Members may receive certain services without prior authorization or referrals. Please refer to Chapter 5: Referrals for specifics regarding direct access services.
Access to Participating Eye Care Providers (CA and CO Only)
If the medical group/IPA is delegated for vision services, the medical group/IPA must allow the member direct access to any eye care provider participating and available under the plan. An eye care provider defined as a network care provider who is an optometrist or ophthalmologist who is appropriately licensed. The medical group/IPA may subsequently require the eye care provider to submit requests for approval of surgical vision-related procedures.
Access to Participating Chiropractor (WA Only)
If the medical group/IPA is delegated for chiropractic services, the medical group/IPA must allow the member direct access to any participating chiropractor and available under the plan. The medical group/IPA may utilize managed care cost and containment techniques.
We will assign each member a PCP at the time of enrollment if the member does not select one. The PCP has the primary responsibility for coordinating the member’s overall health care, including behavioral health care, and the appropriate use of pharmaceutical medications.
The delegated medical group/IPA sets its own policies regarding the responsibilities of care providers.
The member’s PCP is responsible for directing the member to the clinically appropriate in- network provider based on the network specialists, medically necessary clinical criteria, the members’ benefits and in accordance with regulations on geographic and timely access requirements. If a provider of a service required by the member based on their PCP’s medical decision is not available in-network or is available in-network but such referral would not comply with the applicable geographic distance or timely access standards, the member’s PCP shall submit a request for an out-of-network provider review to the delegated medical group/IPA for accessibility. If approved, arrangements for access to an appropriate specialist outside of the PCP’s network will be made and the member’s financial responsibility for services rendered by the out-of-network provider shall not exceed the member’s applicable in-network co-payment, deductible, and coinsurance associated with their benefit plan.
We encourage the medical group/IPA to establish contracts with care providers to whom they refer our members for specialty services. Each contract must have the specific parts described in this section. The medical group/IPA may establish written contracts with referral care providers. They may utilize existing UnitedHealthcare contracts unless they are delegated for claims processing. Delegated medical group/IPAs must negotiate their own contracts. Such contracts must comply with the requirements of this guide.
- No contractual arrangement between the medical group/IPA and any subcontracting care provider may violate any provision of law.
- The medical group/IPA must make sure that all provisions of its agreement with any care provider who provides services to MA members includes all provisions required under the medical group/IPA’s Medicare Advantage participation agreement and regulatory requirements and applicable accreditation standards.
- If a care provider has opted out of the Medicare program, the medical group/IPA will not contract with them to provide services to MA members.
Establishing Contracts for Specialty Services
Any medical group/IPA delegated for claims processing must negotiate contracts with individual specialists or group practices to facilitate the availability of appropriate services to members. All contracts must be in writing and comply with state and federal law, accreditation standards and the MA agreement.
Depending upon the delegate’s contract with us, this may include contracting for services with hospitals, home health agencies and other types of facilities.
Subcontract Review (MA)
CMS regulations require us to make sure applicable provisions are contained in the written agreements the medical group/IPA has in place with its care providers.
We recommend that the medical group/IPA complete an annual review of the most current model subcontracts it uses to help ensure that all are fully compliant with federal law. We will conduct at least an annual review of each delegated medical groups/IPA’s down-stream contracts to
determine compliance with CMS regulations and guidance.
We will require Improvement Action Plans (IAP) for any medical group/IPA with non-compliant contracts. The IAP will identify specific findings, actions and expected time frame for compliance.
The delegated medical group/IPA may be responsible to initiate the referral authorization process when a request made to refer a member for services. Please refer to their Notification/Prior Authorization list. These capitated medical services are examples where a referral authorization may be needed:
- Outpatient services
- Laboratory and diagnostic testing (non-routine, performed outside the delegated medical group/IPA’s facility)
- Specialty consultation/treatment
- Facility admissions
- Out of network services
The medical group/IPA, PCP and/or other referring care provider is responsible for verifying eligibility and participating care provider listings on all referral authorization requests, to help ensure they refer a member to the appropriate network care provider. The medical group/IPA must comply with the following procedure:
- When a member requests specific services, treatment or referral to a care provider, the PCP or treating care provider shall review the request for medical necessity.
- If there is no medical indication for the requested treatment, the care provider shall discuss an alternative treatment plan with the member.
- If the treatment option selected by the member requires referral or prior authorization, the PCP or treating care provider must submit the member’s request to the delegate’s Utilization Management Committee or its designee for a decision. The PCP or treating care provider should include appropriate medical information and commentary on the referral regarding the reason that the requested service is medically necessary. Information should include results of previous treatment efforts.
- If the request is not approved in whole, the medical group/IPA (or if not delegated, UnitedHealthcare) must issue a denial letter to the member, specific to the requested services, treatment or referral and which complies with the applicable state and federal requirements.
The delegated entity is required to develop procedures by which a member may receive a standing referral/extended referral for specialty care. Procedures shall provide for a standing referral or extended referral to a specialist, or specialty care center. If the member and PCP, in consultation with the specialist, determine the member requires: (i) continuing care from a specialist or specialty care center over a prolonged period of time; and/or (ii) extended access to a specialist for a life-threatening, degenerative or disabling condition that requires coordination of care for the member by such specialist. The treatment plan may limit the number of visits to the specialist, limit the period of time that the visit be authorized and/or require that the specialist provide the PCP with regular reports on the health care provided to the member.
For an extended specialty referral, the requesting PCP and the specialist should determine which health care services each of them manage. The PCP shall record the reason, diagnosis, or treatment plan necessitating the standing referral. The specialist must refer the member back to the PCP for primary care.
HIV/AIDS Extended Referrals (CA Commercial Only)
The delegated medical group/IPA must have a written process for extended referrals to HIV/AIDS specialists when the PCP and medical group/IPA Medical Director agree that diagnosis and/or treatment of the member’s condition requires the expertise of an HIV/AIDS specialist. To comply with the state laws and regulations, the delegated medical group/IPA must identify care providers within their group who qualify as HIV/AIDS specialists. If there are no such care providers within the medical group/IPA, then the medical group/IPA must have available a mechanism to refer members to a qualified HIV/AIDS specialist outside of the group. The state regulations contain the qualification of an HIV/AIDS specialist California Health and Safety Code (Ca H&SC 1300.67.60).
The delegate may design its own request for referral and/or authorization forms, without approval by UnitedHealthcare. When the forms are used to communicate approvals to the member, the font of the form must be at least 12-point “Times New Roman” is the preferred style. When the referral or authorization form is not at least 12-point font, then the delegate sends a written notification that is. For Medicare Advantage members, UnitedHealthcare provides an approval template letter.
At a minimum, the form or written notice of approval must include all of the following components:
- Member identification (e.g., member ID number and birth date)
- Services requested for authorization including appropriate ICD-10-CM and/or CPT codes
- Authorized services including appropriate ICD-10-CM and/or CPT codes
- Proper billing procedures (including the medical group/IPA address)
- Verification of member eligibility
The delegate provides copies of the referral and/or authorization form to the following:
- Referral care provider
- Member’s medical record
- Managed care administrative office
CMS regulations 42 CFR 422.568(a) allow a member to make a direct request for services from either the MA plan or the entity responsible for making the determination, which is the utilization management/Medical Management delegated medical group/IPA. This applies to both standard and expedited pre-service Initial Organization Determinations (IODs). The established requirements for pre-service standard and expedited IODs apply. The medical group/IPA must have explicit policies and procedures for the following:
- Starting the referral or authorization processes when a member contacts the delegate to request services. The medical group/IPA must use the date and time the member first called as the received date and time of the request to comply with required turn-around times. The member’s request may have happened before the date and time the request reached the department that processes referrals and authorizations.
- Working with UnitedHealthcare on requests for referrals or authorizations of services for cases in which a member who has contacted us to request services. The medical group/IPA must use the date and time of the member’s request to UnitedHealthcare as the received date and time of the request for compliance with turnaround times.
Capitated/delegated medical group/IPAs that also provide and administer behavioral healthcare services must collect information at least annually about opportunities to work together with its behavioral healthcare providers to improve coordination of care between medical and behavioral healthcare services. Based on that data, the medical group/IPA must work with its behavioral healthcare specialists to identify, analyze and take collaborative action on identified opportunities for improvement. The medical group/IPA submits this report at least annually to its quality improvement committee or the appropriate committee, as determined by the medical group/IPA’s structure. The medical group/IPA must have a documented process that describes how it will complete this cycle. UnitedHealthcare will assess the process and report during its annual assessment of the capitated medical group/IPA.
A medical group/IPA that is capitated for providing and paying for behavioral healthcare services is also responsible for conducting an annual measurement of its members’ experience using behavioral healthcare services. This includes performing a member survey including a description of how it will conduct the survey and its sampling methodology. Based on survey results, the medical group/IPA then assesses the data, analyzes the results, identifies opportunities for improvement and describes its reasons for taking (or not taking) action, and implements interventions that are likely to contribute to improvement of the identified opportunities. The medical group/IPA then measures effectiveness of its interventions. It submits this report at least annually to its quality improvement committee or the appropriate committee, as determined by the medical group/IPA’s structure. UnitedHealthcare will assess the process and report during its annual assessment of the capitated medical group/IPA.