The UCare Provider Manual was developed as a reference guide for UCare policies and procedures relating to our products.
The Public Programs Provider Manual and the UCare Medicare Programs Provider Manual are now combined into one manual. We believe that the combination of various materials into one manual will enable your clinic to run more efficiently when you encounter a UCare member.
If you have questions or concerns regarding this manual, please contact the Provider Assistance Center at 612-676-3300 or toll free at 1-888-531-1493 (toll free).
Once you have used this manual, we would appreciate your feedback. Please use the Provider Feedback Form for your comments.
Table of Contents
› Chapter 1: Introduction to UCare (Revised January 2012)
› Chapter 2: Enrollment and Eligibility (Revised January 2012)
› Chapter 3: Sales and Marketing (Revised January 2011)
› Chapter 4: Benefits Overview (Revised January 2012)
› Chapter 5: Prior Authorization and Notification (Revised March 2011, Reviewed Jan. 2012)
› Chapter 6: Claims Submission Information (Revised September 2011)
› Chapter 7: Nursing Facility (Revised November 2010)
› Chapter 8: Home Care Services (Revised January 2011)
› Chapter 9: Public Health Services (Revised January 2009)
› Chapter 10: Hospital Services (Revised November 2010)
› Chapter 11: Interpreter Services (Revised December 2011)
› Chapter 12: Transportation (Revised October 2010)
› Chapter 13: Provider Resources for Child & Teen Checkups (C&TC) & Blood Lead Testing (Revised January 2012)
› Chapter 14: Obstetrics and Gynecology (Revised November 2010)
› Chapter 15: Comprehensive Outpatient Rehabilitation Facility Services (Revised January 2010)
› Chapter 16: Quality Management (Revised January 2012)
› Chapter 17: Provider Enrollment (Revised December 2011)
› Chapter 18: Member Complaints, Appeals, and Grievances (Revised January 2010)
› Chapter 19: Culturally Responsive Care (Revised January 2010)
› Chapter 20: Delegated Business Services (Revised July 2011)
› Chapter 21: Point-of-Service (POS) UCare for Seniors (Revised November 2010)
› Chapter 22: Fraud, Waste, and Abuse (Revised November 2009)
› Chapter 23: Medical Necessity Criteria (Revised December 2009)
› Chapter 24: Clinical Practice Guidelines (Revised December 2011)
› Chapter 25: Health Promotion Programs (Revised April 2011)
› Chapter 26: HCBS Waiver Services (Revised November 2011)
› Appendices
Chapter 1: Introduction to UCare (Revised January 2012)
About UCare
UCare's Mission
Minnesota Health Care Programs
Special Needs Plan
Medicare Advantage Plans
UCare's Telephone & Address Guide
UCare's Provider Network
Back to top >>
Chapter 2: Enrollment and Eligibility (Revised January 2012)
Eligibility
Enrollment
Primary Care Clinic (PCC) Change
Verification of Eligibility
UCare Provider Portal
Back to top >>
Chapter 3: Sales and Marketing (Revised January 2011)
Guidelines for Provider Marketing Activities
Permitted Provider Marketing Activities
Prohibited Provider Marketing Activities
Back to top >>
Chapter 4: Benefits Overview (Revised January 2012)
UCare Product Tip Sheets
Back to top >>
Chapter 5: Prior Authorization and Notification (Revised March 2011, Reviewed Jan. 2012)
Definitions of Terms
General Guidelines
What Services Require Prior Authorizations and Notifications?
How Do I Submit Prior Authorization and Notification Documentation?
Decision Making on Requests
Authorization Grids for Medical and MH/CD Services
Who to Contact
Back to top >>
Chapter 6: Claims Submission Information (Revised September 2011)
Electronic Data Interchange
Paper Claims/Attachments
CMS 1500 Paper Claim Form
CMS 1450/UB-04 Paper Claim Form
Common Submission Issues
Duplicate Claims Submission
Claims Payment
Chiropractic Claims
Dental Billing
Elderly Waivered Services
Waivered Services
Member Liability
Coordination of Benefits (COB) Claims
Primary Care Reimbursement
Denial/Termination/Reduction (DTR) of Services Notice
Claims Adjustments
Claims Auditing and Recovery Program
Coding
Ambulatory Payment Classification (APC)
Explanation of Payment (EOP) Reference Guide
ANSI Cross-Walk List including EX Codes
Forms
UCare Phone Numbers
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Chapter 7: Nursing Facility (Revised November 2010)
Skilled Nursing Facility Services - Medicare Programs
Skilled and Non-Skilled Nursing Facility Services - Minnesota Health Care Programs and Special Needs Plans
Denial and Discharge Notices
Facility Discharge Notices
Forms
Back to top >>
Chapter 8: Home Care Services (Revised January 2011)
Home Care Services Criteria
Billing Medicare Certified Home Care Services
New Enrollee Rights, New Provider Responsibilities in Medicare Advantage (UCare for Seniors)
Notice of Denial of Medical Coverage (NDMC) Process
Home IV Infusion Services
Personal Care Attendant (PCA) Provider Standards
PCA Individual Training and PCA Agency Training Requirements
PCA Authorization Process
PCA Billing Guidelines
PCA UMPI Numbers (additions/changes/deletions)
Qualified Professional (QP) Supervision Standards
QP Responsibility
Back to top >>
Chapter 9: Public Health Services (Revised January 2009)
UCare Values Coordination with Public Health
Authorizations for Public Health Services
Population Health Improvement Collaboratives
References
Back to top >>
Chapter 10: Hospital Services (Revised November 2010)
Hospital Admission Notification Process
Daily Admission Report
Acute Rehabilitation Process and Guidelines
Notice of Discharge and Medicare Appeal Rights (NODMAR) Process
Care Transitions
Back to top >>
Chapter 11: Interpreter Services (Revised December 2011)
Access to Interpreter Services
Arranging for Interpreter Services
UCare Contracted Interpreter Service Agencies
Interpreter Requirements
Professional Standards for Interpreters
Guidelines for Working with Interpreters
Interpreter Services Requirement and Performance Expectations
Reimbursement and Claims Processing
MN Community Coding Practice/Recommendations for Interpreter Services
Place of Service Codes
How to Bill Interpreter Services
Back to top >>
Chapter 12: Transportation (Revised October 2010)
Types of Transportation Services
Eligible Members for Non-emergency Transportation
Benefits Grid
Transportation Provider Guidelines
Common Carrier Transportation
Common Carrier Provider Guidelines
Common Carrier Services Claim Submission Requirements
Common Carrier Coding Information
Billing Same Day Rides for STS and Common Carrier Services
Special Transportation Services (STS) Provider Guidelines
Special Transportation Services Claims Submission Requirements
Extended Transportation
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Chapter 13: Provider Resources for Child & Teen Checkups (C&TC) & Blood Lead Testing (Revised January 2012)
Overview
Two-Character Referral Code
Missed Opportunity
Resources
Back to top >>
Chapter 14: Obstetrics and Gynecology (Revised November 2010)
Family Planning Services
Sterilization
Abortion Services
UCare's Management of Maternity Services (M.O.M.S)
Billing Information
Prenatal Care Guidelines for Normal Pregnancy
Prenatal Care Guidelines for High Risk Pregnancy
Back to top >>
Chapter 15: Comprehensive Outpatient Rehabilitation Facility Services (Revised January 2010)
CORF Denial and Discharge Notices
Back to top >>
Chapter 16: Quality Management (Revised January 2012)
Program Overview
Quality Improvement Advisory and Credentialing Committee (QIACC)
CMS Health Plan Quality and Performance Ratings
HEDIS Measures and Reporting
Pay-for-Performance (P4P) Program
Medical Record Documentation Requirements
Member Medical Record Requirements for Providers Policy
Clinic Requirements for the Quality Improvement Program
Back to top >>
Chapter 17: Provider Enrollment (Revised December 2011)
Practitioner Types that Require Credentialing
Practitioner Types that do not Require Credentialing
Facility Types that Require Credentialing
Credentialing Process
UCare's Credentialing Policy
Back to top >>
Chapter 18: Member Complaints, Appeals, and Grievances (Revised January 2010)
Medicare Advantage Member Appeal and Grievance Process
Medicare Part D Prescription Drug Benefit Appeal and Grievance Process
Special Needs Program (SNP) Integrated Appeals process (Coming in the future for implementation in 2008)
Minnesota Health Care Programs Member Appeal and Grievance Process
Quality of Care Reviews
Clinic Responsibilities: Complaints, Appeals, and Grievances
Back to top >>
Chapter 19: Culturally Responsive Care (Revised January 2010)
Background: What is Cultural Competence? Why is it Important?
Cultural Competence Self-Assessment Tool
Resources: Web Sites, Local Resources, and Health Care Options for the Uninsured and Underinsured Patients
National Standards for Culturally and Linguistically Appropriate Services (CLAS) in Health Care
Top 10 Innovations in Culturally and Linguistically Appropriate Services (CLAS) from UCare
Guidelines for Working with Interpreters
LEARN: Process for Improved Communication
Back to top >>
Chapter 20: Delegated Business Services (Revised July 2011)
Express Scripts, Inc.
Behavioral Healthcare Providers (BHP)
Mayo Management Services, Inc. (MMSI)
DentaQuest
Chiropractic Care of Minnesota, Inc. (ChiroCare)
Back to top >>
Chapter 21: Point-of-Service (POS) UCare for Seniors (Revised November 2010)
Covered Services
Non-Covered Services
POS Co-insurance
Accessing the POS Benefit
Back to top >>
Chapter 22: Fraud, Waste, and Abuse (Revised November 2009)
Preventing Healthcare Fraud
What is UCare doing about it?
Common Examples of Fraud
How can you help avoid and prevent healthcare fraud?
Contacting UCare
UCare's Code of Conduct
Back to top >>
Chapter 23: Medical Necessity Criteria (Revised December 2009)
Bariatric Surgery
Circumcision
Cosmetic or Reconstructive Surgery Procedures that may be considered cosmetic
Durable Medical Equipment (including Power Wheelchair and Scooters)
ENT Surgery (Septoplasty, Rhinoplasty)
Orthoptic Therapy (Vision Therapy)
Reduction Mammoplasty
Radiofrequency Neuroablation
Rehabilitative Services - Physical, Occupational, or Speech Therapy
Spinal Cord Stimulator Implants
Spine Surgery
Synagis (palivizumab) Injections
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Chapter 24: Clinical Practice Guidelines (Revised December 2011)
Clinical Practice Guidelines Overview
Preventive Services for Adults Guideline
Preventive Services for Children and Adolescence Guideline
Prenatal Care, Routine Guideline
Diabetes, Type 2 Diagnosis and Management Guideline
Asthma, Diagnosis and Outpatient Management Guideline
Obesity, Preventive and Management Guideline
Back to top >>
Chapter 25: Health Promotion Programs (Revised April 2011)
ActiveU: YMCA and Kits
Diabetes and Asthma Camps
Seats, Education, And Travel Safety (S.E.A.T.S.) Program
Children's Preventive Health Incentives (Gold Star Program)
Community Education Classes
Mammogram Reward
Management of Maternity Services (M.O.M.S.) Program
Pregnancy and Childbirth Education Classes
Senior Fitness Program
Smoking and Tobacco Cessation Programs
Important Phone Numbers
Back to top >>
Chapter 26: HCBS Waiver Services (Revised November 2011)
Background for Home and Community Based Service (HCBS) Waivers
UCare products that may include an HCBS Waiver
UCare products that DO NOT include an HCBS Waiver
Requests for HCBS Waivers - Working with the Member's Care Coordinator/Case Manager
Coding Information for Waiver Service Providers
Elderly Waiver Billing Information
Waiver Obligations - Important Notice for Elderly Waiver Providers
Additional Information from DHS Regarding Waiver Services
› 2011 HCBS Provider Directory
Back to top >>
Appendices - Evidence of Coverages (EOCs) for 2012
› UCare for Seniors - Classic and Value Plus Plans
› UCare for Seniors - Standard D Plan
› UCare for Seniors - Value Plan
› UCare's MSHO Plan
› UCare Connect Plan
› Minnesota Senior Care Plus (MSC Plus) Plan
› Prepaid Medical Assistance Program (PMAP)
› MinnesotaCare Plan
Back to top >>