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Provider Responsibilities, Mid-Atlantic Regional - 2019 UnitedHealthcare Administrative Guide

For detailed information and instructions on verifying eligibility, the choice and role of the PCP and other care provider requirements, refer to Chapter 2: Provider Responsibilities and Standards.


Eligibility and Health Care ID Cards

ID card information may vary by health benefit plan. For example, some members may have health care ID cards which indicate M.D. IPA Preferred or Optimum Choice Preferred benefits. You can see an image of the ID card specific to the member when you verify the member’s eligibility. For more information on ID cards and to see a sample health care ID card, refer to the Health Care Identification (ID) Cards section of Chapter 2: Provider Responsibilities and Standards.

Please check the member’s health care ID card during each member visit, and keep a copy of both sides of the health care ID card for your records. Possession of a health care ID card is not proof of eligibility. Before seeing a member, it is important you verify their eligibility and benefits, as well as the member’s PCP selection, to avoid payment issues. Go to UHCprovider.com/eligibility.

The following unique features on located on M.D. IPA and Optimum Choice health care ID cards:

  1. Laboratory provider information is located on the front of the cards; please see the following Laboratory Requirements section of this supplement.
  2. Radiology county information is located on the front of the cards; please see the following Radiology Services section of this supplement.
  3. Information regarding the necessity of referral and prior authorization requirements is now listed on the back of the cards.

Laboratory Requirements

Laboratory Requirements

M.D. IPA and Optimum Choice members must use the medical laboratory noted on their health care ID card for medical laboratory services. Any specimens collected in the office MUST be sent to the laboratory indicated on the member’s health care ID card. Depending on where the member lives, the health care ID card shows: Depending on where the member lives, the health care ID card shows:

  • LAB = LABCORP (Laboratory Corporation of America).
  • LAB = PAR (may use any participating outpatient commercial medical laboratory). Our online directory of health care professionals is available on UHCprovider.com/findprovider.

Refer to UHCprovider.com/Protocols.

Radiology Services

M.D. IPA and Optimum Choice members must use the radiology county noted on the health care ID card.

Depending upon the member’s Primary Care Provider’s office location, the health care ID card shows:

  • RAD = PAR (may use any office based participating provider) A complete list of these providers may be found on UHCprovider.com/findprovider.
  • RAD = County (the name of a county, i.e., “MONT (Montgomery County)” is listed on the card)

A complete list of county specific radiology vendors is found on UHCprovider.com/plans > (choose your state) > Commercial > Radiology Vendors.

Copays

Please verify the member’s copayments when verifying their eligibility.

Member PCP Requirements

A PCP is defined as a physician specializing in family practice, internal medicine, pediatrics, or general practice. Other care providers will be included as primary physicians as required by state mandates. Members are required to see their PCP or a covering physician at the address location that shares the same TIN listed on the Patient Eligibility screen. Some PCPs have multiple TINs but may not participate under each of those TINs for the member’s benefit plan. Before scheduling an appointment, it is important to verify the member’s assigned PCP and the TIN listed on the Patient Eligibility screen is the same TIN for the address location where the member will be seen. Please submit your address corrections through the My Practice Profile Link, or call the phone number on the back of the member’s health care ID card before seeing the member.

UnitedHealthcare of the Mid-Atlantic region may close a PCP panel if a member complains about access, or if UnitedHealthcare of the Mid-Atlantic region identifies a quality-related issue.

For requests about panel status (i.e., Open/Closed to New/Existing Patients), please contact your Network Account Representative 30 calendar days before any action. To find your Network Account Representative, go to UHCprovider.com > (scroll down) > Contact Us > Find a Network Management Contact > Select your state. Members are required to select a network PCP or a PCP is auto-assigned.

Direct Access Services

Female members may receive obstetrical and gynecological (OB/GYN) physician services directly from a participating OB/GYN, family practice physician, or surgeon identified by the medical group/IPA or UnitedHealthcare as providing OB/GYN physician services. This means the member may receive these services without prior authorization or a referral from her PCP. In all cases, the physician must be affiliated with the member’s assigned medical group/IPA and participating with UnitedHealthcare.