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Providers - Provider Manual


Effective January 1, 2024, Advantage U (Medicare Advantage PPO) is no longer offered to our members,  Because timely filing provides 360 days for claim resolution, information regarding Advantage U remains in the Provider Manual until December 31, 2024 to support claims runout.  We thank you for the excellent care you've provided our Advantage U members.

Provider Manual Sections:

INTRODUCTION

About University of Utah Health Plans

Welcome to University of Utah Heath Plans (U of U Health Plans). We are committed to enhancing the member experience, improving the quality of care, strengthening the health of populations, and reducing the cost of care. We are proud to be your community partner and we value and honor the distinctive connection that you share with us and our members.

U of U Health Plans was organized in 1998 with the formation of Healthy U Medicaid, a Medicaid Managed Care plan. Since our inception, we have been recognized as a reliable, innovative health insurance plan committed to enhancing the member experience, improving the quality of care, strengthening the health of populations, and reducing the cost of care.

U of U Health Plans offers a full suite of products providing health insurance coverage and services to plan members in Utah and the greater Mountain West. We specialize in health plan administration of physical and mental health and pharmacy benefits for fully insured and self-funded employers groups, individuals and families, Medicare Advantage and Medicaid beneficiaries. We also function as a third-party benefit and/or claims administrator for other payers, behavioral health programs, and select collaborations within the University of Utah.

Our goal is not to just operate at industry standards, but to exceed them in every possible way. We welcome your suggestions on how we can better serve you and your staff.

For us, this is more than insurance, this is personal.

About this manual

The U of U Health Plans Provider Manual is an administrative reference guide for physicians, facilities, and other healthcare professionals, as well as their practice managers and office staff (referred to collectively as providers) who provide services for our members.

The information communicated in this manual does not take the place of any U of U Health Plans provider service agreement(s) signed by a contracted or employed provider. This provider manual is considered an attachment to, and thereby part of, all executed University of Utah Health Plans Provider Agreements as referenced thereto and incorporated therein.

Thank you for respecting the proprietary nature of the information contained herein and not sharing the information with those outside of your practice, clinic, or facility. The provider manual will be updated as appropriate.

Contact Information

U of U Health Plans Address Information
Mailing Address
University of Utah Health Plans
6056 Fashion Square Dr. Suite 3104
Murray, UT 84107
Claims Submission
EDI Trading Partner Number for all U of U Health Plans and Advantage U:
HT000179-002
All Paper Claims for Commercial, Individual and Family, or Healthy U Medicaid members:
University of Utah Health Plans
PO Box 45180
Salt Lake City, UT 84145-0180
Paper Medical Claims for Advantage U Signature and Advantage U Signature Part B Buyback members:
Advantage U – Claims Cognizant
PO Box 4405
Scranton, PA 18505
Paper Claims with Routine Vision Services for Advantage U Advantage U Signature and Advantage U Signature Part B Buyback members:
Advantage U – Claims Vision Service Plan
P.O. Box 385018
Birmingham, AL 35238-5018
Paper Claims with Nonroutine Audiology Diagnoses for Advantage U Advantage U Signature and Advantage U Signature Part B Buyback members:
Advantage U – Claims Cognizant
PO Box 4405
Scranton, PA 18505
Note: Only providers contracted with TruHearing may offer or bill audiology services with a routine diagnosis. Other diagnoses are considered nonroutine.
U of U Health Plans Department Numbers
Claim Inquiries, Customer Service, Eligibility for members
U of U Health Plans – Commercial: 833-981-0213 | 801-213-4008
U of U Health Plans – Individual/Family: 833-981-0214 | 801-213-4111
Advantage U (Medicare PPO) plans: 855-275-0374
Advantage U Vision (VSP) 800-877-7195 / vsp.com
Advantage U Hearing (TruVision) 844-268-4908 / truhearing.com
Healthy U Medicaid
Claims/Customer Service:
Eligibility:

833-981-0212 / 801-213-4104
medicaid.utah.gov/eligibility 801-538-6155
Utilization Management
Advantage U (Medicare PPO) plans: 888-605-0858 | 801-587-3003
All other plans: 833-981-0213 Opt 2 | 801-213-4008 Opt 2
Fax: 801-281-6121
Quality Improvement
Phone:
Fax:
801-587-2777
801-281-6121
Provider Relations
Phone (toll-free):
Phone (Utah):
Fax:
Email:
833-970-1848 Opt 2
801-587-2838 Opt 2
Fax: 801-281-6121
Provider.relations@hsc.utah.edu
Provider Contracting
Phone (toll-free):
Phone (Utah):
Fax:
Email:
833-970-1848 Opt 4
801-587-2838 Opt 4
Fax: 801-281-6121
Providercontracting@hsc.utah.edu
Provider Credentialing
Phone (toll-free):
Phone (Utah):
Fax:
Email:
833-970-1848 Opt 3
801-587-2838 Opt 3
Fax: 801-281-6121
Provider.credentialing@hsc.utah.edu
Pharmacy
Advantage U Medicare Advantage
Prior Authorizations (CVS Caremark ) Phone:
Formulary:

888-970-0851
Advantage U Formulary
All other plans
Prior Authorizations Phone:
Healthy U:
Individual/Family:
Commercial Groups:
Fax:
Formulary:

855-856-5694
855-869-4769
855-859-4892
888-509-8142
https://uhealthplan.utah.edu/pharmacy
EDI
Phone:
Phone:
Website:
801-587-2638
801-587-2639
EDI

Glossary and Acronyms (Compiled from CMS and U of U Health Plans)

Abuse

(Business definition) – Payment for items or services that are billed by mistake by providers, but should not be paid for by Medicare or the health plan. This is not the same as fraud. The range of the improper behaviors or billing practices include, but is not limited to:

  • Billing for a non-covered service, services that fail to meet professionally recognized standards of care, or services that are medically unnecessary
  • Misusing codes on the claim (i.e., the way the service is coded on the claim does not comply with national or local coding guidelines or is not billed as rendered)
  • Inappropriately allocating costs on a cost report
Access
Ability to get medical care and services when they are needed
ABN
Advance Beneficiary Notice – A notice given to a member with an Original Medicare plan when providing an item or service for which Medicare is expected to deny payment, and for which by signing the ABN, the member agrees to pay.
Note: ABNs may not be used when the patient is a member of a Medicare Advantage plan, such as Advantage U, or a Private Fee-for-Service Plan.
Advance Directives
A written document stating how a member wants medical decisions to made if the member loses the ability to make decisions for themselves. An advance directive may include a Living Will and/or a Durable Power of Attorney for healthcare.
Allowed Amount
Amount established by a carrier to be payment in full for a covered item or service. May also be referred to as a maximum allowed amount, contracted rate, or similar terms.
Appeal
A written request from a member, member's personal representative, or provider for review of a claim determination.
Assignment of Benefits
Mechanism by which a provider agrees to accept payment from an Insurance company rather than from the member. Members may still be responsible for copayment or coinsurance amounts as required by their benefit plan.
Balance Billing
Process by which a provider attempts to collect from the member more than the established allowed amount.
Beneficiary
Person who has healthcare insurance through Medicare or Medicaid.
Benefits
Services covered by a health insurance policy.
Benefit Plan
Any group or individual insured or self-funded healthcare plan offered or administered by University of Utah Health Plans, which entitles members to receive covered services through specified networks of participating providers and facilities under terms and conditions specific to the member’s benefit plan.
Business Associate
Person or organization that performs a function or activity on behalf of a covered entity, but is not part of the covered entity’s workforce.
CAHPS
Consumer Assessment of Healthcare Providers and Systems – Annual survey used to report information on patients’ experiences with healthcare services.
CARC
Claim Adjustment Reason Code – Code on a provider’s Remittance Advice or member’s Explanation of Benefits explaining why a claim or service line was paid differently than it was billed or adjustments thereafter.
CDC
Centers for Disease Control and Prevention
Claim
Request for payment of services provided for a member.
CMS
Centers for Medicare & Medicaid Services – Federal agency that directs the Medicare program.
COB
Coordination of Benefits – Process for determining the respective responsibilities of two or more health plans that have some financial responsibility for a medical claim.
Coinsurance
Payment, usually calculated as a percentage of the cost of services, that a member is required to make for covered services as defined in their benefit plan.
Complaint
Any written or verbal communication of dissatisfaction.
Contract
Written agreement between providers and health plans, providers and hospitals, hospitals and health plans, or all three to manage healthcare costs and charges.
Copayment
Payment, usually a fixed dollar amount, which a Member is required to make for covered services as defined in their benefit plan.
Cost Sharing
Out-of-pocket amount (e.g., coinsurance, copayment, or deductible) that a member pays for medical care in the accordance with their benefit plan.
Covered Services
Medically necessary services and benefits that members are entitled to receive under their benefit plan.
Deductible
Payment, usually a fixed dollar amount that a member is required to make each calendar or contract year, in accordance with their benefit plan, before the payer begins to make payments for covered services.
Determination
A decision made to pay a claim either in full or in part, or deny a claim.
DRG
Diagnosis-Related Groups – A classification system that groups patients according to diagnosis, type of treatment, age, and other relevant criteria. Hospitals are often paid a set fee for treating patients in a single DRG category, regardless of the actual cost of care for the individual.
Dual Eligibles
Persons who are entitled to Medicare (Part A and/or Part B) and who are also eligible for Medicaid.
EDI
Electronic Data Interchange – The exchange of routine business transactions from one computer to another in a standard format, using standard communications protocols.
Election Period
Time when an eligible person may choose to join or leave a Medicare plan. Also known as Enrollment Period.
Emergency Medical Condition
The sudden onset of a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that such that a prudent layperson, who possesses an average knowledge of health and medicine, could reasonably expect the absence of immediate medical attention to result in: placing the patient’s health in serious jeopardy, serious impairment to bodily functions, or serious dysfunction of any bodily organ or part.
EOB
Explanation of Benefits – A statement sent by a health insurance company to covered individuals explaining what medical treatments and/or services were paid for on their behalf.
EOCP
Explanation of Claims Payment – Provides detail on claims that have been paid, denied or adjusted. Also known as Remittance Advice.
ERA
Electronic Remittance Advice – Any of several electronic formats for explaining the payments of healthcare claims.
Federal Register
The official daily publication for rules, proposed rules, and notices of federal agencies and organizations, as well as Executive Orders and other Presidential documents.
Fee Schedule
Maximum allowed payment amount, as established by contract, which a healthcare provider agrees to accept as payment in full for services to a health plan’s member.
Formulary
Listing of prescription medications which are approved for use and/or coverage by the health plan and which will be dispensed through participating pharmacies to covered enrollees.
Fraud
To purposely bill for services that were never given or to bill for a service that has a higher reimbursement than the service produced.
CMS defines fraudulent behavior as knowingly and willfully executing, or attempting to execute, a scheme or artifice to defraud any healthcare benefit program or to obtain (by means of false or fraudulent pretenses, representations, or promises) any of the money or property owned by, or under the custody or control of, any healthcare benefit program.
FWA
Fraud, Waste, and Abuse – see individual descriptions for each term in this section.
Grievance
A written or verbal communication of dissatisfaction by a member, or representative on behalf of a member, about any matter other than an action.
HCC
Hierarchical Condition Category – Categories of diagnostic groups which describe clinically-similar diagnoses (e.g., HCC 17: Diabetes with acute complications; HCC 18: Diabetes with chronic complications; HCC 19: Diabetes without complications).
HEDIS
Healthcare Effectiveness Data Information Set – A set of standard performance measures regarding the quality of care, access, cost, and other measures used to assess the quality of a health plan.
HIPAA Privacy
Health Insurance Portability & Accountability Act of 1996 – A regulation that establishes national standards to protect individuals’ medical records and other personal health information.
Inappropriate Utilization
Utilization of services in excess of a beneficiary’s medical needs and condition (overutilization) or receiving a capitated payment and failing to provide services to meet a beneficiary’s medical needs and condition (underutilization).
LCD
Local Coverage Determination – A determination made by a Medicare Administrative Contractor (MAC) whether to cover a particular service within the MAC’s jurisdiction. Coverage criteria is defined within each LCD.
MAC
Medicare Administrative Contractor – An entity contracted with CMS to administer Medicare benefits and regulations for a specified geographic region.
MAPD
Medicare Advantage plan with prescription drug coverage.
NCD
National Coverage Determination – Document which defines the extent to which Medicare will cover specific services, procedures, or technologies on a national basis.
NCQA
National Committee for Quality Assurance – Non-profit organization that accredits and measure the quality of care in health plans.
Network Providers
Healthcare providers who have entered into an agreement with U of U Health Plans to provide covered services to our members.
Noncovered Service
A service, supply, or drug that is not eligible for payment by the member’s benefit plan; including but not limited to those that do not meet medical necessity requirements, policy criteria, deemed investigational or experimental, are statutorily excluded from coverage as outlined in federal regulation.
Organization Determination
A decision by a Medicare Advantage plan, such as Advantage U, about whether items or services are covered or how much a member will have to pay for covered items or services.
Out-of-Pocket Costs
The amount a member pays for deductible, copayment, coinsurance, and/or noncovered services.
Part A
Medicare hospital insurance. Covered services are included as part of a Medicare Advantage plan.
Part B
Medicare medical insurance. Covered services are included as part of a Medicare Advantage plan.
Part C
A Medicare Advantage plan, such as Advantage U Signature or Advantage U Signature Part B Buyback, which typically provides enhanced benefits beyond what is offered by Medicare Parts A and B. Members electing a Medicare Advantage plan are still responsible to pay their Medicare Parts A and B premiums.
Part D
Medicare prescription drug coverage. May or may not be covered by a Medicare Advantage plan.
PHI
Protected Health Information – Individually identifiable health information transmitted or maintained in any form or medium, which is held by a covered entity or its business associate, including but not limited to: name, address, telephone number, social security number, Medicare number, health plan member ID number, date of birth; any information relating to a past, present, or future physical or mental condition, provision of healthcare, or payment for healthcare.
Postpayment Review
The review of a claim after a determination and payment has been made.
Provider
Physician, facility, or other healthcare professional licensed to provide healthcare services or items.
QMB
Qualified Medicare Beneficiary – Medicaid program for beneficiaries who need help paying for Medicare services. For those who qualify, the Medicaid program pays Medicare Part A premiums, Part B premiums, and Medicare deductibles and coinsurance amounts for Medicare services.
RA
Remittance Advice – An explanation from a health plan to a provider about claims processed, including benefit coverage, contracted fee amounts, secondary payers, patient responsibility (e.g., copays, coinsurance, deductible), and expected health plan payment applicable to the claims included in the RA.
RARC
Remittance Advice Remark Code – Provides additional explanation for an adjustment already described by a Claim Adjustment Reason Code (CARC) or to convey information about remittance processing.
Recoupment
Recovery by the health plan of inappropriately paid funds by reducing present or future payments and applying the amount withheld to the recouped claim.
Risk Adjustment
A payment review system used by health plans to align expected Medicare capitated reimbursement, based on members’ underlying health status and expected healthcare costs, with the actual costs of claims payments.
Segment
A group of related data elements in an electronic transaction.
Service Area
The area where a health plan accepts members.
SNF
Skilled Nursing Facility
TA
Technology Assessment – Study of the medical, social, ethical, and economic implications of the development, diffusion, and use of technologies. In support of NCDs, TAs often focus on the safety and efficacy of technologies.
Telemedicine
Professional services given to a patient through an interactive telecommunications system by a practitioner at a distant site.
TPA
Third Party Administrator – Business associate that performs claims administration and related business functions for a self-insured entity.
TRICARE
A healthcare program for active duty and retired uniformed services members and their families.
TTY
Teletypewriter – Communication device used to assist people who are deaf, hard of hearing, or have a severe speech impairment. Provider without a TTY can communicate with a TTY user through a message relay center operator to send and interpret TTY messages.
Unassigned Claim
A claim submitted for a service or supply by a provider who does not accept Medicare assignment.
Urgent Care
Services required for a sudden illness or injury that needs treatment right away, but is not life- or limb-threatening.
UHIN
Utah Health Information Network – A public-private clearinghouse for electronic exchange of healthcare data.
Voluntary Agreement
Agreements between CMS and various insurers and employers to exchange Medicare information and group health plan eligibility information for the purpose of coordinating health benefit payments.
X12
ANSI-accredited group that defines EDI standards for many American industries, including healthcare insurance. A comprehensive list of X12 healthcare data transactions is available in the Claims and Payment section of this manual.

Benefits and Responsibilities of Participation

Benefits of Participation

Providers contracted to participate on a U of U Health Plans benefit in the following ways:

  • Providers with whom members can schedule an appointment are listed in our provider directories
  • Receive payments promptly and directly, rather than through billing patients
  • Receive predictable payments in accordance with contracted network fee-schedule rates
  • Have access to a dedicated Provider Consultant, as well as our team of Provider Coordinators
  • Members have financial incentive to seek care from participating providers by way of lower out-of-pocket costs and assurance of compliance with quality standards.

 

Responsibilities of Participation

Provision of Covered Services

Participating providers agree to:

  • Deliver covered services and supplies in accordance with the U of U Health Plans benefit plans
  • Inform members of covered services as well as other programs and resources available to them for prevention, education, and treatment
  • Freely communicate with patients about their treatment options, regardless of benefit coverage limitations
  • Bill U of U Health Plans directly for covered services
  • Hold members harmless for any charges in excess of deductible, copayment, or coinsurance amounts specified by their U of U Health Plans benefit plan
  • Hold member harmless for any billed charges in excess of the contracted fee schedule allowed amounts
  • Abide by the contracted U of U Health Plans network(s) grievance and appeal procedures
  • Refer members to participating providers for extended services (e.g., laboratory, consultations, imaging)
  • In regards to U of U Health Plans Individual and Family plans, Healthy U Medicaid, Healthy U Behavioral, and Advantage U (Medicare POS) members, comply with all state and federal regulations

 

Complaint Resolution

Contracted providers agree to cooperate with U of U Health Plans personnel to resolve any complaints identified by U of U Health Plans members, other providers, or state or federal program representatives.

Doctors are Not Rewarded for Denying Care

Decisions about utilization management (effective use of services) are based solely on whether the treatment is a covered service under the member’s benefit plan and is medically appropriate for the member’s condition. U of U Health Plans does not reward doctors or others for denying coverage or care. Utilization Management (UM) decisions are based only on appropriateness of care and service, and existence of coverage. We do not reward providers for issuing denials of coverage or service care and UM decision-makers do not receive financial incentives.

Medical Access Standards

Service Delivery

Professional services:
Participating providers agree that healthcare will be available from the provider, or from a covering provider, twenty-four hours a day, seven days a week. The covering provider must also be a participating provider. If there is a clinical need for services to be rendered by a nonparticipating provider, the referring provider will notify U of U Health Plans prior to referring the member to a nonparticipating provider, and use best efforts to notify the nonparticipating provider of utilization management requirements. In the event of an emergency, provider is not obligated to provide such prior notifications.

Inpatient Facility Services:
Covered services must be available from participating facilities twenty-four hours a day, seven days a week. If facility services are referred to any facility other than a participating facility, the referring facility must notify the U of U Health Plans Utilization Management department prior to referring member to the nonparticipating facility, and use best efforts to notify the nonparticipating facility of the U of U Health Plans Utilization Management requirements. In the event of an emergency admission, the facility should use best efforts to notify our Utilization Management department as soon as possible.

Non-Discrimination

Providers are required to render covered services to U of U Health Plans members in an appropriate, timely, cost-effective manner consistent with customary medical care standards and practices. Services will be delivered in a culturally and linguistically appropriate manner; thereby including those with limited English proficiency or reading skills, those with diverse cultural and ethnic backgrounds, the homeless, and individuals with physical or mental disabilities. Providers may openly discuss with members all appropriate or medically necessary treatment options, regardless of benefit coverage limitations.

In compliance with Title VI of the Civil Rights Act of 1964, section 504 of the Rehabilitation Act of 1973, the Age Discrimination Act of 1975, Title II of the Americans with Disabilities Act of 1990, and the University of Utah Policy and Procedures 1999, providers are also required to provide access and treatment without regard to race, color, sex, sexual orientation, religion, national origin, disability, or age. Additionally provider will not, within their lawful scope of practice, discriminate against members from high-risk populations or who require treatment for costly conditions. Any provider with concerns regarding the provision of services on the basis of disability, or with compliance questions, can call our Customer Service department at 833-981-0213, option 1.

Domestic Violence

U of U Health Plans participating network providers and staff should be knowledgeable about methods to detect domestic violence, about mandatory reporting laws when domestic violence is suspected, and about resources in the community to which patients can be referred.

Physical Facilities

Providers are required to maintain physical facilities that:

  • Are clean and sanitary
  • Are accessible to disabled members in accordance with the ADA (exceptions may be granted on a case-by-case basis)
  • Have adequate fire and safety features
  • Have adequate waiting and exam room space
  • Are equipped with the appropriate medical equipment, devices and supplies commensurate with the type of services offered
  • Store medical records and other PHI appropriately in a secure location

 

Furthermore, providers must write paper prescriptions on tamper-resistant prescription pads or send prescriptions via a secure electronic method to the pharmacy, in accordance with state and federal laws.

Licensure & Insurance

Providers are responsible to maintain:

  • Current licensure
  • Malpractice liability insurance
  • Specialty board certification when applicable
  • Hospital privileges
  • Sufficient documentation related to credentialing questions to ensure compliance with state and/or federal statutes.

 

Providers are required to release this information to U of U Health Plans upon request.

Notification of Changes

Providers are responsible to notify U of U Health Plans Provider Relations in writing immediately upon a change in status.

  • Send demographic updates, such as an address change or a new billing contact, or if a provider leaves your clinic, via our Provider Information Update Form or email provider.relations@hsc.utah.edu.
  • Email provider.credentialing@hsc.utah.edu with information that may impact your credentialing status, including: malpractice claims, licensure, hospital privileges, Medicare/Medicaid sanctions or other disciplinary actions, or other changes in your credentials.

 

Directory Accuracy Attestations

U of U Health Plans is federally required to keep our directories updated with accurate information. To this end, participating network providers are required to review their directory information, submit changes to us as described above, and attest to the accuracy of their information every 90 days.

Attestations are completed through our Provider Portal tool under the “Administration” tab, or through an approved provider roster process.

  • Typically, the office manager or billing manager for each clinic acts as the gatekeeper or Local Administrator for the Portal. If you need access to the Portal, your clinic’s Local Administrator can register you for the correct access.
  • If you are the correct person to be the Local Administrator for your clinic, visit uuhipprovider.healthtrioconnect.com and click on the “Register Here” link in the Provider Login box.

 

Reminders when it is time to review and attest to your directory listings’ accuracy are delivered via the Provider Portal’s Message Center, or through other means of communication.

Note: As this is a federal requirement for many providers, those who do not respond may be removed from the directories. Please do not delay reviewing your directory listing and completing the attestation quarterly.

Appointment Access Standards

Appointment Wait times

University of Utah Health Plans is committed to ensuring that its members have timely access to the services they need. Providers are expected to also ensure members have access to timely care by complying with the Access Standards below.

A PCP is defined as a generalist, including physicians or mid-level clinicians, in any of the following areas:

  • Family Practice
  • General Practice
  • General Internal Medicine
  • Geriatric Medicine
  • Obstetrics/Gynecology (by physician)
  • Pediatrics
  • Preventive Medicine

 

Commercial and Individual/Family Members
Type of Care Primary Care Providers Specialty Providers Behavioral Health Providers
Urgent Care

Not life-threatening
Within 2 days Within 2 days Within 48 hours (2 days)
Routine, Non-Urgent Care

Includes school physicals

Does not apply to appointments for regularly scheduled visits to monitor a chronic condition, if the schedule calls for visits less frequently than once every month.
Within 30 days Within 30 days Initial visit for routine care within 10-business days

Follow-up routine care within 30 days
After-Hours Care Offer after-hours care or provide directions on where to receive after-hours care    
Non-life-threatening emergency     Within 6 hours, or direct patients to the Emergency Room or behavioral health crisis services
Healthy U (Medicaid)
Type of Care Primary Care Providers Specialty Providers Behavioral Health Providers
Urgent Care

Symptomatic, not life-threatening, treated in a provider’s office. Does not indicate dangerousness, but patient’s functioning is seriously impaired and symptom are moderate to severe.
Within 2 days Within 2 days Within 2 days
Routine, Non-Urgent Care

Includes school physicals

Includes symptoms generally less intrusive and less serious than those requiring urgent care
Does not apply to appointments for regularly scheduled visits to monitor a chronic condition if the schedule calls for visits less frequently than once every month
Within 30 days Within 30 days Within 30 days
Initial Contact Requiring Emergency Services

Initial contact includes by telephone or a walk-in basis

Applies to providers participating in the Healthy U Behavioral network
   

Screening within 30 minutes of initial contact
 

  • Face-to-face appointment offered within one-hour of initial contact screening if determined to be an emergency
  • Face-to-face appointment offered within 5 business days of initial contact screening if determined to be urgent
  • Face-to-face appointment offered within 15 business days of initial contact screening if determined to be non-urgent

Note: Medicaid members must be offered appointments during the same hours of operation offered to commercial members or Medicaid FFS members.

Advantage U Signature or Advantage U Signature Part B Buyback (Medicare Advantage)
Type of Care Primary Care Providers Specialty Providers Behavioral Health Providers
Urgent Care

Not life-threatening
Within 2 days Within 2 days Within 2 days
Routine, Non-Urgent Care

Does not apply to appointments for regularly scheduled visits to monitor a chronic condition, if the schedule calls for visits less frequently than once every month.
Within 30 days
Primary Care Providers must offer coverage (backup) for absences
Within 30 days Within 30 days
In Need of Medical Attention

Not urgent or emergent services, but in need of medical attention
Within 1 week Within 1 week  

Appointment Scheduling

Providers are required to have an appropriate scheduling system that reserves adequate time allotments for various types of appointments, as well as adequate time reserved for urgent/acute care.

The provider’s telephone system must be sufficient to manage the volume of calls coming into the office.

After Hours Care

U of U Health Plans requires all providers to have back-up coverage during off hours, or scheduled days out of the office, and to have telephone coverage 24 hours per day, 7 days per week. In-office recordings must state the operating hours of the office, whom to contact if after hours, and direct the member to call 911 if it is an emergency.

PCP providers are required to have a mechanism in place to direct members to the appropriate after-hours care. U of U Health Plans encourages providers to return member calls within two (2) hours of being contacted, whenever possible.

Note: All emergency care services must be immediately available, 24 hours a day, 7 days a week. Provider network practices must provide after-hours instruction to enrollees needing emergency care.

Compliance with Access Standards

To ensure compliance with Appointment and Availability Standards, U of U Health Plans surveys primary care, specialty, and behavioral health network providers no less than annually.

Methods of monitoring access may include:

  • Telephone, online, email, or fax surveys
  • Provider Relations onsite or virtual visits
  • Appointment lag-time reports (as available)

 

Survey results are recorded and analyzed by U of U Health Plans. Deficiencies or failure to meet Appointment and Availability Standards may result in one or more of the following corrective actions:

  • Verbal notification of non-compliance
  • Written notification of non-compliance
  • Additional provider education
  • Suspension of access to new enrollees
  • Provider corrective action plans
  • Suspension or termination of provider contract from U of U Health Plans provider network(s)

 

Our Provider Relations team will notify your office if the survey reveals deficiencies or failure to meet the standards.

Recordkeeping Requirements

Participating providers must maintain confidential, correct, legible, and complete medical records for all U of U Health Plans members. Printed and/or electronic medical records and other Protected Health Information (PHI) must be stored in a secure location.

To fulfill activities such as payment of claims, quality improvement, state and/or federal reporting, credentialing, and HEDIS, U of U Health Plans may conduct medical record audits. The audits may include, but are not limited to, evaluation of:

  • Legibility
  • Patient identifying information
  • Entries dated and timed
  • Complete problem list
  • Complete medication list
  • Clear notation of allergies
  • Documentation of immunizations and preventive health screenings, as applicable
  • Progress notes for each visit that include plans for follow-up and/or return visits
  • Appropriate supporting medical documentation to plan for referral and or prior authorization requests
  • Advance directives

 

Specialists should provide consultation notes to the member’s PCP. Medical records must be provided at no cost to U of U Health Plans, and must be available for inspection by U of U Health Plans, its assigned representatives, and/or federal and state agency representatives during reasonable business hours.

According to Utah Administrative Code R432-100-33 (4c), patient medical records should be maintained for at least seven years. Medical records for minors should be maintained until the patient reaches 18 years of age plus four years, but no less than seven years.

Site Audits and Ensuring Appropriate Physical Facilities

Office Site Audits are one method of ensuring that the providers with whom we contract provide, among other things, services in a clean and accessible environment that is appropriately staffed, have the appropriate medical equipment and devices for the services rendered, practice appropriate medical record-keeping standards, and take reasonable steps to safeguard the integrity and confidentiality of our members’ protected health information.

An official site visit may be completed by a member of the Provider Relations team and an RN or LPN from the Utilization Management team within 60 days, when possible, of a valid member complaint regarding the environmental aspects of the office where member care is delivered. Site visits may also occur if a facility is not accredited or certified, or loses its accreditation.

The Site Audit Questionnaire, in accordance with the Centers for Medicare & Medicaid Services (CMS) and NCQA criteria, addresses the following physical aspects of the office:

  • Physical accessibility
  • Physical appearance
  • Adequacy of waiting room space
  • Adequacy of exam room space
  • Privacy/HIPAA compliance
  • Registration process
  • Medical record-keeping practices
  • Accessibility of medical records
  • Staff/patient interaction
  • Clinic Personnel Conduct

 

The completed Site Audit Questionnaire will be reviewed by the U of U Health Plans Credentialing Committee, in accordance with our Credentialing Policies. Suggestions for improvement—if any—will be documented for the provider in writing. To remain a contracted provider, the provider must provide a corrective action plan to correct at least 90% of the listed deficiencies within an agreed upon time frame. Any outstanding deficiencies will be reviewed every six months until the deficiencies are resolved.

The Credentialing Committee retains the rights to approve or disapprove corrective action plans, determine whether the provider’s plan and actions meet criteria, and recommend termination for noncompliance, if deficiencies are not resolved as outlined above.

Learn more on the University of Utah Health Plans Credentialing Policy.

Compliance

U of U Health Plans actively promotes a culture of ethical, transparent behavior. This culture includes our business decisions and our treatment of employees, members, providers, and other business partners. We hold our providers responsible to respect and abide by the same principles.

Compliance with U of U Health Plans Policies and Procedures

All contracted providers are required to comply and participate with all U of U Health Plans Utilization Management and Quality Improvement programs, credentialing and recredentialing activities, and complaint and grievance policies. Providers agree to allow U of U Health Plans to use their performance data. In addition, providers agree to abide by policies and procedures related to covered services, member billing, emergency services, and other policies and procedures as defined by U of U Health Plans with respect to each plan in which the provider participates. Review U of U Health Plans Coverage Policies at Coverage Policies.

Compliance with Federal and Utah Medicaid Regulations

Healthy U Medicaid and Healthy U Behavioral providers are required to comply with all Federal and Utah Medicaid regulations when providing services to Healthy U Medicaid and Healthy U Behavioral members.

Compliance with Federal Regulations (Medicare)

Advantage U network providers are required to comply with all federal Medicare Advantage regulations when providing services to Advantage U (Medicare PPO) members.

Patient Confidentiality and HIPAA

Providers, their employees, and business associates agree to safeguard the privacy and confidentiality of U of U Health Plans members; and agree to abide by the rules and regulations set forth in the Federal Health Insurance Portability and Accountability Act of 1996 (HIPAA).

Written authorization is required from our members for all uses and disclosures of PHI, except uses and disclosures for treatment, payment, and healthcare operations (TPO). Releases and disclosures of PHI should be done according to a standard of ‘minimum necessary,’ meaning only the amount of information needed to fulfill a specific purpose or task should be released.

TPO may include, but is not limited to:

  • Patient referrals
  • Providing information to an authorized person who cares, or will be caring, for a U of U Health Plans member
  • Providing the necessary information to U of U Health Plans for authorizations or processing and paying claims
  • Complying with U of U Health Plans Quality activities, HEDIS reporting, or other U of U Health Plans programs centered on the improvement and measurement of patient care

 

U of U Health Plans is responsible to ensure members’ privacy and also adheres to stringent confidentiality regulations as required by federal law. Therefore, to verify the identity of a caller purporting to be a provider or staff member from the provider’s office, the caller is required to supply the provider’s Tax ID Number (TIN) and NPI when requesting patient information.

More detailed information on privacy is available on the CMS MLN Fact Sheet: HIPAA BASICS FOR PROVIDERS: PRIVACY, SECURITY, AND BREACH NOTIFICATION RULES.

Fraud, Waste, and Abuse (FWA) Compliance

U of U Health Plans recognizes and understands the financial and personal impact that healthcare fraud, waste, and abuse (FWA) can have on the health plan, its providers, and our members. We are committed to the fight against healthcare FWA.

U of U Health Plans complies with all state and federal rules, laws, and regulations, and reports all suspected fraudulent behavior as required by law. We use a wide variety of resources, tools, and internal controls to detect, prevent, identify, and monitor for potential FWA.

  • Utilization management reviews—prospective, concurrent, and retrospective—in accordance with Federal Regulations 42CFR§438.214(d) Provider Selection and 438.610 Prohibited Affiliations, U of U Health Plans will not include any individual in the provider network who:
    • Has been debarred, suspended, or otherwise excluded from participating in the Medicaid or Medicare programs
    • Has an affiliation with an individual who has been debarred, suspended, or otherwise excluded from participating in the Medicaid or Medicaid programs
    • Has beneficial ownership of five percent or more equity in University of Utah Health Plans, and is ineligible to participate in the Medicare and Medicaid programs or is affiliated with an individual who is ineligible due to debarment, suspension, or exclusion from these programs

 

Compliance Requirements for First-tier, Downstream, and Related (FDR) Entities

The Centers for Medicare & Medicaid Services (CMS) considers all providers, facilities, and other healthcare professionals contracted with Medicare Advantage (MA) Products, such as Advantage U, a First-tier, Downstream, and Related (FDR) entity. FDRs are required to comply with all applicable laws, regulations, and statutory requirements, as outlined in the Advantage U section of this manual.

Compliance Requirements for First-tier, Downstream, and Related (FDR) Entities

To ensure U of U Health Plans complies with all Medicare requirements, each FDR must train staff and contractors who are not separately contracted with Advantage U annually on preventing, detecting, and resolving issues of non-compliance, Code of Conduct, and program fraud, waste, and abuse (FWA) issues. FDRs may create their own training program or use the CMS module, Combatting Medicare Parts C and D Fraud, Waste, and Abuse Web-Based Training.

  • FDRs must attest annually that providers, staff, and contractors have completed all general compliance and FWA training. U of U Health Plans is in the process of developing an attestation tool. Until that tool is made available, please email a copy of a completion certificate or other form of attestation to provider.relations@hsc.utah.edu.
  • Maintain training and attestation records for ten years (e.g., an electronic certification of completion or dated copy of an employee sign-in sheet for the training session)

 

U of U Health Plans encourages all providers to institute a compliance plan to detect, prevent, and report non-compliance and FWA issues. The Office of Inspector General (OIG) has published guidance for physician practices to assist in the development of a compliance plan: Final Compliance Program Guidance for Individual and Small Group Physician Practices (65 FR 59434; October 5, 2000).

Additional information about FWA detection, prevention, and reporting, including definitions and examples of FWA behaviors is available in the Medicare Learning Network’s booklet, Medicare Fraud & Abuse: Prevent, Detect, Report.

Reporting Fraud, Waste, and Abuse (FWA)

If you suspect FWA by a provider participating in any U of U Health Plans network, or member of any of our benefit plans, report it to the University of Utah Health Plans Compliance Office through the following methods:

  • Compliance & Ethics Hotline: 888-206-6025 or online at secure.ethicspoint.com, available 24 hours a day, 7 days a week. Reports can be made anonymously.
  • Email: HealthPlansReportFraud@utah.edu
  • Fax: 801-585-2654
  • Mail: 
    University of Utah Health Plans 
    Attention: Special Investigations Unit 
    6056 Fashion Square Drive, Suite 3104
    Murray, Utah 84107

 

If University of Utah Health Plans suspects fraud, waste, or abuse, incidents will be reported to state law enforcement and regulatory agencies as required by law.

Corrective Action

U of U Health Plans strictly enforces their policies and standards. If misconduct, unethical behavior, FWA, or other suspected violations are identified through complaints, hotline reports, routine auditing, or by regulatory agencies, a prompt investigation is initiated.

If the information received is substantiated, an appropriate corrective action plan is developed and implemented. Disciplinary standards may include training and education, or disciplinary action up to and including termination of a contract.

Claims, Payment, and Appeals

Providers contracted with University of Utah Health Plans agree to submit claims for services and supplies provided to our members. In most circumstances, claims must be submitted under the name of the rendering provider.

Claims Submission Requirements

Providers should submit claims via electronic 837 HIPAA-compliant transactions or on the appropriate standard paper forms (CMS 1500 for professional services and UB04 for facility services). All claims must be filed within timely filing requirements. All necessary information for correct processing of the claim should be included on or attached to the claim form, including:

  • Patient Name
  • Patient’s Member Identification Number
  • Patient’s date of birth
  • Patient’s address
  • Rendering and billing provider, if different
    • Provider’s name
    • Provider’s Tax Identification Number (TIN)
    • Provider’s NPI
    • Provider’s practice and billing addresses
  • Other insurance information (if applicable and known)
  • Date(s) of service of claim
  • Diagnosis ICD-10 Code(s) - obtained from authorized ICD 10 CM reference guides for the year corresponding to the date of service
  • Procedure codes (CPT/HCPCS) or revenue codes identifying services on claim – obtained from authorized reference guides for the year corresponding to the date of service
  • Medical drugs (non-retail) charges administered by a professional provider billed with the appropriate HCPCS code
  • Billed charges for each service on claim
  • Supporting documentation including operative reports, emergency room reports, medical records supporting diagnosis when requested, etc.
  • Explanation of benefits from primary payer (if applicable)

 

Claims are processed and remittance advices sent to the provider in accordance with the timeliness provisions set forth in the providers Participating Provider Agreement. Please be aware that paper claims require a longer time to process. While we will accept claims submitted electronically or on paper, we strongly encourage providers to utilize the efficiencies gained through Electronic Data Interchange (EDI) transactions. EDI transactions are covered in greater detail later in this section.

If electronic claims are not an option in your practice, we will accept paper claims mailed to:

University of Utah Health Plans
Attention: Claims Department
P.O. Box 45180
Salt Lake City, Utah 84145-0180
 

Elements of Clean Claims

A clean claim is any claim submitted by a provider that:

  • Includes substantiating documentation, if required
  • Has a corresponding prior authorization, if required
  • Complies with billing guidelines and coverage policies
  • Has no missing or invalid information (e.g., CPT, DOB, NPI)
  • Is received by U of U Health Plans within the timely filing period
  • Does not require special treatment that prevents timely payment
  • Includes all relevant information to determine other carrier liability
  • If submitted on paper, is submitted on a UB-04, CMS-1500, or successor claim form, with all required elements
  • If submitted electronically, is submitted in compliance with the applicable federal and state regulatory authority (i.e., Medicare or state Medicaid) and uses only permitted standard code sets

 

Corrected Claims

U of U Health Plans prefers to receive corrected claims via EDI transaction. To request a claim be corrected, submit the following information in Loop 2300 of an 837I (Institutional) or 837P (Professional) electronic claim form.

  1. In segment CLM05-3, insert the appropriate “Claim Frequency Type” code (these may be displayed by your software as a dropdown field):
    1. 7Replacement of prior claim
    2. 8Void/cancel prior claim
  2. Enter the original claim number in the REF*F8 “Payer Claim Control Number” field.
    1. If you are submitting a primary payer’s EOB with this corrected claim, you must include the primary payment date, also in REF*F8.
  3. You must report every line associated with this claim to ensure the full claim is reprocessed.
  4. Refer to your 5010 Implementation Guide for additional information.

Note for Healthy U Medicaid claims: To submit an EOB for a denied Healthy U claim, you must submit an electronic correction that includes the EOB information. U of U Health Plans can no longer accept submission of corrected claims or EOBs on paper for Healthy U members.

Paper Claim Forms

If you must submit a corrected claim on a CMS 1500 (02/12) paper claim form:

  • In box 22, enter the appropriate Resubmission Code:
    • 7 – Correction to prior claim
    • 8 – Void of a professional claim
  • Enter the payer’s original claim number in box 22 under the "Original Ref. No." field.
  • Remember, if you’re correcting to add an EOB, you must attach the primary EOB to the corrected claim.

If you must submit a corrected claim on a UB-04 Facility claim form:

  • Enter the CLAIM FREQUENCY TYPE code as the 4th digit of Box 4 "Type of Bill"
    • 7 – Correction to prior claim (e.g., 0137 indicates a correction to a Hospital Outpatient claim)
    • 8 – Void/correction to prior claim
  • Enter the payer’s original claim number in Box 64 "Document Control Number."

Rejected vs. Denied Claims

A rejected claim is a claim that is sent back due to an error in the claim. This could be due to an input error, incorrect data, or data that does not match what the payer has on file.

A denied claim has been processed and adjudicated in the payer system, but is denied and deemed unpayable. The denial could be for a number of reasons.

When a claim has been rejected (i.e., it has not been adjudicated), you can resubmit the claim. To resubmit the claim, simply create a new claim and resubmit it through the clearinghouse. If you resubmit a claim that has been denied, the new claim will be denied as a duplicate claim.

A corrected claim will replace the previously adjudicated claim, so ensure all charges are included on the corrected claim. You can submit a corrected claim if:

  • The plan denied the claim for missing information (i.e., primary insurance EOB not submitted or complete)
    Note: You need to correct information on the original claim submission, even if the claim has already paid

Common reasons to submit a corrected claim

  • Primary insurance EOB missing (you must attach the primary EOB to the corrected claim)
  • Primary insurance EOB amount is changing
  • Incorrect billed amount
  • CPT/Modifier changes
  • Transposed procedure or diagnosis code
  • Inaccurate data entry
  • Denial of claims as duplicates
  • Missing or invalid ordering or referring provider

Timely Filing Requirement

Healthy U Medicaid – The timely filing period for primary and secondary claims is 365 days from the date of service. 
Note: The exception to this rule is if any kind of Medicare is the primary insurance. When Medicare is the primary insurance, the claim must be submitted within the later of 365 days from the date of service or 180 days from the Medicare EOB date. 
Corrections to a Healthy U claim must also be received and/or adjusted within the later of 365 days from the date of service or 180 days from the Medicare EOB date.

U of U Health Plans Commercial or Individual/Family plans – The timely filing limit for primary claims is 365 days from the date of service. The timely filing limit for secondary claims is 180 days from the primary payer’s EOB adjudication date. Any corrections to a claim must also be received and/or adjusted within the same 365 days from the date of service.

Advantage U Medicare - The timely filing period for primary and secondary claims is 365 days from the date of service.

Coordination of Benefits

Coordination of benefits (COB) ensures patients receive benefits from all health insurance plans under which they may be covered; while also ensuring that the total, combined payment does not exceed the amount charged for the services provided.

When your patient has coverage under two or more payers, U of U Health Plans may not always be the payer of first resort (primary plan). Additional payers to consider include other health insurance plans, Medicare or Medicare Advantage, Medicaid, or liability plans such as Worker’s Compensation Fund or property owner’s insurance for injury or illness occurring on or caused by the covered property.

When another payer is the primary plan, submit claims to that plan first; then submit the claim—complete with all payment information (i.e., remittance advice)—to other payers in order of primacy. Always include all insurance coverage information on each claim to ensure each insurance plan is aware of other potential payers.

Coordinating with U of U Health Plans Commercial and Individual or Family Plans

When a U of U Health Plans Commercial or Individual/Family member has another plan that is primary, payment by U of U Health Plans will be reduced by the amount of reimbursement from the primary payer(s); up to, but not exceeding, the lesser of the remaining billed charges or allowed amount(s) had U of U Health Plans been the primary payer.

If compensation is received from a liability plan, the provider is expected to refund any amounts paid by U of U Health Plans for covered medical services.

For specific questions, or to verify a member’s coordination of benefits status, contact a U of U Health Plans Customer Service representative for the member’s benefit plan.

Coordinating with Healthy U Medicaid

Healthy U Medicaid should always be treated as the payer of last resort. If the patient has any coverage in addition to Medicaid, submit the claim to the primary payer first, followed by any additional payer(s) applicable, and then to Healthy U Medicaid. Include the remittance advice(s) from the primary and any other payer(s) with the claim. The Healthy U Medicaid payment for Medicare or third party claims will equal the provider’s contracted allowed amount, less any amounts paid by Medicare or other third party payers.

Coordinating with Advantage U Medicare

Advantage U (Medicare PPO) bases primacy on employment status, and whether certain diseases exist. To understand when Medicare is primary or secondary, please refer to How Medicare Works with Other Insurance, or the CMS Coordination of Benefits brochure.

Claims Editing, Review, and Audit

U of U Health Plans follows standard claims processing guidelines, including but not limited to: current coding manuals and editors, CMS and State of Utah Medicaid rules and regulations, standard bundling and unbundling rules, National Correct Coding Initiative (NCCI) guidelines and edits, and FDA definitions and determinations. These coding edits are developed based on procedures referenced in the American Medical Association’s (AMA) Current Procedural Terminology (CPT) Manual and the Healthcare Common Procedure Coding System (HCPCS) Manual. All claims are subject to the U of U Health Plans coverage policies. We reserve the right to review and audit, adjust, and pay claims in accordance with the Participating Provider Agreement.

Electronic Data Interchange (EDI)

EDI claims and other transactions can help improve efficiency, productivity, and cash flow for providers. Approximately 80 percent of our claims pass through electronic claim processing without adjudicator intervention. This results in fewer data entry errors and faster turnaround time, 15 days on average, from the date we receive a claim to when payment is received in the provider office.

U of U Health Plans is a member of the Utah Health Information Network (UHIN), a nonprofit coalition of payers, providers, government entities, accountable care organizations (ACO), billing services, and other interested parties in Utah. Numerous options are available for electronic claims submission through UHIN.

All electronic claims for U of U Health Plans, and other health plans for which we administer claims, are relayed through the UHIN clearinghouse. UHIN accepts and returns transactions via their Web portal, UTRANSEND; they also connect to most national clearinghouses and support all HIPAA-compliant billing software.

If a provider is not a member of UHIN, other options for sending EDI claims are available. For more information about UHIN and the services they offer, visit uhin.org.

Accepted Transactions

U of U Health Plans is HIPAA-compliant in the following transactions:

  • 837 005010X224 (Dental)
  • 837 005010X222A1 (Professional claims)
  • 837 005010X223A2 (Institutional claims)
  • 277CA Claim Acknowledgement/error report
  • 999 Acknowledgement
  • 835 005010X221A1 (Remittance advice)
  • EFT (Electronic funds transfer) in conjunction with the 835
  • COB (Coordination of Benefits)
  • 270/271 0051010X279A1 Eligibility Request/Response (real-time)
  • 276/277 Claim status inquiry/response (real-time)

 

Trading Partner Registration

If you currently submit electronic transactions through a clearinghouse it is not necessary to register with UHIN. Established clearinghouses already have a trading partner number set up to submit electronic transactions through UHIN to Utah payers.

The U of U Health Plans trading partner number with UHIN is HT000179-002.

EDI Enrollment Process

A Provider must be enrolled with EDI for claims submission (837) to be eligible for Electronic Remittance Advices (ERA or 835) and Electronic Funds Transfer (EFT) transactions. The 835 and EFT transactions are interdependent (i.e., to receive the 835 a provider must be enrolled with the EFT, and to receive the EFT a provider must be enrolled with the 835); therefore, a Provider must enroll in both transactions. Data is associated with the billing provider’s NPI.

Enrollment for Electronic Remittance Advices (ERA) is accomplished through your clearinghouse. Once your enrollment is set up, they will submit the information to U of U Health Plans on your behalf.

Once U of U Health Plans has received the EDI enrollment form, we will begin setting up the EDI connections. We will notify the provider by email once the setup is complete.

Submitting Claims through UHIN

There are several different options for submitting claims through UHIN:

  • Direct link - Providers can transmit a HIPAA-compliant file from their billing system directly to UHIN
  • Clearinghouses - UHIN has a connection to most national clearinghouses and supports all HIPAA-compliant billing software
  • MYUHIN - Billing Software provided by UHIN

 

Other clearinghouses

The following table is a partial list of UHIN-contracted clearinghouses:

CLEARINGHOUSE PAYER ID
Apex EDI # UHUOU
Availity # SX155
Change Healthcare/Emdeon # SX155
Claim MD # SX155
ClaimRemedi # SX155
Eligible # SX155
Med USA # HT000179-002
Office Ally # SX155
Optum Clearinghouse # SX155
Practice Insight # SX155
RelayHealth/McKesson # SX155
SSI Group # SX155
TriZetto # 00179
Zirmed/Waystar # Z1030

Note: Payer ID numbers are assigned by the clearinghouse. U of U Health Plans does not assign or maintain these numbers; therefore, contact your clearinghouse for Payer ID information.

For help with EDI questions, please email uuhpedi@hsc.utah.edu.

Payment

Provider payments will be issued via Electronic Funds Transfer (EFT), if the provider is enrolled for this service, or via virtual credit card.

Remittance Advice

U of U Health Plans generates an explanation of how each claim was processed (remittance advice) when processing is complete. Remittance advices summarize all claims processed for that provider by patient, during that claim period. Each claim is assigned a number and clearly identifies provider, patient, dates of service, billed charges, allowed amount, paid amount and reason codes for any processing decisions.

Providers can view remittance advices by the following methods:

  • Via our secure Provider Portal* for contracted providers – registration is required
  • Via an 835 EDI transaction, if set up for this feature
  • Or by postal mail if not set up for electronic transactions

 

If you have a question on the processing or payment of a claim, please contact a U of U Health Plans Customer Service Representative for the member’s benefit plan. The representative can research the claim based on claim number, patient, provider, and dates of service.

TYPE OF PLAN LOCAL PHONE NUMBER TOLL-FREE PHONE NUMBER
Healthy U Medicaid 801-213-4104 833-981-0212
U of U Health Plans– Commercial 801-213-4008 833-981-0213
U of U Health Plans– Individual 801-213-4111 833-981-0214
Advantage U Medicare 801-893-6645 855-275-0374

* To learn more about our secure Provider Portal, email uofuhpproviderportal@hsc.utah.edu.

Fee Schedule Updates

Fee schedules are based on Relative Value Units (RVU) and reviewed at least annually, or in accordance with the Participating Provider Agreement. Notice is sent to impacted providers when reviews are completed.

For government programs, such as Healthy U Medicaid and Advantage U, fee schedule rates are informed by the respective governing body. Healthy U defines the published date of the state Medicaid fee schedule as the first day of the first month following the quarter. For example, the published date of the state Medicaid July fee schedule is defined as August 1st.

For a sample fee schedule or rate information for specific codes, participating providers can email our Provider Contracting team at ProviderContracting@hsc.utah.edu. Include your Tax ID number, Group NPI, and any specific codes that apply to your practice.

Mid-Level Provider Reimbursement

U of U Health Plans follows Medicare Guidelines for reimbursement of mid-level providers.

Overpayments/Refunds

In the event that U of U Health Plans determines that a claim has been overpaid, we will recover the balance due by way of offset or retraction from current and/or future claims. Provisions for repayment of refunds included in the U of U Health Plans Participating Provider Agreement supersede those contained in this manual. If necessary, U of U Health Plans may refer unresolved recovery of funds to the Utah Attorney General’s Office for collection.

If overpayments are identified through the Fraud, Waste and Abuse department, the provider will be notified in writing and will be given 60 days to dispute or refund the overpayment. If the provider fails to submit the balance due within 60 days of notification, U of U Health Plans may recover the balance due by way of offset or retraction from current and/or future claims. If necessary, U of U Health Plans may refer unresolved recovery of funds to the Utah Attorney General’s Office for collection.

Please notify us immediately if you discover an error requiring the claim to be reprocessed.

Claims Appeal Process

U of U Health Plans has a Grievance and Appeals System to ensure providers and members can express a complaint (grievance), or request review of a claim or prior authorization request that has been reduced or denied. Processes are in place to accommodate grievances, appeals, and external review. Providers are required to follow the respective policies and procedures listed for each specific plan when appealing claim remittances.

Note: U of U Health Plans requires that providers obtain consent from a Commercial or Individual / Family plan member to appeal on their behalf, for denied claims or prior authorizations relating to clinical services. 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.

Definitions

Adverse Benefit Determination (ABD) is a denial, reduction, suspension or termination of requested or previously requested service or payment of service.

Appeal is a request for a review of an ABD.

Grievance is a complaint or expression of dissatisfaction about any matter other than an adverse benefit determination. For example, failure of a provider to respect a member’s rights or provide quality care.

Independent External Review is an independent organization that, upon request, conducts external reviews of adverse determinations. The IRO conducts these reviews as an independent contractor for University of Utah Health Plans and/or as assigned via state regulatory requirements. The IRO is unbiased and is not controlled or influenced by the health plan.

Provider Dispute is a request from a contracted provider to review a previous claim decision made by a health plan concerning claims processing or payment rates (e.g., bundling/unbundling, multiple procedures).

Timeliness

Appeals must be submitted within the time frame specified by each members’ benefit plan.

Commercial or Individual and Family plan – 180 days from the date of a Notice of Adverse Benefit Determination letter or Explanation of Benefits (EOB).

Healthy U Medicaid – 60 days from the date of a Notice of Adverse Benefit Determination or EOB.

Advantage U Medicare PPO – 60 days from the date of the initial adverse benefit determination (for prior authorizations) or the remittance advice (for payment disputes).

Huntsman Mental Health Institute and Miners – Please contact appeal coordinators at 801-213-4008 or 833-981-0213.

Appeal Process

Providers are required to follow the respective policies and procedures listed in each specific plan when appealing claim remittances.

 

 

Complete and submit the appropriate Appeal Form

Note: Attach any necessary documentation by uploading documents in the “Appeal Documents” section prior to submitting the form.

 

 

If you prefer, you can print and mail or fax the completed appeal form, and necessary documentation to:
Appeals and Grievances Department
6056 Fashion Square Dr. Suite 3104
Murray, UT 84107
Fax: 801-587-9985
 

U of U Health Plans will assist members or providers in filing appeals, grievances, or an external level of appeal upon request. If you or your member-patient need help filing an appeal or checking on an appeal’s status, call Customer Service for the member’s benefit plan.

TYPE OF PLAN LOCAL PHONE NUMBER TOLL-FREE PHONE NUMBER
Healthy U Medicaid 801-213-4104 833-981-0212
U of U Health Plans– Commercial 801-213-4008 833-981-0213
U of U Health Plans– Individual 801-213-4111 833-981-0214
Advantage U Medicare 801-893-6645 855-275-0374

Response Time

How long will it take for a decision to be made? 
 

  • Commercial group and Individual/Family plans
    • Pre-service appeal – within 30 calendar days of receipt of the request
    • Post-service appeal – within 45 calendar days of receipt of the request
  • Healthy U Medicaid – 30 calendar days
  • Advantage U (Medicare)
    • Pre-Service appeal – within 30 calendar days of receipt of the request
    • Post-Service appeal – within 60 calendar days of receipt of the request

 

If additional information is requested, we can take an additional 14 calendar days to make our decision. If we need to take extra time, we will notify you and the member by phone or postal mail.

If you believe the member’s life or immediate health is in danger, you may ask for an expedited appeal by calling Customer Service. If we agree the decision needs to be made quickly, we will make a decision in 72 hours from receipt of the request. If we need more time to make the decision, we can take up to another 14 calendar days. If we need more time, we will send you and the member a letter explaining why. Once we make a decision, we will mail you and the member an Appeal Resolution Letter, and call you if you requested an expedited appeal.

In addition to the appeal processes outlined for each plan in this manual, refer to the Appeals Process link on our website for further appeal information, or call Customer Service for the member’s benefit plan.

Filing a Grievance

A grievance is an expression of dissatisfaction (complaint) about a process or provider, rather than an appeal for reconsideration of a claim or other determination. Members and providers have the right to file a grievance against a benefit plan, service, or provider. Members, providers, or another authorized person may submit a grievance on behalf of a member.

Grievances will be accepted from members or providers by completing and submitting a Complaint Form on our website.

If you prefer, you can print and mail or fax the completed complaint form, and necessary documentation to:
Appeals and Grievances Department
University of Utah Health Plans
6056 Fashion Square Dr. Suite 3104
Murray, UT 84107
Fax: 801-587-9985
 

If needed, Customer Service for the member’s benefit plan is available to help file a complaint:

TYPE OF PLAN LOCAL PHONE NUMBER TOLL-FREE PHONE NUMBER
Healthy U Medicaid 801-213-4104 833-981-0212
U of U Health Plans– Commercial 801-213-4008 833-981-0213
U of U Health Plans– Individual 801-213-4111 833-981-0214
Advantage U Medicare 801-893-6645 855-275-0374

Upon request, a Customer Service representative can assist a member in completing the required steps to file a complaint (e.g., interpreter services, TTY).

Grievance regarding U of U Health Plan Policies

A complaint about our coverage policies may be submitted to the Provider Relations department.

  • Phone: 801-587-2838 or 833-970-1848
  • Mail:
    Provider Relations 
    University of Utah Health Plans 
    6056 Fashion Square Dr. Suite 3104
    Murray, UT 84107
  • Email: provider.relations@hsc.utah.edu
  • Fax: 801-281-6121

 

Upon receipt of your complaint, the Provider Relations representative will send a letter of acknowledgment to the complainant.

Billing Members

Member Hold Harmless

University of Utah Health Plans members share in the responsibility of their medical expenses, which helps to keep the cost of healthcare as low as possible. Members share in the cost of healthcare through copayments, deductibles, and coinsurance.

Billing Members

The “No Billing of Members” clause outlined in the Participating Provider Agreement, is in accordance with state and federal law. Participating providers cannot seek payment directly from members, except for required copayments, annual deductibles, or coinsurance. Providers should collect fees for any noncovered services directly from the member. Providers should not balance bill the member for the difference between the contracted amount and the total billed charges.

Provider can collect payment from members for services that are not medically necessary, provided that the member or a person legally responsible for the member has been notified by the provider in advance and in writing that such services are not medically necessary and that the member or a person legally responsible for the member has explicitly consented to pay for such services prior to the services being rendered. The written notification must be specific to the services rendered and not part of the provider’s general financial policy, and not signed under duress.

Copayments

A copayment is a fixed amount that a member is responsible to pay to the provider at the time of service (e.g., office visits). Some benefit plans have an equal copayment for PCP and Specialists. Some benefit plans may have a split copayment where the specialist copayment is higher than the PCP copayment. Copays are generally excluded from the out-of-pocket maximum.

Copayments vary according to the member’s particular benefit plan. Each member’s ID card indicates the amount of copayment the member is required to pay. The member is responsible for only one copayment per office visit and is responsible for paying the copayment to providers participating with University of Utah Health Plans at the time of service.

Deductibles

A deductible is an amount the member must pay out of their own pocket before benefits for a specific service are paid by the plan. Each plan will indicate separate deductible amounts for individual and family deductibles. A family deductible is satisfied when the combined family members’ deductibles meet the amount set for the family deductible. One family member cannot satisfy the entire family deductible. Deductible amounts are identified on the provider’s remittance advice. Members may have an in-network deductible that is separate from the out-of-network deductible.

Coinsurance

Coinsurance is the percentage of an eligible medical expense that is payable by the member after the deductible is met. This amount, combined with any amount paid by University of Utah Health Plans will total 100 percent of the provider's contracted rate. Coinsurance usually applies to the out-of-pocket maximum.

Out-of-Pocket Maximum

An out-of-pocket maximum is the amount of covered expenses that must be paid each calendar year by a member toward the cost of their healthcare. The individual out-of-pocket maximum applies separately to each member. The family out-of-pocket maximum applies collectively to all members in the same family. Members may have an in-network out-of-pocket maximum that is separate from the out-of-network out-of-pocket maximum. University of Utah Health Plans will pay 100 percent of the allowable rate—except for copayments and any charges excluded, including the PPO discount—for any covered family member during the remainder of the year. Some products and services that do not apply toward the annual out-of-pocket maximum include copayments, deductibles, prescription copayments, mental healthcare services, and noncovered services.

Contact Customer Service for specific information regarding the University of Utah Health Plan member’s copayment, annual deductible, coinsurance, noncovered services, and benefit maximum amounts. Please use the appropriate Customer Service phone number for the member's benefits plan.

TYPE OF PLAN LOCAL PHONE NUMBER TOLL-FREE PHONE NUMBER
Healthy U Medicaid 801-213-4104 833-981-0212
U of U Health Plans– Commercial 801-213-4008 833-981-0213
U of U Health Plans– Individual 801-213-4111 833-981-0214
Advantage U Medicare 801-893-6645 855-275-0374

Network Contracting & Credentialing

Introduction

University of Utah Health Plans contracts with physicians, facilities, and other healthcare professionals for a variety of provider networks to support the healthcare benefits covered in our benefit plans. We are committed to facilitating the “triple aim” of improving experience and quality of care, improving the health of populations, and reducing the per-capita cost of care in the communities we serve.

Contracting strong networks ensures every member has access to the care they need, at the lowest appropriate cost. Our network options serve Commercial Group, Individual and Family (on and off the ACA Marketplace exchange), Medicaid, and Medicare members. Providers can participate in one or more networks, according to the U of U Health Plans business and geographic needs.

Review the U of U Health Plans networks.

Contracting

Providers who contract (participate) with U of U Health Plans networks enjoy direct and predictable payments, are listed in our online provider directories, and have access to a dedicated provider consultant and our team of provider coordinators. Participating providers also have access to proprietary online tools to make doing business with U of U Health Plans even easier.

Provider applications to participate in one or more U of U Health Plans networks are considered in accordance with any of the following elements:

  • Provider applications to participate in one or more U of U Health Plans networks are considered in accordance with any of the following elements:
  • Consideration of enrollee’s ability to access current provider practices within existing network(s); namely, accepting new patients or not, timely access to care, or transportation barriers
  • Network adequacy requirements and expected utilization based on the current or expected population of a given geographic area (usually defined by county or zip code, expressed as enrollee to provider ratios)
  • Network adequacy requirements based on provider type and/or specialty, including consideration of types of training, experience, and specialization
  • Network composition based on scope of services required by payer, such as employer, health plan, union/trust, or government entity
  • Performance in terms of cost/utilization, quality measures, outcomes, access, and/or patient or physician satisfaction, as applicable and available
  • Practice access considerations, such as appointment wait time, accommodations for persons with physical and/or mental disabilities, age restrictions, or extended hours of operation
  • Enrollee demographic needs and preferences, including but not limited to cultural, ethnic, racial, and linguistic considerations
  • Existing, non-compensated referral patterns or admitting privileges, as compared to current network providers and/or on behalf of U of U Health Plans members
  • Proximity to other participating providers
  • Types of services offered
  • Essential Community Provider status, as defined by 45 CFR 156.235
  • Administrative ease; such as ability to meet timely filing requirements, adhere to Utilization Management procedures, or submit electronic claims

 

To submit a contract application, review our Provider Application Process, including current network limitations. The information provided in Exhibit B of the Provider Application Form is used both for contracting and credentialing processes.

Provider applications are reviewed by our Contracting Committee within 15 to 20 business days.

  • Incomplete applications will automatically be denied due to the lack of information necessary to evaluate the provider request against network criteria.
  • If the application is approved, one of our Contract Executives will extend a contract to you. When we receive the signed and returned contract, we will initiate the credentialing of all providers listed in Exhibit B of the application.
  • If the application is not approved, you will be notified.

 

For questions about our contracting process, email providercontracting@hsc.utah.edu or call 801-587-2838 or 833-970-1848, option 2.

Notes:

Providers may begin to treat members only after a fully executed contract is final and only after the provider’s credentialing approval date, as noted on the letter they receive when credentialing is complete. Claims with a date of service prior to the latter of the contract effective date or the credentialing approval date will be paid as out-of-network for PPO plans and denied for EPO plans and Healthy U Medicaid.

If you need to make an update to your practice’s information, please do so via our secure Provider Portal, using the “Provider Updates” link under the Administration tab, or use the Provider Information Update Form. Do not submit a new application.

Credentialing

U of U Health Plans strives to uphold the highest credentialing standards. Credentialing helps ensure that our provider networks consist of high-quality providers who have met clearly defined standards. Most providers, including Advanced Practice Professionals (APPs)—such as Physician Assistants (PA), Certified Nurse Midwives (CNM), and Advance Practice Registered Nurses (APRN)—must be approved through our credentialing process before they can participate in any network.

The credentialing process includes, but is not limited to, verifying appropriate licensure, education and training, board certification, DEA licensure, accreditation/certification status, review of sanctions, and review of an acceptable history of professional liability claims. Initial credentialing typically takes six to eight weeks to complete, depending on whether you are credentialing a facility organization or a provider. Recredentialing occurs every three (3) years. The U of U Health Plans Credentialing Committee is responsible to determine whether a provider meets our credentialing criteria. This committee is chaired by our Medical Director. The Credentialing Committee meets the first Monday of each month, excluding holidays.

Practitioners

Newly contracted providers - Once your contract application is reviewed and accepted, you will be notified that your application has been sent to our Credentialing Committee.

New providers in an existing practice - To initiate credentialing for new providers with your practice, complete one of the following processes:

  • Submit the Provider Information Update Form
  • Send the following information for each practitioner to be credentialed, or via a roster containing the information below, to our Credentialing team at provider.credentialing@hsc.utah.edu.
    • Provider’s first and last names, and middle initial
    • Provider’s title
    • Provider’s specialty
    • Provider’s date of birth
    • Provider’s CAQH Provider ID
    • Provider NPI
    • Primary Practice Location
    • Credentialing contact name and email address

 

Initial credentialing and subsequent recredentialing every three years is required for all physicians and other healthcare professionals with whom members schedule appointments.

The decision to accept or reject a practitioner’s credentialing application is based on information generated through primary source verifications of application information, complaints and grievances, malpractice history, and board certifications. Other sources of information may be considered as appropriate and relevant at the sole discretion of the Credentialing Committee. Review “Practitioner Rights” in this document, for information regarding unfavorable credentialing decisions, or consult the Practitioner Appeal Rights in the U of U Health Plans Credentialing Policy.

Monitoring Provider Sanctions and Disciplinary Actions

U of U Health Plans monitors provider sanctions and disciplinary actions monthly, via reports from the National Practitioner Data Bank (NPDB), Health & Human Services (HHS), Office of Inspector General (OIG), System for Award Management (SAM), and state licensing boards.

  • Providers with Medicare or Medicaid sanctions, or who have a business relationship with a debarred or excluded provider or entity, will be terminated from U of U Health Plans networks.
  • Providers who have had restrictions placed upon their license to practice will be reviewed by the Credentialing Committee for appropriate action.

 

Practitioner Rights

 

  • Credentialing applicants have the right to be informed of their application status (i.e., Ready for Committee, App In-process, App Incomplete, or Missing Information) upon request. Email provider.credentialing@hsc.utah.edu, or call 833-970-1948, option 3 with your request. Emails will be responded to within 24 hours, and voice mails within 48 hours.
  • Credentialing applicants can correct erroneous information at any time during the credentialing process. Erroneous information must be lined through with black ink, with corrections noted above or to the side and initialed. No white-out will be accepted. Submit corrections to provider.credentialing@hsc.utah.edu. Corrections will be communicated to our CVO within 2 business days.
  • Upon request, applicants can review the information submitted in support of their credentialing or recredentialing application, including but not limited to:
    • Information from outside sources
    • Malpractice insurance carrier face sheet
    • State licensing board
    • DEA agency verification
    • Education verification letter from a school
    • Board certification verification, if applicable
  • U of U Health Plans is not required to reveal sources of information that are not part of our verification requirements or as prohibited by federal or state law (e.g., NPDB reports). The applicant may view their file in the presence of the U of U Health Plans Medical Director and a member of the credentialing team.

 

Credentialing Organizational and Supply Providers

U of U Health Plans verifies that all organizational and supply providers have met their respective certifications, have current state licenses, are in good standing with state and federal authorities, and have adequate liability coverage. Credentialing is completed upon initial contracting and then every three years, thereafter.

View the Organizational Provider Credentialing Application.

Nondiscrimination toward Providers

U of U Health Plans does not discriminate against providers with respect to participation based on race, gender, nationality, age, sexual orientation, the type/cost of treatment or patient in which the provider specializes including providers serving high-risk populations, or in terms of participation, reimbursement, or indemnification, against any health care professional who is acting within the scope of their license or certification under state law, solely on the basis of the license or certification.

Not to be construed as discriminatory:

  • Limiting a network to a number sufficient to adequately meet the access needs of members
  • Establishing reimbursement amounts for different specialties or in accordance with contract negotiations
  • Establishing measures designed to ensure our members receive quality services or control costs, as appropriate, in compliance with our responsibilities to our members

 

Providers denied participation on a U of U Health Plans network will be notified in writing of the reason for the decision.

Additional information: Policy: University of Utah Health Plans: Practitioner Denials, Terminations, and Fair Hearing Policy.

Learn more about our Contracting process.

Learn more about our Credentialing process.

Member Rights & Responsibilities

Member Rights

  • Be treated with respect and dignity and a right to privacy by practitioners/providers, nurses, medical staff, administrative staff, and other employees.
  • Receive information about the plans offered by UUHP, our practitioners/providers, our services, and members’ rights and responsibilities.
  • Members also have the right to know about any procedures that need to be followed for the member to get care.
  • Be informed about their health in a way that they can understand. If the member is sick, they have the right to be told about their illness, care options and prospects for recovery.
  • Openly discuss with their practitioner/provider all appropriate or medically necessary treatment options, regardless of cost or benefit coverage including alternative treatments that may be self-administered.
  • Be involved in decisions about their healthcare. Members have the right to approve any medical service after receiving the information needed to make a choice. Members have the right to refuse medical treatment even when the practitioner/provider says the member needs it.
  • Be free from any form of restraint or seclusion used as a means of coercion, discipline, convenience or retaliation.
  • Privacy - Members have the right to keep their medical information and records confidential subject to Federal and State law.
  • See their medical record. Members also have the right to ask for corrections to it and receive a copy of it.
  • Voice complaints or appeals about the health plan or the care it provides. Members can call Member Services if they have a complaint.
  • Appeal University of Utah Health Plan decisions.
  • Receive a reasonable and timely response to a request for service, including evaluations and referrals.
  • Dis-enroll from one of the plans offered.
  • Ask for a second opinion about their medical condition.
  • Receive interpreter services, and not be asked to bring a friend or family member with them to act as an interpreter.
  • Request information about their plan, their practitioners/providers, or their health in the member’s preferred language.
  • Receive a copy of their plan’s drug formulary on request.
  • Receive non-discriminatory medical care from University of Utah Health Plan providers (applicable to provider’s scope of practice) regardless of age, gender, color, ethnic origin, sexual orientation, marital status, income status or medical diagnosis or condition.
  • Continue enrollment in their selected plan without regard to adverse changes in health or medical condition.
  • Receive the appropriate, highest quality of medical care.
  • Members are free to exercise their rights without any fear of retaliation or being treated differently.
  • Providers must provide information regarding treatment options in a culturally-competent manner, including the option of no treatment. Providers must ensure that members with disabilities have effective communications with participants throughout the health system in making decisions regarding treatment options.

Member Responsibilities

  • Be familiar with and ask questions about their health benefits, plan requirements, covered services, and contact information. If members have a question about their benefits, call Member Services.
  • Provide information to U of U Health Plans, its practitioners, and providers, including their Member ID Card, or plan information as needed in order to provide care.
  • Obtain services only from participating providers unless in an emergency when participating providers are not available or closest provider or when services out-of-network have been approved by the plan.
  • Understand their health problems. Be active in making decisions with their practitioner to develop agreed-upon treatment goals and do all they can to meet the goals.
  • Follow an agreed-upon healthcare plan of care and healthcare instructions, or obtain a second opinion if they do not agree with the plan of care.
  • Build and keep a strong patient-provider relationship. Members have the responsibility to cooperate with their provider and staff. This includes being on time for visits or calling their provider if they need to cancel or reschedule an appointment.
  • Report fraud or wrongdoing to University of Utah Health Plans or the proper authorities. Pay their premiums and co-payments as required by their health care coverage.
  • Notify University of Utah Health Plans Member Services immediately upon a change in status: marriage, divorce, death in the family or addition to the family. (If a “Healthy U” member, also notify the Utah Medicaid Department).
  • Make best effort to maintain good health through healthy lifestyle and obtaining necessary and appropriate medical care.
  • Always discuss health information in any newsletter or on any web site with your doctor to make sure it is appropriate for you. Never use this information to replace your doctor’s advice.

Products & Services

Products & Services

U of U Health Plans group product offerings include PPO, EPO, HSA, and QHDHP.

PPO (Preferred Provider Organization)

A PPO gives members the freedom to choose any doctor, specialist, or hospital to provide their care. The level of member responsibility is determined by whether or not the provider or facility chosen is contracted with UUHP. Although the member may choose any provider there are advantages to choosing network providers. These include lower copays and reduced out-of-pocket expenses.

EPO (Exclusive Provider Organization)

A managed care plan where services are covered only if you go to doctors, specialists, or hospitals in the plan’s network (except in an emergency).

Fully Insured, Self-Funded or Level-Funded Options

We offer an extensive variety of products for large, medium and small businesses, including employee health benefit plans and value-added services that can be tailored to meet an organization’s specific needs.

HSA (Healthcare Savings Account)

A tax-advantaged medical savings account available to enrollees in a high-deductible health plan (HDHP). The funds contributed to an account are not subject to federal income tax at the time of deposit. Unlike a flexible spending account (FSA), HSA funds roll over and accumulate year to year if they are not spent. HSAs are owned by the individual, which differentiates them from company-owned Health Reimbursement Arrangements (HRA) that are an alternate tax-deductible source of funds paired with either HDHPs or standard health plans.

Qualified High Deductible Health Plan (QHDHP) and High Deductible Health Plan (HDHP)

A high-deductible health plan (HDHP) is a health insurance plan with lower premiums and higher deductibles than a traditional health plan. Being covered by an HDHP is also a requirement for having a health savings account. Some HDHP plans also offer additional "wellness" benefits, provided before a deductible is paid. High-deductible health plans are a form of catastrophic coverage, intended to cover for catastrophic illnesses.

Rules and Regulations

Advanced Directives

UUHP members have the right to make decisions about their health care, including a written Advance Directive. Under Utah law, there are four types of written advance directives:

  • Special Power of Attorney for Health Care: a person chooses someone else to make health care decisions if that person can’t make decisions for himself/herself.
  • Living Will: a written statement of the health care a person wants if he or she can’t make independent decisions.
  • Directive for Medical Services after Injury or Illness: a directive made between a person (or the individual who has Special Power of Attorney for the person) and a doctor for care when the person has a serious illness or disease, or if he or she is about to have an operation that could result in further illness, injury, or death.
  • Emergency Medical Services/Do Not Resuscitate: a directive alerting emergency workers that the person does not want CPR or life-saving techniques. A doctor must determine that the person is suffering from a life-threatening illness before this directive can be made.

 

Providers must display the Advance Directive in a prominent place in the medical record.

UUHP encourages members to tell their family members, the person who has Special Power of Attorney for them, and their providers about their wishes, and give them a copy of their advance directive.

Health care providers and health care facilities shall cooperate with a patient’s advance directive. In instances where an individual provider, or facility, or their overall institution objects to complying with a patient’s advance directive, whether based on policies, conscious objection, or other reasons as permitted under Utah state law (SB 75 2a-1114), providers shall meet all resulting requirements outlined in SB 75 2a-114.

Medicaid members may also contact Utah Legal Services at (801) 328-8891. If a Medicaid member feels a provider did not carry out the advance directive, he or she may call the Medicaid Bureau of Program Certification at 801-538-6158 or 1-800-662-4157.

Additional Information

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Domestic Abuse, Neglect and/or Exploitation

To ensure the health and safety of children and adults, UUHP is committed to educating contracted providers about mandatory reporting requirements, reporting procedures, and opportunities for provider and patient education. Therefore, University of Utah Health Plans providers MUST report abuse, neglect, and/or exploitation of children, adults, or families.

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 addition, any person who has reason to believe that an elder or disabled adult is being abused, neglected or exploited must by law

(62A-3-305 and 76-5-111.1) immediately report the situation to Adult Protective Services (a division of Aging and Adult Services) or the nearest law enforcement office. Under these laws, all reporters are immune from civil and criminal liability related to the report.

In addition to reporting to law enforcement agencies, providers may wish to notify the following divisions at the Utah Department of Health, specifically established for reporting purposes:

Child & Family Services Adult & Aging Services
120 North 200 West
Room 225
Salt Lake City, Utah 84103
(801) 538-4100
(801) 538-3993
24-Hour Child Abuse Reporting (801) 281-5151
24-Hour Adult Protective Reporting (800) 371-7897 or (801) 264-7669
Domestic Violence Information Line (800) 897-5465
Adult Protective Services
120 North 200 West Room 325
Salt Lake City, UT 84103
(801) 538-3910
(801) 538-4395
To Report Adult Abuse, Neglect or Exploitation call our 24-Hour Adult Protective Reporting
(800) 371-7897 or (801) 264-7669

Providers who are employed by the University of Utah Hospitals and Clinics should also familiarize themselves with the University of Utah policy on prevention, detection, and reporting requirements in the Abuse, Neglect and/or Exploitation Policy: https://intercomm.utah.edu/policies/Lists/Policies/DispForm.aspx?ID=1962

UUHP encourages providers to educate themselves and their staff about the prevention and detection of abuse, neglect, and/or exploitation, and resources available for victims. Providers may contact the agencies above for additional prevention, detection, and resource information. Providers may also wish to direct patients to the agencies above for additional education.

Providers may also refer patients who are victims of domestic abuse to the Domestic Violence Information Line at 1-800-897-5465 (LINK) for available resources.

Fraud Abuse Prevention and Detection

To ensure that health care dollars are used as intended, UUHP is committed to preventing and detecting fraudulent and/or abusive behavior by providers, members, and other individuals or organizations associated with the operations of UUHP.

Fraud Detection & Prevention

UUHP will prevent and detect fraudulent/abusive behavior and comply with state and federal fraud and abuse requirements by:

  • Utilizing controls to prevent and detect fraudulent/abusive behaviors.
  • Claims system pre-processing checks
  • Claims system edit reports
  • Member and provider complaints/fraud and abuse reports
  • Utilization management reviews - prospective, concurrent, and retrospective.
  • Credentialing and re-credentialing reviews to identify patterns of suspected incidents, and detect confirmed incidents in the form of Medicare or Medicaid exclusions.

 

In accordance with federal regulation 42CFR 438.214 (d), University of Utah Health Plans will not include any individual in the provider network who:

  • Has been debarred, suspended, or otherwise excluded from participation in Medicaid or Medicare programs;
  • Has an affiliation with an individual who has been debarred, suspended or otherwise excluded from participation in Medicaid or Medicaid programs;
  • Owns 5% or more in the University of Utah Health Plan's equity and is ineligible for participation in Medicare and Medicaid, or is affiliated with an individual who is ineligible, due to debarment, suspension, or exclusion from these programs.

 

UUHP encourages providers to institute a compliance plan to prevent and detect fraud and abuse. The Office of Inspector General (OIG) has published guidance for physician practices to assist in the development of a compliance plan: Final Compliance Program Guidance for Individual and Small Group Physician Practices PDF (65 FR 59434; October 5, 2000).

For further information about fraud and abuse detection and prevention, please visit the OIG’s web site at http://www.oig.hhs.gov/fraud/report-fraud/index.asp , or the National Health Care Anti-Fraud Association web site at http://www.nhcaa.org/.

Reporting Fraud and Abuse

If you suspect fraud and abuse, you may report it to the University of Utah Health Plan Compliance Officer at 833-981-0213, Option 1.

If the University of Utah Health Plan suspects fraud and abuse, suspected incidents will be reported to the following Medicaid agencies after a preliminary internal audit: Health Care Financing, Bureau of Managed Care and the Medicaid Fraud Control Unit.

Newborn and Mothers’ Health Protection Act

UUHP honors the Newborn’s and Mothers’ Health Protection Act of 1996. The Newborns’ Act regulates that all health plans and insurance issuers do not restrict a mothers’ or newborns’ benefits for a hospital length of stay that is connected to childbirth to less than 48 hours

following a vaginal delivery and 96 hours following a cesarean section. However, the attending provider may decide, after consulting with the mother, to discharge the mother or newborn child earlier.

If the delivery is in the hospital, the 48-hour (or 96-hour) period starts at the time of delivery. If the delivery is outside the hospital and then later admitted to the hospital in connection with childbirth, the period begins at the time of admission.

Follow-up care is required for women and infants discharged early following vaginal and cesarean section births. Women and infants discharged less than 48 hours following vaginal birth or 96 hours following a cesarean section delivery should receive post-delivery follow-up care within 24-72 hours following the discharge.

Utilization and Care Management

University of Utah Health Plans (U of U Health Plans) has a Utilization and Care Management Program with key components to conform to the Health Plan’s requirements. It is our belief that this program is essential to meeting the requirements of internal and external customers.

U of U Health Plans shall cooperate with the providers in an interactive educational role. Out interest is to assure that together with the providers the UUHP systems and resources will support the highest quality of medical care and meet the service demands of the UUHP patients in an efficient manner.

The UM Request Form and Utilization Review Guidelines can be found on our Policy & Forms website

UM Requests can be submitted electronically. Visit our Policy & Forms website for the information on how to submit the requests.

Key Program Components

Key components of the Utilization / Care Management program include prior authorization reviews, demand management, comprehensive case management, link to disease management, and outcome analysis.

Program Purpose

The U of U Health Plans Utilization / Care Management Department supports processes for the delivery of health care services to patients in a way that assures timely access to quality healthcare, patient satisfaction, and continuous improvement in the quality of that healthcare. The U of U Health Plans Utilization / Care Management Program will ensure that adequate resources and systems are in place to accomplish these goals.

U of U Health Plans is committed to providing timely access to high-quality health care services in an effective manner that meets or exceeds patients’ needs and expectations. While supporting the delivery of these high-quality services the Utilization / Care Management Program will monitor outcomes and data so as to provide a basis for continuous improvement and cost management.

The Utilization / Case Management Program will:

  • Facilitate prior authorization reviews

 

Program Goals

The goal of the U of U Health Plans Utilization / Care Management Program is to provide oversight and management of utilization thereby guaranteeing the highest quality health care services are provided to all UUHP patients at the appropriate level of care and in the most timely and cost-effective manner.

This goal applies to health care services provided in both the in-patient and outpatient settings by providers in the U of U Health Plans contracted network. All U of U Health Plans patients shall have equal access to health care, appropriate to their medical plan, throughout the network.

The program is designed to achieve the following specific goals:

  • Encourage provision of high-quality health care services.
  • Provide services that encourage the prevention and early detection of disease.
  • Encourage the efficient and effective use of health care resources.
  • Achieve high customer satisfaction.
  • Provide service through a select and coordinated health care provider network.
  • Promote provider and patient behavior that results in medical compliance and appropriate utilization of health care resources.
  • Develop data measurement and outcome tools that foster the achievement of our purpose and goals.
  • Benchmark our achievements to the best of national and regional standards while identifying areas for continuous improvement.

 

General Structure

The scope of the Utilization / Care Management program includes:

  • Prior authorization review

 

Utilization / Case Management Authority, Activities, and Accountability

  • The authority for Utilization /Care Management lies with the University of Utah Hospital. The Utilization / Care Management function is carried out through The Quality Improvement Committee, The Operations Committee, the Director, Manager, and staff.
  • The UUHP General Medical Director and Quality Medical Director have direct authority over the Utilization / Case Management Program and Quality Improvement Program.
  • The adequacy of the Utilization / Care Management protocols and systems will be monitored to assure quality outcomes as well as appropriate utilization by providers. Systems and procedures will be used to identify, track and take action on over and underutilization, quality, and risk issues.
  • The UUHP General Medical Director will ultimately be responsible for review and approval of all provider requests to assure the appropriate and effective use of medical resources. Denials on the basis of medical considerations will only be issued by a Board Certified licensed and designated physician.

Utilization Management Clinical Criteria

  • The U of U Health Plans Utilization Management Department shall maintain a set of written utilization review decision guidelines, which are based on InterQual and Hayes criteria, nationally recognized guidelines, to help determine medical necessity.
  • The established criteria will be applied and adjusted uniformly appropriate to an individual patient’s circumstances with regard to such factors as age, co-morbidity or psychosocial considerations.
  • The criteria will be consistent with practice guidelines.
  • Additional health plan documents such as the Medicaid Provider Manuals, plan contracts, and benefit plan documents will be reviewed and considered as criteria.

Medical Information

When making a determination of coverage based on medical necessity the UUHP Utilization Management Department will obtain all relevant clinical information and consults from the treating physician(s).

Information to be collected to support the decision may include:

  • Member eligibility
  • Benefit coverage / level
  • Verification of other insurance, if applicable
  • All relevant clinical information
  • Limitations and/or exclusions
  • Clinical practice guidelines and medical necessity criteria

 

Prior Authorization Reviews

The basic elements of prior authorization include eligibility verification, benefit interpretation, and medical necessity review. Services are reviewed, and determinations are made by Utilization Management licensed professional staff and referred to the Medical Director as necessary. Only the Medical Director can deny a service for reasons of medical appropriateness or necessity. Any quality of care issues will be reported to the Quality Improvement Specialist.

Visit Search Codes Requiring Prior Authorization to view all codes that require prior authorization. Claims for these services, received without prior authorization, will be denied.

Utilization Management staff are available seven days a week to ensure urgent requests are reviewed in a timely manner. Any extensions and/or denials will be documented with supporting data.

Except for healthy maternity and healthy newborns, all hospital admissions and inpatient services require prior authorization to assure appropriateness, continued length of stay, and levels of care.

Acute care hospital review requirements:

  • Aberrant days will be assigned as appropriate.
  • Plan eligibility should be identified at time of admission
  • Urgent/emergent admissions will be reviewed based on criteria standards and layperson definition.
  • As deemed necessary, the case manager will provide an onsite interview with the patient regarding discharge needs within the continuum of care.

 

Comprehensive Case Management

Patients are identified through health needs assessments at the earliest possible time for case management intervention.

The mechanism for identification may be through enrollment, primary care physician referral, claims history, high risk profiles, total costs, emergency room log, utilization discharge, planning, social workers, member services, pharmacy, survey tools or notification by state or federal agencies.

A designated case manager will follow patients across the continuum of care in both inpatient and ambulatory settings.

Coordination of care by primary as well as specialty providers will be augmented by use of ancillary health care and community social services. This coordination may be facilitated by phone, email, or case conferences.

Demand management will expedite case management-like processes as emergent coordination of care issues arise.

The frequency and duration of case management services are defined by the population in the specific case management policies.

Link to Disease Management
 

  • Case management will work collaboratively with disease management efforts to improve educational efforts and improve outcomes.
  • Led by the Quality Improvement Department Manager, disease management teams will be created to actively improve identification techniques and educational resources.
  • The case manager assigned to the diseased population will be a participant in the disease management team and act as the liaison to case management.
  • Referrals will actively be generated and passed between the disease management team and case management depending on the evaluation and needs of the member.

 

Second Opinion Survey

Patients have a right to a second medical opinion in the following situations:

  • When they are concerned about a diagnosis or medical plan of care.
  • If they question the reasonableness or necessity of recommended procedures.
  • If the clinical indications are not clear or are complex and confusing.
  • If the treatment plan in progress is not improving the medical condition within an appropriate period of time.

 

Healthy Premier and U Health Plus, Individual and Family Plans

Healthy Premier Individual and Family Plan is offered to eligible members on or off the Health Insurance Exchange Marketplace.

U Health Plus is an Individual/Family plan offered to Marketplace members living within the defined footprint in Salt Lake County. The supporting network of the same name included University of Utah Health Hospitals and Clinics, supplemented with strategic provider partners within the defined boundary, to ensure members have adequate access to services.

The information provided in this section is designed to assist Healthy Premier and U Health Plus providers.

Plan Categories and Benefits

Plan documents and additional information can be found on our website at: http://uhealthplan.utah.edu/individual/

Individual Plan Provider Appeals

Appeals must be received within 180 days from the date of the UUHP determination notification/Notice of Action (NOA) letter or Explanation of Benefit (EOB). UUHP will review and provide notification of decisions to the member for Appeals and Panel-level Expedited Appeals. See below for Voluntary External (Routine or Expedited) Appeal Information.

UUHP will respond to appeals: Pre-service Appeals within 30 calendar days of receipt of the request. Post-service Appeal within 45 calendar days of receipt of the request. Expedited Appeals within 72 hours of receipt of the request. Voluntary External Appeals within 45 days of the receipt of request and Voluntary Expedited External Appeals within 72 hours of the receipt of your request.

UUHP may extend the timeframes for appeal resolutions, including expedited appeals, by up to 14 calendar days if the enrollee requests or agrees to extend the appeal timeframe or UUHP determines and documents that there is need for additional information and how the delay is in the enrollee’s interest. If UUHP extends the timeframes, a written notice of the reason for the delay will be given to the enrollee.

Appeals may be received via mail, in-person delivery, fax, or orally. Oral appeals may be made by calling: (801) 213-4008 opt. 1 or (833) 981-0213 and must be followed with a written signed appeal from the entity submitting the appeal within 5 business days unless it is an expedited appeal. Written requests can be sent to: University of Utah Health Plan, 6056 Fashion Square Dr. Suite 3104, Murray, UT 84107; or Faxed to: (801) 281-6121. The appeal may be completed, using the online form, located on the University of Utah Health Plans website: uhealthplan.utah.edu .

A Provider or other authorized representative may appeal on behalf of the member, as long as the member or member’s legal guardian authorize, in writing, disclosure of personal information for the purposes of the appeal. A Consent to Appeal on Behalf of Member form is available on the website: uhealthplan.utah.edu .

Voluntary External (Routine or Expedited) Appeal: Available to members/Policyholders. The review and decision is made by an Independent Review Organization (IRO) at no cost to the member, for issues involving medical judgement, or determination that a treatment is investigational, after the member has exhausted the applicable non-voluntary levels of appeals, or if UUHP has failed to adhere to internal appeal requirements. The Voluntary External appeals must be requested within 180 days of the member receipt of the notice of the prior adverse decision. The IRO will make a decision within 45 days after receipt of the request.

Members should use the Independent Review Request form, available at www.insurance.utah.gov . Submit the request and documentation to the Utah Insurance Department by: mail: Suite 3110 State Office Building, Salt Lake City UT 84114; email: healthappeals.uid@utah.gov; or fax: 801-538-3829. If you are not able to access the request form by computer, call 801 538-3077 or toll-free 800 439-3905 to have the form mailed to you.

Coverage and Eligibility

When Coverage Begins

What is the Effective Date of Coverage?

The policy owner is covered under this policy upon our receipt of the application and remittance of the required premium payment. The effective date of coverage is the same as the policy effective date shown in the application which is filed.

Eligible Dependents are covered under this policy as follows:

  • On the date the coverage is effective if they are included in the application for this policy;
  • On the date the Dependent is eligible for coverage, meaning: (1) birth; (2) adoption (3) placement for adoption; (4) a marriage that results in the spouse or Domestic Partner and stepchildren being added to coverage; and (5) minor dependents required to be covered by court order or administrative order.

 

When members may Enroll for Coverage

Members may enroll for coverage during the Enrollment Period set by CMS or the State, or during a special enrollment period, or outside of the open enrollment period because of a qualifying event as defined by the Health Insurance Portability and Accountability Act.

Coverage for Dependent Child Due to Court or Administrative Order

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 child’s coverage.

We will not deny coverage for the child on the grounds that the child:

  • Was born out of wedlock and is entitled to coverage as a noncustodial parent;
  • Was born out of wedlock and the custodial parent seeks enrollment for the child under the custodial parent’s policy;
  • Is not claimed as a dependent on the parent’s federal tax return; or
  • Does not reside with the parent within our service area.

How do You Enroll Dependents After the Policy Effective Date?

If after the Policy Effective Date, the policy owner acquires a Dependent as a result of:

  • Marriage or the establishment of a Domestic Partnership;
  • Birth;
  • Placement for adoption; or
  • A court or administrative order;

The Dependent may be enrolled for coverage within the time period indicated below in the Adding a Dependent Due to Marriage/Domestic Partnership, Adding a Dependent Child, and Adding a Dependent Due to Court or Administrative Order provisions or by Exchange Rules if this Policy is purchased on the Exchange.

Adding a Dependent Due to Marriage/Domestic Partnership:

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. The Policyowner must notify us within 60 days from the date of marriage or establishment of Domestic Partnership. If there is a change in premium, it will be included in the first billing date after the change, adjusted back to the effective month of the change.

Adding a Dependent Child Due to Birth or Placement for Adoption:

The policy owner must notify us when they acquire a new Eligible Dependent Child due to:

  • Birth; or
  • Placement for adoption.

The effective date of coverage for the new Eligible Dependent will be:

  • The date of birth for a newborn natural child;
  • The date of birth for newborn adopted child if placement for adoption occurs within 60 days of birth; and
  • The date of Placement for an adopted child, if Placement for adoption occurs 60 days or more after the child’s birth.

We must receive notification and any required premium for the new Eligible Dependent Child within 60 days in order for coverage to be continued under this Policy. If such notification and any required premium are not received by us within the 60-day period, coverage under this Policy for the child only will be continued through the end of the month in which the notification is due.

With regard to an adopted child, coverage under this Policy will cease prior to end of the 60-day period if:

  • The Placement is disrupted prior to legal adoption; and
  • The child is removed from Placement.

"Placement for adoption" or "Placement" means the assumption and retention by a person of a legal obligation for total or partial support of a child in anticipation of the adoption of the child.

Adding a Dependent Child Due to Court or Administrative Order:

If a court or administrative order requires a policy owner to provide coverage for a Dependent Child, We must receive notification and any required premium for the child’s coverage under this Policy within 30 days (or 60 days if purchased on the exchange) of the court or administrative order. Refer to “Coverage for Dependent Child Due to Court or Administrative Order” for additional coverage details.

How Long Is Coverage Effective Under This Policy?

A Policyowner may elect to continue this Policy or discontinue this Policy during an open enrollment period or due to a qualifying event. Coverage under this Policy will be continued if the Policyowner elects to continue this Policy. If the Policyowner elects to discontinue this Policy, provide a written notice 30 days in advance of the requested termination date.

When policy owner is no longer eligible for coverage: This Policy will terminate on the first of the month following the date:

  • They enter active duty in the military service. However, if the policy owner retains coverage for the Covered Dependents, this policy will remain in force to insure the Covered Dependents provided the required premiums continue to be paid;
  • Of policy owner death;
  • This policy terminates for any other reason.

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. 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;
  • Your death
  • This Policy terminates.

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.

Continued Coverage for Former Spouse

If the coverage for a Covered Dependent spouse is terminated under this Policy due to divorce or policy owner death, the spouse will be entitled to have issued to him or her an individual policy upon entry of the divorce decree or annulment or upon the date of death. The individual policy that will be issued will be the same as this Policy, with a carryover of the Deductible and Coinsurance.

When We receive the actual notice that the Covered Dependent spouse is to be terminated because of a divorce or annulment or policy owner death, We will promptly provide the spouse written notification of (1) the right to obtain an individual policy; (2) the premium amounts required; and (3) the manner, place, and time in which premiums may be paid. The spouse may include coverage for Covered Dependent Children insured under this Policy.

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 the spouse applies for the individual policy and submits the first monthly premium to us within 30 days after receiving the written notification regarding the individual policy, we will issue the spouse with the individual policy which will be effective immediately upon termination of his or her coverage under this Policy.

When May We Rescind this Policy?

If we find that policy owner committed fraud or intentionally misrepresented material information on an application for this Policy within two (2) years from the Policy Effective Date, this Policy will be rescinded and will be considered as never having been in effect provided we give 30 days prior notice. Any premiums paid for coverage for the ineligible person will be refunded minus any claims paid for that person. We are entitled to recover the claim amounts that exceed the amount of premium paid.

When Can We Terminate this Policy?

We will terminate this Policy at 12:01 a.m. local time at policy owner place of residence on the earliest of the following:

  • During any open enrollment period that the policy is not renewed;
  • If policy owner fails to pay the required premium payment when due, subject to the Grace Period; or
  • If policy owner obtained this Policy through fraudulent means;
  • For any other reason for termination of this Policy as specified in this Policy, provided we give policy owner at least forty-five (45 days) prior written notice.

What Is Our Responsibility for Payment of Claims if this Policy Terminates?

We will only pay a claim for covered services that were received prior to the termination date of this Policy. We will not pay Covered Medical Expenses for Covered Benefits that are incurred after the date this Policy terminates for any reason.

Premiums

When are Premiums Due?

All premium, any charges or fees for this Policy (hereinafter referred to as “premium”) must be paid to us. The premium for this policy is shown in the Application. If policy owner does not pay premiums when due, this Policy will terminate subject to the Grace Period. The Premium Due Date is shown in the Application.

Grace Period

This Grace Period provision applies if policy owner is NOT receiving any federal subsidies for this Policy.

After the first due premium payment, if a premium is not paid on or before the date it is due, it may be paid during the next thirty (30) days. These thirty (30) days are called the Grace Period. Coverage under this Policy will remain in force during the Grace Period. If any premium is unpaid at the end of the Grace Period, this Policy will automatically terminate at the end of the Grace Period.

This Grace Period provision applies if policy owner is receiving any federal subsidies for this Policy.

After the first due premium payment, if a premium is not paid on or before the date it is due, it may be paid during the next ninety (90) days. These ninety (90) days are called the Grace Period. Coverage under this Policy will remain in force during the Grace Period.

During the first month of the grace period, we will continue to pay claims incurred for Covered Medical Expenses. During the second and third months of the grace period, we will suspend payment of any claims until we receive the past due premiums. 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. policy owner will be responsible for the cost of any health care services they receive after the last day of the first month of the grace period.

Can the Company Change the Premium Rates?

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. Any rate change will be made only when we change rates for all policies in the same rate class on the same form as this Policy that are issued in Utah. We will give policy owner at least 45 days advance written notice prior to the effective date of any rate change.

When is a Premium Refund Applicable?

In the event the Policy is canceled for a reason other than a material misrepresentation any unearned amount of collected premium will be refunded. In the event of material misrepresentation on the application collected premium minus claims paid will be refunded.

If this Policy is Terminated, Can It be Reinstated?

If any renewal premium is not paid within the time granted to policy owner for payment, a subsequent acceptance of premium by University Health Plans or by any agent duly authorized by University Health Plans to accept the premium, without also requiring an application for reinstatement, shall reinstate the policy. However, if University Health Plans or agent requires an application for reinstatement and issues a conditional receipt for the premium tendered, the policy shall be reinstated upon approval of this application from University Health Plans or, lacking this approval, upon the 45th day following the date of the conditional receipt, unless University Health Plans has previously notified policy owner in writing of our disapproval of the application. The reinstated policy shall cover only loss resulting from such accidental injury as may be sustained after the date of reinstatement and loss due to such sickness as may begin more than 10 days after that date. In all other respects policy owner and University Health Plans have the same rights under the reinstated policy as they had under the policy immediately before the due date of the defaulted premium, subject to any provisions endorsed on or attached to this policy in connection with the reinstatement. Any premium accepted in

connection with a reinstatement shall be applied to a period for which premium has not been previously paid, but not to any period more than 60 days prior to the date of reinstatement.

Utilization Review Guidelines

Utilization Review Guidelines and limitations can be found on our website at: Policy & Forms website

Healthy Premier, Healthy Preferred and Grand Valley Preferred Group Plans

At University of Utah Health Plans (U of U Health Plans) we offer a wide range of product options, including traditional HMO plans, PPO plans, and HSA compatible plans. We are flexible and effective in benefit design and provider network combinations. With an emphasis on population health management we focus on keeping employees healthy while managing utilization to lower costs. Fully – Insured Products:

UUHP has an experienced actuarial team that develops solutions specifically for Utah employers. A variety of plans for employers with 51 or more employees makes it easy to obtain high satisfaction.

Third-Party Administration (TPA)

UUHP has been providing TPA services for employers in Utah since 1998. Local and attentive staff are ready to manage custom plans effectively and efficiently.

Healthy Premier Group Plans

Healthy Premier Group plans are available to eligible Employer Groups across the state of Utah and surrounding states.

Additional information can be found on our website at: http://uhealthplan.utah.edu/employer- groups/#

Healthy Preferred Group Plans

Healthy Preferred Group plans are available to eligible Employer Groups across the Wasatch Front.

Additional information can be found on our website at: http://uhealthplan.utah.edu/employer- groups/#

Grand Valley Preferred Group Plans

Grand Valley Preferred Group plans are available to eligible Employer Groups in Colorado.

Additional information can be found on our website at: http://uhealthplan.utah.edu/employer- groups/#

Healthy Premier, Healthy Preferred and Grand Valley Preferred Group Appeals

Appeals must be received within 180 days from the date of the UUHP determination notification/Notice of Action (NOA) letter or Explanation of Benefit (EOB). UUHP will review and provide notification of decisions to the member for first-level, second-level, and expedited appeals.

UUHP will respond to appeals: Pre-service Appeals within 30 calendar days of receipt of the request. Post-service Appeal within 45 calendar days of receipt of the request. Expedited Appeals within 72 hours of receipt of the request. Voluntary External Appeals within 45 days of

the receipt of request and Voluntary Expedited External Appeals within 72 hours of the receipt of your request.

UUHP may extend the timeframes for appeal resolutions, including expedited appeals, by up to 14 calendar days if the enrollee requests or agrees to extend the appeal timeframe or UUHP determines and documents that there is need for additional information and how the delay is in the enrollee’s interest. If UUHP extends the timeframes, a written notice of the reason for the delay will be given to the enrollee.

Appeals may be received via mail, in-person delivery, fax, or orally. Oral appeals may be made by calling: (801) 213-4008 opt. 1 or (833) 981-0213 and must be followed with a written signed appeal from the entity submitting the appeal within 5 business days unless it is an expedited appeal. Written requests can be sent to: University of Utah Health Plan, 6056 Fashion Square Dr. Suite 3104, Murray, UT 84107; or Faxed to: (801) 281-6121. The appeal may be completed, using the online form, located on the University of Utah Health Plans website: uhealthplan.utah.edu.

A Provider or other authorized representative may appeal on behalf of the member, as long as the member or member’s legal guardian authorize, in writing, disclosure of personal information for the purposes of the appeal. A Consent form is available on the website: uhealthplan.utah.edu.

Voluntary External (Routine or Expedited) Appeal

Available to members/Policyholders. The review and decision is made by an Independent Review Organization (IRO) at no cost to the member, for issues involving medical judgment, or determination that a treatment is investigational, after the member has exhausted the applicable non-voluntary levels of appeals, or if UUHP has failed to adhere to internal appeal requirements. The Voluntary External appeals must be requested within 180 days of the member receipt of the notice of the prior adverse decision. The IRO will make a decision within 45 days after receipt of the request.

Members should use the Independent Review Request form, available at www.insurance.utah.gov Submit the request and documentation to the Utah Insurance Department by: mail: Suite 3110 State Office Building, Salt Lake City UT 84114; or email: healthappeals.uid@utah.gov; or fax: 801-538-3829. If you are not able to access the request form by computer, call 801 538-3077 or toll-free 800 439-3905 to have the form mailed to you.

Healthy U (Medicaid Managed Care)

Healthy U is a managed care health plan exclusively for Medicaid-eligible members throughout the state of Utah. The information provided in this section is designed to assist providers contracted with Healthy U to recognize Healthy U members and be familiar with the services that must be accessible to these members.

Claims and Payment Process

Providers contracted with Healthy U Medicaid agree to submit claims to U of U Health Plans for services and supplies provided to our members. As many of these requirements and processes overlap with other U of U Health Plans network requirements, please visit the Claims, Payment, and Appeals section of the Provider Manual to view information for all networks, as well as Healthy U.

The following Healthy U claims and payment topics are addressed in the above-referenced section:

  • Claim submission process
  • Timely filing requirements
  • Coordination of benefits
  • Payment and remittance advices
  • Fee schedule updates
  • Billing members and cost-sharing responsibilities
  • Electronic Data Interchange (EDI)
  • Overpayments and refunds
  • Healthy U Customer Service contact information

Note: Because of the singular nature of the Healthy U appeal process, please view the Medicaid Appeals Process information later in this section of the Provider Manual.

Verifying Eligibility

Healthy U members are responsible to present proof of Medicaid eligibility and enrollment in Healthy U at the time of service. Patients who fail to advise the provider of their Medicaid eligibility may be liable for services rendered on that date.

Medicaid eligibility can change from month to month; therefore, eligibility for every Medicaid enrollee—whether enrolled with Medicaid Fee-For-Service (FFS) or with an Accountable Care Organization (ACO) such as Healthy U—should be verified prior to every visit or service. Verify that the patient is eligible for Medicaid on the date of service and whether the patient is enrolled in a Managed Care Organizations (MCO), in a Prepaid Mental Health Plan (PMHP), in the “restriction” program, or has a designated Primary Care Provider (PCP). Eligibility information is available via the Utah Medicaid PRISM Portal (preferred), or by calling Utah Medicaid at 801-538-6155 or 800-662-9651.

Medicaid Restriction Program

The Medicaid Restriction Program identifies members who may be overutilizing the healthcare system, according to specific criteria established by Utah Medicaid. Examples include, but are not limited to, members seeing multiple providers who are prescribing controlled medications, using multiple pharmacies, and excessive use of the emergency department. The goal of the program is to help the restricted member learn a more prudent way to obtain healthcare services, while decreasing excessive costs to Medicaid. Once placed in the Restriction program, the member is required to choose a PCP, hospital, and pharmacy, and is restricted to using only these providers. For the duration of the “restriction” these members are required to contact the State Department of Health Restriction Program to have their primary care provider, hospital, or pharmacy changed.

The member’s eligibility and benefits statement in PRISM will identify the member as being in the Restriction program, as well as list the PCP, hospital, and pharmacy they are allowed to use. Although the member may present a Medicaid Identification Card, verifying eligibility via PRISM will ensure you have the most recent information.

Restricted members are required to obtain medical services from their PCP. If, as determined by their PCP, the member is to receive services from another provider, the member must obtain and present a referral from their PCP provider. Any services rendered without a referral by anyone other than the member’s PCP will be denied for payment.

Healthy U conducts an orientation with each Restricted Medicaid member to ensure the member understands the limitations and requirements. Care Management is always available to answer questions and assist members and providers in navigating the restriction program. Questions regarding this program should be directed to University of Utah Health Plans Care Management department at 833-981-0212, option 2, or 801-587-2851.

Use of Healthy U Provider Network

Except in the case of emergency, Healthy U members must obtain covered services from providers and facilities—including urgent care centers—that participate in the Healthy U network.

  • Utah Medicaid may require certain members to pay a cost-sharing amount (i.e., copayments, deductibles, coinsurance, premiums) for services or benefits. Refer to Utah State Plan Attachments 4.18-A through 4.18-H for additional cost-sharing information, or view the state’s Copay Chart.
  • Services received at a hospital emergency department will be paid at 100% of the prevailing Medicaid rate with no copayment. Nonemergency use of the ED does require a copayment, as noted in PRISM.

Out-of-Network

“Out-of-network” refers to services rendered by any provider that is not a participating, contracted provider in the Healthy U Medicaid network. Out-of-network services will only be reimbursed by Healthy U when they are:

  • Medically necessary services that were unavailable through the Healthy U network of participating providers and are approved by the plan via a single-case agreement or benefit exception.
  • Services that meet the definition of “emergency services” or urgent care services.
  • Court-ordered services that are Medicaid-covered services and have been coordinated with Healthy U.

Provider Network Directory

U of U Health Plans provides a link to Healthy U Provider Directories to all its members via the Healthy U handbook upon enrollment in the plan. The most current provider directory is maintained under the Find a Provider link on our website.

Directories are also made available to Utah Medicaid representatives and to participating providers upon request. Because information in the directory is subject to change, Healthy U encourages members to check their provider’s participating status prior to obtaining services.

Use of Primary Care Providers

Healthy U members are encouraged, though not required, to choose a PCP to manage and coordinate their care. A PCP is defined as a generalist in any of the following areas:

PCP area of specialty:

  • Family Practice
  • General Practice
  • General Internal Medicine
  • Obstetrics/Gynecology

PCP credentials:

  • Medical Doctor (MD)
  • Doctor of Osteopathic Medicine (DO)
  • Nurse Practitioner (NP)
  • Physician Assistant (PA)
  • Resident in listed PCP specialty

Referrals

While referring a member to a specific provider is useful to help your patient receive specialized care, Healthy U members are not required to obtain a referral prior to receiving care from a specialist.

General Policies Regarding Covered Services

All covered services must be medically necessary, and all Healthy U plan utilization management requirements must be met for services to be reimbursed. All services must be obtained from a participating provider to be covered, except in the case of “emergency services” or when a Singe-case agreement or benefit exception has been obtained from the plan. If you have a question about whether a service or supply is covered, please contact Healthy U. View the following resources for additional details on covered services, including applicable definitions, regulations, and limitations.

Direct Billing of Services

Aside from state mandated patient responsibilities, such as copayments, coinsurance, and noncovered services, healthcare providers who agree to treat Medicaid patients, such as Healthy U members, are prohibited by Federal law from billing Medicaid patients directly for covered services. Additionally, providers should not bill Healthy U members for any amount in excess of the contractually agreed upon allowed amount paid by U of U Health Plans for covered services, and the provider must accept Healthy U’s payment as payment in full. Failure to abide by state billing rules and regulations, and/or Healthy U Policies and Procedures, may result in the claim(s) being denied for payment. In such cases, the provider is prohibited from billing the member. Refer to the Utah Medicaid Provider Manual for additional rules and regulations.

Medically Necessary

Medically Necessary means any medical services or supplies that are necessary and appropriate for the treatment of an enrollee’s illness or injury, and for the preventive care of the enrollee according to accepted standards of medical practice in the community in which the provider practices and consistent with practice guidelines developed and approved by Healthy U. Covered services must meet the definition of medically necessary to be covered by the plan. Please contact the Healthy U Utilization Management department for questions on medical necessity.

Emergency Services

Emergency services includes services provided in a hospital, clinic, office, or other facility that is equipped to furnish necessary care after the sudden onset of a medical condition which manifests itself by acute symptoms of sufficient severity (including severe pain) that a prudent layperson who possesses an average knowledge of health and medicine could reasonably expect that the absence of immediate medical attention could result in placing the health of the individual (or with respect to a pregnant woman, the health of a woman or her unborn child) in serious jeopardy.

Emergency providers are expected to use prudent judgment in determining whether the member requires treatment in the emergency room. If the initial screening examination determines that the enrollee’s condition is not an emergency, the patient should be referred to a local urgent care center or to their Primary Care Physician—whichever is most appropriate—for further treatment and follow up care.

The initial screening examination to make a clinical determination on whether an actual medical emergency exists is covered by Healthy U. If the emergency room provider provides treatment for the patient even after determining the condition is not for a medical emergency, Healthy U will only cover a triage fee for the initial screening examination. If, however, the patient’s condition does warrant emergency medical services, all services required to stabilize the patient will be covered by the Healthy U Medicaid benefit plan.

The Healthy U Care Management department should be notified within 24 to 48 hours (same day or next working day for weekends and holidays) of all emergency visits that result in an inpatient admission.

For more information regarding emergency services, visit:

Translation Services

Healthy U covers interpretation/translation services, with no out-of-pocket cost for medical or vision visits, for members who speak little to no English, or are deaf, hard of hearing, or sight-impaired. To arrange interpreting/translation services, call Healthy U Customer Service at 833-981-0212 or 801-213-4104.

GENERAL POLICIES REGARDING COVERED SERVICES

A provider may be reimbursed for the provision of noncovered services if one of these two conditions are met:

  • A benefit exception is obtained from Healthy U. To obtain a benefit exception, contact the Healthy U Care Management department. Where benefit exceptions are granted, the provider is bound by the billing policies established above.
  • The provider has informed (in writing) the Healthy U member of all of the following:
    • The services to be rendered are not covered under the member’s Medicaid benefits
    • The total charges for which the member would be liable
    • And obtains the member’s authorization signature prior to the services being rendered

Note: This must be done each time a noncovered service is to be rendered. A single, one-time statement covering all future services is not acceptable.

Refer to the PRISM Coverage and Reimbursement Code Lookup tool to ensure the coverage of upcoming services.

General Exclusions

  • Services rendered during a period the patient was ineligible with the Healthy U Medicaid plan
  • Services not medically necessary or appropriate for the treatment of a patient’s diagnosis or condition
  • Services that fail to meet the existing standards of professional practice, are investigational, or experimental
  • Services obtained out-of-network that are not emergency services, not urgent care services, or where a single-case agreement or benefit exception was not obtained from Healthy U.
  • Elective services requested or provided solely due to the patient’s personal preference. Provider must notify patient in writing that the service(s) are not covered and that financial responsibility will be the patient’s if the elective services are performed.

This list is not inclusive of all Medicaid noncovered services and supplies, but rather is intended to provide basic guidelines for determining noncovered services. Refer to the Utah Medicaid Provider Manual or the Healthy U Member Handbook for the full list and detailed information about noncovered services, or contact a Healthy U representative.

Women’s Services

Healthy U has special programs in place to ensure that women receive the highest quality healthcare.

U Baby Care

Healthy U offers a specialized team of nurses to help members who are pregnant access services and support to have a healthy baby. To ensure members are aware of the resources available, please notify us of all pregnant Healthy U members in your care.

The U Baby Care program is available for all pregnant members upon notification of pregnancy. A case manager (RN) is on staff to take calls from members who have questions or concerns regarding their pregnancy and to provide care management services.

When Healthy U is notified (via state report, provider notification, member notification, hospital admit) of a pregnant member, one of the U Baby staff will reach out to complete a pregnancy risk survey. Based on the results of the survey the risk of preterm birth is stratified as low, medium or high. The survey also evaluates psycho-social needs that may impact pregnancy. Depending on the survey results the care manager assists the member to identify a plan of care that will support her throughout her pregnancy.

Healthy U services for members who are pregnant include, but are not limited to, prenatal, perinatal and postpartum care coordination, connecting to community resources (WIC, Safe Kids, etc.), group prenatal education, referrals to maternal fetal medicine, and to doula services. Screening for depression is also conducted on U Baby members, with support and referrals provided as needed. The RN care managers also provide education about sexually transmitted disease and family planning, depending on member interest.

Providers may refer members for any of these services. Please call the Healthy U Care Management department at 833-981-0212, option 2, or 801-587-2851 for questions about services or to refer a member to the U Baby Program. We want to collaborate and be part of the healthcare team.

Healthy U honors the Newborn’s and Mother’s Health Protection Act. Mother and baby have the right to stay inpatient for 48 hours after a vaginal delivery and 96 hours after a cesarean section.

For additional information please visit Newborns' and Mothers' Health Protection Act (NMHPA).

Mammography

Mammography reminder letters and follow up calls go out to members meeting the mammogram criteria that have not had a mammogram within two years. Mammogram screenings are covered for Healthy U members.

Family Planning Services

Family planning services are Medicaid covered services and must be made available to Healthy U patients free of charge. This includes disseminating information, counseling, and treatment-related to family planning services. Healthy U members may go to any Medicaid provider for family planning, even if they are not a Healthy U provider.

Birth control services include information and instructions related to birth control pills, including emergency contraceptive pills; medroxyprogesterone acetate injections, intrauterine devices; birth control patches, vaginal rings, spermicides; barrier methods including diaphragms, male and female condoms, and cervical caps; and vasectomy or tubal ligations. Office calls, examinations and counseling related to contraceptive devices are also covered and must be made available to Healthy U members. The removal of a contraceptive implant is also a covered benefit.

Notes regarding family planning:

  • Tubal ligations and vasectomies must have the Medicaid Sterilization Consent form completed and signed 30 days prior to the procedure. The form expires 180 days after the consent form is signed.
  • Any provider participating with Healthy U who does not wish to offer family planning services because of religious or personal reasons should contact U of U Health Plans Provider Relations at 801-587-2838, or 833-970-1848 so patients can be directed to an alternate provider.

Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) Program

Formerly known as Child Health Evaluation and Care (CHEC), the federally mandated Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) program includes three main components: prevention, outreach, and expanded services; each available with no out-of-pocket cost to Medicaid-eligible children. This section of the provider manual includes information on each component, other EPSDT services, and reimbursement.

Families of Medicaid-eligible children are encouraged to seek early and repeated well child health care visits beginning, ideally, at birth and continuing until the child turns 21 years of age. The Utah Department of Health and Healthy U provide outreach services to families to ensure they are informed of the importance of well-child care and that a visit is due. Healthy U also conducts education sessions for primary care physician’s offices to keep them up-to-date with the EPSDT Medicaid program. For more information about outreach education, please call our Case Management department at 801-587-2851, option 2 or 833-981-0212, option 4.

Section 1905 (a) of the Social Security Act provides expanded coverage for EPSDT enrollees when services are medically necessary to prevent, or ameliorate defects, and/or improve physical and behavioral health conditions identified during EPSDT screening - even when the service is not covered on the Medicaid fee schedule. Coverage is based upon a medical necessity review.

Call Healthy U Case Management at 801-587-2851, option 2 or 833-981-0212, option 4, with any coverage questions, or for a medical necessity review.

Screening and Prevention Services

Screenings (periodic comprehensive child health assessments) are regularly scheduled well-child examinations which include an assessment of physical and behavioral health, growth, development, and nutritional status of infants, children, and youth. Utah Medicaid recommends the assessment should include the following elements:

  • Comprehensive health and development histories, including an assessment of physical and behavioral development obtained from the parent, guardian, or other responsible adult who is familiar with the child’s history
  • Developmental history – Medicaid advises that “Each of these screening services is described more fully in the following sources:
  • Comprehensive unclothed physical examination
  • Age-Appropriate Immunizations – Assess whether the child’s immunizations are up-to-date. Provide all appropriate immunizations according to the schedules in our Clinical Practice Guidelines under the Preventive tab. There are separate schedules for pediatric—newborn through age 18, and adult—for EPSDT-eligible members ages 19 until their 21st birthday.
    You may also refer the child to the local health department for immunizations.
  • Health Education is an EPSDT requirement that includes anticipatory guidance. It should be provided to parents/guardians and children, and include information regarding developmental expectations, techniques to enhance development, benefits of healthy lifestyles, accident, injury, and disease prevention, and nutrition counseling.
    Note: A table with the recommended screening and prevention components and administration intervals is available in Section 2 – Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) Services of the Utah Medicaid Provider Manual.
  • Appropriate laboratory tests – Determine the applicability of specific tests for each child. Perform the following laboratory tests at the time of the EPSDT screening using the American Academy of Pediatrics Recommendations for Preventive Pediatric Health Care to determine the specific periodicity of each of the recommended tests.
  • Cholesterol Screening – Conduct at your discretion based on the risk of the child.
  • Lead Toxicity Screening – The Centers for Disease Control and Prevention and the American Academy of Pediatrics recommend a lead risk assessment and a blood lead level test for all Medicaid eligible children between the ages of 6 and 72 months. All children in this age group are considered at risk and must be screened. This component of the EPSDT screening is mandated by federal rules.
  • Verbal Lead Risk Assessment – Complete a verbal risk assessment for all Medicaid-eligible children, ages 6 to 72 months, at each EPSDT screening. Beginning at 6 months of age, a verbal risk assessment should be performed at every EPSDT visit. The Utah Lead Coalition provides a short, yet comprehensive, Childhood Lead Risk Questionnaire that can be printed or added to the child’s electronic health record (EHR).
  • Complete a blood lead level test at required intervals:
    • At 12 and 24 months – Complete for all children regardless of verbal assessment score.
    • Between 24 and 72 months – Complete a blood lead level test if the child has not had it at 12 and 24 months regardless of the verbal assessment score. In addition, complete a test anytime the verbal assessment indicates the child is at high risk for lead poisoning.
    • Reportable blood lead levels
      Blood lead level samples can be capillary or venipuncture.
    • A blood lead test result equal to or greater than 10 ug/dL, obtained by capillary specimen, must be confirmed using a venous blood sample.
    • In accordance with the Utah Injury Reporting Rule (R386-703), all confirmed blood lead levels greater than 15 ug/dL must be reported to the Utah Department of Health Bureau of Epidemiology, which maintains a blood lead registry.
    • 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.
  • Genetic testing – Genetic tests are complex examinations of human deoxyribonucleic acid (DNA), chromosomes, genes, or gene products to determine risk of having or transmitting a genetic disorder. Genetic testing must be medically necessary and ordered by a Medicaid-enrolled provider practicing within the scope of their license.
    • Coverage of genetic testing is determined by using an evidence-based criteria tool and may require prior authorization (PA) and/or review by a Medicaid consultant.
    • Information about specific genetic tests is available via the PRISM Coverage and Reimbursement Code Lookup tool.
    • Prior authorization for a Healthy U Medicaid member can be requested via the following methods:
    • Visit Utah Medicaid Official Publications and click on “Medicaid Provider Manuals,” then on “EPSDT (Formerly Child Health Evaluation and Care (CHEC))” for additional Medicaid details.
  • Other Tests – Consider other tests based on the appropriateness of the test. Take into account the child’s age, sex, health history, clinical symptoms, and exposure to disease.

Expanded Services

Vision Services include diagnosis and treatment for defects in vision, including eyeglasses. When needed, refer the child to the appropriate specialist. Detailed information regarding Medicaid’s vision protocols is available in the Utah Medicaid Provider Manual. Section 2 – Early and Periodic Screening, Diagnostic and Treatment (EPSDT) Services, 3-1 Vision Services

Dental Screenings and Services are not covered by Healthy U Medicaid, but may be covered by Utah Medicaid when furnished by direct referral to a dentist for children beginning at 3 years of age. Refer to Section 2 – Early and Periodic Screening, Diagnostic and Treatment (EPSDT) Services, 3-2 Dental Services

Dental services are covered by Utah Medicaid rather than by Healthy U. The Utah Medicaid program covers dental services for children including dental examinations, prophylaxis, fluoride treatment, sealants, relief of pain and infections, restoration of teeth, and maintenance of oral health

Orthodontic Treatment is provided in cases of severe malocclusions and requires prior authorization. Refer the child to a dentist as follows:

  • Make the initial referral for most children beginning at age one year and yearly thereafter.
  • Make a referral to a pediatric dentist at 6 months if warranted by an oral risk assessment.
  • Make the referral if the child is at least four years and has not had a complete dental examination by a dentist in the past 12 months.
  • Make the referral at any age if the oral inspection reveals cavities, infection, or significant abnormality.

Audiology Services include diagnosis and treatment for defects in hearing, including hearing aids. Screening should be supervised by a state-licensed audiologist.

If a newborn was not screened in the birthing facility before discharge, a screening test should be conducted as soon as possible after birth. Conduct screening exams on all children during the first EPSDT exam and perform at each periodic visit if indicated by historical findings or the presence of risk factors. When indicated, screen infants every six months until three years of age and refer the child to an appropriate specialist as required.

Age-appropriate hearing screening intervals, protocols, and procedures, and screening indicators are available in the Medicaid Provider Manual. Section 2 – Early and Periodic Screening, Diagnostic and Treatment (EPSDT) Services, 3 3 Audiology Services

Speech and Language Development (SLP) Services

EPSDT-eligible members are allowed one speech evaluation per year to screen for appropriate development and to identify developmental delays. Coverage includes examination, diagnosis, and treatment of speech/communication disabilities and related factors stemming from accident, injury, illness, or birth defect. Articulatory deviations, voice disorders, language impairment, or dysfluencies may be included in some instances.

Visit Section 2 – Early and Periodic Screening, Diagnostic and Treatment (EPSDT) Services, 3-4 Speech – Language Pathology (SLP) Services for recommended screening landmarks and covered services.

Pediatric Screenings

Healthy U covers a spectrum of developmental screenings for children, which help clinicians and parents with early identification of potential developmental or behavioral health issues. Services that support young children’s healthy development can reduce the impact of developmental and behavioral disorders which have high costs and long-term consequences for health, education, child welfare, and juvenile justice systems.

Broadly defined, screening is the process by which a large number of asymptomatic individuals are tested for the presence of a particular trait. Screening tools offer a systematic approach to this process. Ideally, tools that screen for the behavioral development of young children should:

  • Help to identify those children with or at risk of behavioral developmental problems
  • Be quick and inexpensive to administer
  • Be of demonstrated value to the patient and provide information that can lead to action
  • Differentiate between those in need of follow-up and those for whom follow-up is not necessary
  • Be accurate enough to avoid mislabeling many children
  • Screen the child for possible behavioral health needs using a standardized behavior checklist to do this screen. We recommend the following social-emotional screening tools for screening infants 0-12 months:
    • Ages and Stages Questionnaire (ASQ)
    • Ages and Stages Questionnaire: Social-Emotional (ASQ:SE)
    • Parent’s Evaluation of Developmental Status (PEDS)
    • Temperament and Atypical Behavior Scale (TABS)

Screening accompanied by referral and intervention protocols, along with parental education, can play an important role in linking children at-risk for developmental problems with appropriate interventions.

Refer children with suspected developmental or behavioral health needs to the appropriate provider to address those needs, and help parents identify training resources. If you or the parent/guardian need help identifying an appropriate in-network provider, consult our Provider Directory or call our Care Management team at 833-981-0212, option 2, or 801-587-2851, option 4. Care Managers can also help parents locate support and educational resources. Note: Utah Medicaid emphasizes that maternal depression can also have a strong impact on parenting and child outcomes. Healthy U and Medicaid encourage providers to refer children and/or their mothers with suspected behavioral health needs to the behavioral health provider listed in the member’s PRISM record. If a behavioral health provider is not listed in PRISM, refer the member to a provider in the Healthy U Behavioral or Healthy U Integrated directory. If a member is enrolled with Healthy U (medical only), behavioral health services are available through Medicaid Fee-For-Service or their local PMHP. Behavioral health services, at a minimum, include diagnosis and treatment for behavioral health conditions. Visit Section 2 – Early and Periodic Screening, Diagnostic and Treatment (EPSDT) Services, 3-5 Mental Health Services for additional information.

Reimbursement for EPSDT Services

The EPSDT fee includes payment for all components of the EPSDT exam. Services such as administration of immunizations, laboratory tests, and other diagnostic and treatment services may be billed in addition to the EPSDT screening.

Please use the Preventive Medicine codes listed in the table below each time you complete a EPSDT exam. Use these codes even if the child presents with a chronic illness and/or other health problem. Please avoid billing EPSDT exams using Evaluation and Management codes. If you do use an Evaluation and Management code, it should be accompanied by the appropriate ICD-10 V code in the table below to identify it as a EPSDT exam.

Codes for Preventive Medicine Services
New Patient Established Patient Other
99381 Infant – less than 1 year of age 99391 Infant – less than 1 year of age 99431 History and examination for new born infant
99382 Early childhood – age 1 through 4 years 99392 Early childhood – age 1 through 4 years 99432 Normal newborn care in other than hospital or birthing room setting.
99383 Late childhood – age 5 through 11 years 99393 Late childhood – age 5 through 11 years  
99384 Adolescent – age 12 through 17 years 99394 Adolescent – age 12 through 17 years  
99385 Young adult – age 18 through 20 years 99395 Young adult – age 18 through 20 years.  

To bill for an EPSDT screening electronically, enter the procedure code in Loop 2400 - Service Line. The element is SV101-2 - Product/Service ID. In element SV111, enter a Y to indicate EPSDT. On a paper claim, enter the procedure code in Box 24-D and enter a Y in Box 24-H EPSDT.

For additional information regarding women’s and pediatric preventive services, view the U of U Health Plans Preventive Care Screening medical policy.

Foster Children

Healthy U Medicaid also provides healthcare coverage for children in the custody of the State of Utah Department of Human Services. This group includes children who have been removed from their homes by the Division of Child and Family Services (DCFS) due to suspected abuse or neglect, as well as children under the direction of the Division of Youth Corrections (DYC).

A Medicaid case is routinely opened for children in these groups and they are enrolled in one of the available Medicaid health plans. Healthy U contracts with providers who have experience and training in abuse and neglect to ensure quality care for these children and is responsible to coordinate appointments with DCFS or DYC.

If a child in State custody has an established relationship with a provider contracted with Healthy U, every effort is made to ensure the child continues his or her care with that provider. For children in State custody because of suspected abuse or neglect, specific guidelines must be adhered to when scheduling provider visits. Healthy U providers are responsible to ensure the child has an appropriate examination within 24 hours of notification of removal from the home.

In all other cases an initial health screening by a provider must take place within five calendar days of notification of removal from the home. This exam serves to identify any medical problems or conditions that require immediate attention or that might inform the selection of suitable placement for the child.

Prior Authorization Reviews

Healthy U Medicaid utilizes the experienced staff of U of U Health Plans Utilization Management department to conduct prior authorization reviews and decisions in alignment with all of our other benefit plans.

The basic elements of prior authorization include eligibility verification, benefit interpretation, and medical necessity review. Services are reviewed and determinations are made by Utilization Management’s licensed professional staff, and referred to the Medical Director as necessary. Only the Medical Director can deny a service for reasons of medical appropriateness or necessity. Any quality-of-care issues will be reported to the Quality Improvement Specialist.

Medicaid Appeals Process

With respect to Medicaid plans, it is important your provider practice understand the Medicaid appeals process, including the right to a State Fair Hearing. Below are the definitions, standards, and timelines applicable to Medicaid plans; including Healthy U, Healthy U Behavioral, and Healthy U Integrated. The process below applies to Medicaid plans only. Visit Claims, Appeals & Complaints on our website for information regarding the appeals process for Commercial group and Individual/Family exchange members.  For “Advantage U Signature” and “Advantage U Signature Part B Buyback” Medicare Advantage members, view Advantage U Appeals.

Definitions

  1. Adverse Benefit Determination means:
    1. The denial or limited authorization of a requested service, including determinations based on the type or level of service, requirements for Medical Necessity, appropriateness, setting or effectiveness of a Covered Service;
    2. The reduction, suspension, or termination of a previously authorized service;
    3. A denial, in whole or in part, of a payment for a service solely because the claim does not meet the definition of a “clean claim" at § 447.45(b) of this chapter is not an adverse benefit determination
    4. The failure to provide services in a timely manner, as defined as failure to meet performance standards for appointment waiting times;
    5. The failure of the Contractor to act within the time frames established for resolution and notification of Grievances and Appeals;
    6. For a resident of a rural area with only one Medicaid ACO, the denial of an Enrollee’s right to exercise his or her right to obtain services outside the network; or
    7. The denial of an Enrollee’s request to dispute a financial liability, including cost sharing, copayments, premiums, deductibles, coinsurance, and other Enrollee financial liabilities.
  2. Appeal means a review of an Adverse Benefit Determination.
  3. Provider Dispute: An Appeal action occurs when the provider disagrees with a University of Utah Health Plans (UUHP/Healthy U) decision regarding claims processing concerns (e.g., Bundling/Unbundling, Modifiers, Coding, Multiple Procedures, claims filing procedures, etc.). A request made by the provider to review claim processing or contracted payment rates.
  4. Grievance means an expression of dissatisfaction about any matter other than an Adverse Benefit Determination.

Appeals Filing Process

  1. The Member must be eligible on the date of service.
  2. The member or provider can file an appeal. The appeal form and instructions are included in the Notice of Adverse Benefit Determination (NOABD) for a prior authorization denial, partial authorization, or reduction in service. Appeals can be submitted online, or printed and faxed or mailed. Complete information is available on the University of Utah Health Plans Appeal Form. Timeframe instructions and reference to appeals information and the website address is also included in the Explanation of Benefits (EOB).
  3. The Appeal must be filed within 60 calendar days of the date on the Adverse Benefit Determination notification. §438.402
    1. Appeals not received within 60 calendar days of the notification date will be returned with a letter noting the receipt date of the Appeal, and that it is past the timely filing deadline for submitting an Appeal. A State Fair Hearing Form and instructions on filing a State Fair Hearing will be included with the letter.
  4. Providers, enrollees and authorized representatives may call Healthy U Customer Service to resolve claim or service concerns by phone. However, this does not replace or extend the timely filing of an appeal. If the member or provider does not agree with a decision, they should submit an appeal.
  5. Members/Providers may submit any information that they feel is relevant to the appeal.
  6. Reasonable language assistance is available through Translation Services or Utah Relay Services, upon the member's request.
  7. U of U Health Plans will accept oral (in person, telephone) or written (fax, mail, email, online) appeals from providers, members, or a member's authorized representative. Oral inquiries seeking to review an adverse benefit determination are treated as appeals—to establish the earliest possible filing date for the appeal.
  8. Oral appeal requests can be made by calling Healthy U Customer Service at 833 981 0212 or 801 213 4104.
    1. The Customer Service Advocate will enter oral appeals on the online Appeals Form that automatically records the receipt date.
    2. If a member is requesting an oral appeal, they can give their verbal consent to the Customer Advocate assisting them so that the oral appeal can be considered as a valid appeal.
  9. Written appeal requests are made by mailing or faxing the completed appeal form to:
    University of Utah Health Plans Appeals Department
    P.O. Box 45180
    Salt Lake City, UT 84145

    Fax: 801-587-9985
    1. Appeals received via mail, in person delivery, or fax will be date stamped, with the date received.
    2. Online appeal requests are made using the University of Utah Health Plans Appeal Form.

Appeal Classifications and Decision Timeframes

Routine Standard Appeal

An appeal regarding the initial determination of coverage of care or services in advance of the member obtaining services, or services that have already been received by the member. A written notice of the Appeal decision will be sent to the member within 30 days of the receipt of the Appeal.

Expedited Appeal

An appeal for coverage of urgent care. An expedited Appeal is available if the member or provider indicates that taking time for a standard resolution could seriously jeopardize the member's life, health, or ability to attain, maintain, or regain maximum function.

  • A written notification of the expedited Appeal decision will be sent to the member within 72 hours of receipt of the Appeal.
  • U of U Health Plans must ensure that no punitive action is taken against a provider who requests an Expedited Appeal resolution or supports a member Appeal.
  • If U of U Health Plans denies the request for expedited resolution, the Appeal request will be transferred to a standard timeframe appeal. [§438.408(b)(2)]. U of U Health Plans will make reasonable efforts to give the enrollee and provider prompt oral notice of the denial, and will follow up with written notice in 72 hours.
    • The notification to members will include information about the member’s right to file a grievance if they disagree with the downgrade.

Timeframe Extension

U of U Health Plans may extend the time frames for resolution of appeals (expedited and standard) by up to 14 calendar days if:

  • The member requests or agrees to extend the appeal timeframe
  • U of U Health Plans can document (to the satisfaction of the Utah Department of Health, upon request) that there is need for additional information and how the delay is in the member's interest
  • If U of U Health Plans extends the timeframes, it must give the member written notice of the reason for the extension within two business days and inform the member of the right to file a Grievance if they disagree with that decision
  • U of U Health Plans must act as quickly as the member's health condition requires, and no later than the date the extension expires

If U of U Health Plans extends the time frames, it must, for any extension not requested by the member:

  • Make reasonable efforts to give the member prompt oral notice of the delay
  • Within two calendar days, give the member written notice of the reason for the delay and inform the member of the right to file a Grievance if they disagree with that decision
  • If U of U Health Plans fails to adhere to the notice and timing requirements for extension of the appeal resolution time frame, the member may initiate a State Fair Hearing

Additional Levels of Appeal

  1. The Healthy U Appeals process must be exhausted before the member or provider may request a State Fair Hearing.
  2. A member (or their representative) or provider may request a State Fair Hearing within 120 days from the date on the Notice of Appeal Resolution.
  3. The State Fair Hearing Request Form will be included with the Notice of Appeal Resolution. Alternatively, a copy can be requested from Healthy U Medicaid by calling 833-091-0213 or 801-213-4008. Visit Hearings on the Medicaid website for additional information about filing for a State Fair Hearing and access the “State Fair Hearing Request Form.”
    Mailing Address:
    Office of Administrative Hearings
    Division of Integrated Healthcare
    PO Box 143105
    Salt Lake City, UT 84114-3105
  4. Parties to the State Fair Hearing include U of U Health Plans; as well as the enrollee and their representative—who may include legal counsel, treating provider, a relative, a friend or other spokesperson, or the representative of a deceased enrollee's estate.
  5. The parties to the State Fair Hearing are given opportunity to: examine the content of the enrollee's file and all documents and records to be used by U of U Health Plans at the hearing, bring witnesses, establish all pertinent facts and circumstances, and present an argument without undue interference. They may question or refute any testimony or evidence, including opportunity to confront and cross-examine adverse witnesses.
  6. Requirements for continuation or reinstatement of benefits while an Appeal and State Fair Hearing are pending are as follows:
    1. The member or provider files the Appeal timely
    2. The Appeal involves the termination, suspension, or reduction of a previously approved service
    3. The services were ordered by an authorized provider
    4. The original period covered by the original authorization has not expired
    5. An enrollee requests an extension of benefits within 10 calendar days of the NOABD
  7. Continued benefits will end when one of the following occurs:
    1. The member or provider fail to file a state fair hearing and continuation of benefits within 10 calendar days of the NOABD
    2. The state fair hearing request is withdrawn
    3. The state fair hearing office issues a decision adverse to the member
  8. If the final resolution of the Appeal is adverse to the member (U of U Health Plans decision is upheld), U of U Health Plans may recover the cost of the services provided to the member while the Appeal was pending, to the extent that they were provided solely because of the requirements §438.420.

Healthy U Behavioral (Medicaid Managed Care for Behavioral Health)

Healthy U Behavioral is a managed care plan that provides behavioral health and substance use disorder services exclusively for Medicaid patients in Summit County, Utah. The information provided in this section is designed to assist Healthy U Behavioral network providers identify Healthy U Behavioral members and the services that must be accessible to these members.

Service Area

Healthy U Behavioral is currently available to eligible Medicaid enrollees residing in Summit County, Utah.

Receiving Care

Professional care: Except in the case of an emergency, enrollees must obtain covered services from a contracted Healthy U Behavioral network provider. Services rendered by noncontracted providers will be denied with no payment.

Facility services: Except in the case of an emergency, enrollees must obtain covered services from a contracted Healthy U Behavioral network facility. Services rendered by non-contracted facilities will be denied with no payment.

University of Utah Health Plans provides Healthy U Behavioral Provider Directories to all of its members upon enrollment in the plan. The most current provider directory can be viewed here

Healthy U Behavioral members are not required to obtain a referral prior to visiting a behavioral health specialist.

Covered Services

All covered services must be medically necessary and meet all Healthy U Behavioral plan requirements for services to be reimbursed. All services must be obtained from a participating provider to be covered, except in the case of “emergency services” or when a referral has been obtained from the plan.

Healthy U Behavioral covers inpatient and outpatient behavioral health and substance abuse services, including:

  • Crisis support
  • Peer support
  • Care management
  • Case management
  • 72-hour drug testing
  • Psychological testing
  • Court-ordered counseling
  • Medication management
  • Incarcerated crisis support
  • Behavioral health evaluations
  • Therapeutic behavioral services
  • Incarcerated behavioral services
  • School-based behavioral services
  • Community behavioral education
  • Individual, group, and family therapy
  • Individual skills training and development
  • Psychosocial rehabilitation services (day treatment)
  • Other services as deemed appropriate by Medicaid guidelines

Crisis and Telephonic Care

Members of Healthy U Behavioral, as well as all members of the community, have access to crisis response programs to provide immediate behavioral therapy—even if their established behavioral professional is not available.

  1. Initial Screening - If it appears patients need emergency behavioral health therapy care, the provider practice should conduct an initial screening within 30 minutes of the patient’s call requesting emergency care.
  2. Face-to-Face Visit – Following the telephonic emergency care assessment, if the provider determines the patient needs emergency services, the provider should arrange a face-to-face visit within an hour.
  3. Following the telephonic emergency care assessment – If the provider determines the patient needs urgent care, the provider should arrange a face-to-face visit within 5 days.

 

The following options are provided by the Huntsman Mental Health Institute (HMHI) 24 hours a day, 365 days a year:

  • HMHI CrisisLine – 800-273-8255 – Crisis intervention and suicide prevention
  • HMHI WarmLine – Triaged through the CrisisLine – Noncrisis support by Certified Peer Specialists offering engagement, a sense of hope, and self-respect
  • HMHI Receiving Center - Triaged through the CrisisLine – Therapeutic crisis management, assessment, and discharge planning in a short-term setting (up to 23 hours)

 

For Immediate Outpatient Assessment and Stabilization – Call our dedicated Advanced Practice Registered Nurse (APRN) at 801-585-1212, 24 hours a day, 365 days a year.

Submitting Claims and Receiving Payment

Because the Healthy U Behavioral network is contracted directly through U of U Health Plans, claims are submitted to and payment received from the health plan. Visit the Billing & Claims Payment section of this manual for specifics of how to submit claims and receive payment. Claims for patients who are not eligible for Medicaid or private insurance will be paid on a “sliding scale,” according to the patient’s ability to pay.

Coordinating Care

All Healthy U members, including Healthy U Behavioral, are encouraged to choose a Primary Care Provider (PCP) to manage and coordinate all of their care. As a Healthy U Behavioral provider, coordinating care with the member’s PCP will optimize the integrated care available to members, providing the best outcomes.

Care Management

Healthy U Behavioral members may utilize our professional Care Management staff for assistance in coordinating care throughout the continuum of their care, including inpatient and ambulatory settings, social and community services, and PCP or specialty providers. Care Managers will also coordinate care and pharmacy services for Medicaid “Restricted” members.

Care Managers can also assist Healthy U Behavioral members to identify an appropriate Healthy U Behavioral network provider and help schedule appointments if needed.

Verification of Eligibility

All Healthy U Behavioral members must show their Medicaid Identification Card BEFORE receiving any type of service. Eligibility of a Medicaid member can change at any time; therefore, the provider’s office must verify that the patient is eligible for Medicaid on the date of service.

To verify the eligibility of a Healthy U Behavioral member:

 

All other information and guidelines found in the Healthy U section of this manual apply to Healthy U Behavioral members and network providers.

Provider Acknowledgements

  • U of U Health Plans is responsible for payment of covered services rendered by the provider on behalf of Healthy U Behavioral members. State and/or county governments, with their respective divisions or departments, cannot be held liable for any uncollected payments.
  • Providers will report in writing to the appropriate county, the Utah State Attorney General, and DSAMH any suspected fraud or abuse committee by U of U Health Plans, a provider, or an enrollee.
  • Providers agree to grant the appropriate county, the Department, and CMS and their authorized representatives unrestricted access to all buildings, grounds, records, data, information systems, and other information under the control of the provider as necessary to audit, monitor, and review the financial and program activities and services associated with Healthy U Behavioral contract obligations.
  • If any of the information presented in the Preferred Provider Agreement or Provider Manual is in conflict with the Healthy U Behavioral Exhibit, the Exhibit controls.

Questions? Contact the dedicated Healthy U Customer Service team at 833-981-0212, Option 4, or your Provider Relations Consultant.

Healthy U Integrated (Medicaid Managed Care for Medical and Behavioral Health)

Healthy U Integrated is a managed care plan that provides medical and behavioral health, as well as substance use disorder services to income-qualified families and childless adults who live in Davis, Salt Lake, Utah, and Weber counties in Utah. Healthy U Integrated members have access to the combined medical and behavioral health benefits of Healthy U and Healthy U Behavioral members, respectively.

Service Area

Healthy U Integrated is currently available to eligible Medicaid enrollees residing in Davis, Salt Lake, Utah, and Weber counties in Utah.

Receiving Care

Except in the case of an emergency or SCA, enrollees must obtain covered services from a contracted Healthy U Integrated network provider or facility. Services rendered by noncontracted providers will be denied with no payment.

Verification of Eligibility

All Healthy U Integrated members must show their Medicaid Identification Card BEFORE receiving any type of service. Eligibility of a Medicaid member can change at any time; therefore, the provider’s office must verify that the patient is eligible for Medicaid on the date of service.

Eligibility information is available via the Utah Medicaid PRISM Portal (preferred), or by calling Utah Medicaid at 801-538-6155 or 800-662-9651.

All other information and guidelines found in the Healthy U section of this manual apply to Healthy U Integrated members and network providers.

Questions?

Contact the dedicated Healthy U Customer Service team at 833-981-0212 or 801-213-4104, option 4, or your Provider Relations Consultant.

Advantage U (Medicare Advantage PPO) and Advantage U Signature Part B Buyback (PPO)

Note: Effective January 1, 2024, Advantage U (Medicare Advantage PPO), which includes Advantage U Signature and Advantage U Signature Part B Buyback (PPO), is no longer offered to our members. Because timely filing provides 365 days for claim submission, information regarding Advantage U remains in the Provider Manual until December 31, 2024 to support claims runout.

University of Utah Health Plans added Advantage U Signature (PPO), a Medicare Advantage product, to our fully insured Group commercial, Individual and Family (both available on and off the ACA Marketplace), and Healthy U and Healthy U Behavioral Medicaid products. In January 2023, U of U Health Plans added Advantage U Signature Part B Buyback (PPO) to our Medicare Advantage benefit plans, as well. Advantage U Signature and Advantage U Signature Part B Buyback were available to Medicare beneficiaries living in Davis, Salt Lake, Tooele, Utah, and Weber counties.

Network Name

The provider network for Advantage U Signature and Advantage U Signature Part B Buyback (PPO) is “Advantage U.” The information listed in this section applies only to Advantage U providers and supplements the information available elsewhere in this Provider Manual, which is common to all U of U Health Plans lines of business.

Advantage U Fee Schedule

Advantage U fee schedule rates are based on published Medicare rates. In the event that 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. No retroactive adjustments will be made to claims payments in response to the updated rate.

Medicare Advantage Administrative Partner

University of Utah Health Plans delegated Cognizant® TMG HealthSM to perform the following administrative functions for the Advantage U network and our Advantage U Signature and Advantage U Signature Part B Buyback members:

  • Print fulfillment
  • System configuration
  • Billing and financial administration
  • Encounter and RAPS data administration
  • Customer Service 
  • Returned mail handling
  • Claims and provider administration
  • Enrollment and disenrollment administration

Cognizant is based in Jessup, PA, and provides reliable business process solutions for numerous Medicare Advantage plans throughout the United States.

Advantage U Contact Information

Description Contact Information
Claim inquiries, Customer Service, member eligibility Phone: 855-275-0374 | 801-893-6645
Medical management and prior authorizations Phone: 888-605-0858 | 801-587-3003
Website: uhealthplan.utah.edu/providers/policy-forms
Quality Improvement Phone: 801-587-2777
Fax: 801-281-6121
Provider Relations and Contracting Phone: 833-970-1848 | 801-587-2838
Fax: 801-281-6121
Email: Provider.relations@hsc.utah.edu

Pharmacy

  • Formulary and prior authorization
  • Prior authorization assistance through CVS Caremark
Website: AdvantageUMedicare.com
Phone: 888-970-0851
Electronic Data Interchange (EDI) Phone: 801-587-2638 or 801-587-2639
TPN: HT000179-002
Website: uhealthplan.utah.edu/EDI
Email: uuhpedi@hsc.utah.edu
Paper claims for Advantage U Signature members Advantage U Claims
Cognizant
PO Box 4405
Scranton, PA 18505

Contact Information for All Other U of U Health Plans Products

Description Contact Information
General (non-claims) mailing address Advantage U
University of Utah Health Plans
6056 Fashion Square Dr. Suite 3104
Murray, UT 84107
EDI Trading Partner Number:
(All non-Advantage U claims)
Phone: 801-587-2638 or 801-587-2639
TPN: HT000179-002
Website: uhealthplan.utah.edu/providers/edi.php
Email: uuhpedi@hsc.utah.edu
Paper claims
(For all non-Advantage U members)
University of Utah Health Plans
PO Box 45180
Salt Lake City, UT 84145-0180

Member Information

Identification Card

Advantage U Signature and Advantage U Signature Part B Buyback members should present their member ID card at each visit or admission. If the member does not present their card, contracted Advantage U providers can check benefits and eligibility on our secure Provider Portal or call Customer Service at 855-275-0374. Noncontracted providers can call Customer Service for member or claim information.
Front Back
AdvantageU-MembershipCard AdvantageU-MembershipCard

Member Benefits

Advantage U Signature and Advantage U Signature Part B Buyback members are covered for all of the services available through Original Medicare Parts A and B, and prescription medications covered through Part D. We also offer coverage for dental, vision, fitness, hearing aids, and over-the-counter benefits. Additional supplemental services may also be included. Advantage U Signature Part B Buyback members have a Part B Premium Reduction.

  • Preventive Benefits – Advantage U Signature covers the same preventive services as are covered by Original Medicare, at no cost to our members. Please visit the MLN Educational Tool: Medicare Preventive Services for an interactive listing of covered services.

In addition to preventive benefits covered by Original Medicare, Advantage U Signature offers:

  • Annual Physical Exam – One per year
  • Vision – annual allowance for exam and eyeglasses or contacts through a VSP Choice network provider
  • Dental – annual allowance for preventive and comprehensive dental services through DentaQuest network providers

Member Rights and Responsibilities

Advantage U Signature and Advantage U Signature Part B Buyback members receive complete plan details annually in their “Evidence of Coverage” materials, including what benefits are covered, appeal rights, contact information, and rights and responsibilities. The following rights and responsibilities are in addition to those listed in the Member Rights and Responsibilities section of this manual.

  • Receive sufficient information to decide among all relevant treatment options
  • Right to express preference about future treatment decisions
  • Right to refuse treatment
  • Stay current with Medicare premiums
  • Pay any cost-share amounts assigned for medical or other health care, noncovered services, or medications
  • Contact Advantage U Customer Service if they have questions or concerns
  • Notify providers and Advantage U Signature if they move

Advantage U Provider Responsibilities

The following responsibilities are in addition to those listed in the Benefits and Responsibilities section of this manual:

  • Access standards
  • Provider responsibilities
  • Site audits and ensuring appropriate physical facilities

Record Retention

For Advantage U Signature and Advantage U Signature Part B Buyback members, medical records must be maintained for 10 years from the end of the contract between U of U Health Plans and CMS, or the provider and U of U Health Plans; or 10 years from the date of completion of an audit.

Compliance with Federal Regulations (Medicare)

Advantage U network providers are required to comply with all federal Medicare Advantage regulations when providing services to Advantage U Signature and Advantage U Signature Part B Buyback members.

Inpatient Services

U of U Health Plans is responsible for covered in-network inpatient hospital acute services until the beneficiary is discharged.

If the member’s Advantage U coverage begins during an inpatient stay:

  • Payment for inpatient services until the discharge date is the responsibility of the previous Medicare Advantage organization or original Medicare, as appropriate
  • U of U Health Plans is not responsible for inpatient services until the date after the beneficiary’s discharge

If the member’s Advantage U coverage ends during an inpatient stay:

  • Payment for inpatient services is the responsibility of U of U Health Plans until the date of discharge

Outpatient Observation

Hospitals and critical access hospitals (CAH) observing a Medicare beneficiary for longer than 24 hours are required to provide the patient with a Medicare Outpatient Observation Notice (MOON), informing them that they are outpatients receiving observation services, not inpatients of the hospital or CAH.

View Medicare Outpatient Observation Notice for details and a sample copy of the form.

Discharge Planning

CMS requires that Medicare members be fully informed prior to being discharged from an inpatient facility. Hospitals and Home Health Agencies are required to follow the discharge planning processes outlined in the most current version of the CMS’ Discharge Planning Rule Supports Interoperability and Patient Preferences fact sheet.

Claims and Payment

The following information applies only to Advantage U providers, and supplements information listed in the Billing and Claims Payment section of this manual.

Submitting Claims

We prefer you submit claims electronically through UHIN, using TPN HT000179-002; however, if you need to submit a paper claim, please mail the claim to: 
Advantage U Claims
Cognizant
PO Box 4405
Scranton, PA 18505

Timely Filing Requirements

  • Primary claims – 365 days from date of service 
  • Secondary claims when any insurer other than Medicare is primary – 365 days from date of service

Coordination of Benefits

Standard Medicare Coordination of Benefits (COB) guidelines apply to Advantage U Signature claims. For questions about COB, contact Customer Service at 855-275-0374

Balance Billing

Advantage U network providers have agreed to accept the Advantage U fee schedule maximum allowed amounts as full payment for services rendered to Advantage U Signature and Advantage U Signature Part B Buyback members, and never bill the member for amounts in excess of the allowed amount or for noncovered services.

CMS does not allow providers to use the Advance Beneficiary Notice of Noncoverage (ABN) for Medicare Advantage enrollees, including Advantage U Signature or Advantage U Signature Part B Buyback members. (See Medicare Claims Processing Manual, Chapter 30, Section 50.3.)

When there is question about whether a service or item is covered under the member’s Advantage U Signature and Advantage U Signature Part B Buyback benefits, contact Advantage U Customer Service.

Correct Coding and Documentation

Health plans and CMS rely on the accuracy and completeness of claims data and documentation to efficiently process claims, design benefit plans, establish fee schedules, and review administrative practices. Additionally, by being aware of differences in complexity, as reported on claims, CMS and health plans can design better quality programs for similar populations and more accurately measure cost performance.

You can help ensure your patients’ conditions and treatment are properly reported and documented by incorporating these tips into your business practice:

Providers

  • Record all conditions to the highest specificity (e.g. “Type 2 diabetes with diabetic polyneuropathy” instead of “Type 2 diabetes”; “Morbid obesity with a BMI of 37.4” instead of “Overweight”)
  • Review and document every ongoing condition (with subjective, objective, assessment, and plan [SOAP] notes) at least annually

Coders

  • Always code to the most specific ICD-10 code (e.g., E08.5 Diabetes mellitus due to underlying condition with circulatory complications, instead of E08 Diabetes mellitus due to underlying condition)
  • Report every ICD-10 recorded in the encounter with the claim, regardless of whether it was the purpose of this visit or is an ongoing condition

Documentation excellence is essential for many facets of healthcare delivery. We appreciate your efforts toward establishing coordinated and dedicated reporting practices within your clinic.

Advantage U Appeals

An appeal, or request for reconsideration, includes a review of a denial or other adverse determination.

Who May File an Appeal

 

  • Members are informed of their appeal rights any time a denial or other adverse determination is completed by Advantage U. Included in the denial notice are instructions on how and where to file an appeal for reconsideration. Read Member Information about Organization & Coverage Determinations, Appeals and Grievances, Exceptions.
  • Providers contracted with the Advantage U Network may appeal an adverse determination only in the following circumstances:
    • Preservice determinations – Appeals must be received within 60 calendar days from the date of initial determination notification.
    • Provider payment disputes – Requests for reconsideration of claim billing errors or claim denials specifically related to the provider’s contract with Advantage U must be submitted within 60 calendar days of the date on the remittance advice.
  • Noncontracted Providers may appeal a post-service payment denial within 60 calendar days of the date on the remittance advice. A completed Waiver of Liability form must accompany the request.

Advantage U Response to Appeals

Advantage U will respond to appeals in the following timeframes:

  • Preservice Part C appeal – within 30 calendar days of receipt of the request
  • Preservice Part B appeal for (medical) drug – within 7 calendar days of receipt of the request
  • Post-service appeal – within 60 calendar days of receipt of the request
  • Expedited Part C appeal – within 72 hours of receipt of the request
  • Expedited Part B appeal – within 24 hours of receipt of the request

Advantage U may extend the timeframes for Part C appeal resolutions—including expedited appeals—by up to 14 calendar days in most cases, if the enrollee requests or agrees to extend the appeal timeframe or Advantage U determines and documents that there is need for additional information and how the delay is in the enrollee’s interest. If Advantage U extends the timeframes, a written notice of the reason for the delay will be given to the enrollee.

Note: Advantage U cannot extend the timeframe if the appeal involves a Part B drug.

Part C appeal requests can be completed using the Appeal and Reconsideration Form. Appeals can be submitted via mail, in-person delivery, or fax.

 

  • Mail or deliver written request forms to:
    Advantage U
    Attn: Appeals
    PO Box 3389
    Scranton, PA 18505
  • Fax Appeal Request Forms to 855-215-6952.
  • Note: Only expedited appeals can be accepted orally.
    Oral appeals can be made by calling 855-275-0374.

Part D appeal requests may be completed online using the Redetermination of Prescription Drug Denial form. If preferred, you may also submit your request by mail or fax.

 

  • Mail or deliver written request forms to:
    CVS Caremark
    Appeals Dept. – MC109
    PO Box 52000
    Phoenix, AZ 85072-2000
  • Fax Appeal Request Forms to 855-633-7673.

Independent Review Entity (Routine or Expedited) Appeal

If Advantage U upholds an adverse decision on a Part C appeal, we will automatically prepare a written explanation and send the complete case file to the Independent Review Entity (IRE) contracted by CMS. For Part D upheld appeals, the provider or member can submit a request to the IRE if additional review is desired. The review and decision is made by the IRE—at no cost to the member.

Pharmacy

Advantage U has contracted with CVS Caremark® to administer pharmacy benefits for Advantage U Signature and Advantage U Signature Part B Buyback members.

Description Contact Information
Pharmacy Prior Authorizations 888-970-0851
CVS Caremark Mail Order Pharmacy Advantage U Signature
PO Box 94467
Palatine, IL 60094-4467
Online Formulary AdvantageUMedicare.com

Compliance Requirements

The following information applies only to Advantage U providers and supplements compliance information listed in the Rules and Regulations section of this manual.

U of U Health Plans relies on our contracted providers and other contracted partners to help us meet the needs of our members. These individuals and organizations are considered First tier, Downstream, and Related Entities (FDRs). FDRs provide health or administrative services to Advantage U Signature and Advantage U Signature Part B Buyback members and are a vital part of our Medicare Advantage program.

U of U Health Plans has a policy against retaliation toward any individual who in good faith files a complaint, reports a potential compliance issue, expresses a concern, or assists with an investigation.

FDRs have specific responsibilities under Medicare guidelines, including:

  • Distribute Code of Conduct/Compliance Policies
    • To employees and downstream contractors
    • At time of hire/contracting and annually thereafter
  • Distribute general compliance and FWA training/education
    • To employees and downstream contractors
    • At time of hire/contracting and annually thereafter
  • Complete exclusion and preclusion list screenings
    • Prior to hiring/contracting
    • Monthly thereafter
  • Make employees/contractors aware of reporting mechanisms (e.g., Compliance Hotline)
  • Report FWA and compliance concerns to U of U Health Plans
  • Disclose use of offshore operations to U of U Health Plans
    • Conduct an annual audit of the offshore entity and its operations
    • Complete an annual attestation regarding offshore arrangements
  • Fulfill applicable statutory, regulatory, and other Part C or Part D requirements
  • Monitor and audit any of your own subcontractors (downstream entities)
    • Ensure contracts include CMS required provisions
    • Promptly resolve identified issues
  • Provide data and documentation for a CMS audit
  • Participate in auditing and monitoring activities conducted by U of U Health Plans, including providing compliance attestations and, upon request, documentation to demonstrate compliance with the above requirements.

Definitions

  • Abuse – includes actions that may, directly or indirectly, result in unnecessary costs to the health benefit program, improper payment, payment for services that fail to meet professionally recognized standards of care, or services that are medically unnecessary. Abuse involves payment for items or services when there is no legal entitlement to that payment and the provider has not knowingly and/or intentionally misrepresented facts to obtain payment.
  • Downstream Entity – any party that enters into a written arrangement, acceptable to CMS, with persons or entities. These persons or entities are involved with the MA benefit or Part D benefit, below the level of the arrangement between an MA organization or applicant or a Part D plan sponsor or applicant and a First Tier Entity. These written arrangements continue down to the level of the ultimate provider of both health and administrative services.
  • FDR – First tier, downstream, and related entity providing administrative or health care services under the Medicare Advantage or Part D program.
  • FWA – Fraud, waste, and abuse.
  • First Tier Entity – any party that enters into a written arrangement, acceptable to CMS, with an MA organization or Part D plan sponsor or applicant. These arrangements involve providing administrative or health care services to a Medicare-eligible individual under the MA program or Part D program.
  • Fraud – Knowingly and willfully executing, or attempting to execute, a scheme or artifice to defraud any health care benefit program or to obtain (by means of false or fraudulent pretenses, representations, or promises) any of the money or property owned by, or under the custody or control of, any health care benefit program. Fraud is intentionally submitting false information to the government or a government contractor to get money or a benefit.
  • Related Entity – entity related to an MA organization or Part D sponsor by common ownership or control and: (a) Performs some of the MA organization or Part D plan sponsor’s management functions under contract or delegation; (b) Furnishes services to Medicare enrollees under an oral or written agreement; or (c) Leases real property or sells materials to the MA organization or Part D plan sponsor (this occurs at a cost of more than $2,500 during a contract period).
  • Waste – overutilization of services, or other practices that, directly or indirectly, result in unnecessary costs to the health benefit program. Waste is generally not considered to be caused by criminally negligent actions but rather the misuse of resources. Waste is using, consuming, spending or expending resources thoughtlessly or carelessly.

Reporting Fraud, Waste, and/or Abuse (FWA)

Providers, including all First-Tier, Downstream, and Related Entities (FDRs), such as provider’s employees and/or provider’s subcontractors, must report any suspected fraud, waste or abuse, misconduct, noncompliance with applicable regulations, or criminal acts. Reports can be made anonymously through the University of Utah Ethics and Compliance Hotline at 855-275-0374 or at secure.ethicspoint.com. The Compliance Hotline is available 24 hours a day, 7 days a week.

Medicare Advantage Marketing Guidelines for Providers

Medicare Advantage plan marketing is regulated by CMS. Providers must comply with applicable laws, regulations, and CMS guidance regarding Medicare Advantage plan marketing. Providers should be familiar with the Medicare Communications and Marketing Guidelines (MCMG), including but not limited to Section 60 “Activities in a Healthcare Setting.”

Providers are not authorized to engage in marketing activities on behalf of U of U Health Plans without the express written consent of U of U Health Plans and advance review and approval of any marketing materials by U of U Health Plans.

Advantage U network providers should remain neutral when assisting beneficiaries with enrollment decisions.

Quality Improvement

U of U Health Plans is committed to ensuring all of our members receive quality health care. As noted elsewhere in this manual, we achieve quality outcomes through our Utilization and Care Management. Our quality initiatives support the care you provide in alignment with our common triple aim: providing the right care at the right time in the right place.

Advantage U Quality Programs - [In Development]

Star Ratings

To provide Medicare Advantage members with greater information to help them distinguish between Medicare Advantage plans, CMS instituted the Star rating program in 2008. Health plans are rated on various quality measures, including:

  • Members receiving preventive screenings, tests, and vaccines
  • Managing chronic conditions
  • Members’ reported experiences with the health plan, their providers, and overall improvement in their health
  • Member complaints and changes in the health plan’s performance
  • Health plan customer service

Members and providers alike benefit from a health plan’s strong Star rating through better relations with each other and the health plan, greater focus on preventive medicine and early disease detection, and strong benefits that support management of chronic conditions.

We look forward to partnering with you to deliver the highest quality health care available.