Benefits & Coverage
The member's plan must have preventive care benefits in order for preventive vaccinations to be covered.
What is Vaccine Benefits?
Replacement ID cards can only be issued in sets. If the size of the family is six or less individuals, a set is two cards. If the size is seven to nine, a set is four cards.
What is Replacement ID Cards (UNET)?
If there is no PHI indicator, do not release the provider's TIN or the bank account information to the member.
What is Confidentiality Job Aid?
If the provider is appealing on the member's behalf, they must have a written authorization letter from the member.
What is Provider Address Inquiry?
UHC provides coverage for 3D Mammography (or DBT) for breast cancer screening (preventive) and diagnostic testing under standard benefit plans.
What is 3D Mammography?
A CGM is a system that continuously monitors glucose (sugar) in the body using a sensor placed under the skin. It is a type of diabetic supply sometimes used in conjunction with an insulin pump.
What is Diabetes?
This section only provides navigational steps for updating COB in CDB. Follow the appropriate process for Updating COB in conjunction with this section to ensure correct handling.
What is Updating COB in CDB?
Strict adherence to this policy is needed to protect the confidentiality of PHI from improper or illegal disclosure and to ensure Customer Care and Provider Service centers are in compliance with applicable federal and state confidentiality and privacy laws and UnitedHealth Group's corporate policies governing the confidentiality of health information.
What is Call Authentication Process?
This process applies only to denials of pre-service treatment/prospective denials (when the service is not yet rendered) or concurrent denials (when the review takes place the same time the services were rendered, e.g., inpatient stay).
What is Expedited Appeal/Grievance Process?
Have 45 days passed since claim was last processed?
What is Balance Billing Process?
Utilize this process when a member has benefit questions around foreign services incurred while traveling or living out-of-country.
What is Foreign/Out-of-Country?
A qualifying event terminates an individual's normal coverage under a health care plan. The event qualifies the employee or spouse/child to continue the same coverage the individual had on the day before the event.
What is COBRA?
Active coverage letter (COC), also known as eligibility letter, may be issued at the member's request to provide proof of active medical coverage. Each family member would receive an individual letter; there is no group letter for all family members.
What is POLC and COC?
The member is inquiring about a pre-service adverse determination.
What is Pre-Service Denial?
Utilize the process below when an adjustment is needed but there are no other applicable SOPs available that provide additional triage instructions and/or route instruction.
What is Standard Adjustments?
UnitedHealthcare continues to support preventive care, including colon cancer screening. We provide coverage for screening colonoscopies, virtual colonoscopies, sigmoidoscopies, and stool-based colon cancer screening.
What is Stool-Based Colon Cancer Screening?
The following list of services are not covered by original Medicare plan. The patient's out-of-pocket expense is not limited to the list.
What is Medicare Non-Covered Services?
If you receive an email requesting the medical information about a member who is not one making the inquisition, UnitedHealthcare must have an authorization from the member in question before you can proceed, consistent with how incoming phone calls are handled.
What is Email/Secure Messaging Disclosure?
The mailing address for the appeal/grievance is included on the EOB and is listed in AVA/ACET in the Final Claim Fiduciary section.
What is Member Address Inquiry?
The Newborn and Mother Health Protection Act does not apply to dependent maternity or the grandchild(ren) of a subscriber.
What is Newborn Claim Research?
Members can receive better benefits when using tiered benefit products and receiving services from tiered physicians, free-standing facilities, and hospitals.
What is Tiered Benefit Products?
A claim closed with 7Y or denied with SF for COB will be reconsidered through auto-recall. The claim will be considered to have failed auto-recall if it has been more than seven days since the COB update.
What is Updating COB?
Call is received from a member/provider of a relative, a friend, or a known or casual acquaintance.
What is Receiving a Call From Someone You Know?
Advise the member that the standard time frame allowed for filing a first-level appeal/grievance is 180 days from the date the claim was processed.
What is First Appeal/Grievance Filing Time Frame?
This process applies when member states they did not receive services billed.
What is Service Not Rendered or Received - Error in Billing?