Skip left navigation

Virtual Visits, Capitation and/or Delegation (Commercial HMO Plans CA only) - 2019 UnitedHealthcare Administrative Guide

UnitedHealthcare of California added a new benefit for Virtual Visits to some member benefit plans in January 2017. Members can use Virtual Visits for primary care services that include the diagnosis and treatment of low acuity medical conditions. Virtual Visits provide communication of medical information in real-time between the member and a care provider or health specialist, through use of interactive audio and video communications equipment outside of a medical facility (for example, from home or from work). When covered by a member’s benefit plan, the Virtual Visit benefit has a separate defined copayment.

The Commercial HMO members with the new benefit may access Virtual Visits from a Designated Virtual Network Care Provider. We prefer members to access Virtual Visits through their selected PCP or medical group/IPA, if available. If the member’s medical group/IPA or PCP does not offer the Virtual Visit services, we will make a nationally contracted Virtual Visit care provider available. The network care provider groups intending to offer Virtual Visit services must comply with the service standards.

Service Standards

Access — When the care provider group develops Virtual Visit technology, it may offer services to assigned members who have the coverage as a part of their benefit plan. We pay for Virtual Visit primary care services delivered by care providers covered under professional capitation. Not all UnitedHealthcare West benefit plans will have the Virtual Visit benefit option. The care provider group must confirm member eligibility and cost share for Virtual Visit service. This applies only if medical group/IPA chooses to develop its own virtual visit technology.

24 Hour/Seven Day Availability — Virtual Visit technology services are available 24 hours a day, seven days a week.

Staffing Credentials — All professional staff are certified or licensed in their specialty or have a level of certification, licensure, education and/or experience in accordance with state and federal laws.

Staff Orientation and Ongoing Training — The care provider group must participate in a written orientation plan with documented skill demonstrations as well as initial and ongoing training programs including policies and procedures. The care provider group will pursue accreditation of its Virtual Visit program with the American Telemedicine Association.

Service Response Time —Within 30 minutes after a member requests a visit the care provider group will contact the member to either schedule or initiate a Virtual Visit.

Technology Security - The care provider group will conduct all member Virtual Visits via interactive audio and/or video telecommunications systems using a secure technology platform, which meets state and federal law requirements for security and confidentiality of electronic patient information. It will maintain member records in a secure medium, which meets state and federal law requirements for encryption and security of electronic patient information.

Professional Accreditation — The care provider group will pursue applicable accreditation by the American Telemedicine Association (or other mutually agreed upon accreditation body) with the objective of becoming accredited within one year after the accreditation program release date.

Continuous Quality Improvement (CQI) — The care provider group must have a documented CQI program for identifying through data opportunities for real, time measured improvement in areas of core competencies. There must be demonstrated ties between CQI findings and staff orientation, training and policies and procedures.

Member Complaints — The care provider group will log, by category and type, member complaints with specific improvement action plans for any patterns. There should be complaints registered on less than two percent of member cases.

Regulatory Assessment Results — If we ask, the care provider will have available and permit access to any applicable regulatory audit results.

Utilization — The care provider group will submit Virtual Visit encounters with proper coding as part of its existing encounter submission process.

Electronic Billing/Encounter Coding — The care provider group will submit Virtual Visit encounters or claims with proper coding as part of its existing encounter submission process.

Eligibility Verification — The care provider group will use existing eligibility validation methods to confirm Virtual Visit benefits.

Case Communication — The care provider group will support patient records management for Virtual Visits using existing EMR systems and standard forms. Its EMR records should contain required medical information including referrals and authorizations.

Joint Operating Committee — The care provider will meet with us up to quarterly at our request to review data reports, quality issues, and address any administration issues. Professional Environment  — The care provider group will help ensure that, when conducting Virtual Visits with members, the rendering care provider is in a professional and private location. The care provider group (rendering care providers) will not conduct member Virtual Visits in vehicles or public locations.

Medical Director — The care provider will employ or engage a licensed care provider as medical director. The medical director will be responsible for clinical direction.