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UCare - Providers - Provider Manual

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.

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 December 2007)
›  Chapter 2: Enrollment and Eligibility (Revised September 2006)
›  Chapter 3: Sales and Marketing (Revised November 2007)
›  Chapter 4: Benefits Comparison (Revised July 2008)
›  Chapter 5: Prior Authorization, Referral and Notification (Revised December 2008)
›  Chapter 6: Claims Submission Information (Revised November 2009)
›  Chapter 7: Skilled Nursing Facility (Revised May 2009)
›  Chapter 8: Home Care Services (Revised February 2009)
›  Chapter 9: Public Health Services (Revised January 2009)
›  Chapter 10: Hospital Services (Revised June 2009)
›  Chapter 11: Interpreter Services (Revised June 2009)
›  Chapter 12: Transportation (Revised February 2009)
›  Chapter 13: Provider Resources for Child & Teen Checkups (C&TC) & Blood Lead Testing (Revised October 2008)
›  Chapter 14: Obstetrics and Gynecology (Revised November 2008)
›  Chapter 15: Comprehensive Outpatient Rehabilitation Facility Services (Revised October 2008)
›  Chapter 16: Quality Management (Revised March 2009)
›  Chapter 17: Provider Enrollment (Revised October 2009)
›  Chapter 18: Member Complaints, Appeals, and Grievances (Revised November 2007)
›  Chapter 19: Culturally Responsive Care (Revised August 2005)
›  Chapter 20: Delegated Business Services (Revised September 2008)
›  Chapter 21: Point-of-Service (POS) UCare for Seniors (Reviewed October 2008)
›  Chapter 22: Fraud,Waste, and Abuse (Revised November 2009) 
›  Chapter 23: Medical Necessity Criteria (Revised September 2008)
›  Chapter 24: Clinical Practice Guidelines (Revised July 2008)
›  Chapter 25: Health Promotion Programs (Revised October 2009)
›  Chapter 26: HCBS Waiver Services (Revised October 2008)

›  Appendices

 

Chapter 1: Introduction to UCare (Revised December 2007)
UCare Background Information
The UCare Mission
Health Care Programs
Medicare Programs
UCare Telephone & Address Guide
UCare Provider Network

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Chapter 2: Enrollment and Eligibility (Revised September 2006)
Eligibility
Enrollment
Primary Care Clinic Change
Member Verification
MN-ITS
Access UCare
Member Identification Cards

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Chapter 3: Sales and Marketing (Revised November 2007)
Provider Marketing Activities

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Chapter 4: Benefits Comparison (Revised July 2008)
MA, GAMC, GHO, MSHO, and MnDHO Benefit Reference Sheet
MinnesotaCare Benefit Summary Reference Sheet

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Chapter 5: Prior Authorization, Referral and Notification (Revised December 2008)
Definitions of Terms
General Guidelines
What Services Require Prior Authorizations, Referrals, and Notifications?
Authorization Grids for Health Care Programs: MA, GAMC, MnCare, MSHO, and UCare Complete (MnDHO)
UCare for Seniors Authorization Grid
How Do I Submit the Referral, Prior Authorization and Notification Documentation?
Decision Making on Requests
Who to Contact
Denials of Services

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Chapter 6: Claims Submission Information (Revised November 2009) 
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
Reimbursement for Services Without a DHS or Medicare Rate
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: Skilled Nursing Facility (Revised May 2009)
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 - Medicare Advantage Products: UCare for Seniors, UCare Secure
Denial and Discharge Notices - Dual Special Needs Plan Products: MSHO, MnDHO, UCare Connect
Facility Discharge Notices: Enrollee Rights, New Provider Responsibilities in Medicare Advantage (applies to Medicare Advantage and Dual Special Needs Plan Products)

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Chapter 8: Home Care Services (Revised February 2009)
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
Specific Coding for Home IV Infusion Services
Personal Care Attendant (PCA) Provider Standards
PCA Training Guidelines
PCA Authorization Process
Specific PCA Billing Guidelines
Making Changes to Individual PCA UMPI Numbers
UCare PCA UMPI Information Form 
Qualified Professional (QP) Supervision Standards

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Chapter 9: Public Health Services (Revised January 2009)
UCare Values Coordination with Public Health
Authorizations for Public Health Services
Population Health Improvement Collaboratives
References

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Chapter 10: Hospital Services (Revised June 2009)
Hospital Admission Notification Process
Birth Notification Form (link)
Daily Admission Report
Acute Rehabilitation Process and Guidelines
Notice of Discharge and Medicare Appeal Rights (NODMAR) Process
Care Transitions

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Chapter 11: Interpreter Services (Revised June 2009)
Access to Interpreter Services
Arranging for Interpreter Services
UCare Contracted Interpreter Service Agencies
Interpreter Requirements
Interpreter Services Performance Expectations
Service Reimbursement and Claims Processing
Professional Standards for Interpreters
Guidelines for Working with Interpreters

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Chapter 12: Transportation (Revised February 2009)
Types of Transportation Services
Eligible Members for Non-emergency Transportation
Transportation Benefit by Product
Transportation Provider Guidelines
Common Carrier Transportation
Common Carrier Provider Guidelines
Completing the CMS 1500 Claim Form for Common Carrier Services
Special Transportation Services (STS) Provider Guidelines
Completing the CMS 1500 Claim Form for Special Transportation Services
Extended Transportation Services under waiver benefits

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Chapter 13: Provider Resources for Child & Teen Checkups (C&TC) & Blood Lead Testing (Revised October 2008)
Resources List and Links
Childhood Blood Lead Screening Guidelines
Childhood Blood Lead Case Management Guidelines
Child & Teen Checkups (C&TC)
C&TC Billing Information
Sample Child & Teen Checkups (C&TC) Clinic Flow
Blood Lead Test chart flag
Child & Teen Checkups Checklist
Child & Teen Checkups Frequently Used Billing Codes

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Chapter 14: Obstetrics and Gynecology (Revised November 2008)
Family Planning Services
Sterilization
Obstetrics and Gynecology Services
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

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Chapter 15: Comprehensive Outpatient Rehabilitation Facility Services (Revised October 2008)
CORF Denial and Discharge Notices
Notice of Medicare Non-Coverage (NOMNC) Form, "The Advance Notice"
NOMNC Valid Delivery Documentation Form
Detailed Explanation of Non-Coverage (DENC) Form, "The Detailed Notice"

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Chapter 16: Quality Management (Revised March 2009)
Program Overview
Quality Improvement Advisory and Credentialing Committee (QIACC)
HEDIS and Pay for Performance Overview
Medical Record Documentation Requirements
Member Medical Record Requirements for Providers Policy
Clinic Requirements for Quality Management

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Chapter 17: Provider Enrollment (Revised October 2009)
Practitioner Types that Require Credentialing
Practitioenr Types that do not Require Credentialing
Facility Types that Require Credentialing
Credentialing Process

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Chapter 18: Member Complaints, Appeals, and Grievances (Revised November 2007)
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
Quality Complaint Reporting Form

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Chapter 19: Culturally Responsive Care (Revised August 2005)
What is Cultural Competence? Why is it Important?
Six Steps Toward Cultural Competence
Hallmarks of the Culturally Competent Clinician
Competence Self-Assessment Tool
Guidelines for Working with Interpreters
LEARN: Process for Improved Communication
Resource List
UCare's Culturally and Linguistically Appropriate Services

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Chapter 20: Delegated Business Services (Revised September 2008)
RxAmerica (Pharmacy Benefit Management)
Behavioral Healthcare Providers (BHP)
Doral Dental Services of Minnesota, Inc. (Doral)
Chiropractic Care of Minnesota, Inc. (ChiroCare)

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Chapter 21: Point-of-Service (POS) UCare for Seniors (Reviewed October 2008)
Point-of-Service Benefits
Coordination of Care When the POS Benefit is Used

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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

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Chapter 23: Medical Necessity Criteria (Revised September 2008)
Legislated Utilization Requirements
Bariatric Surgery
Blepharoplasty
Circumcision
Electric Wheelchair and Scooters
ENT Surgery (Septoplasty, Rhinoplasty)
Orthoptic/Pleoptic Therapy (Vision Therapy)
Panniculectomy
Reduction Mammoplasty
Rehabilitative Services - Physical, Occupational, or Speech Therapy
Synagis (palivizumab) Injections

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Chapter 24: Clinical Practice Guidelines (Revised July 2008)
Clinical Practice Guidelines Overview
Preventive Services for Adults Guideline
Preventive Services for Children Guideline
Prenatal, Routine Care Guideline
Diabetes, Type 2 Management Guideline
Asthma, Diagnosis and Management Guideline
Pressure Ulcer Guideline for MnDHO

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Chapter 25: Health Promotion Programs (Revised October 2009)
ActiveU
Diabetes and Asthma Camps
Seats, Education, And Travel Safety (S.E.A.T.S.) Program
Gold Star Gift Certificates
Community Education Classes
Mammogram Reward
Management of Maternity Services (M.O.M.S.) Program
Pregnancy and Childbirth Education Classes
Senior Wellness Program
Smoking and Tobacco Cessation Programs
Important Phone Numbers

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Chapter 26: HCBS Waiver Services (Revised October 2008)
2009 Home and Community Based Services Provider Directory
Background for Home and Community Based Service (HCBS) Waivers and Highlights for Waiver Services
UCare products that may include an HCBS Waiver
UCare products that DO NOT include an HCBS Waiver
Approvals for HCBS Waivers - Working with the Member's Care Coordinator
Coding Information for Waiver Service Providers
Elderly Waiver Billing Information
Waiver Obligations - Important Notice for Elderly Waiver Providers
For Additional Information from DHS Regarding Waiver Services

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Appendices

›  UCare for Seniors Evidence of Coverage - Value Plus or Classic
›  UCare for Seniors Evidence of Coverage Amendment - Value Plus
or Classic

›  UCare for Seniors  Evidence of Coverage - Value
›  UCare Secure Evidence of Coverage
›  UCare Complete Certificate of Coverage
›  UCare Connect Certificate of Coverage

›  Minnesota Senior Health Options (MSHO) Certificate of Coverage
›  Minnesota Senior Care Plus (MSC+) Certificate of Coverage
›  Minnesota Senior Care Plus (MSC+) Certificate of Coverage
Addendum

›  Prepaid Medical Assistance Program/Prepaid General Assistance
Medical Care Certificate of Coverage

›  Prepaid Medical Assistance Program/Prepaid General Assistance
Medical Care Certificate of Coverage Addendum

›  MinnesotaCare Certificate of Coverage
›  MinnesotaCare Certificate of Coverage Addendum

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