You may also verbally request an appeal by calling the Customer Service phone number for the member's benefit plans:Customer Service Phone Numbers. For more information about outreach education, please call Case Management at (801) 587-6480 or 800-271-5870, option 2. University of Utah Health Plans The IRO will make a decision within 45 days after receipt of the request. The exception to this rule is if Medicare is the primary insurance. Providers are encouraged to contact the U Baby Care case manager (RN) with any information that is pertinent to the member for coordination of care. The phone number is, 801-587-6480, option 1. For questions about COB, contact Customer Service at 855-275-0374. Services are reviewed, and determinations are. You must report every line associated with this claim to ensure the full claim is reprocessed. A Covered Dependent will cease to be a Covered Dependent upon the occurrence of any of the following events: The Covered Dependent no longer meets the eligibility requirements specified in this Policy; The spouse is no longer an eligible Dependent as a result of a divorce decree or legal separation; policy owner and Domestic Partner are no longer in a Domestic Partnership relationship; Dependent Child reaches his or her 26th birthday, except as provided for Handicapped Children; Your Dependent enters active duty in the military; No coverage will be available for a Covered Dependent upon attainment of the limiting age for a Covered Benefit specifying a limiting age for coverage under this Policy. A Clinical appeal means services that were denied in a pre-service review, or services that were billed and require medical review, that were denied. She will use an average of three to four words per utterance. Grand Valley Preferred is a commercial plan that we offer to employer groups in Grand Junction, Colorado and the surrounding areas. University of Utah Health Plans will pay 100% of the allowable (except for copayments and the charges excluded, including the PPO discount) for any covered family member during the remainder of the year. Mammography reminder letters and follow up calls go out to members meeting the mammogram criteria that have not had a mammogram within two years. Advantage U Quality Programs -[In Development]. Subject to the rate requirements in the state of Utah, where this Policy is issued, we may change the rates for this Policy on any Policy Anniversary Date. If UUHP extends the timeframes, a written notice of the reason for the delay will be given to the enrollee. Some products and services that do not apply toward the annual out-of-pocket maximum include copayments, deductibles, prescription copayments, mental healthcare services, and non-covered services. Once we make a decision, we will mail you an Appeal Resolution Letter, and call you if you requested an expedited appeal. a written statement of the health care a person wants if he or she cant make independent decisions. Generally, health providers who agree to treat Medicaid patients are prohibited by Federal law from billing Medicaid patients directly for covered services. Electronic Data Interchange | Healthy Blue in Louisiana The effective date of coverage is the same as the policy effective date shown in the application which is filed. The Credentialing Committee retains the rights to approve or disapprove corrective action plans, determine whether the providers plan and actions meet criteria, and recommend termination for noncompliance, if deficiencies are not resolved as outlined above. Under Utah Law (26-23a-2), any health care provider who treats or cares for a person who suffers from any wound or other injury inflicted by the person's own act or by the act of another must immediately report it to a law enforcement agency. In 1999, the University Health Care Plus plan was added. (Note This must be done each time a non-covered service is to be rendered. The removal of Norplant is also a covered benefit. 34167. A Grievance is a complaint about something that is not an Action. Inc. ONLY. UHIN will forward the enrollment information directly to University of Utah Health Plans to complete your set-up to submit EDI transactions electronically. The Department may not cite, use, or rely on any guidance that is not posted on . Appeals may be received via mail, in-person delivery, fax, or orally. Coordination of care by primary as well as specialty providers will be augmented by use of ancillary health care and community social services. If a court or administrative order requires a policy owner to provide coverage for a Dependent Child, and the child is enrolled for coverage under this policy on or after the Policy Effective Date, the following provisions will apply to the childs coverage. Demographic needs including but not limited to languages spoken, Existing, non-compensated, referral patterns with current network providers and/or UUHP members. Use of Provider Network Except in the case of an emergency, enrollees must obtain covered services in the following manner: Members must receive ALL services from a Healthy U PARTICIPATING provider in order to receive coverage. Age-appropriate hearing screening intervals, protocols, and procedures, and screening indicators are available in the Medicaid Provider Manual (Section 2 CHEC Services) at http://health.utah.gov/medicaid/pdfs/chec.pdf. Effective July 1, 2016, University Health Care Plus is administered by Regence BlueCross BlueShield of Utah in a joint venture between Cambia and the University of Utah. Healthy U offers Enhanced Services for pregnant members, including perinatal care coordination, prenatal and postnatal home visits, group prenatal and postnatal education such as Lamaze classes, nutritional assessment and counseling, and prenatal and postnatal psychosocial counseling. The timely filing limit for secondary claims is 180 days from the primary payers EOB adjudication date. Once the Test File is good, the provider can move to production right away. Providers should submit claims on standard forms (CMS 1500 for professional services and UB04 for facility services), or the appropriate 837 HIPAA compliant transaction EDI file within timely filing requirements. Medicaid pays for medical services for the following: Low-income pregnant women. Ask for a second opinion about their medical condition. Healthy U Medicaid: The timely filing for both primary and secondary claims is 365 days from the date of service. To conduct other HIPAA transactions not listed, please contact our EDI department at 1-800-225-2573, ext. Medicaid and Medicare together provide health coverage for approximately 12.2 million low-income seniors and people with disabilities who are dually eligible for both programs. (Participate in provider profiling), Consistently review data and processes for improvement opportunities. A five-digit payer ID is required when adding a client's insurance information. If a child in State custody has an established relationship with a provider contracted with Healthy U every effort will be made to ensure that child continues his or her care with that provider. The manual can be used as a reference guide for University of Utah Health Plans (U of U Health Plans) policies and procedures for commercial and government plans. View Medicare Outpatient Observation Notice for details and a sample copy of the form. Note: A table with the recommended screening and prevention components and administration intervals is available in Appendix C of Utah Medicaid Provider Manual at http://health.utah.gov/medicaid/pdfs/chec2_0104.pdf. Supporting Documentation including operative reports, emergency room reports, medical records supporting diagnosis when requested, etc. If facility services are rendered by any facility other than a participating facility, facility shall (i) notifyU of U Health Plans' utilization management department prior to referring member to a non-participating facility, and (ii) use best efforts to notify such facility of UUHPs utilization management requirements. The following rights and responsibilities are in addition to those listed in the Member Rights & Responsibilities section of this manual. Healthy U Behavioral covers inpatient and outpatient behavioral health and substance abuse services, including: Members of Healthy U Behavioral, as well as all members of the community, have access to crisis response programs to provide immediate behavioral therapyeven if their established behavioral professional is not available. Provider shall comply with all State & Federal Medicaid regulations in providing services to enrollees in such plans. A designated case manager will follow patients across the continuum of care in both inpatient and ambulatory settings. Restricted members are required to obtain medical services from their PCP. Our goal is not to just operate at industry standards, but to exceed them in every possible way. Does the child live near a heavily traveled major highway where soil and dust may be contaminated with lead? Healthy U will send a request for an extension of 14 days, if necessary. Referrals Healthy U members may consult a specialist without obtaining a referral from their primary care provider. Contact UHIN and receive a copy of the UHIN Electronic Commerce Agreement (ECA). Claims and Payment Information | Ohio Medicaid for Providers | Humana If EDI Connection issues occur during off-hours for real-time 270/271 and 276/277 transactions please contact U of U Help Desk at 801-587-6000. Indian Health Service (IHS)/Tribal Organizations 04412 . Call us if a provider tries to make you pay for your care (except for your co-pay if you have one). Electronic claims can help improve efficiency, productivity and cash flow for providers, while payers can see benefits in reduction of data entry errors and faster turnaround times. Providers with Medicare / Medicaid sanctions, or who have a business relationship with another provider or entity that has been debarred or excluded, will be terminated from the UUHP participating networks. When Covered Dependents are no longer eligible for coverage under this Policy: The coverage for Covered Dependents will continue in force through the last day of the month in which he or she ceases to be a Covered Dependent. HLTHT. We recommend the following social-emotional screening tools for screening infants 0-12 months: Ages and Stages Questionnaire: Social-Emotional (ASQ:SE), Parents Evaluation of Developmental Status (PEDS), Temperament and Atypical Behavior Scale (TABS). Health Services Preferred (HSP) by Emerald Health. U of U Health Plans is responsible for payment of covered services rendered by the provider on behalf of Healthy U Behavioral members. Updates can be sent to provider.relations@hsc.utah.edu or you can complete the online form at http://uhealthplan.utah.edu/for-providers/prov_update_form.php. Healthy U Integrated Medical and Behavioral, University of Utah Health Plans An Introduction, Site Audits & Ensuring Appropriate Physical Facilities, Healthy Premier Individual and Family Plans, Healthy Premier, Healthy Preferred and Grand Valley Preferred Group Plans, Healthy U Behavioral for Behavioral Health (Medicaid Managed Care), Effective January 1, 2016, the University of Utah Health Plans (UUHP) will require that providers obtain, http://www.caqh.org/sites/default/files/solutions/proview/guide/PR-QuickRef.pdf, In compliance with CORE requirement, 270 U of U Health Plans uses the UHIN clearinghouse for all EDI transactions. 99432 Normal newborn care in other than hospital or birthing room setting. Provide information toU of U Health Plans, its practitioners, and providers, including their Member ID Card, or plan information as needed in order to provide care. Children living in neighborhoods where the case rate is higher than the national average. In the event CMS makes a change to their published rates, U of U Health Plans will implement the updated rate within 45 days of the CMS publication. A doctor must determine that the person is suffering from a life-threatening illness before this directive can be made. 99395 Young adult age 18 through 20 years. Providers should not balance bill the member for the difference between the contracted amount and the total billed charges. Post-service Appeal within 45 calendar days of receipt of the request. Services obtained out-of-network that are not emergency services, urgent care services, or where a referral was not obtained from Healthy U. Make sure that you select all transaction types you will be exchanging (837, 835, 270, etc.). In such cases, the Provider is prohibited from billing the member. A Medicaid case is routinely opened for children in these groups and they are enrolled in one of the available Medicaid health plans. This also encourages and supports the development of effective alternatives to traditional modes of medical practice without compromising the quality of care rendered to UUHP patients. JH Part A Locale . The timely filing limit for secondary claims is 180 days from the primary payers EOB adjudication date. Covered services for illnesses and injuries sustained directly from a catastrophic occurrence or disaster, including but not limited to, earthquakes or acts of war. U of U Health Plans is committed to ensuring all of our members receive quality health care. Patients are identified through health needs assessments at the earliest possible time for case management intervention. Copayments vary according to the members particular benefit plan. Medium and high-risk members qualify for case management. http://build.fhir.org/ig/HL7/davinci . Any EDI enrollment questions can be sent to uuhpedi@hsc.utah.edu. Numerous options are available for electronic claims submission through UHIN. If you or your provider believes your life or immediate health is in danger, you may ask for an expedited (quick) appeal by calling Customer Service. All HIPAA-compliant transactions with University of Utah Health Plans route through the Utah Health Information Network (UHIN). University of Utah Health Plans 6053 Fashion Square Dr. Suite 110, University of Utah Health Plans PO Box 45180, U of U Health Plans Telephone and Fax Numbers, http://uhealthplan.utah.edu/for-providers/box.php, Provider.relations@hsc.utah.edu Fax 801-281-6121, Provider.credentialing@hsc.utah.edu Fax 801-281-6121, NPS Ventegra 1-877-895-7163 l NPS 1-800-546-5677. Public MD Family Medicine 01/01/1951 CAQH 12345678 NPI 1234567890 Doctors Medical Clinic, 123 Main Street, Murray, UT 84117 Mary Smith mary.smithcredentialing@gmail.com), If your provider has a completed CAQH application please ensure that UUHP has been granted permission to access the application, as well as confirm that the practitioner has recently attested to the accuracy and completeness of the information provided. At a minimum, the following questions must be asked to determine the childs risk for lead exposure: Does the child live in or regularly visit a house built before 1978? The Utilization / Care Management function is carried out through The Quality Improvement Committee, The Operations Committee, the Director, Manager, and staff. Final. All necessary information for correct processing of the claim should be included on or attached to the claim form, including: Identification Number of Patient/Subscriber. Reports of children with blood lead levels of 20 ug/dL or greater will be shared with the Utah Department of Health, Bureau of Environmental Services. Corrections can be submitted to provider.credentialing@hsc.utah.edu. Healthy U members may go to any Medicaid provider for family planning even if he or she is not a Healthy U provider. Elements in the file will indicate if you are sending an attachment, the type of attachment you are sending, and identification number for the attachment and the mode for sending the attachment (fax, email, etc.). Surrogate motherhood, including all services, tests and related charges. A Provider must obtain an UHIN Trading Partner number to receive EDI Transactions from the University of Utah Health Plans. Medical necessity review requests can be sent to UUHP UM department via fax or mail. Fee Schedule Updates University of Utah Health Plans also offers the online capability to verify processing or payment of a claim through U Link. All services required to stabilize the enrollee with an emergency medical condition will be covered by the plan. The funds contributed to an account are not subject to federal income tax at the time of deposit. U of U Health Plans does on-going monitoring of provider sanctions and disciplinary actions. If a policy owner has a new Dependent(s) due to marriage or the establishment of a Domestic Partnership, the effective date of coverage for the eligible Dependent(s) will be the first of the month following the event, provided we receive notification of the new Dependent(s) and approve the Dependent(s) for coverage under this Policy. Since eligibility of a Medicaid member can change frequently, the providers office should request a copy of the members Medicaid Identification Card upon each visit and prior to rendering services, Providers offices may contact UUHP member services to verify eligibility information: Salt Lake County: 801-587-6480, Or providers may utilize the Medicaid Hotline: Salt Lake County: 801-538-6155. Explanation of Benefits from Primary Payer (if applicable). Please note: Please reference our website for current plan information. Member Information: Current Medical Plans, ID Cards, Provider Directories, Dental & Vision Plans. U of U Health Plans is currently accepting the following HIPAA-compliant transactions: EFT (Electronic funds transfer) in conjunction with the 835, 270/271 0051010X279A1 Eligibility Request/Response (real-time), 276/277 Claim status inquiry/response (real-time). Claim Inquiries, Customer Service, Member Eligibility, Medical Management and Prior Authorizations, Phone: 888-605-0858 | 801-587-3003 Website: uhealthplan.utah.edu/for-providers/forms.php, Phone: 833-970-1848 | 801-587-2838 Fax: 801-281-6121 Email: Provider.relations@hsc.utah.edu, Formulary and Prior Authorization Prior Authorization Assistance, Phone: 801-587-2638 or 801-587-2639 TPN: HT000179-002 Website: uhealthplan.utah.edu/EDI, Contact Information for All Other U of U Health Plans Products, University of Utah Health Plans 6053 Fashion Square Dr. Suite 110 Murray, UT 84107, Paper Claims (For all non-Advantage U members), University of Utah Health Plans PO Box 45180 Salt Lake City, UT 84145-0180. within 30 calendar days of receipt of the request. Healthy Premier Group plans are available to eligible Employer Groups across the state of Utah and surrounding states. Coordination is achieved via phone, e-mail, fax or through case conferences. This fee would not be covered by Medicaid. Follow-up care is required for women and infants discharged early following vaginal and cesarean section births. The following Healthy U services will be reviewed for medical necessity prior to paying claims: Durable medical equipment: over $5,000 of billed charges, Hysterectomies and sterilization procedures inclusive of abdominal, vaginal or laparoscopic-assisted. Led by the Quality Improvement Department Manager, disease management teams will be created to actively improve identification techniques and educational resources. The CHEC program recommends using the following landmarks for screening: At six months a child babbles and initiates social approach through vocalization. Living Will: a written statement of the health care a person wants if he or she cant make independent decisions. The premium for the individual policy will be determined in accordance with our table of premium rates applicable to: (1) the age of the spouse; and (2) the type and amount of coverage provided. If payment is not received for all outstanding premium by the end of the grace period, this Policy will be terminated effective at 12:01 a.m. on the first day of the second month of the three month grace period. Provider agrees that the covering provider shall be a participating provider.

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