U of U Health Plans reminds our practitioners/providers that decisions about utilization management (effective use of services) are based only on whether care is appropriate and whether a Member has coverage. The following responsibilities are in addition to those listed in the Benefits and Responsibilities section of this manual: For Advantage U Signature members, medical records must be maintained for 10 years from the end of the contract between U of U Health Plans and CMS, or the provider and U of U Health Plans; or 10 years from the date of completion of an audit. Additional supplemental services may also be included. COMMERCIAL. If the member decides to continue to get the service and the decision about their service/s is not in the members favor, the member may have to pay for the service. Healthy U Medicaid: The timely filing for both primary and secondary claims is 365 days from the date of service. U of U Health Plans currently administers the following plans: Healthy Premier- Group; Healthy Preferred- Group; Medicaid Products; Healthy U Traditional Medicaid; Healthy U Non-Traditional Medicaid; Healthy U Behavioral; HOME (Healthy Outcomes Medical Excellence) University of Utah Health Plans Marketplace; Healthy Premier Individual & Family . . UnitedHealthcare Community Plan of North Carolina Homepage The program is designed to achieve the following specific goals: Encourage provision of high-quality health care services. A child with unequal distant visual acuity (a two-line discrepancy or greater). Receive interpreter services, and not be asked to bring a friend or family member with them to act as an interpreter. Claims for patients who are not eligible for Medicaid or private insurance will be paid on a sliding scale, according to the patients ability to pay. If policy owner does not pay premiums when due, this Policy will terminate subject to the Grace Period. Learn more about filing electronic claims, PDF. Office calls, examinations and counseling related to contraceptive devices are also covered and must be made available to Healthy U patients. Healthy Premier Group plans are available to eligible Employer Groups across the state of Utah and surrounding states. The right to appeal is still valid if received within timely filing rules for each plan, from the UUHP Notice of Action (NOA). Complete a blood lead level testing at required intervals: At 12 and 24 months: Complete for all children regardless of verbal assessment score. It allows healthcare providers and insurance systems to interchange data with each another for eligibility and benefits verification, claims submission, and to check status of claims. Providers are expected to be familiar with the Utah Minors Consent to Treatment Law. Electronic Billing & EDI Transactions | CMS - Centers for Medicare Coverage under this Policy will remain in force during the Grace Period. Healthy U Behavioral members may utilize our professional Care Management staff for assistance in coordinating care throughout the continuum of their care, including inpatient and ambulatory settings, social and community services, and PCP or specialty providers. For further information about fraud and abuse detection and prevention, please visit the OIGs web site at http://www.oig.hhs.gov/fraud/report-fraud/index.asp , or the National Health Care Anti-Fraud Association web site at http://www.nhcaa.org/. To file a written Grievance, please fax to (801) 281-6121, or mail it to University of Utah Health Plans. Children in households with one or more cases of tuberculosis. Step 2 span class="s19">: Complete the UHIN Enrollment form. FDRs provide health or administrative services to Advantage U Signature members and are a vital part of our Medicare Advantage program. This includes specialty and primary care services. University of Utah Health Plans (U of U Health Plans) will send a summary remittance advice to the providers office for each claim period summarizing all claims processed for that provider by patient. Welcome to the University of Utah Health Plans (U of U Health Plans). Financial Alignment Initiative for Beneficiaries Dually Eligible for Medicaid and Medicare. Arkansas 07101 Arkansas 07102 . A child who scored abnormally on the fixation test, the pupillary light reflex test, alternate cover test, or corneal light reflex in either eye. Insurance Information - University of Utah Health If something is not working, or if were doing a great job, please let us know. Members should use the Independent Review Request form, available at www.insurance.utah.gov . Post-service Appeal within 45 calendar days of receipt of the request. electronic billing systems may refer to this code as a Medicare Payer ID, Contractor ID, or a Receiver ID. This group includes both children who have been removed from their homes by the Division of Child and Family Services (DCFS) due to suspected abuse or neglect as well as children under the direction of the Division of Youth Corrections (DYC). Key components of the Utilization / Care Management program include pre-payment review, demand management, comprehensive case management, link to disease management, and outcome analysis. The reinstated policy shall cover only loss resulting from such accidental injury as may be sustained after the date of reinstatement and loss due to such sickness as may begin more than 10 days after that date. This includes disseminating information, counseling, and treatment-related to family planning services. Do you or anyone give the child home or folk remedies that may contain lead? Written requests can be sent to: University of Utah Health Plan, 6053 South Fashion Square Dr., Suite 110, Murray, UT 84107; or Faxed to: (801) 281-6121. There may be instances when you need to submit your claims on paper. Providers may also refer patients who are victims of domestic abuse to the Domestic Violence Information Line at 1-800-897-5465 (LINK) for available resources. (Examples are construction, welding, pottery, or other trades practiced in your community. The Centers for Disease Control and Prevention and the American Academy of Pediatrics recommend a lead risk assessment and a blood lead level test for all Medicaid eligible children between the ages of 6 and 72 months. 1 or (888) 271-5870 and must be followed with a written signed appeal from the entity submitting the appeal within 5 business days unless it is an expedited appeal. Our research indicates that payers pursuing innovative managed-care models outperform their peers on most Stars outcome and experience measures, including HOS (Health Outcome Survey), HEDIS (Health Effectiveness Data and Information Set), and CAHPS measures. Eligible Dependents are covered under this policy as follows: On the date the coverage is effective if they are included in the application for this policy; On the date the Dependent is eligible for coverage, meaning: (1) birth; (2) adoption (3) placement for adoption; (4) a marriage that results in the spouse or Domestic Partner and stepchildren being added to coverage; and (5) minor dependents required to be covered by court order or administrative order. The U Baby Care program is provided for all pregnant members upon notification of pregnancy. Coinsurance is the percentage of an eligible medical expense that is payable by the member (1) and University of Utah Health Plans (2) which will total 100% of the provider's contracted amount. Make the referral at any age if the oral inspection reveals cavities, infection, or significant abnormality. Effective April 1, 2019, we will no longer accept Modifier CC on the service line of claims. Only the Medical Director can deny a service for reasons of medical appropriateness or necessity. 15. Members may terminate their coverage with UUHP without surrendering their cards. Advantage U Quality Programs -[In Development]. Led by the Quality Improvement Department Manager, disease management teams will be created to actively improve identification techniques and educational resources. Women and infants discharged less than 48 hours following vaginal birth or 96 hours following a cesarean section delivery should receive post-delivery follow-up care within 24-72 hours following the discharge. Screen the child for possible mental health needs. Members also have the right to ask for corrections to it and receive a copy of it. U of U Health Plans will assist members in filing appeals, grievances, or an external level of appeal. Professional care: Except in the case of an emergency, enrollees must obtain covered services from a contracted Healthy U Behavioral network provider. Members also have the right to know about any procedures that need to be followed for the member to get care. We are entitled to recover the claim amounts that exceed the amount of premium paid. The Payer IDs are: Dual Advantage 00551; Medicaid 00661 ; Availity Payer IDs: Access the Availity Payer List. University of Utah Health Plans prefers you to submit claims electronically. Services are reviewed, and determinations are. State Fair Hearing Forms may also be obtained on the Utah Medicaid website athttps://medicaid.utah.gov/Documents/pdfs/Forms/HearingRequest2015.pdf. AL ; 10201 . To ensure the health and safety of children and adults, UUHP is committed to educating contracted providers about mandatory reporting requirements, reporting procedures, and opportunities for provider and patient education. Make sure that you select all transaction types you will be exchanging (837, 835, 270, etc.). Children from Asia, Africa, the Middle East, Latin America or the Caribbean (or children whose parents have emigrated from these locations). Services include diagnosis and treatment for defects in hearing, including hearing aids. Oral appeals may be made by calling: (801) 587-6480 opt. Availity | Ohio Medicaid for Providers | Humana Surgical procedures, unproven or experimental procedures, medications for appetite suppression, or educational, nutritional support programs for the treatment of obesity or weight control are non-covered Medicaid services. Children living in neighborhoods where the case rate is higher than the national average. Encourage the efficient and effective use of health care resources. Effective Jan. 1, 2022, the Payer ID for all UCare plans will shift to Payer ID 55413 for electronic claims submitted with dates of service (DOS) on and after Jan. 1, 2022. U of U Health Plans follows Medicare Guidelines for reimbursement of mid-level providers. Health Medicaid. Rhinoplasty unless there is evidence of recent accidental injury resulting in significant obstruction of breathing. 99395 Young adult age 18 through 20 years. All covered services must be medically necessary and meet all Healthy U Behavioral plan requirements for services to be reimbursed. Upon receipt of your complaint, the Grievance Coordinator will then send a letter of acknowledgement to the complainant. 99392 Early childhood age 1 through 4 years. JH Part A ; Payer ID . Providers with Medicare / Medicaid sanctions, or who have a business relationship with another provider or entity that has been debarred or excluded, will be terminated from the UUHP participating networks. Child is embarrassed or disturbed by his own speech. or request a copy from our office by calling (801) 587-6480 or 1 (888) 271-5870. Advantage U Signature members are covered for all of the services available through Original Medicare Parts A and B, and prescription medications covered through Part D. We also offer coverage for dental, vision, fitness, hearing aids, and over-the-counter benefits. If you are not able to access the request form by computer, call 801 538-3077 or toll-free 800 439-3905 to have the form mailed to you. Additional Specifications. Any rate change will be made only when we change rates for all policies in the same rate class on the same form as this Policy that are issued in Utah. Providers who have had restrictions placed upon their license to practice will be presented to the Credentialing Committee for a decision on the appropriate action to be taken. When needed, refer the child to an appropriate specialist. The applicant shall have the right to be informed of their application status (Ready for Committee, App In-process, App Incomplete or Missing Information) upon request. All services required to stabilize the enrollee with an emergency medical condition will be covered by the plan. - Payer ID numbers are assigned by the clearinghouse. 99432 Normal newborn care in other than hospital or birthing room setting. Supporting Documentation including operative reports, emergency room reports, medical records supporting diagnosis when requested, etc. Electronic claims can help improve efficiency, productivity and cash flow for providers, while payers can see benefits in reduction of data entry errors and faster turnaround times. If Provider fails to submit the balance due with sixty (60) days of notification, UUHP may recover the balance due by way of offset or retraction from current and/or future claims. If we agree the decision needs to be made quickly, we will make a decision in three working days. If you suspect fraud and abuse, you may report it to the University of Utah Health Plan Compliance Officer at 888-271-5870, Option 1. This includes being on time for visits or calling their provider if they need to cancel or reschedule an appointment. Non-Covered Services: A provider may be reimbursed for the provision of Non-covered services if one of the two conditions are met: A benefit exception is obtained from Healthy U. The level of member responsibility is determined by whether or not the provider or facility chosen is contracted with UUHP. Please do not use Humana's traditional Payer ID for fee-for-service claims (61101) when submitting Humana Healthy Horizons in Ohio Medicaid claims. See the following page for examples of UUHP ID cards. Always discuss health information in any newsletter or on any web site with your doctor to make sure it is appropriate for you. As such, our goal is to provide GREAT customer service to our providers. Emergency Medical Services/Do Not Resuscitate: a directive alerting emergency workers that the person does not want CPR or life-saving techniques. The plan must include the name(s) of the Hospital and the OB/GYN practitioner(s) providing backup. The Premium Due Date is shown in the Application. Members may have an in-network out-of-pocket maximum that is separate from the out-of-network out-of-pocket maximum. Measure at each exam and compare against age-specific percentiles for all children three years and older. FDRs have specific responsibilities under Medicare guidelines, including: Reporting Fraud, Waste, and/or Abuse (FWA): Providers, including all First-Tier, Downstream, and Related Entities (FDRs), such as providers employees and/or providers subcontractors, must report any suspected fraud, waste or abuse, misconduct, noncompliance with applicable regulations, or criminal acts. The representative can research the claim based on claim number, patient, provider and dates of service. U of U Health Plans is currently accepting the following HIPAA-compliant transactions: EFT (Electronic funds transfer) in conjunction with the 835, 270/271 0051010X279A1 Eligibility Request/Response (real-time), 276/277 Claim status inquiry/response (real-time). If additional information is needed, we may request a 14-day extension, to complete the review. Build and keep a strong patient-provider relationship. Medical necessity review requests can be sent to UUHP UM department via fax or mail. The steps in setting up EDI with UUHP are relatively simple: Review information on our website- http://uhealthplan.utah.edu/EDI/. Each plan will indicate separate deductible amounts for individual and family deductibles. Medicare Advantage Marketing Guidelines for Providers, Medicare Advantage plan marketing is regulated by CMS. Services will be paid according to Medicaid benefits and medical necessity. A PPO gives members the freedom to choose any doctor, specialist, or hospital to provide their care. Members have 180 days to appeal from Notice of Action Letter/EOB. Expedited Appeals within 72 hours of receipt of the request. Health Services for Children with Special Needs. Please contact the Healthy U Case Management Department for questions on medical necessity. Once the UUHP has received the EDI Enrollment form, UUHP will begin setting up the EDI connections. Demand management will expedite case management-like processes as emergent coordination of care issues arise. Payer ID valid only for claims with billing submission address of P.O. Screening accompanied by referral and intervention protocols can play an important role in linking children with and at-risk for developmental problems with appropriate interventions. Request information about their plan, their practitioners/providers, or their health in the members preferred language. U of U Health Plans does not reward doctors or others for denying coverage or care. Provider acknowledges UUHPs right to audit and review on a line-item basis, or other such as basis as deemed appropriate by UUHP, and UUHPs right to exclude inappropriate line items, to adjust payment, and to reimburse Provider at the revised allowed level. Does the child frequently come in contact with an adult who works with lead? A variety of plans for employers with 51 or more employees makes it easy to obtain high satisfaction. https://intercomm.utah.edu/policies/Lists/Policies/DispForm.aspx?ID=1962, Individual and Small Group Physician Practices, http://www.oig.hhs.gov/fraud/report-fraud/index.asp, , or the National Health Care Anti-Fraud Association web site at, University of Utah Health Plans Credentialing Policy, http://uhealthplan.utah.edu/for-providers/forms.php, http://uhealthplan.utah.edu/for-providers/pdf/howto-box.pdf, Members should use the Independent Review Request form, available at. Please contact the University of Utah Healthy U Case Management at (801) 587-6480 or 800- 271-5870, option 2, with any coverage questions, or for a medical necessity review. Use of Provider Network Except in the case of an emergency, enrollees must obtain covered services in the following manner: Members must receive ALL services from a Healthy U PARTICIPATING provider in order to receive coverage. U of U Health Plans business needs which may include and are not limited to: Network adequacy requirements based on state and/or federal guidelines, Network adequacy requirements based on the current or expected population of a given geographic area (usually defined by county or zip code), Network adequacy requirements based on provider type and/or specialty. The following information applies only to Advantage U providers and supplements compliance information listed in the Rules and Regulations section of this manual. Since our inception, we have grown our Healthy U membership, and have added several lines of business. We will give policy owner at least 45 days advance written notice prior to the effective date of any rate change. Refer the child to a dentist as follows: Make the initial referral for most children beginning at age one year and yearly thereafter. All reviews are conducted by a licensed health professional and referred to the Medical Director as necessary. We prefer you submit claims electronically through UHIN, using TPN HT000179-002; however, if you need to submit a paper claim, please mail the claim to: Standard Medicare Coordination of Benefits (COB) guidelines apply to Advantage U Signature claims. UHINT An internet-based product, UHINT is free to UHIN members. Provider acknowledges U of U Health Plans' right to review Providers claims prior to payment for appropriateness in accordance withU of U Health Plans' medical necessity policies and procedures, and in accordance with industry-standard billing rules including, but not limited to, current UB manuals and editors, CPT and HCPCs coding, CMS & Utah State Medicaid billing and payment rules & regulations, CMS, and/or other industry-standard bundling and unbundling rules, National Correct Coding Initiatives (NCCI) Edits, and FDA definitions and determinations of designated implantable devices. It is our belief that this program is essential to meeting the requirements of internal and external customers. UUHP members have the right to make decisions about their health care, including a written Advance Directive. Please note: Oral appeals must be followed by a written appeal. Provider is not prohibited from collection from members payment for services that are not medically necessary, provided that member or a person legally responsible for member has been notified by provider in advance in writing that such services are not medically necessary and that member or a person legally responsible for member has explicitly consented to pay for such services prior to the services being rendered.

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