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Physician, Health Care Professional, Facility and Ancillary Provider

Administrative Guide – 2006/2007

guide

how to contact us. . . . . . . . . . . . . . . . 1

our claims process . . . . . . . . . . . . . . . 4

customer identification card . . . . . . . 9

our products . . . . . . . . . . . . . . . . 10-12

notification requirements . . . . . . 13-17

network participation . . . . . . . . 18-23

Medicare Addendum . . . . . . . . . . . . 24

Golden Rule

Part 1

Part 2

Part 3

Important information regarding the use of this Guide

In the event of a conflict or inconsistency between your state RegulatoryRequirements Appendix and this Guide, the provisions of the RegulatoryAppendix will control, except with regard to benefit contracts outside thescope of that Regulatory Appendix.

Additionally, in the event of a conflict or inconsistency between your contractand this Guide, the provisions of your agreement with us will control.

Note: “Customer” is used in this Guide to refer to a person eligible andenrolled to receive coverage for covered services in connection with ourAgreement.

1

Voice Enabled Telephone Self-ServiceSystem (VETSS)

Care Coordination/Notification

Pharmacy Services

Mental Health,Substance Abuse,Vision orTransplant Services

Customer Care

Electronic Paymentsand Statements

call (877) 842-3210

www.unitedhealthcareonline.comor call

(877) UHC-3210(877) 842-3210

www.unitedhealthcareonline.com

(877) 842-1508

(877) 842-1435

(888) 327-9791

See customer's ID card for carrierinformation and contact numbers.

See customer’s ID card formember/customer service contact information

(866) UHC-FAST or [email protected]

To inquire about a customer’s eligibility or bene-fits, check claim status, update facility/practicedata, check credentialing status or request forparticipation inquiries, appeal submissionprocess information, claim project submissionprocess information, care notification processinformation, and privacy practices information.

To notify us of the procedures and servicesoutlined in the notification requirementssection of this Guide (page 13).

To view the Prescription Drug List (PDL)

To request a copy of the PDL

For medications requiring notification

For easy Rx fax service

To inquire about a customer’s behavioral health, vision or transplant benefits.

For services as indicated in this Guide.

To sign up for Electronic Payments and Statements

www.unitedhealthcareonline.com

(866) UHC-FAST (842-3278)

www.unitedhealthcare.com

Confidential and Proprietary 100-6088 UnitedHealthcare

Part 1 how to contact us

• Review a customer’s eligibility or benefits• Provide inpatient facility notification • Check claims status• Submit claims• Update facility/practice data• Review the physician and health care professional

directory• Print EOBs • Lookup your fee schedule • Review/print a current copy of this Guide• Recredential• View UnitedHealthcare policies

To register for UnitedHealthcare Online®, askquestions about online capabilities, for informa-tion about our EDI Connections or for a list of ourclearinghouse options, or receive assistance.

To review the online physician and health careprofessional directory if you are not a registereduser of UnitedHealthcare Online.

2 2


quick reference guidevoice enabled telephone self-service system(VETSS)

SAYClaims

SAYBenefits & Eligibility*

SAYRepresentative

SAYInpatient

SAYOutpatient

SAYHome

Health Care

SAY Office Visits

System Determines Whether or Not

Notification is Required**

SAY Repeat, Fax Request, New Notification,

or Check Another Patient

SAYMedical

EquipmentSAY

InpatientSAY

OutpatientSAY

Home HealthCare

SAYMedical

EquipmentSAY

Ambulance

SAYMedical or Mental

Health

SAYClaim Status or

Mailing Address

SAYPatient‘s Member #

Date of Birth Date of Service

Transfer toUnited

BehavioralHealth (UBH)


Date of Birth

SAYNew Notification

SAYGet Status

Claim Status

MailingAddress Medical Mental

Health

SAYCare Notifications

What Type of Notification Would

You Like?

Transfer toRepresentative

IF YES

IF NO


3

SAYCredentialing

Status

SAYTransplantServices

SAYJoin Network

SAY CredentialingInformation

Status Retrievedand Voice Reported

Transfer toCredentialing

Service Center

Voice ReportedCredentialing

ProcessInformation

Provided

SAYPremium

DesignationSAY

NCQASAY

Get Status

InformationalRecording


Transfer toService Center



SAYDesignation

Programs

Dial1-877-UHC-32101-877-842-3210

Main Menu

SAYAppeal

Submissions

Transfer to ServiceCenter For Practice

& Facility DataChanges

SAYClaim ProjectSubmissions

SAYWeb Site

Technical Support



Transfer to Support Center

SAYBenefits & Eligibility*

SAYPrivacy Practices

SAYHealth Care

Professional Services

SAY More Options

SAY Ambulance

SAYCredentialing

SAYDemographic

ChangesSAY

More Options


Date of BirthPrivacy Message

SAY Go Backto return to Main Menu

SAY Tax ID #Tax ID# Authentication - Access to claims is only

available for Tax ID#’s found on our system

SAYCancer

Treatment

SAYCongenital

Heart Disease

SAYRepresentative

For All Other Services

*Eligibility verification is subject to the terms of your agreement with us. This is not a guarantee of payment.Payment is based on the terms of your agreement with us, and the terms of the customer’s benefit plan.

**Coverage determination is a separate process. The notification number is not a coverage determination.This notification reference number confirms notification only.

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1 Register for UnitedHealthcare Online®

Service(www.unitedhealthcareonline.com), ourfree service for network physicians, healthcare professionals and facilities. At UnitedHealthcare Online, you can checkeligibility; notify us of procedures and servicesrequired in our notification guidelines; checkbenefits and claims status; update demographicchanges; recredential; or review the physicianand healthcare professional directory – andsubmit claims electronically, for faster claimspayment. UnitedHealthcare Online is also yoursource for important updates, UnitedHealthcarepolicies, product and process information andnews bulletins. To register, call (866) UHC-FAST(842-3278).

2 Once you’ve registered, review thecustomer’s eligibility on the Web site atwww.unitedhealthcareonline.com.Alternatively, to check customer eligibility byphone, call the Voice Enabled Telephone SelfService (VETSS) line or Customer Care numberon the back of the Customer ID Card.

3 Notify us of planned procedures and serv-ices on our Standard NotificationRequirements list (page 13).

4 Prepare a complete and accurate claimform (see “Complete Claims” on page 5).

5 Submit the claim online at www.united-healthcareonline.com or use another electronic option.If you currently use a vendor to submit claimselectronically, be sure to use our electronic payer(ID 87726) to submit claims to us. For moreinformation, contact your vendor or our EDI(Electronic Data Interchange) Support Line at(800) 842-1109.

For those claims that UnitedHealthcare cannotaccept electronically, mail paper claims to theclaims address on the customer’s ID card.

Paper claims add a significant amount ofadministrative effort and expense to the healthcare industry. They consume more of your staff’stime to prepare, may be more prone to error, and

are expensive to print and mail. They are alsoexpensive for health plans and payers to receiveand process, and they introduce more time to thepayment cycle, creating payment delays notencountered with electronic submissions andelectronic funds transfer. Please review youragreement with us and abide by anyrequirements it contains regarding electronicclaims submission.

6 Receive Electronic Payments andStatements (EPS)Receive Electronic Payments and Statements(EPS) to improve your cash flow. We transferclaims payments electronically via the automatedclearinghouse network to the financial institutionyou designate. You can choose from individualtransactions or lump-sum payments. Yourelectronic remittance advice can come in theform of an electronic “835” file sent directly orthrough a clearinghouse. Alternatively, you canuse www.unitedhealthcareonline.com to review,sort, store, and print your electronic remittanceadvice.

Early in 2006, UnitedHealthcare will begin workingwith its contracted physicians, hospitals and otherhealthcare professionals on a market by market basis to transition from hard copy EOBs and paperchecks to the use of electronic payments andstatements (EPS). This will result in faster and easierpayment to you. You will hear more from us as wereach your market in the implementation process. Or you can begin receiving electronic payments and statements now by contacting us [email protected] or (866) 842-3278, Option#5 or print and complete the enrollment form foundon www.unitedhealthcareonline.com.

If you are a physician, practitioner, or medical group, you mustonly bill for services that you or your staff perform. Pass thoughbilling is not permitted and may not be billed to our customers.

For laboratory services, you will only be reimbursed for the serv-ices that you are certified through the Clinical LaboratoryImprovement Amendments (CLIA) to perform, and you must notbill our customers for any laboratory services for which you lackthe applicable CLIA certification.

Payment of a claim is subject to our payment policies (reim-bursement policies), which are available to you online or uponrequest. You must not bill our customer for amounts unpaid dueto application of a payment policy.

Our claims process

We know that you want to be paid promptly for the services you provide.Here’s what you can do to help promote prompt payment:

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• Customer’s name, address, gender, date ofbirth and relationship to subscriber

• Subscriber’s name and ID number

• Subscriber’s employer group name and groupnumber

• Name, signature, address where service wasrendered, “remit to” address, and phonenumber of physician or health care providerperforming the service; provide this informationin a manner consistent with how thatinformation is presented in your agreement with us

• Physician’s or health care provider’s federal tax ID number

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

• Current CPT-4 and HCPCS procedure codeswith modifiers where appropriate

• Current ICD-9 diagnostic codes by specificservice code to the highest level of specificity

• Referring physician’s name (if applicable)

• Charges per service and total charges

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

• Attach operative notes with paper claims

submitted with modifiers 22, 62, 66 or anyother team surgery modifiers as well as CPT99360 (physician standby)

• Retail purchase cost or a cumulative retailrental cost for DME greater than $1,000.

• If you need to correct and re-submit a claim,submit a new CMS 1500, or successor form,or UB-92 indicating the correction beingmade. Hand corrected claim re-submissions

will not be accepted.

Additional information needed for acomplete UB-92 form:

• Date and hour of admission and discharge aswell as customer status-at-discharge code

• Type of bill code

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

• Current four digit revenue code

• Current principal diagnosis code (highest levelof specificity)

• Current other diagnosis codes, if applicable(highest level of specificity)

• Current ICD-9-CM procedure codes forinpatient procedures

• Attending physician ID

Complete ClaimsBecause a customer’s level of coverage under his or her benefit plan may vary for different services,it is particularly important to correctly code, according to national coding guidelines, all diagnosisand services for proper payment and application of deductible and coinsurance.

You must submit a claim for your services regardless of whether you have collected the copayment,deductible or coinsurance from the customer at the time of service.

Whether you use an electronic or a paper form, a CMS 1500, or successor form, or UB-92 form, acomplete claim includes the following information. Additional information may be required by us forparticular types of services or based on particular circumstances or state requirements. Additionalclaim submission requirements for Medicare customers can be found on page 24.

Second submissions, tracers, claim status requests should be submitted electronically no soonerthan 45 days after original submission, but you can always use www.unitedhealthcareonline.com tocheck the status of a claim for benefit plans supported by UnitedHealthcare.

If you have questions about submitting claims to us, please contact Customer Care at the phonenumber listed on the customer’s ID card.

• Bill all outpatient procedures with theappropriate revenue and CPT or HCPCS codes

• Provide specific CPT or HCPCS codes andappropriate revenue code (e.g. laboratory,radiology, diagnostic or therapeutic) foroutpatient services

• Complete box 45 for physical, occupational orspeech therapy services (revenue code 0420-0449) submitted on a UB-92

• Submit claims according to any special billinginstructions that may be indicated in youragreement with us.

Submission of CMS 1500 or SuccessorForm Claims with Unlisted Codes andExperimental or Reconstructive Services

Submission of Medical or Surgical Codes

Attach a detailed description of the procedure orservice provided for claims submitted withunlisted medical or surgical CPT or “other”revenue codes as well as experimental orreconstructive services.

Submission of CMS 1500 Unlisted Drug Codes

Attach the current NDC (National Drug Code)number for claims submitted with unlisted drugcodes (e.g. J3490, J3590, etc). The NDC numbermust be entered in 24D field of the CMS1500paper form or the LINo3 segment of the HIPAA837 electronic form.

Reporting Requirements for AnesthesiaServices

• One of the CMS required modifiers (AA, AD,QK, QX, QY, QZ, G8, G9 or QS) must be usedfor anesthesia services reporting.

• For CMS 1500 or successor form paperclaims, report the actual number of minutes inBox 24 G with qualifier MJ in Box 24H. Forelectronic claims report the actual number ofanesthesia minutes in loop 2400 SV104 withan 'MJ" qualifier in loop 2400 SV103.

• When medically directing residents foranesthesia services, the modifier GC must bereported in conjunction with the AA or QK.

• When reporting obstetrical anesthesiaservices, it is recommended that add-oncodes 01968 or 01969 be reported on thesame claim as the primary procedure 01967.

• When reporting qualifying circumstancequalifier codes 99100, 99116, 99135 and/or99140, it is recommended that the qualifier bereported on the same claim with theanesthesia service.

National Provider Identification (NPI)

In compliance with HIPAA, all “covered” healthcare professionals and organizations mustobtain NPI enumeration prior to May 23, 2007,to identify themselves in HIPAA standardtransactions. All HIPAA "covered entities" mustaccept and use NPIs in standard electronictransactions as of May 23, 2007 (except smallhealth plans which have until May 23, 2008, tocomply)

UnitedHealthcare will begin collecting NPIs andNUCC taxonomy codes from all healthcareprofessionals and organizations starting inJanuary 2006. This will facilitate the building ofa crosswalk of NPIs to proprietary identifierseven ahead of the CMS Data Disseminationinstructions and NPI disclosure capabilities.

UnitedHealthcare will collect NPI and relatedprovider information by one of the followingmethods in the future:

1. The “Provider Experience” Phone/FaxNumbers for demographic changes.

2. UnitedHealthcare Online(www.unitedhealthcareonline.com) will bemodified to allow NPI and NUCC TaxonomyCodes to be entered online.

3. Physicians and other health care professionalswill have the ability to include NPI and NUCCtaxonomy indicator(s) on the CAQHcredentialing/recredentialing application.


6

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4. Facilities will have the ability to include theirNPI and NUCC taxonomy indicators on theirUnitedHealthcare credentialing application.

5. NPI and taxonomy indicator(s) will becollected as part of recontracting efforts.

6. NPI and taxonomy indicator(s) will becollected as part of new provider contracting.

UnitedHealthcare may provide further guidanceregarding how NPI enumeration will becollected through claims submission uponadoption of new claims submission forms,which provide for collection of the NPIelectronically or otherwise.

Claim AdjustmentsCustomers are responsible for applicablecopayments, deductibles and coinsuranceassociated with their plans. Although youshould collect copayments at the time ofservice, we recommend that you submit claimsfirst and refer to the appropriate Explanation ofBenefits (EOB) to determine the exact patientresponsibility related to plan deductibles andcoinsurance. This will help promote accuratecollections and avoid over- or underpaymentsituations. In the event your patient pays morethan the amount indicated on the medical claim EOB, you are responsible for promptlyrefunding the difference.

If you believe you were underpaid by us, youcan simplify the submission of requests forclaim adjustments and receive more efficientresolution of claim issues by usingwww.unitedhealthcareonline.com. You maysubmit a single claim in a paid or denied statusdirectly to UnitedHealthcare for research andreconsideration online or you can call CustomerCare to request an adjustment. If you have 20 ormore paid or denied claims, you can aggregatethese claims on the Network Services/FacilityResearch Request online form and submit themfor research and review.

If you identify a claim where you were overpaidby us or if we inform you of an overpaid claimthat you do not dispute, you must send us theoverpayment within 30 calendar days from thedate of your identification of the overpayment orour request. If your payment is not received bythat time, we may apply the overpaymentagainst future claim payments in accordancewith your agreement with us and applicable law.

Refunds of all overpayments received from usor credit balances existing on your recordsshould be sent to: Receivable Strategies, LLC,P.O. Box 260, Parsippany, NJ 007054. Pleaseinclude appropriate documentation that outlinesthe overpayment including patient ID andnumber, date of service and amount paid.

When we determine that a claim was paidincorrectly, we may make claim adjustmentswithout requesting additional information fromthe network physician. You will see theadjustment on the EOB or Provider RemittanceAdvice (PRA). When additional or correctinformation is needed, we will ask you toprovide it.

If you disagree with a claim adjustment or ourdecision not to make a claim adjustment, youcan appeal the determination (see Claim Appeals).

Claim AppealsIf you disagree with a claim adjustment or ourdecision not to make a claim adjustment youmay appeal by completing the UnitedHealthcareRequest for Reconsideration Form, found onwww.unitedhealthcareonline.com. You may alsosend a letter of appeal to the claim officeidentified on the back of the customer’s ID cardor call the Customer Care number listed on theEOB, PRA or customer’s ID card. Your appealmust be submitted to us within 12 months fromthe date of processing shown on the EOB or PRA.

If you are appealing a claim that was deniedbecause filing was not timely, for:

1 Electronic claims – include confirmationthat UnitedHealthcare or one of its affiliatesreceived and accepted your claim.

2 Paper claims – include a copy of a screenprint from your accounting software toshow the date you submitted the claim.

If you disagree with an overpayment refundrequest, send a letter of appeal to the addressnoted on the refund request letter. Your appealmust be received within 30 days of the refundrequest letter in order to allow sufficient time forprocessing the appeal and avoid possible offsetof the overpayment against future claimpayments to you. When submitting the appeal,please attach a copy of the refund request letterand a detailed explanation of why you believethe refund request is in error.

If you disagree with the outcome of the claimappeal, you may pursue dispute resolution asdescribed on page 22 and in your agreementwith us.

Subrogation and Coordinationof BenefitsOur benefits plans are subject to subrogationand coordination of benefits (COB) rules.

1 Subrogation - To the extent permittedunder applicable law and the applicablebenefit plan we reserve the right to recoverbenefits paid for a customer's health careservices when a third party causes thecustomer's injury or illness.

2 COB - Coordination of benefits isadministered according to the customer'sbenefit plan and in accordance withapplicable statutes and regulations.UnitedHealthcare can accept secondaryclaims electronically. To learn more, contactyour EDI vendor or call EDI support at 800-842-1109.

Retroactive Eligibility ChangesEligibility under a benefit contract may changeretroactively if:

1 We receive information that an individual isno longer a customer;

2 The individual’s policy/benefit contract hasbeen terminated;

3 The customer decides not to purchasecontinuation coverage; or

4 The eligibility information we receive is laterdetermined to be false.

If you have submitted a claim(s) that is impactedby a retroactive eligibility change, a claimadjustment may be necessary. The reason forthe claim adjustment will be reflected on theEOB or PRA. (If you are enrolled in EPS you willnot receive an EOB).


8


9

UnitedHealthcare customers receive an ID card containing information that helps you submit claimsaccurately and completely. Information may vary in appearance or location on the card due to

employer or UnitedHealthcare requirements. However, cards display essentially the sameinformation (e.g., claims address, copayment information, telephone numbers such as those forCustomer Care and Care Coordination).

Be sure to check the customer’s ID card at each visit – especially the first visit of a new year, wheninformation may change – and to copy both sides of the card for your files.

With the new UnitedHealthcare® Medical ID Card, you can obtain customer information in seconds,just by swiping the card through your credit card terminal*. And it will be issued at the family level,so information about subscribers and dependents will be available on one card. Look for the newUnitedHealthcare Medical ID Card as it replaces the paper card.

Customer identification cards

*Your current fee with your credit card vendor to process bankcard transactions applies.

Sample Customer ID Card

Member IDNumber

Name

Specifics ofIndividual Plan

10

UnitedHealthcareOptions PPO

Customers can choose anynetwork physician orhealth care professionalwithout a referral andwithout designating aprimary physician.*

Options PPO provides out-of-network coverage.

No, a referral is notneeded.

No. Customers areresponsible for notifyingCare Coordination at thephone number on their IDcard.

Please refer customers toCustomer Care for questions about their responsibilities.


Attributes

How do customers

access physicians

and health care

professionals?

Is a referral from a

primary physician* a

requirement for cover-

age of a specialty

service? If those

requirements exist,

they will be noted in

our agreement’s state

regulatory appendix.)

Is the treating physi-

cian and/or facility

required to notify

Care Coordination?

UnitedHealthcareSelect and Select Plus

Customers choose aprimary physician from thenetwork of physicians foreach family member. Theprimary physiciancoordinates their care.*

Select Plus provides out-of-network coverage,Select does not.(except foremergency)


Yes, on selectedprocedures. See guidelineson page 13.

* Primary physician is defined as a physician or other health care professional whom a customer or enrollee has designated as his/her primary care physician.

UnitedHealthcareChoice and Choice Plus

Customers can choose anynetwork physician orhealth care professionalwithout a referral andwithout designating aprimary physician.*

Choice Plus provides out-of-network coverage,Choice does not.(except foremergency)


Yes, on selectedprocedures. See guidelineson page 13.

Our productsThis table provides information about some of the most common UnitedHealthcare products (youragreement with us may use “benefit contract types” or “Benefit Plan types” or some similar term to referto our products). Visit www.unitedhealthcareonline.com for more information about our products in yourarea. Medicare and/or Medicaid products are offered in select markets, your agreement with us willdetermine if you are participating. If a customer presents an identification card with a product name withwhich you are not familiar, please contact Customer Care. This product list is provided for yourconvenience and is subject to change over time. Medicare products are listed separately in the MedicareAddendum to this Guide.

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UnitedHealthcareIndemnity

Customers can choose anyphysician or health careprofessional.*


No. Customers are responsible for notifyingCare Coordination at thenumber on their ID card.

Please refer customers toCustomer Care forquestions about theirresponsibilities.

UnitedHealthcareMedicareProducts

Medicare Product information can be foundin the MedicareAddendum beginning onpage 24.

UnitedHealthBasics

Customers can chooseany network physicianor health careprofessional without areferral and withoutdesignating a primaryphysician.*

UnitedHealth Basicsprovides out-of-network coverage.


No. Customers are responsible fornotifying CareCoordination at thenumber on their IDcard.

Please refer customersto Customer Care forquestions about theirresponsibilities.

* Physicians and health care professionals must be licensed for the health servicesprovided and covered under the customer’s benefit contract.


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DefinitySM and iPlan®

Consumer-driven health plans

UnitedHealthcare currently offers consumer-driven health plans to our customers under twodifferent names: DefinitySM and iPlan®. Theseproducts offer enrollees a high deductiblemedical coverage plan linked to a savings orspending account for health care services. TheDefinity or iPlan account can be either anemployer-funded Health ReimbursementAccount (HRA) (previously called a PersonalBenefit Account (PBA)) or a Health SavingsAccount (HSA). Funds in these accounts can beused to cover some of the out-of-pocket costs,such as deductibles and coinsurance.

To ensure fast and accurate reimbursement forservices you may render to enrollees with HRAsor HSAs, please keep in mind the following tips:

• Verify eligibility and benefits online atwww.unitedhealthcareonline.com beforeyour patient’s appointment. Alternatively,you can call the Customer Service phonenumber on the back of the patient’s medicalID card.

• Many Definity HRA or HSA benefit plans donot have copayments. When they do,copayments should be collected at the timeof service.

• Exact patient responsibility related todeductibles or coinsurance is difficult tocalculate until after your claim is adjudicated.

• Please submit your claim for processingelectronically (throughwww.unitedhealthcareonline.com or throughyour clearinghouse relationship) or to theaddress on the back or the medical ID card.

• Please wait until after a claim in processedand you receive your EOB before collectingfunds from your patient because the patientresponsibility may be reimbursable throughtheir HRA or HSA account and paid directlyto you. We will not automatically transfer theHSA balance for payment; however, thepatient can pay with their HSA debit card orconvenience checks linked directly to theiraccount balance. The EOB will indicate anyremaining patient balance.

Providers may now receive faster payment

from patients by charging the patient’s FSA

or HRS consumer account card for qualified

medical expenses.

Providers may charge United Healthcare HRA orFSA consumer account cards only for expensesthat are “qualified medical expenses” (as definedin Section 213(d) of the Internal Revenue Code)incurred by the card holder or the cardholder’sspouse or dependent. “Qualified medicalexpenses” are expenses for medical care, whichprovides diagnosis, cure, mitigation, treatment,or prevention of any disease, or for the purposeof affecting any structure or function of the body.Providers may not process charges on theconsumer account cards for any expenses thatdo not qualify as qualified medical expenses,including (but not limited to):

• Cosmetic surgery/procedures (whichincludes procedures directed at improving apatient’s appearance that does notmeaningfully promote the proper function ofthe body or prevent or treat illness ordisease), including the following:

• Face Lifts

• Liposuction

• Hair Transplants

• Hair Removal (electrolysis)

• Breast Augmentation or Reduction

• Teeth whitening and similar cosmetic dental procedures

(However, surgery or a procedure that isnecessary to ameliorate a deformity arising froma congenital abnormality, a personalreconstruction surgery following a mastectomyfor cancer is a qualified medical expense.)

-Advance expenses for future medical care.

-Weight loss programs (unless prescribed totreat a specific disease, including obesity.)

-Illegal operations or procedures.

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Procedures and Services Explanation

Accidental Dental Services Dental services that meet the following criteria may be eligible for medicalcoverage depending on the customer’s benefit contract:• Date of initial contact for dental evaluation is within plan limits followingthe accident.• Initiation of definitive treatment services within guidelines.• Completion date of treatment services is known.• Certification that the injured tooth was a sound natural tooth.

Ambulance Transportation Non-urgent ambulance transportation between specified locations for (Non-Urgent) customers who cannot travel by other forms of transportation.

Blepharoplasty, upper lid Reconstructive upper eyelid procedures including repair of brow ptosis.

Breast Reconstruction Reconstruction of breast other than following mastectomy.

Breast Reduction Removal of breast tissue in men or women other than mastectomy for cancer.

Standard notification requirements

All notifications must contain all information necessary to record the notification, including but notlimited to customer name, customer ID, physician or health care professional name, physician orhealth care professional TIN, ICD-9 code for primary diagnosis (maximum of two additionaldiagnoses), anticipated dates of service, type of service and volume of service when applicable. Inaddition, such notifications must be made to the appropriate place as described in this section or asotherwise communicated to you by UnitedHealthcare.

This notification list may change from time to time. If there is such a change, we will provide youwith information about the change before it takes effect.

Notify us at www.unitedhealthcareonline.com for any inpatient or outpatient facility notificationrequired under this guide. For other notifications or if you do not have electronic access, please callCare Coordination at the number on the back of the customer ID card.

Notify Care Coordination within the following time frames (unless your agreement with us provides

for a different timeframe):

Emergency Facility Admission

Within one business day after an emergency orurgent admission.

Home Health Services

Home health is subject to notification within one business day.

Inpatient Admissions After AmbulatorySurgery

Within one business day after an inpatientadmission that immediately followedambulatory surgery.

Non-Emergency Admissions and/or out-patient services (except maternity)

At least five business days prior to non-emergent, non-urgent facility admissions and/oroutpatient services (see additional detail onpages 14-17); in cases in which the admission isscheduled less than five business days inadvance, notify at the time the admission isscheduled.


Notify us prior to:


14

Durable Medical Equipment In general we require notification for DME with a retail purchase cost or(DME) Greater than $1,000 a cumulative retail rental cost over $1000. Prosthetics are not DME. Some

employer groups may have different DME notification requirements imposed upon the customer through their benefit plan. For further information please call Customer Care.

End Stage Renal Disease Services such as dialysis provided for end stage renal disease Services inclusive of the following codes;

Dialysis

90935 - 90940 - hemodialysis90945 - peritoneal90947 - peritoneal90918-90925 - ESRD90997 - hemoperfusion90989 - patient training, completed course90993 - patient training, per session93990 - hemodialysis, duplex scan of accessRevenue Codes:

0800 – Renal Dialysis0820 – Hemo/op or home 0821 – Hemodialysis/composite or other rate0829 – Other outpatient hemodialysis0830 – Peritoneal/op or home0831 – Peritoneal/composite or other rate0839 – Other outpatient peritoneal dialysis0840 – Capd/op or home0841 – CAPD/composite or other rate0849 – Other outpatient CAPD0850 – Ccpd/op or home0851 – CCPD/composite or other rate0859 – Other outpatient CCPD0880 – Dialysis / misc

Home Health Care Services All services which are based in the home including, but not limited to: HomeInfusion Therapy, Home Health Aid (HHA), Occupational Therapy(OT),Physical Therapy (PT), Private Duty Nursing, Respiratory Therapy (RT),Skilled Nursing (SNV), Social Worker (MSW) and Speech Therapy (ST).

Hospice Home Care and Inpatient Hospice services.

Inpatient Facility Admissions All inpatient admissions (except maternity) including: acutehospitalizations (includes long term acute care), rehabilitation facilities,and skilled nursing facilities (includes hospice). Includes notification ofnewborns who remain hospitalized after the mother is discharged.Includes maternity admissions that 48 hours for vaginal delivery or 96hours for cesarean delivery.

Ligation, Vein Stripping Removal of varicose veins.

Referral for Non-Network A referral from a network physician or health care provider to a hospital,Services physician, or other health care provider who does not participate in

UnitedHealthcare.


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Sclerotherapy An alternative method for removing varicose veins and other veinabnormalities.

Transplant Services: Request for transplant or transplant related services prior to pre-treatmentFor services listed in this or evaluation including the following CPT Procedure Codes forsection call United Resource Specifically Requested Transplantations:Networks(URN) directly at HEART / LUNG

1-888-936-7246 or the 33930 Donor cardiectomy-pneumonectomy, with preparation notification number on and maintenance of allograftthe back of the customer 33935 Heart-lung transplant with recipient cardiectomy-pneumonectomyID card, rather than HEART

Care Coordination. 33940 Donor cardiectomy, with preparation and maintenance of allograft33945 Heart transplant, with or without recipient cardiectomy0051T Implantation of a total replacement heart system (artificial

heart) with recipient cardiectomy0052T Replacement or repair of thoracic unit of a total replace

ment heart system (artificial heart)0053T Replacement or repair of implantable component or

components of total replacement heart system (artificial heart), excluding thoracic unit

LUNG

32850 Donor pneumonectomy(ies) with preparation and maintenance of allograft (cadaver)

32851 Lung transplant, single; without cardiopulmonary bypass32852 with cardiopulmonary bypass32853 Lung transplant, double (bilateral sequential or en bloc);

without cardiopulmonary bypass32854 with cardiopulmonary bypassKIDNEY

50300 Donor nephrectomy, with preparation and maintenance of allograft, from cadaver donor, unilateral or bilateral

50320 Donor nephrectomy, open from living donor (excluding preparation and maintenance of allograft)

50340 Recipient nephrectomy 50360 Renal allotransplantation, implantation of graft; excluding

donor and recipient nephrectomy50365 with recipient nephrectomy50370 Removal of transplanted renal allograft50380 Renal autotransplantation, reimplantation of kidney50547 Laparoscopic…donor nephrectomy from living donor

(excluding preparation and maintenance of allograft)PANCREAS

48160 Pancreatectomy, total or subtotal, with autologous transplantation of pancreas or pancreatic islet cells

48550 Donor pancreatectomy, with preparation and maintenance of allograft from cadaver donor, with or without duodenal segment for transplantation

48554 Transplantation of pancreatic allograft48556 Removal of transplanted pancreatic allograft

LIVER

47135 Liver allotransplantation; orthotopic, partial or whole, from cadaver or living donor, any age


16

47136 heterotopic, partial or whole, from cadaver or living donor, any age

INTESTINE

44132 Donor enterectomy, open, with preparation and maintenance of allograft; from cadaver donor

44133 partial, from living donor44135 Intestinal allotransplantation; from cadaver donor44136 from living donor

Initiation of Cancer Treatment Stage IV and Bone marrow CA when routine treatment will not be other than surgery. sufficient inclusive of the following codes;For services listed in this CPT Procedure Codes:

section call Cancer Resource 38230 Bone marrow harvesting for transplantationServices (CRS)* at 38240 Bone marrow…transplantation; allogenic1-866-936-6002 or the 38241 Bone marrow…transplantation; autologousnotification number on 38242 Bone marrow…allogenic donor lymphocyte infusionsthe back of the customer ICD-9 Diagnosis Codes:

ID card, rather than Malignant Neoplasm Of Lymphatic and Hematopoietic TissueCare Coordination 200.00 to 200.88 Reticulosarcoma & Lymphosarcoma

201.00 to 201.98 Hodgkin’s disease202.00 to 202.98 Other203.00 to 203.81* Multiple myeloma and immunoproliferative

neoplasms204.00 to 204.91* Lymphoid leukemia205.00 to 205.91* Myeloid leukemia206.00 to 206.91* Monocytic leukemia207.00 to 207.81* Other specified leukemia208.00 to 208.91* Unspecified leukemia* includes codes for cancers in remission198.5 Secondary malignant neoplasm of bone and

bone marrowICD-9 Diagnosis Codes:

Other complex cancersHead and neck cancers141.0-148.9; 160.0-161.9Pharynx, Lip and Oral Cavity149.0-149.9Cancer of the esophagus150.0-150.9Cancer of the stomach151.0-151.9 Cancer of the liver155.0-155.2 Cancer of gall bladder156.0-156.9Cancer of the kidney and other and unspecified urinary organs189.0-189.9Cancer of the pancreas157.0-157.9Bone and soft tissue sarcoma170.0-170.9; 171.0-171.9Brain and central nervous system tumors191.0-191.9; 192.0-192.9Cancer of the ovary and other uterine adnexa183.0-183.9

*For Commercial only,please see the numberon the back of the IDcard for Medicare.

17


Congenital Heart Disease Request for CHD related services including the following codes;For services listed in this CPT Procedure Codes:section call United Resource 93580 Percutaneous transcatheter closure of a congenital Networks (URN)* directly at intertribal communication (i.e., Fontan fenestration,1-888-936-7246 or the atrial septal defect) with implantnotification on the back of 93581 Percutaneous transcatheter closure of a congenitalthe customer ID card, rather ventricular septal defect with implantthan Care Coordination

ICD-9 Diagnosis Codes

Atrial Septal Defects745.5 Atrial septal (ostium secundum type)745.61 Ostium primum type745..8 Sinus venosus745..0 Aortic septal

Ventricular Septal Defects745.4 Ventricular septal745.69 Atrioventricular canal type745.2 In Tetralogy of Fallot

Peripheral Vascular Disease747.60 Congenital peripheral vascular defect, unspecified747.69 Congenital peripheral vascular defect, other specified site

Other Notification Requirements

Specific Medications as Call (877) 842-1435 when prescribing medications that require notification.Indicated on the PDL These medications are so designated on the Prescription Drug List

(PDL).To view the Prescription Drug List (PDL), visit www.unitedhealthcareonline.com. Call (877) 842-1508 to request a copyof our PDL.

Behavioral Health Services Many of our benefit plans only provide coverage for behavioral healthservices through a designated behavioral health network. Therefore, it isimportant for you to call the number on the customer ID card whenreferring for any mental health or substance abuse services.

Radiology In some markets, UnitedHealthcare has additional notificationrequirements for some radiology procedures. See UnitedHealthcareOnline to view the radiology notification protocol and obtain notificationtelephone numbers, or contact your local Network Managementrepresentative.

Note: The CPT and ICD-9 codes listed in the notification table were current at the time this document wascreated. Coding requirements may periodically change. Please refer to the CPT or HCPC coding guide forappropriate codes or visit UnitedHealthcare Online (www.unitedhealthcareonline.com) or call Voice EnabledTelephone Self-Service System at 877-842-3210.

This list does not signify coverage for benefits. Coverage is determined by the customer’s benefit plan.If you have questions about a customer’s coverage, visit UnitedHealthcare Online (www.unitedhealthcareonline.com) or call Voice Enabled Telephone Self-Service System at 877-842-3210.

*For Commercial only,please see the numberon the back of the IDcard for Medicare.


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Network participation

Comply with ProtocolsYou will cooperate with, and be bound by,UnitedHealthcare’s and Payer’s Protocolsincluding those Protocols contained in thisGuide. A complete list of protocols can beviewed at www.unitedhealthcareonline.com.

Additional Fees for Covered ServicesYou may not charge our customers fees forCovered Services beyond copayments,coinsurance, or deductible as described in theirbenefit plans, You may not charge ourcustomers retainer, membership, oradministrative fees, voluntary or otherwise. Thisincludes but is not limited to concierge/boutiquepractice fees as well as fees to cover increasesin malpractice insurance and office overhead.This does not prevent you from chargingnominal fees for missed appointments orcompletion of camp/school forms.

Provide Official NoticeYou must notify us at the address in yourcontract of the following events, in writing,within ten calendar days of your knowledge oftheir occurrence:

1 Material changes in, cancellation ortermination of liability insurance;

2 Bankruptcy or insolvency;

3 Any indictment, arrest or conviction for afelony or any criminal charge related to yourpractice or profession;

4 Any suspension, exclusion, debarment orother sanction from a state or federallyfunded health care program;

5 Loss or suspension of your license to practice.

Transition Customer CareFollowing Termination of Your ParticipationIf your network participation terminates for anyreason, you are required to participate in thetransition of your patient toward timely andeffective care. This may include providingservice(s) for a reasonable time, at ourcontracted rate. Customer Care is available tohelp you and our customers with the transition.

Arrange Substitute CoverageIf you are unable to provide care and arearranging for a substitute, we ask that you try toarrange for care from other physicians andhealth care professionals who participate withUnitedHealthcare. For the most current listing of network physicians and health careprofessionals, review our physician and healthcare professional directory at www.unitedhealthcareonline.com. In order for services to be covered under the customer’sin-network benefit, a non-network physician orhealth care professional will need to join ournetwork by applying for participation and, ifaccepted, signing a participation agreement.

After-Hours CareWhile true emergencies and life-threateningsituations require the immediate services of anemergency department, treatment after hourscan be provided quickly and efficiently at anurgent care center where available, andappropriate for conditions such as sprains,sinus, ear or bladder infections, and minorlacerations needing suturing. When your officeis contacted by one of your patients after hoursasking where to seek urgent care and youbelieve an urgent care center is appropriate fortreating the patient, please refer them to anurgent care center if you are not able toaccommodate them in your schedule.

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Reimbursement PoliciesUnitedHealthcare policies are available online atwww.unitedhealthcareonline.com by selectingInside UHC and then the link UnitedHealthcareReimbursement Policies.

Return calls from CareCoordinators and Medical Directors.Provide complete health information as requiredwithin four hours if request is received before 1p.m. local time, or by 12-noon the next businessday if request is received after 1 p.m. local time.

Evidence-based Clinical andQuality InitiativesUnitedHealthcare has adopted evidence-basedclinical guidelines to guide our quality andhealth management programs. You mustcooperate with our quality assessment andimprovement activities, and comply with our clinical guidelines, customer safety(risk reduction) efforts, and data

confidentiality procedures.

The guidelines upon which UnitedHealthcareclinical quality initiatives are based defineoptimal delivery of health care for particulardiseases and conditions as determined byUnited States government agencies andprofessional specialty societies. Guidelines maybe viewed at www.unitedhealthcareonline.com,or you may request a hard copy by contactingyour local health plan representative.

Provide Access to Your RecordsYou must provide access to any medical,financial or administrative records related to theservices you provide to UnitedHealthcarecustomers within 14 calendar days of ourrequest or sooner for cases involving allegedfraud and abuse, a customer grievance/appeal,or a regulatory or accreditation agency

requirement. Such records must be maintainedfor six years, or longer if required by applicablestatutes or regulations.

Follow Medical RecordStandardsMedical records will contain all informationnecessary and appropriate to support claims forservices submitted by you.

In providing care for UnitedHealthcarecustomers, we expect that you have policies toaddress the following:

1 Maintain a single, permanent medicalrecord that is current, detailed, organizedand comprehensive for each customer thatis available at each visit.

2 Protect customer records against loss,destruction, tampering or unauthorized use.

3 Maintain medical records in accordancewith state and federal regulations.

General Documentation Guidelines

We also expect you to follow these commonlyaccepted guidelines for medical recordinformation and documentation:

• Date all entries, and identify the author.

• Make entries legible.

• Cite medical conditions and significantillnesses on a problem list. Include dates ofonset and resolution.

• Give prominence to notes on medication allergies and adverse reactions. Also note ifthe customer has no known allergies oradverse reactions.

• Make it easy to identify the medical history,and include serious illnesses, injuries andoperations for customers seen three or moretimes.

• For medication record, include name ofmedication, dosage, amount dispensed anddispensing instructions. Also, list over thecounter drugs taken by the customer.

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Document these important items:

• Tobacco habits, alcohol use and substanceabuse for customers age 11 and older

• Immunization record

• Family and social history

• Preventive screenings and services

• Blood pressure, height and weight, bodymass index

Goals

• 90% of medical records will containdocumentation of critical elements. Criticalelements appear in bold text on this page.

• 80% of medical records will containdocumentation of all other elements

• Documentation of allergies and adversereactions must be documented in 100% of therecords.

Demographic Information

The medical record for each customer shouldinclude:

• Customer name and/or customer ID numberon every page

• Gender

• Age or date of birth

• Address

• Marital status

• Occupational history

• Home and work phone numbers

• Name and phone number of emergencycontact

• Name of spouse or relative

• Insurance information

Customer Encounters

When you see one of our customers, documentthe visit by noting:

• Customer’s complaint or reason for the visit

• Physical assessment

• Unresolved problems from previous visit(s)

• Diagnosis and treatment plans consistentwith your findings

• Growth charts for pediatric customers

• Developmental assessment for pediatriccustomers

• Customer education, counseling orcoordination of care with other providers

• Date of return visit or other follow-up care

• Review by the primary physician (initialed) onconsultation, lab, imaging, special studies,outpatient and inpatient records

• Consultation and abnormal studies includingfollow-up plans

• Reasons for referrals documented

Clinical Decision and Safety Support Toolsin place to ensure evidence-based care isprovided. Examples include:

• Immunization tracking sheet

• Flow sheet for chronic diseases (e.g. diabetes,asthma)

• Customer reminder system

• Electronic medical records

• Eprescribing/epocrates

21


Customers have the right to:

• Be treated with respect and dignity byUnitedHealthcare personnel and networkphysicians and health care professionals.

• Privacy and confidentiality for treatments,tests or procedures received.

• Voice concerns about the service and care youreceive and to register complaints andappeals concerning your health plan or thecare provided to you.

• Receive timely responses to your concerns.

• Participate in a candid discussion ofappropriate and medically necessarytreatment options for your conditions,regardless of cost or benefit coverage.

• Be provided with access to health care,physicians and health care professionals.

• Participate with your doctor and othercaregivers in decisions about your care.

• Make recommendations regarding theorganizations customer’s rights andresponsibilities policies.

• Receive information about UnitedHealthcare,our services and network physicians andhealth care professionals.

• Be informed of, and refuse to participate in,any experimental treatment.

• Have coverage decisions and claimsprocessed according to regulatory standards.

• Choose an advance directive to designate thekind of care you wish to receive should yoube unable to express your wishes.

Customers have the responsibility to:

• Know and confirm your benefits beforereceiving treatment.

• Contact an appropriate health careprofessional when you have a medical needor concern.

• Show your identification card before receivinghealth care services.

• Access our web site www.myuhc.com® or callCustomer Member Service to verify that yourphysician or health care professional isparticipating in the UnitedHealthcare networkbefore receiving services.

• Pay any necessary copayment at the time youreceive treatment.

• Use emergency room services only for injuryor illness that, in the judgement of areasonable person, requires immediatetreatment to avoid jeopardy to life or health.

• Keep scheduled appointments.

• Provide information needed for your care.

• Follow the agreed-upon instructions andguidelines of physicians and health careprofessionals.

• Participate in understanding your healthproblems and developing mutually agreedupon treatment goals.

• Notify your employer’s human resourcedepartment of a change in address, familystatus or other coverage information.

• Visit our web site www.myuhc.com or call theCustomer Care number on the back of theCustomer ID Card when you have a questionabout your eligibility, benefits, claims andmore.

UnitedHealthcare Customer Rights and ResponsibilitiesWe tell our customers they have the following rights and responsibilities, all of which are intended tohelp uphold the quality of care and services they receive from you. These rights and responsibilitiesare reprinted from our customer handbook.


22

Inform Customers of Advance DirectivesThe federal Patient Self-determination Act(PSDA) gives individuals the legal right to makechoices about their medical care in advance ofincapacitating illness or injury through anadvance directive.

Under the federal act, physicians and providersincluding hospitals, skilled nursing facilities,hospices, home health agencies and othersmust provide written information to customerson state law about advance treatment directives,about customers’ right to accept or refusetreatment, and about your own policiesregarding advance directives.

To comply with this requirement, we also informcustomers of state laws on advance directivesthrough our customer handbooks and othercommunications.

Resolving DisputesContract concern or complaint

If you have a concern or complaint about yourAgreement with us, send a letter containing thedetails to the address in your contract. Arepresentative will look into your complaint andtry to resolve it through informal discussions. Ifyou disagree with the outcome of thisdiscussion, an arbitration proceeding may befiled as described below and in our Agreement.

If your concern or complaint relates to a matterwhich is generally administered by certainUnitedHealthcare procedures, such as thecredentialing or Care Coordination process, youand we will follow the dispute procedures setforth in those plans to resolve the concern orcomplaint. After following those procedures, ifone of us remains dissatisfied, an arbitrationproceeding may be filed as described below andin our Agreement.

If we have a concern or complaint about youragreement with us, we’ll send you a lettercontaining the details. If we can’t resolve thecomplaint through informal discussions withyou, an arbitration proceeding may be filed asdescribed in our agreement.

Arbitration proceedings will be held at thelocation described in your Agreement with us.

In the event that a customer has authorized youto appeal a clinical or coverage determinationon their behalf, that appeal will follow theprocess governing customer appeals outlined inthe customer’s benefit contract or handbook.

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Arbitration Counties by Location.Unless your agreement with us provides otherwise, the following list contains locations wherearbitration proceedings will be held. Locations listed under the state in which you provide careare the locations appliable to you.

Alabama

Jefferson County, AL

Alaska

Anchorage, AK

Arizona

Maricopa County, AZ

Arkansas

Pualski County, AR

Colorado

Arapahoe County, CO

Connecticut

Hartford County, CTNew Haven County, CT

Delaware

Montgomery County, MD

District of Columbia


Florida

Broward County, FLHillsborough County, FLOrange County, FL

Georgia

Gwinnett County, GA

Hawaii

Honolulu County, HI

Idaho

Boise, IDSalt Lake County, UT

Illinois

Cook County, IL

Indiana

Marion County, IN

Iowa

Polk County, IA

Kansas

Johnson County, KS

Kentucky

Fayette County, KY

Louisiana

Jefferson Parish, LA

Maine

Cumberland County, ME

Maryland


Massachusetts

Hampden County, MASuffolk County, MA

Michigan

Oakland County, MI

Mississippi

Hinds County, MS

Missouri

St. Louis County, MOJackson County, MO

Montana

Yellowstone, MT

New Mexico

Bernalillo County, NM

Nebraska

Douglas County, NE

Nevada

Clark County, NVWashoe County, NVCarson City County, NV

New Hampshire

Merrimack County, NHHillsboro County, NH

New Jersey

Essex County, NJ

New Mexico

Bernalillo County, NM

New York

New York County, NYOnondaga County, NY

North Carolina

Guiford County, NC

Ohio

Butler County, OHCuyahoga County, OHFranklin County, OH

Oklahoma

Tulsa County, OK

Oregon

Multnomah County, OR

Pennsylvania

Allegheny County, PAPhiladelphia County, PA

Rhode Island

Kent County, RI

South Carolina

Richland County, SC

Tennessee

Davidson County, TN

Texas

Dallas County, TXHarris County, TXTravis County, TX

Utah

Salt Lake County, UT

Vermont

Chittenden County, VTWashington County, VTWindham County, VT

Virginia

Montgomery County, VA

Washington

King County, WA

West Virginia


Wisconsin

Milwaukee County, WIWaukesha County, WI

Wyoming

Salt Lake County, UT



24

Medicare Advantage Addendum

Part 2 – Medicare Addendum

As a Medicare Advantage contracted

provider for UnitedHealthcare's Medicare

products such as Medicare Complete®

products, you are required to follow a

number of Medicare laws, regulations and

Centers for Medicare & Medicaid Services

(CMS) instructions. Some of these

program requirements are stated in our

Agreement; other significant require-

ments are listed here:

You may not discriminate against Medicare customers in any way based on health status;

You must allow customers to directly access screening mammography and influenza vaccina-tion services;

You may not impose cost-sharing on customersfor influenza vaccine or pneumococcal vaccine;

You must provide women customers with directaccess to a women’s health specialist for routineand preventive health care services;

You must ensure that customers have adequateaccess to covered health services;

Each of us must provide the other at least 60days written notice if electing to terminate ouragreement without cause, or as described inyour participation agreement if greater than 60 days;

You must ensure that your hours of operationare convenient to customers and do not discrim-inate against Medicare Advantage customers,and that necessary services are available tocustomers 24 hours a day, 7 days a week.Primary Care Physicians must have backup forabsences;

You may not distribute marketing materials orforms to Medicare beneficiaries without CMSapproval of the materials or forms;

You must provide services to customers in aculturally competent manner, taking intoaccount limited English proficiency or readingskills, hearing or vision impairment and diversecultural and ethnic backgrounds;

You must make a best effort attempt to ensurethat each new customer has an initial healthassessment within 90 days of enrollment;

You must cooperate with plan procedures toinform customers of health care needs thatrequire follow-up and provide necessary train-ing to customers in self-care;

You must document in a prominent part of the customer’s medical record whether thecustomer has executed an advance directive;

You must provide covered services in a mannerconsistent with professionally recognized stan-dards of health care;

You must ensure that any payment and incen-tive arrangements with subcontractors arespecified in a written contract, that such provi-sions do not encourage reductions in medicallynecessary services, and that any physicianincentive plans comply with CMS standards;

You understand that you are subject to lawsapplicable to persons or entities receivingfederal funds, and must notify all subcontractorsthat they are also subject to these laws;

You must cooperate with plan processes todisclose to CMS all information necessary forCMS to administer and evaluate the MedicareAdvantage program, and all information neces-sary for CMS to permit beneficiaries to make aninformed choice about Medicare coverage.

You must cooperate with plan processes fornotifying plan customers of provider contractterminations;

You must comply with any plan medical poli-cies, quality improvement programs andmedical management procedures;

You will cooperate with plan in fulfilling itsresponsibility to disclose to CMS quality,performance and other indicators as specifiedby CMS;

You will comply with all applicable laws andregulations;

You must not employ or contract with an indi-vidual or entity who is excluded fromparticipation with Medicare or other federalhealth care programs for the provision of healthcare or administrative services; and

You must cooperate with plan procedures for handling grievances, appeals and expeditedappeals.

You must provide full disclosure to MedicareCustomers before providing a service, if you feelthat such service will not be covered by theMedicare benefit plan, or if the enrollee mayassume additional responsibility in accordancewith the customer’s benefit plan, and thecontract language. A document similar to theMedicare Advanced Beneficiary Notice (ABN)must be signed by the beneficiary before liabil-ity of payment can be passed to the Customer. Ifthe service is performed and there is not signedadvance notice on record, the claim will bedenied with provider liability.

You must follow CMS marketing guidelinesfound in the CMS Managed Care Manual ifmarketing a Medicare Advantage plan toyour Medicare customers.

You must follow the standard notificationrequirements on page 13 or on this MedicareAddendum, with the exception of those areasidentified where notification varies fromcommercial standard.

Beginning January 1, 2004, you must deliverrequired notice to a plan’s Medicarecustomer at least two calendar days prior totermination of services in skilled care, homehealth care or comprehensive rehabilitationfacilities. If the customer’s services areexpected to be fewer than two days in dura-tion, the notice should be delivered at thetime of admission, or commencement ofservices in a noninstitutional setting. If in anoninstitutional setting, the span of timebetween service exceeds two days, thenotice should be given no later than the nextto last time services are furnished. Deliveryof notice is valid only upon signature anddate of customer or customer’s authorizedrepresentative. The notice must be written inCMS required language and is entitled,“Notice of Medicare Non-Coverage”(NOMNC). The text may be found at the CMSweb site or you may contact your regionalQuality Improvement Organization (QIO) byreferring tohttp:www.medqic.org/content/qio/qio.jsp?pageID+4 for information. Any appeals of suchservice terminations are called “fast track”appeals, and are reviewed by the QIO.

You must provide requested records anddocumentation to the plan Care CoordinationUnit or CMS-approved independent qualityreview and improvement organization (QIO)as requested no later than by close of busi-ness of the day that you are notified by theplan or QIO if the customer has requested afast track appeal.


25

26


Additional Medicare Claim Requirements:

• A complete claim includes all ICD-9-CM codes,to the highest level of specificity, considered inthe evaluation and provision of health careservices. This includes chronic conditions andpast injuries that are considered in providingcare or treatment to the Customer.

• Current principle diagnosis code to thehighest level of specificity, current otherdiagnosis codes, if applicable to the highestlevel of specificity or Medicare claims, all ICD-9-CM codes, to the highest level of specificity,considered in the evaluation and provision ofhealth care services. This includes chronicconditions and past injuries that areconsidered in providing care or treatment tothe Customer.

• On each claim submitted, you must provideall ICD-9 diagnosis codes, to the highest levelof specificity, considered in the evaluationand provision of health services to theCustomer. This includes all chronic conditionsand past injuries that are considered inproviding care or treatment to the Customer.

Risk Adjustment Information

In 1997 the Center for Medicare and MedicaidServices (“CMS”) created a new paymentmethodology for Medicare Advantage plans.The new methodology uses the health status ofMedicare beneficiaries to determine accuratepayment rates. This new risk adjustment modelwill be fully implemented by CMS in 2007.

Physicians play an important role in the newmodel because CMS looks at physicianencounter data (extracted by UnitedHealthcarefrom claims) to determine payment rates.

Please review the following information toensure that the encounter data you submit toUnitedHealthcare is accurate and complete.

• Remember that risk adjustment is based onICD-9 diagnosis codes, not CPT codes.

Therefore it is critical for your office to referto an ICD-9-CM coding manual and codeaccurately, specifically and completely whensubmitting claims to UnitedHealthcare.

• Diagnosis codes must be supported by themedical record. If it’s not documented in themedical record, then it didn’t happen.Therefore medical records must be clear and complete.

• Never use a diagnosis code for a “probable”or “questionable” diagnosis. Instead codeonly to the highest degree of certainty.

• Be sure to distinguish between acute vs.chronic conditions in the medical record andin coding. Only choose diagnosis code(s) thatfully describe the customer’s condition, andpertinent history at the time of the visit.

• Always carry the diagnosis code all the waythrough to the correct digit for specificity. Forexample, do not use a 3-digit code if a 5-digit code more accurately describes theCustomer’s condition.

• CMS will conduct an encounter datavalidation study on an annual basis byreviewing a sample of physician medicalrecords to ensure coding accuracy.UnitedHealthcare may contact you to requestmedical records for data validation.

• Be sure that diagnosis code is appropriate forthe Customer’s gender.

27

Medicare customers receive an ID card containing information that helps you fileclaims accurately. Information will vary in appearance or location due to employergroup or Medicare product requirements. However, cards display essentially thesame information (e.g. claims address, copayment information, contact numbers,etc.). Be sure to check the Customer’s ID card at each visit, especially the first visit ofthe new year as information may change. Keep a copy of both sides of the card foryour records.

Beginning January 1, 2005, Medicare Complete by UnitedHealthcare is phasing in anew customer identification process. Medicare Complete will no longer use SocialSecurity numbers as part of the enrollee number for select individuals. Instead,select Medicare Complete customers will receive a 9-digit alternate ID as a numericidentifier, which will replace the use of subscriber’s Social Security number in theMedicare Complete enrollee number. You are asked to record the new alternateenrollee numbers in your patient records and be prepared to accept and administerthe alternate enrollee number when it is received. For individuals receiving analternate enrollee number, the Medicare Complete claims system will only recognizethe new enrollee number.

Medicare Customer ID Cards



28

Attributes

How do customers access

physicians and health care

professionals?

Does a primary physician have to

make a referral to a specialist?

(Some states have enacted direct

access requirements. If those

requirements exist, they will be

noted in the contract state

amendment appendix.)

Is the treating physician required

to notify Care Coordination?

Does the physician or health care

professional collect a co-payment

from customers?

UnitedHealthcare Insurance CompanyMedicare CompleteChoice (PPO)Customers can choose any physicianor health care professional.

The benefit level for services fromnon-network physicians and healthcare professionals may be less thanthat for services from networkphysicians and health careprofessionals.

No. A referral is not needed.

Yes. See guidelines on page 13.

Some services may require acopayment or coinsurance; ifapplicable the copay or coinsuranceshould be collected at the timeservices are rendered.

**Markets currently requiring referrals for Medicare Complete HMO: Missouri (St. Louis market) and South Florida.If you are participating in a PHO or other entity contracting on your behalf, a referral from the primary carephysician may be required for specialty services.

UnitedHealthcare Medicare Complete (HMO)

Please refer the Medicare customer to the Medicare Complete providerdirectory or have them call theirpersonal service specialist (PSS). Thephone number is found on thecustomer identification card.

A referral may or may not berequired to see a specialist based onservice area.** For furtherinformation, call the number on theback of the customer ID card. Please have the member IDand your tax ID available.

Primary care physicians shouldcoordinate care with the appropriatenetwork specialists.Exceptions: See Medicare appendixfor direct access services.

Yes. See guidelines on page 13.

Some services may require acopayment or coinsurance; ifapplicable the copay or coinsuranceshould be collected at the timeservices are rendered.

Our Medicare productsThis table provides information about some of the most common UnitedHealthcare Medicareproducts. Visit www.unitedhealthcareonline.com for more information about our products inyour area. If a customer presents an identification card with a product name with which youare not familiar, please contact the Voice Enabled Telephone Self-Service System at 877-842-3210. This product list is provided for your convenience and is subject to change over time.

29

What Is Medicare Select?

• Medicare Select is a Medicare Supplementproduct available only to AARP members whoreside within the service area of aparticipating hospital. It is a lower costalternative to Standardized MedicareSupplement coverage.

Responsibilities of Medicare SelectInsureds

• To offer the plan at a lower premium, werequire that Medicare Select insureds utilize aparticipating hospital for all inpatient andoutpatient hospital services (exceptemergency care and travel).

Hospital Responsibilities

• Participating hospitals agree to a reducedreimbursement of Medicare’s Part A In-Hospital deductible. Cost savings associatedwith hospitals’ waiver of Medicare’s Part A In-Hospital deductible are passed on to MedicareSelect insureds in the form of lower premiumcost.

• To submit a Medicare Part A or Part BIntermediary claim for a Medicare Selectinsured, mail a copy of the UB92 along with aMedicare Explanation of Benefits or MedicareRemittance Advice to :

AARP Health Care Options

United HealthCare Claim DivisionP.O. Box 740819

Atlanta, GA 30374-0819

Note: Medicare Part B claims billed to aMedicare carrier are, in most cases, receivedelectronically directly from the Medicare carrier.

• To ensure timely processing on all claimsubmissions, follow standardized Medicarebilling practices. Be sure to include the 11-digit AARP Health Care Options memberidentification number on the UB92.

What Does Medicare Select Cover?

• In-hospital Part A co-insurance for days 61 to150 in a Medicare Benefit Period andcoverage once Medicare benefits exhaust.

• Medicare Part B co-insurance (20% ofMedicare’s approved amount not paid byMedicare).

• Medicare Part B deductible amount appliedeach calendar year.

• Skilled Nursing Facility stays - the daily co-insurance amount for days 21 to 100 for stayseligible under Medicare.

• Medicare Parts A and B Blood deductible:Charge incurred for the first three pints ofunreplaced blood furnished in a calendar year.

• UnitedHealthcare reimburses participatinghospitals for all Medicare eligible expensesnot paid by Medicare, except for thecontracted reduction of Medicare’s Part A In-Hospital deductible.

Medicare Select (AARP Health Care Options)


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What benefits does Medicare Select giveto the provider?

• Medicare Select will increase the hospital’saccess to AARP members. The hospital will beincluded in AARP Health Care Options’Medicare Select marketing materials withintheir service area.

• By participating in Medicare Select thehospital will be limiting their financialexposure. The hospital agrees to a reducedreimbursement of Medicare’s Part Adeductible. UnitedHealthcare reimburses allother Medicare eligible expenses not paid forby Medicare.

• Hospitals will receive claim payment in atimely fashion - more than 90% of all claimsare paid within 10 business days. This lessenshospital collections, which directly correlatesto hospital savings.

• The population of seniors age 65 and olderwill grow to 74 million by 2010. This meansmore AARP members.

• This product complies with “Safe Harbor”legislation.

Sample AARP Health Care OptionsMedicare Select ID Card

For More Information

• For more information on Medicare Select andother AARP Health Care Options productofferings, contact our Customer ServiceCenter at 800-523-5800.

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Medicare Complete Customers have the right to:

• To be treated with respect and in a mannerthat recognizes your need for privacy anddignity.

• To receive assistance in a prompt, courteous,responsible and culturally competent manner.

• To be provided with information about yourhealth care benefits and any limitations andexclusions associated with your coverage.

• To be informed by your physician or otherhealth care professional of your diagnosis, prognosis and plan of treatment in terms youunderstand.

• To participate in decisions with your physicianregarding your care.

• To expect UnitedHealthcare not to interferewith any contracted physician or health careprofessional’s discussion with you about yourtreatment options whether covered byMedicare Complete or not.

• To have UnitedHealthcare refer you to anothercontracted physician or health care profes-sional if your physician or health careprofessional objects to a treatment based onmoral or religious grounds.

• To be provided with information about the network of contracted physicians and healthcare professionals in your service area.

• To be informed by your physician or otherhealth care professional about any treatmentyou may receive.

• To have your physician or health care profes-sional request your consent for all treatment,unless there is an emergency and you areunable to sign a consent form and your healthis in serious danger.

• To refuse treatment, including any experimen-tal treatment, and be advised of the probable consequences of your deci-sion.

• To choose an advance directive to designatethe kind of care you wish to receive shouldyou become unable to express your wishes.

• To select a primary care physician of yourchoice from within UnitedHealthcare’snetwork of contracted physicians.

• To express a complaint aboutUnitedHealthcare.

• To express a complaint about the care youhave received and to receive a response in atimely manner.

• To initiate the grievance procedure if you arenot satisfied with UnitedHealthcare’s decisionregarding your complaint.

• To receive “timely access” to the records andinformation that pertain to you.

Medicare Complete Customer Rights and Responsibilities

We tell our customers they have the following rights and responsibilities, all of which are intended to help uphold the quality of care and services theyreceive from you. These rights and responsibilities are reprinted from ourcustomer handbook.



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Medicare Complete Customers have theresponsibility to:

• To know and confirm your benefits prior toreceiving treatment.

• To show your Medicare Complete ID cardbefore receiving services and to protectagainst the wrongful use of your ID card byanother person.

• To verify that the physician or health careprofessional you receive services from isparticipating within the Medicare Completenetwork.

• To keep scheduled appointments and pay anynecessary copayments/coinsurance at thetime you receive treatment.

• To ask questions and seek clarification untilyou understand the care you are receiving.

• To follow the advice of your physician orhealth care professional and be aware of thepossible consequences if you do not.

• To express your opinions, concerns and complaints to us.

• To provide information as necessary toUnitedHealthcare and contracted physiciansand health care professionals that would helpenhance your health status.

• To use emergency room services only for aninjury or illness that appears to pose a seriousthreat to your life or health if not treated immediately.

• To follow the treatment plan agreed upon byyou and your physician.

• To treat all UnitedHealthcare personnel respectfully and courteously.

• To notify us of any change in address.

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