Community Plan within one business day of the incident and conduct an internal critical incident investigation and submit a report on the investigation to UnitedHealthcare Community Plan within the timeframes specified. The timeframe for submitting the report shall be as soon as possible, may be based on the severity of the incident, and, except under extenuating circumstances, shall be no more than 30 calendar days after the date of the incident.

UnitedHealthcare Community Plan shall review the provider’s report and follow-up with the provider as necessary to help ensure that an appropriate investigation was conductedand corrective actions were implemented within applicable timeframes.

Compliance with Unable to Contact requirementsUnable to Contact shall be defined as an MLTSS member who

is absent, without notification, from a program or service offered and MLTSS provider is unable to identify the location of the member using contact information available. In the event that an MLTSS member is unable to be contacted, MLTSS care providers must take the following steps in investigating and reporting unable to contact events:

1. Immediate outreach to the client using contact information on file

2. If no response, immediate outreach to emergency contact(s) for the member.

3. If unsuccessful to the above, immediately notify the member’s MLTSS Care Manager.

Compliance with Gap in Care requirementsA Gap in Care shall be defined as the difference between the number of hours or services scheduled in a member’s plan of care and the hours or services that are actually delivered to that member. When a care provider is aware of an upcoming gap in care, it is required to contact the member before the scheduled service to advise him/her that the regular caregiver will be unavailable, that the member may choose to receive the service from a back- up substitute caregiver, at an alternative time from the regular caregiver or from an alternate caregiver from the member’s informal support system.

Whenever there is a gap in services, the provider must contact the member immediately, acknowledging the gap and provide an explanation as to the reason for the gap, and the alternative plan being created to resolve the particular gap and any likely future gaps. The provider must also notify the member’s MLTSS Care Manager of any gaps in care.

In addition to the general Provider Responsibilities listed in Chapter 12 in this Provider Manual, the following are service requirements for HCBS (Home and Community Based Services):

• Services are provided in accordance with the plan of care including the amount, frequency, duration, and scope of each service in accordance with the member’s service schedule.

• In the event a member is admitted to the hospital, MLTSS care providers can reach NJ MLTSS Prior Authorization Intake at 800-262-0305.

• Care providers must notify UHCCP within 24 hours when any authorized non-MLTSS service has not been provided to the member. For more information providers may reference the Prior Authorization section below and Chapter 3 in this Provider Manual.



• If there is a gap in MLTSS services, the care provider must contact the member immediately. Care providers must acknowledge the gap and provide an explanation including an alternative plan to resolve. The care provider must also notify the member’s MLTSS Care Manager of any gaps.

• A Gap in Care is defined as the difference between the number of hours or services scheduled in a member’s plan of care and the hours or services that are actually delivered to that member. When a care provider is aware of an upcoming gap in care, it is required to contact the member before the scheduled service to advise him/her that the regular caregiver will be unavailable, that the member may choose to receive the service from a back-up substitute caregiver, at an alternative time from the regular caregiver or from an alternate caregiver from the member’s informal support system.

• Care providers must be compliant with Unable to Contact requirements.

• Unable to Contact is defined as an MLTSS member who is absent, without notification, from any program or service offered and MLTSS care provider is unable to identify the location of the member using contact information available. In the event that an MLTSS member is unable to be contacted, MLTSS care providers must take the following steps in investigating and reporting unable to contact events:

a. Immediate outreach to the client using contact information on file.

b. If no response, immediate outreach to emergency contact(s) for member.

c. If unsuccessful to the above, immediately notify the member’s MLTSS Care Manager.

• HCBS care providers must comply with critical incident reporting and management requirements outlined in the MLTSS Provider Critical Incident Reporting section.

Prior AuthorizationFor MLTSS services (including Personal Care Assistant Services and Adult/Pediatric Medical Day Care Services), providers should call or fax the LTC Intake Prior Authorization Form to the number indicated below.

Prior Authorization – 24 hrs / seven days a week – Listen to prompts. You can fax requests to 855-583-4041 or 855-489-1553 or call in requests to 800-262-0305.

Background Check RequirementsYou must comply with N.J.S.A. 45:1-30 et seq. requiring a criminal history background check for every person whopossesses a license or certificate as a health care professional. All care providers who provide direct support and/or services to MLTSS members must have policies and procedures that demonstrate compliance with state requirements to have apre-employment criminal history check and/or background investigation on all staff members. All employees and/or agents of a provider or subcontractor and all care providers who provide direct care must have a criminal background check as required by federal and state law.

Nursing facilities shall continue to perform background checks in accordance with Health Facilities survey and CMS survey requirements.

MLTSS Provider Critical Incident ReportingCompliance with Critical Incident Reporting Pursuant to the state managed care contract and all applicable federal and state regulations, every care provider and subcontractor must comply with Critical Incident reporting and related requirements.

Critical Incidents include, but are not limited to, the following when they occur in a NF/SCNF, inpatient behavioral health, home and community-based long-term care service delivery setting, community alternative residential settings, adult day care centers, other HCBS provider sites, and a member’s home:

1. Unexpected death of a member;

2. Missing person or unable to contact;

3. Suspected or evidenced physical or mental abuse (including seclusion and restrains, both physical and chemical);

4. Theft with law enforcement involvement;

5. Law enforcement contact;

6. Severe injury or fall resulting in the need for medical treatment;

7. Medical or psychiatric emergency, including suicide



attempt;

8. Medication error;

9. Inappropriate or unprofessional conduct by a provider involving the member;

10. Sexual abuse and/or suspected sexual abuse; and

11. Abuse and neglect, including self-neglect, and/or suspected abuse and neglect.

12. Incident likely to result in media attention

All care providers and subcontractor are required to fully adhere to the mandatory training and reporting requirements set forth in Section 9 of the state managed care contract and those applicable to Adult Protective Services, Office ofInstitutionalized Elderly, Department of Health, the Department of Children and Families and the Division of Disability Services including, but not limited to:

1. N.J.A.C. 8:39- 9.4

2. N.J.A.C. 8:36-5.10(a)

3. N.J.A.C. 8:43F-3.3

4. N.J.A.C. 8:43J-3.4

5. N.J.S.A. 52:27D-409

6. N.J.A.C. 8:57 Contracted MLTSS care providers are required to conduct an internal critical incident investigation and submit a report on the investigation to UnitedHealthcare Community Plan within the timeframes specified. The timeframe for submitting the report shall be as soon as possible, may be based on the severity of the incident, and, except under extenuating circumstances, shall be no more than 30 calendar days after the date of the incident. UnitedHealthcare Community Plan shall review the provider’s report and follow-up with the care provider as necessary to help ensure that an appropriate investigation was conducted and corrective actions were implemented within applicable timeframes.

MLTSS Claims

• You must include your National Provider Identifier (NPI) when submitting claims.

• A-typical providers (non-medical service providers) who do not have NPI numbers must include their Medicaid Number (if applicable) and Tax ID number when submitting claims.

• MLTSS care providers may call 888-702-2168 for MLTSS claims/service issues.

• Nursing facility and assisted living providers are responsible for collecting patient payment liability from residents. The patient payment liability for cost of care is that portion of the cost of care that NF residents must pay based on their Available Income as determined and communicated by the County Welfare Agency. Collection of both the room and board and patient payment liability for the cost of care is delegated to the provider. UHCCP will pay claims net of the applicable patient liability amount.

• Claims for certain MLTSS providers will be processed according to the following timeframes:

1. 90% of HIPAA compliant electronically submitted clean claims shall be processed within 15 calendar days of receipt;

2. 90% of manually submitted clean claims shall be processed within 30 calendar days of receipt; and

3. 99.5% of all claims shall be processed within 45 calendar days of receipt.

• For additional guidance on Claims Policies and Procedures refer to Chapter 5.

Provider Credentialing/VerificationParticipation in the UHCCP MLTSS Provider Network requires satisfaction of application and credentialing/verification requirements.

HCBS MLTSS ProvidersParticipation and Credentialing:

To reach MLTSS Provider Relations, please contact the call center at 888-702-2168 or reach out to your Provider Relations Advocate.

To request participation and credentialing for MLTSS care providers:

• Please email UHCCP at [email protected] or contact your regional Provider Relations Advocate. In addition, you may contact the MLTSS Provider Call Center at 888-702-2168 and follow the prompts below:

– Enter Tax ID

– Select “Option 5”



– Select “credential”

– Select “medical”

– Select “Join the network”UHCCP requires the following:

1. Medicaid ID issued by NJ FamilyCare/Medicaid

2. Completed application

3. Licensure for the services listed in the application

4. General/comprehensive liability Insurance

5. Procedures governing financial responsibility and documentation of sufficient cash flow for three months financial statements, and no filing or history of bankruptcy in the last seven years

6. Documented methods to monitor and review services and to assure quality of care

7. Monthly verification that agency and/or employees have not been excluded from Medicare/Medicaid participation

8. Evidence of compliance with all applicable laws and regulations, including Workman’s Compensation and unemployment insurance and general liability insurance

9. For agency and employees, no felonies or listings on abuse and sex offender registries

10. Documentation of staff member background checks, qualifications, trainings, and certification

11. Membership of Board of Directors

12. Documented service delivery assurances

13. Compliance with HIPAA requirements

14. Accurate completion of a Disclosure of Ownership and Control Interest Statement and disclosure of ownership information at any time upon request

15. Submission of a W-9 Form

16. Signed attestation for the accuracy and completion of all required forms

17. Submission of adequate Proof of Liability insurance ($500,000)

18. Standards Assessment and Documentation Review

Providers currently credentialed with UHC who would like to request UHCCP NJ FamilyCare participation should call the MLTSS Provider Call Center at 888-702-2168 and follow the prompts below:

• Enter Tax ID


• Request to speak with a Network Management representative for Nursing Facility contract

• Provider must submit the signed disclosure forms and Medicaid Provider Number with signed contract

To check Credentialing Application Status:

• Call United Voice Portal at 877-842-3210

• Select “HealthCare Professional Services”

• Select “Credentialing”

• Select “Get Status”

• You can also contact a MLTSS Provider Relations Advocate by phone at (888) 702-2168 or by email at [email protected]

UHCCP will require the following:

• Completed Application

• Licensed as appropriate for the service being contracted

• Proof of accreditation or Medicare certification

• Site visit required only if there is not Medicare certification or accreditation by an approved entity.

• Meet qualifications at outlined in the credentialing plan under CMS and NCQA

• Monthly verification that agency and/or employees have not been excluded from Medicare/Medicaid participation

• Evidence of compliance with all applicable laws and regulations, including Workman’s Compensation and unemployment insurance and general liability insurance

• For agency and employees, no felonies or listings on abuse and sex offender registries

• Documentation of verifying financial capacity to operate

• Documented service delivery assurances

• Compliance with HIPAA requirement

• Accurate completion of a Disclosure of Ownership and Control Interest Statement and disclosure of Ownership information at any time up on request.

• Submission of a substitute W-9 Form

• Signed attestation for the accuracy and completion of all required forms

• Assignment of a valid Medicaid number

• Site visits to help ensure adequate record keeping

• Standards assessment and documentation review

mailto:NJ_MLTSS_CRED%40uhc.com?subject=


Demographic Changes:Providers must notify UHCCP of demographic changes 30 days prior to the change becoming effective. Examples of such changes include location, telephone number, license changes, Tax Identification Number, or panel status changes.

To notify UHCCP of demographic changes email your requests to [email protected].

Change requests should include return contact information as well as any applicable documentation required as proof of demographic change.

mailto:NJ_MLTSS_CRED%40uhc.com?subject=


Chapter 20: Glossary

ABD — The Aged, Blind, and Disabled population of the NJ FamilyCare/Medicaid Program.

Abuse (as in Fraud, Waste and Abuse) — means provider practices that are inconsistent with sound fiscal, business, or medical practices, and result in an unnecessary cost to the Medicaid/NJ FamilyCare program, or in reimbursement for services that are not medically necessary or that fail to meet professionally recognized standards for health care. It also includes enrollee practices that result in unnecessary cost to the Medicaid/NJ FamilyCare program.

AFDC or AFDC/TANF — Aid to Families with Dependent Children administered by counties under State supervision. For cash assistance, it is now called “TANF.” For Medicaid, the former AFDC rules still apply.

Affordable Care Act (ACA) — Federal health reform statute signed into law in March 2010, also known as the Patient Protection and Affordable Care Act.

Alternative Benefit Plan (ABP) — Benefit package for individuals in the new adult group (Medicaid Expansion) under the Affordable Care Act (ACA). Section 1937 Medicaid Benchmark or Benchmark Equivalent Plans are now called Alternative Benefit Plans (ABPs). ABPs must cover the 10 Essential Health Benefits (EHB) as described in section 1302(b) of the ACA.

Ameliorate — to improve, maintain, or stabilize a health outcome, or to prevent or mitigate an adverse change in health outcome.

Anticipatory Guidance — the education provided to parents or authorized individuals during routine prenatal or pediatric visits to prevent or reduce the risk to their fetuses or children developing a particular health problem.

Appeal — a request for review of an action.

Authorized Person or Authorized Representative — in general means a person authorized to make medical determinations for an enrollee, including, but not limited to, enrollment and disenrollment decisions and choice of a PCP. For individuals who are eligible through the Division of Child

Protection and Permanency (DCP&P), Department of Children and Families (DCF), the authorized person is authorized to make medical determinations, including but not limited to enrollment, disenrollment and choice of a PCP, on behalf of or in conjunction with individuals eligible through DCP&P/DCF. These persons may include a foster home parent, an authorized health care professional employee of a group home, an authorized health care professional employee of a residential center or facility, a DCP&P/DCF employee, a pre-adoptive or adoptive parent receiving subsidy from DCP&P/DCF, a natural or biological parent, or a legal caretaker. For individuals who are eligible through the Division of Developmental Disabilities (DDD), the authorized person may be one of the following:

A. The enrollee, if he or she is an adult and has the capacity to make medical decisions;

B. The parent or guardian of the enrollee, if the enrollee is a minor, or the individual or agency having legal guardianship if the enrollee is an adult who lacks the capacity to make medical decisions;

C. The Bureau of Guardianship Services (BGS); or

D. A person or agency who has been duly designated by a power of attorney for medical decisions made on behalf of an enrollee.

Regarding MLTSS Members, authorized representative means a person or entity empowered by law, judicial order or power of attorney, or otherwise authorized by the MLTSS Member to make decisions on behalf of the Member.

Beneficiary — any person eligible to receive services in the New Jersey Medicaid/NJ FamilyCare program.

Capitation — a contractual agreement through which a Contractor agrees to provide specified health care services to enrollees for a fixed amount per month.

Care Management — a set of enrollee-centered, goal-oriented, culturally relevant, and logical steps to assure that an enrollee receives needed services in a supportive, effective, efficient, timely, and cost-effective manner. Care management emphasizes prevention, continuity of care, and coordination of care, which advocates for, and links enrollees to, services as necessary across providers and settings. At a minimum, Care


Management functions must include, but are not limited to:

1. Early identification of enrollees who have or may have special needs,

2. Assessment of an enrollee’s risk factors,

3. Development of a plan of care,

4. Referrals and assistance to help ensure timely access to providers,

5. Coordination of care actively linking the enrollee to providers, medical services, residential, social, and other support services where needed,

6. Monitoring,

7. Continuity of care, and

8. Follow-up and documentation.

Care management is driven by quality-based outcomes such as: improved/maintained functional status, improved/maintained clinical status, enhanced quality of life, enrollee satisfaction, adherence to the care plan, improved enrollee safety, cost savings, and enrollee autonomy.

Case Management — case management, a component of Care Management, is a set of activities tailored to meet a Member’s situational health-related needs. Situational health needs can be defined as time-limited episodes of instability. Case managers will facilitate access to services, both clinical and non-clinical, by connecting the Member to resources that support him/her in playing an active role in the self-direction of his/her health care needs.

As in Care Management, case management activities also emphasize prevention, continuity of care, and coordination of care. Case management activities are driven by quality-based outcomes such as: improved/maintained functional status; enhanced quality of life; increased Member satisfaction; adherence to the care plan; improved Member safety; and to the extent possible, increased Member self-direction.

Care Plan — based on the comprehensive needs assessment, and with input from the Member and/or caregiver and PCP, the HMO Care Manager must jointly create and manage a care plan with short/long-term Care Management goals, specific actionable objectives, and measureable quality outcomes individually tailored to meet the identified care/case management needs. The care plan should be culturally appropriate and consistent with the abilities and desires of the Member and/or caregiver. The Care Manager must also

continually evaluate the care plan to update/change it in accordance with the Members’ needs.

Centers for Medicare and Medicaid Services (CMS) — formerly the Health Care Financing Administration (HCFA) within the U.S. Department of Health and Human Services.

Children with Special Health Care Needs — those children who have or are at increased risk for chronic physical, developmental, behavioral, or emotional conditions and who also require health and related services of a type and amount beyond that required by children generally. This includes all children who are MLTSS Members.

Chronic Illness (Chronic) — a disease or condition of long duration (repeated inpatient hospitalizations, out of work or school at least three months within a twelve-month period, or the necessity for continuous health care on an ongoing basis), sometimes involving very slow progression and long continuance. Onset is often gradual and the process may include periods of acute exacerbation alternating with periods of remission.

Clinical Peer (peer) — a physician or other health care professional who holds a non-restricted license in New Jersey and is in the same or similar specialty as typically manages the medical condition, procedure, or treatment under review.

Cognitive Rehabilitation Therapy — a systematic, functionally oriented service of therapeutic cognitive activities based on an assessment and an understanding of the behavior of a person served. Services are directed to achieve functional improvement by:

1. Reinforcing, strengthening, or reestablishing previously learned patterns of behavior; or

2. Establishing new patterns of cognitive activity or mechanisms to compensate for impaired neurological systems.

Comprehensive Orthodontic Treatment — the utilization of fixed orthodontic appliances (bands/brackets and arch wires) to improve the craniofacial dysfunction and/or dentofacial deformity of the patient. Active orthodontic treatment begins with banding of teeth or when tooth extractions are initiated as the result of and in conjunction with an authorized orthodontic treatment plan.



Condition — a disease, illness, injury, disorder, or biological or psychological condition or status for which treatment is indicated.

Consultation — A referral between different provider types or referral from a PCP or PCD to a specialist or in the case of dentistry, to a dentist that provides dental services to special needs patients. A member cannot be denied access to the consultation or when needed to medically necessary services provided by that specialty provider.

Contested Claim — a claim that is denied because the claim is an ineligible claim, the claim submission is incomplete, the coding or other required information to be submitted is incorrect, the amount claimed is in dispute, or the claim requires special treatment.

Continuity of Care — the plan of care for a particular enrollee that should assure progress without unreasonable interruption.

Credentialing — the Contractor’s determination as to the qualifications and ascribed privileges of a specific provider to render specific health care services.

Critical Incident — an occurrence involving the care, supervision, or actions involving a Member that is adverse in nature or has the potential to have an adverse impact on the health, safety, and welfare of the Member or others. Critical incidents also include situations occurring with staff or individuals or affecting the operations of a facility/institution/school.

Dental records – the complete, comprehensive records of dental services, to include chief complaint, treatment needed and treatment planned to include charting of hard and soft tissue findings, diagnostic images to include radiographs and digital views and to be accessible on site of enrollees participating dentist and in the records of a facility for enrollees in a facility.

Developmental Disability — a severe, chronic disability of a person which is attributable to a mental or physical impairment or combination of mental and physical impairments; is manifested before the person attains age 22; is likely to continue indefinitely; results in substantial functional limitations in three or more of the following areas of major life activity: self-care, receptive and expressive language, learning, mobility, self-direction, capacity for independent living and economic self-sufficiency; and reflects the person’s need for

a combination and sequence of special, interdisciplinary, or generic care, treatment, or other services which are lifelong or of extended duration and are individually planned and coordinated. Developmental disability includes but is not limited to severe disabilities attributable to an intellectual disability, autism, cerebral palsy, epilepsy, spina bifida and other neurological impairments where the above criteria are met.

Diagnostic Services — any medical procedures or supplies recommended by a physician or other licensed practitioner of the healing arts, within the scope of his or her practice under State law, to enable him or her to identify the existence, nature, or extent of illness, injury, or other health deviation in an enrollee.

Disability — a physical or mental impairment that substantially limits one or more of the major life activities for more than three months a year.

Disability in Adults — for adults applying under New Jersey Care Special Medicaid Programs and Title II (Social Security Disability Insurance Program) and for adults applying under Title XVI (the Supplemental Security Income [SSI] program), disability is defined as the inability to engage in any substantial gainful activity by reason of any medically determinable physical or mental impairment(s) which can be expected to result in death or which has lasted or can be expected to last for a continuous period of not less than 12 months.

Disability in Children — a child under age 18 is considered disabled if he or she has a medically determinable physical or mental impairment(s) which results in marked and severe functional limitations that limit the child’s ability to function independently, appropriately, and effectively in an age-appropriate manner, and can be expected to result in death or which can be expected to last for 12 months or longer.

Disenrollment — the removal of an enrollee from participation in the Contractor’s plan, but not from the Medicaid program.

Division of Developmental Disabilities (DDD) — a Division within the New Jersey Department of Human Services that provides evaluation, functional and guardianship services to eligible persons. Services include residential services, family support, contracted day programs, work opportunities, social supervision, guardianship, and referral services.

Division of Disability Services (DDS) — a Division within the Department of Human Services that promotes the maximum



independence and participation of people with disabilities in community life. The DDS administers seven Medicaid waiver programs, the work incentives Medicaid buy-in program, the New Jersey personal assistance services program (PASP) and the New Jersey cash and counseling demonstration program.

Division or DMAHS — the New Jersey Division of Medical Assistance and Health Services within the Department of Human Services which administers the contract on behalf of the Department.

DOBI — the New Jersey Department of Banking and Insurance in the executive branch of New Jersey State government.

DOH — the New Jersey Department of Health in the executive branch of New Jersey State government. Its role and functions are delineated throughout the contract.

Dual Eligible — individual covered by both Medicaid and Medicare.

Durable Medical Equipment (DME) — equipment, including assistive technology, which: a) can withstand repeated use; b) is used to service a health or functional purpose; c) is ordered by a qualified practitioner to address an illness, injury or disability; and d) is appropriate for use in the home or work place/school.

Early and Periodic Screening, Diagnostic and Treatment (EPSDT) — a Title XIX mandated program that covers screening and diagnostic services to determine physical and mental defects in enrollees under the age of 21, and health care, treatment, and other measures to correct or ameliorate any defects and chronic conditions discovered, pursuant to Federal Regulations found in Title XIX of the Social Security Act.

Early and Periodic Screening, Diagnostic and Treatment/Private Duty Nursing (EPSDT/PDN) Services — the private duty nursing services provided to all eligible EPSDT beneficiaries under 21 years of age who live in the community and whose medical condition and treatment plan justify the need. Private duty nursing services are provided in the community only, and not in hospital inpatient or nursing facility settings. See Appendix B 4.1 for eligibility requirements.

Effective Date of Disenrollment — the last day of the month in which the enrollee may receive services under the Contractor’s plan.

Effective Date of Enrollment — the date on which an enrollee can begin to receive services under the Contractor’s plan.

Elderly Person — a person who is 65 years of age or older.

Emergency Medical Condition — a medical condition manifesting itself by acute symptoms of sufficient severity, (including severe pain) such that a prudent layperson, who possesses an average knowledge of medicine and health, could reasonably expect the absence of immediate medical attention to result in placing the health of the individual (or, with respect to a pregnant woman, the health of the woman or her unborn child) in serious jeopardy; serious impairment to bodily functions; or serious dysfunction of any bodily organ or part. With respect to a pregnant woman who is having contractions, an emergency exists where there is inadequate time to effect a safe transfer to another hospital before delivery or the transfer may pose a threat to the health or safety of the woman or the unborn child.

Emergency Services — covered inpatient and outpatient services furnished by any qualified provider that are necessary to evaluate or stabilize an emergency medical condition.

Encounter — the basic unit of service used in accumulating utilization data and/or a face-to-face contact between a Member and a health care provider resulting in a service to the Member. Encounter Data — the set of encounter records that represent the number and types of services rendered to Members during a specific time period, regardless of whether the provider was reimbursed on a capitated, or fee for service basis.

Encounter Record — a single electronic record that captures and reports information about each specific service provided each time a Member visits a provider, regardless of the contractual relationship between the Contractor and provider or subcontractor and provider. Enrollee — an individual who is eligible for Medicaid/NJ FamilyCare, residing within the defined enrollment area, who elects or has had elected on his or her behalf by an authorized person, in writing, to participate in the Contractor’s plan and who meets specific Medicaid/NJ FamilyCare eligibility requirements for plan enrollment agreed to by the Department and the Contractor. Enrollees include individuals in the AFDC/TANF, AFDC/TANF-Related Pregnant Women and Children, SSI-Aged, Blind and Disabled, DCP&P/DCF, NJ FamilyCare, and Division of Developmental Disabilities/Community Care Waiver (DDD/CCW) populations.



Enrollee with Special Needs — for adults, special needs includes complex/chronic medical conditions requiring specialized health care services and persons with physical, mental/substance use disorder, and/or developmental disabilities, including persons who are eligible for the MLTSS program. See also “Children with Special Health Care Needs”.

Enrollment — the process by which an individual eligible for Medicaid voluntarily or mandatorily applies to utilize the Contractor’s plan in lieu of standard Medicaid benefits, and such application is approved by DMAHS.

Existing Provider-recipient relationship — one in which the provider was the main source of Medicaid services for the recipient during the previous year.

Fair Hearing — the appeal process available to all Medicaid Eligibles pursuant to N.J.S.A. 30:4D-7 and administered pursuant to N.J.A.C. 10:49-10.1 et seq.

Fee-for-Service or FFS — a method for reimbursement based on payment for specific services rendered to an enrollee. Fraud — an intentional deception or misrepresentation made by a person with the knowledge that the deception could result in some unauthorized benefit to him/herself or some other person. It includes any act that constitutes fraud under applicable federal or State law.

Grievance — means an expression of dissatisfaction about any matter or a complaint that is submitted in writing, or that is orally communicated and could not be resolved within five business days of receipt.

Health Care Professional — a physician or other health care professional if coverage for the professional’s services is provided under the Contractor’s contract for the services. It includes podiatrists, optometrists, chiropractors, psychologists, dentists, physician assistants, physical or occupational therapists and therapist assistants, speech-language pathologists, audiologists, registered or licensed practical nurses (including nurse practitioners, clinical nurse specialists, certified registered nurse anesthetists, and certified nurse midwives), licensed certified social workers, registered respiratory therapists, and certified respiratory therapy technicians.

Health Care Services — are all preventive and therapeutic medical, dental, surgical (including any medical or psychiatric clearances required prior to proceeding with a medical or surgical procedure), ancillary (medical and non-medical) and supplemental benefits provided to enrollees to diagnose, treat, and maintain the optimal well-being of enrollees provided by physicians, other health care professionals, institutional, and ancillary service providers. Health Insurance — private insurance available through an individual or group plan that covers health services. It is also referred to as Third Party Liability.

Health Maintenance Organization (HMO) — any entity which contracts with providers and furnishes at least basic comprehensive health care services on a prepaid basis to enrollees in a designated geographic area pursuant to N.J.S.A. 26:2J-1 et seq., and with regard to this contract is either:

A. A Federally Qualified HMO; or

B. Meets the State Plan’s definition of an HMO which includes, at a minimum, the following requirements:

1. It is organized primarily for the purpose of providing health care services;

2. It makes the services it provides to its Medicaid enrollees as accessible to them (in terms of timeliness, amount, duration, and scope) as the services are to non-enrolled Medicaid eligible individuals within the area served by the HMO;

3. It makes provision, satisfactory to the Division and Department of Banking and Insurance, against the risk of insolvency, and assures that Medicaid/NJ FamilyCare enrollees will not be liable for any of the HMO’s debts if it does become insolvent; and

4. It has a Certificate of Authority granted by the State of New Jersey to operate in all or selected counties in New Jersey.

HEDIS — Healthcare Effectiveness Data and Information Set.

HIPAA — Health Insurance Portability and Accountability Act.

Home and Community-Based Services (HCBS) — Services that are provided as an alternative to long-term institutional services in a nursing facility or Intermediate Care Facility for the Intellectually Disabled (ICF/ID). HCBS are provided to individuals who reside in the community or in certain community alternative residential settings.



Indicators — the objective and measurable means, based on current knowledge and clinical experience, used to monitor and evaluate each important aspect of care and service identified.

Insolvent — unable to meet or discharge financial liabilities.

Institutional Provider — An acute care, psychiatric or rehabilitation hospital, nursing facility.

Managed Care — a comprehensive approach to the provision of health care which combines clinical preventive, restorative, and emergency services and administrative procedures within an integrated, coordinated system to provide timely access to primary care and other medically necessary health care services in a cost effective manner.

Managed Care Organization (MCO) — an entity that has, or is seeking to qualify for, a comprehensive risk contract, and that is any public or private entity that meets the advance directives requirements and is determined to make the services it provides to its Medicaid enrollees as accessible (in terms of timeliness, amount, duration, and scope) as those services are to other Medicaid recipients within the area served by the entity.

Medical Director — the licensed physician, in the State of New Jersey, i.e. Medical Doctor (MD) or Doctor of Osteopathy (DO), designated by the Contractor to exercise general supervision over the provision of health service benefits by the Contractor.

Medical Group — a partnership, association, corporation, or other group which is chiefly composed of health professionals licensed to practice medicine or osteopathy, and other licensed health professionals who are necessary for the provision of health services for whom the group is responsible.

Medical Records — the complete, comprehensive records, accessible at the site of the enrollee’s provider, that document all physical, behavioral, dental and MLTSS services received by the enrollee, including inpatient, ambulatory, ancillary, and emergency care, prepared in accordance with all applicable DHS rules and regulations, and signed by the rendering provider. Medical Screening — an examination 1) provided on hospital property, and provided for that patient for whom it is requested or required, and 2) performed within the capabilities of the hospital’s emergency room (ER) (including ancillary services routinely available to its ER), and 3) the purpose of which is to determine if the patient has an emergency medical condition,

and 4) performed by a physician (M.D. or D.O.) and/or by a nurse practitioner, or physician assistant as permitted by State statutes and regulations and hospital bylaws.

Medically Necessary Services — services or supplies necessary to prevent, evaluate, diagnose, correct, prevent the worsening of, alleviate, ameliorate, or cure a physical or mental illness or condition; to maintain health; to prevent the onset of an illness, condition, or disability; to prevent or treat a condition that endangers life or causes suffering or pain or results in illness or infirmity; to prevent the deterioration of a condition; to promote the development or maintenance of maximal functioning capacity in performing daily activities, taking into account both the functional capacity of the individual and those functional capacities that are appropriate for individuals of the same age; to prevent or treat a condition that threatens to cause or aggravate a handicap or cause physical deformity or malfunction, and there is no other equally effective, more conservative or substantially less costly course of treatment available or suitable for the enrollee. The services provided, as well as the type of provider and setting, must be reflective of the level of services that can be safely provided, must be consistent with the diagnosis of the condition and appropriate to the specific medical needs of the enrollee and not solely for the convenience of the enrollee or provider of service and in accordance with standards of good medical practice and generally recognized by the medical scientific community as effective. Course of treatment may include mere observation or, where appropriate, no treatment at all. Experimental services or services generally regarded by the medical profession as unacceptable treatment are not medically necessary.

Medically necessary services provided must be based on peer-reviewed publications, expert pediatric, psychiatric, and medical opinion, and medical/pediatric community acceptance.

In the case of pediatric enrollees, this definition shall apply with the additional criteria that the services, including those found to be needed by a child as a result of a comprehensive screening visit or an inter-periodic encounter whether or not they are ordinarily covered services for all other Medicaid enrollees, are appropriate for the age and health status of the individual and that the service will aid the overall physical and mental growth and development of the individual and the service will assist in achieving or maintaining functional capacity.

Medicare — the program authorized by Title XVIII of the Social Security Act to provide payment for health services to federally defined populations.



Medicare Advantage (MA) Organization — means a public or private entity organized and licensed by the State as a risk-bearing entity (with the exception of provider sponsored organizations receiving waivers) that is certified by CMS and meeting the Medicare Advantage contract requirements. Member — an enrolled participant in the Contractor’s plan; also means enrollee.

Mental Health/Substance Use (MH/SA) Services — Mental health services include, but are not limited to comprehensive intake evaluation; off-site crisis intervention; family therapy; family conference; psychological testing; inpatient medical detoxification; and medication management.

MLTSS Eligibility — Applies to individuals who have been assessed for long term services and supports and have met both the financial and clinical eligibility requirements established by the State for MLTSS.

Mobile Dental Practice — Care provider traveling to various locations and using portable dental equipment to render dental services to facilities, schools and residences. These care providers provide on-site comprehensive dental care, as well as necessary dental referrals to general dentists, specialists and emergency dental care providers based on New Jersey State Board of Dentistry regulations and the New Jersey FamilyCare MCO contract. The sites that the mobile dental practice serves must allow members access to treatment and continuity of care. The MCO helps the member and facility locate a dentist when referrals are issued. Long-term care facilities and skilled nursing facilities must maintain patient records. Duplicate records may be maintained in a central and secure area based on State Board of Dentistry regulations.

Mobile Dental Van — A vehicle specifically equipped with stationary dental equipment providing dental services within the van. A mobile dental van is not a dental practice. Care providers using a mobile dental van to render dental services must also be associated with a dental practice located in a brick-and-mortar facility in New Jersey. The facility must serve as a dental home offering complete care, emergency care and appropriate dental specialty referrals to the mobile dental van’s patients of record (members). Maintain patient records in the brick-and-mortar location based on State Board of Dentistry regulations.

NCQA — the National Committee for Quality Assurance.

Newborn — an infant born to a mother enrolled in a Contractor’s plan at the time of birth.

N.J.A.C. — New Jersey Administrative Code.

NJ FamilyCare Program Eligibility Groups Include:

1. NJ FamilyCare A — means the State-operated program which provides comprehensive managed care coverage to:

• Uninsured children below the age of 19 with family incomes up to and including 142 percent of the federal poverty level;

• Pregnant women up to 200 percent of the federal poverty level;

• Beneficiaries eligible for MLTSS services.

In addition to covered managed care services, eligibles under this program may access certain other services which are paid fee-for-service by the State and not covered.

2. NJ FamilyCare B — means the State-operated program which provides comprehensive managed care coverage to uninsured children below the age of 19 with family incomes above 142 percent and up to and including 150 percent of the federal poverty level. In addition to covered managed care services, eligibles under this program may access certain other services which are paid fee-for-service and not covered under this contract.

3. NJ FamilyCare C — means the State-operated program which provides comprehensive managed care coverage to uninsured children below the age of 19 with family incomes above 150 percent and up to and including 200 percent of the federal poverty level. Eligibles are required to participate in cost-sharing in the form of a personal contribution to care for most services. Exception – Both Eskimos and Native American Indians under the age of 19 years old, identified by Race Code 3, shall not participate in cost sharing, and shall not be required to pay a personal contribution to care. In addition to covered managed care services, eligibles under this program may access certain other services which are paid fee-for-service and not covered under this contract.

4. NJ FamilyCare D — means the State-operated program which provides managed care coverage to uninsured:

• Children below the age of 19 with family incomes



between 201 percent and up to and including 350 percent of the federal poverty level.

Eligibles with incomes above 150 percent of the federal poverty level are required to participate in cost sharing in the form of monthly premiums and/or copayments for most services with the exception of both Eskimos and Native American Indians under the age of 19 years. These groups are identified by Program Status Codes (PSCs) or Race Code on the eligibility system as indicated below. For clarity, the Program Status Codes or Race Code, in the case of Eskimos and Native American Indians under the age of 19 years, related to NJ FamilyCare D non-cost sharing groups are also listed. Some of the Program Status Codes listed below can include certain restricted alien adults.

5. NJ FamilyCare ABP — means the State-operated program which provides managed care coverage to parents between 19-64 with income up to and including 133% FPL, and childless adults between 19-64 with income up to and including 133% FPL. In addition to covered managed care services, eligibles under this program may access certain other services which are paid fee-for-service by the State and not covered by the contract.

Non-Participating Provider — a provider of service that does not have a contract.

Non-Traditional Provider — An entity that qualifies as a provider of services pursuant to the approved New Jersey MLTSS criteria to address the authorized non-medical needs documented in an MLTSS Member’s plan of care.

Nursing Facility Transitions — An interdisciplinary team approach that assists individuals with transitions from Nursing Facilities to the community and helps the State to strengthen and improve community based systems of long-term care for low-income seniors and individuals with disabilities.

Outcomes — the results of the health care process, involving either the enrollee or provider of care, and may be measured at any specified point in time. Outcomes can be medical, dental, behavioral, economic, or societal in nature.

Outpatient Care — treatment provided to an enrollee who is not admitted to an inpatient hospital or health care facility.

Participating Provider — a provider that has entered into a provider contract or other arrangement with the Contractor to provide services.

Patient — an individual who is receiving needed professional services that are directed by a licensed practitioner of the healing arts toward the maintenance, improvement, or protection of health, or lessening of illness, disability, or pain.

Patient Payment Liability — The Patient Payment Liability for Cost of Care is that portion of the cost of care that nursing facility, assisted living services residents, AFC residents, and CRS residents must pay based on their available income as determined and communicated by the County Welfare Agency.

Payments — any amounts the Contractor pays physicians or physician groups or subcontractors for services they furnished directly, plus amounts paid for administration and amounts paid (in whole or in part) based on use and costs of referral services (such as withhold amounts, bonuses based on referral levels, and any other compensation to the physician or physician groups or subcontractor to influence the use of referral services). Bonuses and other compensation that are not based on referral levels (such as bonuses based solely on quality of care furnished, patient satisfaction, and participation on committees) are not considered payments for purposes of the requirements pertaining to physician incentive plans.

Peer Review — a mechanism in quality assurance and utilization review where care delivered by a physician, dentist, or nurse is reviewed by a panel of practitioners of the same specialty to determine levels of appropriateness, effectiveness, quality, and efficiency.

Person Centered Planning — Planning process which looks at the person’s needs, strengths and preferences around services and desired outcomes.

Physician Group — a partnership, association, corporation, individual practice association, or other group that distributes income from the practice among Members. An individual practice association is a physician group only if it is composed of individual physicians and has no subcontracts with physician groups.

Preventive Services — services provided by a physician or other licensed practitioner of the healing arts within the scope of his or her practice under State law to:



1. Prevent disease, disability, and other health conditions or their progression;

2. Treat potential secondary conditions before they happen or at an early remediable stage;

3. Prolong life; and

4. Promote physical and mental health and efficiency

Primary Care Dentist (PCD) — a licensed dentist who is the health care provider responsible for supervising, coordinating, and providing initial and primary dental care to patients; for initiating referrals for specialty care; and for maintaining the continuity of patient care.

Primary Care — all health care services and laboratory services customarily furnished by or through a general practitioner, family physician, internal medicine physician, or pediatrician, and may be furnished by a nurse practitioner to the extent the furnishing of those services is legally authorized in the State in which the practitioner furnishes them.

Primary Care Provider (PCP) — a licensed medical doctor (MD) or doctor of osteopathy (DO) or certain other licensed medical practitioner who, within the scope of practice and in accordance with State certification/licensure requirements, standards, and practices, is responsible for providing all required primary care services to enrollees, including periodic examinations, preventive health care and counseling, immunizations, diagnosis and treatment of illness or injury, coordination of overall medical care, record maintenance, and initiation of referrals to specialty providers described in this contract and the Benefits Package, and for maintaining continuity of patient care. A PCP shall include general/family practitioners, pediatricians, internists, and may include specialist physicians, physician assistants, CNMs or CNPs/CNSs, provided that the practitioner is able and willing to carry out all PCP responsibilities in accordance with these contract provisions and licensure requirements.

Prior Authorization (also known as “pre-authorization” or “approval”) — authorization granted in advance of the rendering of a service after appropriate medical/dental review.

Private Duty Nursing (PDN) — individual and continuous nursing care, as different from part-time or intermittent care, provided by licensed nurses in the community to eligible EPSDT beneficiaries.

Provider (also referred to as care provider) — means any physician, hospital, facility, health care professional or other provider of enrollee services who is licensed or otherwise authorized to provide services in the state or jurisdiction in which they are furnished.

Provider Capitation — a set dollar payment per Member per unit of time (usually per month) that the Contractor pays a provider to cover a specified set of services and administrative costs without regard to the actual number of services. See also Sub-capitation.

Provider Contract — any written contract between the Contractor and a provider that requires the provider to perform specific parts of the Contractor’s obligations for the provision of services under this contract.

Reassignment — the process by which an enrollee’s entitlement to receive services from a particular Primary Care Practitioner/Dentist is terminated and switched to another PCP/PCD.

Referral Services — those health care services provided by a health professional other than the primary care practitioner and which are ordered and approved by the primary care practitioner or the Contractor.

Exception A: An enrollee shall not be required to obtain a referral or be otherwise restricted in the choice of the family planning provider from whom the enrollee may receive family planning services.

Exception B: An enrollee may access services at a Federally Qualified Health Center (FQHC) in a specific enrollment area without the need for a referral when neither the Contractor nor any other Contractor has a contract with the Federally Qualified Health Center in that enrollment area and the cost of such services will be paid by the Medicaid fee-for-service program.

Residential Treatment Center (RTC) — a live-in health care facility providing therapy for substance use disorder, mental illness, or other behavioral problems.

Routine Care — treatment of a condition which would have no adverse effects if not treated within 24 hours or could be treated in a less acute setting (e.g., physician’s office) or by the patient.

Scope of Services — those specific health care services for which a provider has been credentialed, by the plan, to provide to enrollees.



Screening Services — any encounter with a health professional practicing within the scope of his or her profession as well as the use of standardized tests given under medical direction in the examination of a designated population to detect the existence of one or more particular diseases or health deviations or to identify for more definitive studies individuals suspected of having certain diseases.

SSI — the Supplemental Security Income program, which provides cash assistance and full Medicaid benefits for individuals who meet the definition of aged, blind, or disabled, and who meet the SSI financial needs criteria.

Sub-Capitation — a payment in a contractual agreement between the Contractor and provider for which the provider agrees to provide specified health care services to enrollees for a fixed amount per month.

Subcontract — any written contract between the Contractor and a third party to perform a specified part of the Contractor’s obligations under this contract.

Subcontractor — any third party who has a written contract with the Contractor to perform a specified part of the Contractor’s obligations under this contract.

Subcontractor Payments — any amounts the Contractor pays a provider or subcontractor for services they furnish directly, plus amounts paid for administration and amounts paid (in whole or in part) based on use and costs of referral services (such as withhold amounts, bonuses based on referral levels, and any other compensation to the physician or physician group to influence the use of referral services). Bonuses and other compensation that are not based on referral levels (such as bonuses based solely on quality of care furnished, patient satisfaction, and participation on committees) are not considered payments for purposes of physician incentive plans.

Substantial Contractual Relationship — any contractual relationship that provides for one or more of the following services: 1) the administration, management, or provision of medical services; and 2) the establishment of policies, or the provision of operational support, for the administration, management, or provision of medical services.

TANF — Temporary Assistance for Needy Families, which replaced the federal AFDC program.

TDD — Telecommunication Device for the Deaf.

Third Party — any person, institution, corporation, insurance company, public, private or governmental entity who is or may be liable in contract, tort, or otherwise by law or equity to pay all or part of the medical cost of injury, disease or disability of an applicant for or recipient of medical assistance payable under the New Jersey Medical Assistance and Health Services Act N.J.S.A. 30:4D-1 et seq.

Third Party Liability — the liability of any individual or entity, including public or private insurance plans or programs, with a legal or contractual responsibility to provide or pay for medical/dental services. Third Party is defined in N.J.S.A. 30:4D-3m.

Traditional Providers — those providers who have historically delivered medically necessary health care services to Medicaid enrollees and have maintained a substantial Medicaid portion in their practices.

Urgent Care — treatment of a condition that is potentially harmful to a patient’s health and for which his/her physician determined it is medically necessary for the patient to receive medical treatment within 24 hours to prevent deterioration.

Utilization — the rate patterns of service usage or types of service occurring within a specified time.

Utilization Review — procedures used to monitor or evaluate the clinical necessity, appropriateness, efficacy, or efficiency of health care services, procedures or settings, and includes ambulatory review, prospective review, concurrent review, second opinions, Care Management, discharge planning, or retrospective review.

WIC — A special supplemental food program for Women, Infants, and Children.


2019 care provider manual · • role of network dental providers 94 • primary care physicians...

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