Provider Manual Sections: (Updated: 08-11-2020)

University of Utah Health Plans – An Introduction

Welcome to the University of Utah Heath Plans (UUHP). We value and honor the distinctive connection that you share with our members. UUHP was organized in 1998 with the formation of Healthy U (a Medicaid Managed Care Plan) as a managed care entity to handle the administrative functions of Healthy U. Our initial enrollment was approximately 3,000 members. Since our inception, we have grown our Healthy U membership , and have added several lines of business. In 1999, the University Health Care Plus plan was added. University Health Care Plus (UHCP) is a self-funded health plan for the employees of the University of Utah and their dependents. Effective July 1, 2016, University Health Care Plus is administered by Regence BlueCross BlueShield of Utah in a joint venture between Cambia and the University of Utah. In subsequent years we became the claims administrator for the other University and State projects – UNI HOME, as well the University’s behavioral health benefits. Healthy Premier is a commercial plan that we offer to employer groups and individuals throughout the state of Utah and surrounding intermountain areas. Healthy Preferred is a commercial plan that we offer to employer groups, primarily along the Wasatch Front, for their employees. Grand Valley Preferred is a commercial plan that we offer to employer groups in Grand Junction, Colorado and the surrounding areas. As a member of the University Health Care team, we hold ourselves to the highest standards in the services we provide to our members and to the providers who care for our members. Our goal is not to just operate at industry standards, but to exceed them in every possible way. For us, this is more than insurance, this is personal. We welcome your comments and suggestions on how we can better serve you and your staff.

General Information

The University of Utah Provider Manual is intended for use by physicians, ancillary providers, and contracted facilities/vendors as well as their practice managers and office staff. The manual can be used as a reference guide for University of Utah Health Plans (UUHP) policies and procedures for commercial and government plans. The information communicated in this manual does not take the place of physician service agreement signed by the contracted or employed provider. This provider manual is considered an attachment to and thereby part of all executed University of Utah Health Plans Provider Services agreements as referenced thereto and incorporated therein. The provider manual will be updated occasionally.

Access Standards

Appointment Wait times

UUHP is committed to ensuring that its members have timely access to the services they need. Providers are expected to assist UUHP in ensuring access to timely care by complying with the Access Standards below:
Type of Care Primary Care Providers Specialty Providers
Urgent Care Same day Same day
Non-urgent, but in need of medical attention Within one week Within one week
Routine care Within 30 days Within 30 days
Preventive Care Within 30 days
School Physicals Within 30 days

A PCP is defined as a generalist in any of the following areas:

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

Appointment Scheduling

Providers are required to have implemented an appropriate scheduling system which allows for adequate allotments of time for different appointment types, and allows for adequate slots reserved for urgent / acute care.
The provider’s telephone system shall be adequate enough to handle the volume of calls coming into the office.

Office Wait Times

For scheduled appointments with PCPs and Specialists, members should not wait longer than 45 minutes before being taken back to an exam room. Once in the exam room, the member should not wait longer than 15 minutes before seeing the provider.

After Hours Care

UUHP 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. The use of 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 return member calls within two (2) hours of being contacted, or have a mechanism in place to direct members to the appropriate after hours care.

Billing & Claims Payment

Claims Submission Requirements

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

  • Enrollee/Patient Name.
  • Identification Number of Patient/Subscriber.
  • Patient’s Date of Birth.
  • Patient’s Address.
  • Provider’s Name.
  • Provider’s Tax Identification Number.
  • Provider’s NPI
  • Provider’s Practice and Billing Addresses.
  • Other Insurance Information (if applicable and known).
  • Date(s) of Service of Claim.
  • Medical Diagnosis ICD-10 Code(s) (Codes should be obtained from the Medical Diagnosis Code Handbook for the year corresponding to the date of service.
  • Procedure codes (CPT) or Revenue codes identifying services on claim (CPT codes should be obtained from the CPT Code Handbook for the year corresponding to the date of service).
  • 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).

University of Utah Health Plans prefer you to submit claims electronically. If you need to submit a paper claim, please submit paper claims to the following address:

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

Claims shall be processed and remittance advices sent to the provider in accordance with the timeliness provisions set forth in the providers participating provider agreement.

Clean Claims

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

  • Is received timely by UUHP;
  • Has a corresponding referral, if required;
  • If submitted on paper, is submitted on a UB04, CMS-1500 or successor claim form(s) with all required elements;
  • If submitted electronically, is submitted in compliance with the applicable federal and state regulatory authority and uses only permitted standard code sets;
  • Includes all relevant information to determine other carrier liability or to investigate possible fraud;
  • Complies with the billing guidelines and medical policies;
  • Has no defect or impropriety;
  • Includes substantiating documentation; and
  • Does not require special processing that would prevent timely payment.

Claims Review and Audit

Provider acknowledges UUHP’s right to review Provider’s claims prior to payment for appropriateness in accordance with UUHP’s medical necessity policies and procedures, and in accordance with industry standard billing rules including, but not limited to, current UB manuals and editors, CPT and HCPCs coding, CMS & Utah State Medicaid billing and payment rules & regulations, CMS, and/or other industry standard bundling and unbundling rules, National Correct Coding Initiatives (NCCI) Edits, and FDA definitions and determinations of designated implantable devices. Provider acknowledges UUHP’s right to audit and review on a line item basis, or other such as basis as deemed appropriate by UUHP, and UUHP’s right to exclude inappropriate line items, to adjust payment, and to reimburse Provider at the revised allowed level.

Remittance Advice

University of Utah Health Plans (UUHP) will send a summary remittance advice to the provider’s office for each claim period summarizing all claims processed for that provider by patient. 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.

Provider payments will be issued via Electronic Funds Transfer (EFT) or via Virtual Credit Card. UUHP no longer issues paper checks for provider payments.

If you have a question on processing or payment of a claim, please contact a UUHP Member Service Representative. The representative can research the claim based on claim number, patient, provider and dates of service. The phone number is, 801-587-6480, option 1.

University of Utah Health Plans also offers online capability to verify processing or payment of a claim through U Link. If you would like to learn more about U Link, please contact Provider Relations at 801-587-2838 or provider.relations@hsc.utah.edu.

Timely Filing Requirement

Healthy U Medicaid : The timely filing for both primary and secondary claims is 365 days from the date of service. The exception to this rule is if Medicare is the primary insurance. When Medicare is the primary insurance, the claim must be submitted within 180 days of the Medicare EOB. Any corrections to a claim must also be received and/or adjusted within the same 365 days from the date of service.

University Health Care Plus, Healthy Premier, Healthy Preferred and Grand Valley Preferred : 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.

Overpayments/Refunds

In the event that UUHP determines that a claim has been overpaid, UUHP 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 Provider’s agreement with UUHP shall supersede those contained in this manual). In addition, UUHP may refer this matter to the Utah Attorney General’s Office for collection.

If overpayments are identified through the Fraud, Waste and Abuse department, provider will be notified in writing and will be given sixty (60) days to dispute or refund the overpayment. If Provider fails to submit the balance due with sixty (60) days of notification, UUHP may recover the balance due by way of offset or retraction from current and/or future claims.

Please notify UUHP immediately if you discover an error requiring reprocessing of the claim.

Coordination of Benefits

UUHP may not be the primary payer in certain circumstances, including services covered by a property owner’s liability insurance policy, the Medicare Program, or an injury or illness caused by a third party. Healthy U Medicaid should always be treated as the payer of last resort. The provider should submit the claim to the payer or party primarily responsible for the claim. If the claim is subject to coordination of benefits, the remittance advice from the primary payer will need to be submitted with the claim if you are submitting a paper claim.

In the event a commercial plan or third party is primary, UUHP will pay the lesser of the remaining billed charges or the allowable amount had UUHP been the primary payer. Payment by UUHP will be reduced by the amount of reimbursement from the primary payer. If compensation is recovered from a third-party payer, the provider is expected to refund any amounts paid by UUHP for covered medical services.

For specific questions regarding coordination of benefits, please contact a UUHP Customer Service Representative.

Corrected Claims

U of U Health Plans prefers to receive corrected claims via Electronic Data Interchange (EDI) transaction. To request a claim be corrected, submit the following information in Loop 2300 of an X-837 electronic claim form:

  • In segment CLM05-3, insert the appropriate “Claim Frequency Type” code (may be displayed by your software as a dropdown field):
    • 6 – Adjustment of prior claim
    • 7 – Replacement of prior claim
    • 8 – Void/cancel prior claim
  • Enter the Original Claim Number in the REF*F8 “Payer Claim Control Number” field.

  • Effective April 1, 2019, we will no longer accept Modifier CC on the service line of claims.
  • You must report every line associated with this claim to ensure the full claim is reprocessed.
  • Refer to your 5010 Implementation Guide for additional information.

If you must submit a corrected claim on a paper claim form:

UB-04 Facility Claim Form:

  • Enter the “Claim Frequency Type” code (6, 7, or 8) as the 3rd digit of box 4 “Type of Bill” (e.g., 137 indicates a correction to a Hospital Outpatient claim)
  • Enter the payer’s original claim number in box 64 “Document Control Number”

Claims Appeal Process

UUHP has policies and procedures for claim appeals. Providers are required to follow the respective polices and procedures listed in the Appeals Process link under each specific plan when appealing claim remittances.

Member Appeal Rights

Grievance and Appeals System is an overall system that includes a Grievance process, an Appeal process, and access to an additional level of external review. (Example: UUHP: IRO Healthy U: State Fair Hearing).

An Action is a denial, reduction, suspension or termination of requested or previously requested service or payment of service. It also includes the failure to provide services in a timely manner.

A Grievance is an expression of dissatisfaction about any matter other than an Action. A Grievance is also known as a complaint. Examples: Failure to respect a member’s rights or quality of care from a provider.

An Appeal is a request for a review of an Action.

UUHP will assist members in filing appeals, grievances or an external level of appeal.

Medicaid: Appeals must be received within 60 days from the date on Notice of Action or EOB.

Group Plan and Individual Plan Appeals: Members have 180 days to appeal from Notice of Action Letter/EOB.

UNI and Miners: Please contact appeal coordinators at (801) 587-6480 or (888) 271-5870.

NOTE: Effective January 1, 2016, the University of Utah Health Plans (UUHP) will require that providers obtain consent from a Healthy U or commercial member, to appeal on their behalf, for denied claims or referrals, 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.

Instructions for Members/Providers to File an Appeal

You, your legally authorized representative, or your provider may file your appeal. If you need help filing your appeal, call us at (801) 587-6480, option 1. If you are deaf or hard of hearing, you can call Utah Relay Services at 711 or 1-800-346-4128.

Español

Si necesita esta carta en Español, por favor llamenos al (801) 587-6480 o 1-888-271-5870 opcion 1. Deaf or hard of hearing: If you speak Spanish, you can call Spanish Relay Utah at 1- 888-346-3162. These are free public telephone relay services or TTY/TDD. Sordas o con problemas de audición: Si habla español, puede llamar al español Relay Utah al 1-888-346- 3162. Estos son los servicios de transmisión telefónica pública libres o TTY / TDD.

Submission Address

Send the complete written appeal to this address:

Appeals Committee Chairperson
6053 South Fashion Square Dr., Suite 110
Murray, UT 84107

We will accept appeals by mail, fax, or phone. Click here for the Appeal Request Form. You may also verbally request an appeal by calling the Customer Service phone number for the member's benefit plans:

Type of Plan Local Phone Number Toll-Free Phone Number
Healthy U Medicaid 801-213-4104 833-981-0212
U of U Health Plans– Commerical  801-213-4008 833-981-0213
U of U Health Plans– Individual  801-213-4111 833-981-0214

Please note: Oral appeals must be followed by a written appeal within 5 business days or your appeal will be closed (except for expedited clinical appeals). The right to appeal is still valid if received within timely filing rules for each plan, from the UUHP Notice of Action (NOA).

Response Time

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

UHCP:45 calendar days.

Medicaid: 30 calendar days.

Individual and Group 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.

Sometimes we may need more information. If so, we may take an additional 14 calendar days to make our decision. If we need to take extra time, we will send you a letter or contact you directly.

If you or your provider believes your life or immediate health is in danger, you may ask for an expedited (quick) appeal by calling Customer Service. If we agree the decision needs to be made quickly, we will make a decision in three working days. 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 a letter telling you why. Once we make a decision, we will mail you an Appeal Resolution Letter, and call you if you requested an expedited appeal.

Note: You may refer to additional information in this manual under each plan for further appeal information. Providers are required to follow the respective policies and procedures listed in the Appeals Process link under each specific plan when appealing claim remittances. You may also refer to appeals information on our website at www.uhealthplan.utah.edu for specific policies and procedures listed in the Appeals Process link under each plan or call Customer Service.

Filing a Grievance

Members, providers, or another authorized person may submit a Grievance on behalf of a member.

Members have the right to file a complaint against their plan, service or provider.

Grievances will be accepted by completing a complaint form on our website uhealthplan.utah.edu, by mail, by fax 801-587-9958, or over the phone.
Member Services is available to help file a complaint; call 801-213-4104 or 1-833-981-0212, option 1.

Assistance will be provided to enrollees, upon request, in completing the required steps to file a complaint (e.g., interpreter services, TTY).

To file a written Grievance, please fax to (801) 281-6121, or mail it to University of Utah Health Plans ATTN: Grievance Committee Chairperson

Claims Editing

U of U Health Plans follows the National Correct Coding Initiative (NCCI) guidelines/edits. 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.

Mid-Level Provider Reimbursement

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

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 health care as low as possible. Members share in the cost of health care through copayments, deductibles, and coinsurance.

Billing Members

The “No Billing of Members” clause, outlined in the Provider Agreement, is in accordance with state and federal law. Participating providers may not seek payment directly from members, except for required copayments, annual deductibles, or coinsurance. Providers should collect fees for any non-covered 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 is not prohibited from collection from members payment for services that are not medically necessary, provided that member or a person legally responsible for member has been notified by provider in advance in writing that such services are not medically necessary and that member or a person legally responsible for member has explicitly consented to pay for such services prior to the services being rendered. The written notification must be specified 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 (i.e. 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. Refer to the member’s ID card.

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 member’s deductibles meet the amount set for the family deductible. One family member cannot satisfy the 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 (1) and University of Utah Health Plans (2) which will total 100% of the provider's contracted amount. Coinsurance applies after the deductible has been met. 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 health care. 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% of the allowable (except for copayments and the charges excluded, including the PPO discount) for any covered family member during the remainder of the year. Some products and services that do not apply toward the annual out-of-pocket maximum include copayments, deductibles, prescription copayments, mental healthcare services, and non-covered services.

Contact Customer Service for specific information regarding the University of Utah Health Plan member’s copayment, annual deductible, coinsurance, non-covered service or copayment, and benefit maximums. 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– Commerical 801-213-4008 833-981-0213
U of U Health Plans– Individual 801-213-4111 833-981-0214

Contracting & Criteria

Contracting Criteria

The University of Utah Health Plans (U of U Health Plans) contracts with physicians and other health care professionals and facilities for all of our product lines including commercial, marketplace and Medicaid to offer provider networks essential to the delivery of health care and services to our members. U of U Health Plans is committed to the “triple aim” of improving experience and quality of care, improving the health of populations, and reducing the per capita cost of care.

We recognize the importance of population health and payment reform and have developed extensive care management and value-based payment programs that improve health and align provider reimbursement with value and positive outcomes.

Provider applications to participate in any U of U Health Plans network are considered based on the following:

  • U of U Health Plans business needs which may include and are not limited to:
    • Network adequacy requirements based on state and/or federal guidelines
    • Network adequacy requirements based on the current or expected population of a given geographic area (usually defined by county or zip code)
    • Network adequacy requirements based on provider type and/or specialty
    • Network composition based on the scope of services required by payer such as employer, health plan, union/trust, government entity, etc.
    • Demographic needs including but not limited to languages spoken
    • Existing, non-compensated, referral patterns with current network providers and/or UUHP members
  • Quality, patient experience, and cost data as available which may include and is not limited to:
    • Comparisons of provider practice data to benchmark market averages related to compliance with industry-standard quality measures. Examples include: Hemoglobin A1c (HbA1c) testing in diabetic patients, breast cancer screening prevention rates, and child immunization rates;
    • Industry published and available patient surveys and reviews;
    • Comparisons of provider practice cost data to benchmark market averages on a per-member-per-month basis for similar populations;
  • The credentialing process which may include and is not limited to, verifying appropriate licensure, education, and training, board certification, DEA licensure, accreditation/certification status, review of sanctions and a review of an acceptable history of professional liability claims.

All providers must be approved through our credentialing process before they may participate in any network.

U of U Health Plans plans are designed based on specific criteria that we apply to select participating primary care physicians and specialists which include:

  • Cardiology
  • General Surgery
  • Neurology
  • Urology
  • Orthopedics
  • Obstetrics and gynecology

Additional primary care physicians, specialists, and facilities are included if they meet our credentialing requirements to ensure members have access within a reasonable distance to the number and types of providers needed.

Credentialing & Recredentialing

Practitioners

As a member of the University Health Care team, U of U Health Plans strives to uphold the high standards of health care adopted by the University. The purpose of the UUHP Credentialing Program is to ensure that the UUHP provider networks consist of high-quality providers who have met clearly defined standards. The credentialing program follows the standards set forth by the National Committee for Quality Assurance (NCQA).

In order to offer our providers an efficient credentialing process and minimize the time between contracting with UUHP and providing services to our members, our credentialing team has collaborated with NCQA, CredSimple, our NCQA certified Credentials Verification Organization (CVO), and CAQH Pro View, the trusted electronic solution and industry standard for universal credentialing applications.

To initiate credentialing for new providers with your practice, simply send the following information for each practitioner to be credentialed, or a roster containing the information below, to our credentialing team at provider.credentialing@hsc.utah.edu

  • Provider’s first and last names with 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

(Example: John Q. Public – MD – Family Medicine – 01/01/1951 – CAQH 12345678 – NPI 1234567890 – Doctors Medical Clinic, 123 Main Street, Murray, UT 84117 – Mary Smith – mary.smithcredentialing@gmail.com)

If your provider has a completed CAQH application please ensure that UUHP has been granted permission to access the application, as well as confirm that the practitioner has recently attested to the accuracy and completeness of the information provided. If your provider does not already gave a CAQH application, the link to complete this one-time credentialing application used by multiple national healthcare organizations, at no cost to you, follows: http://www.caqh.org/sites/default/files/solutions/proview/guide/PR-QuickRef.pdf

The decision to accept or reject a practitioner’s 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 members. For unfavorable decisions, providers may consult the Practitioner Appeal Rights in the Credentialing Policy found on the UUHP website.

Initial credentialing and subsequent re-credentialing every three (3) years is required for all physicians and other types of health care professionals practicing under their own license as permitted by state law with whom members schedule appointments.

University of Utah Health Plans requires that Advanced Practice Professionals (APP), including PAs, complete credentialing. For Healthy U Medicaid, PAs will need to submit claims under the supervising physician as this is a requirement of State Medicaid. All other APPs will need to submit claims under their own name and NPI for both commercial plans and Healthy U Medicaid.

Monitoring of Provider Sanctions and Disciplinary Actions

U of U Health Plans does on-going monitoring of provider sanctions and disciplinary actions. Reports from the Health & Human Services (HHS), Office of Inspector General (OIG), System for Award Management (SAM), and the Department of Professional Licensing (DOPL) are reviewed monthly. Providers with Medicare / Medicaid sanctions, or who have a business relationship with another provider or entity that has been debarred or excluded, will be terminated from the UUHP participating networks. Providers who have had restrictions placed upon their license to practice will be presented to the Credentialing Committee for a decision on the appropriate action to be taken.

Practitioner Rights

  • The applicant shall have the right to be informed of their application status (Ready for Committee, App In-process, App Incomplete or Missing Information) upon request. The request shall be made via email to provider.credentialing@hsc.utah.edu, or by phone to 801-587-2838, opt 3. Information on Practitioner Rights can be found in the Credentialing Policy. Emails will be responded to within 24 hours, and voice mails returned within 48 hours.
  • The Practitioner will have the opportunity to correct any erroneous information, as applicable, during the 2-3 month credentialing process. Applicants are notified of this right through our Provider Manual and website: www.uhealthplan@hsc.utah.edu
  • Erroneous information must be lined through with black ink, corrections above or to the side, and initialed. No white-out will be accepted. Corrections will be communicated to our CVO within 2 business days. Corrections can be submitted to provider.credentialing@hsc.utah.edu
  • Upon request, applicants may review the information s/he has submitted in support of their credentialing or re-credentialing 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 if federal or state law prohibits us, such as NPDB reports. The applicant may view their file in the presence of the UUHP Medical Director and a member of the credentialing team. Applicants are notified of these rights in the Provider Manual and website: healthplan.utah.edu

Organizational & Supply Providers

U of U Health Plans ensures 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 (3) years.

  • Birthing centers must have a clear, written plan of transfer and transition of care in emergency circumstances. The plan must include the name(s) of the Hospital and the OB/GYN practitioner(s) providing backup.

The Organizational Provider Credentialing Application is available here.

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 his or her 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.

EDI & EFT

EDI

Electronic data interchange (EDI) offers significant benefits for both providers and payers. Electronic claims can help improve efficiency, productivity and cash flow for providers, while payers can see benefits in reduction of data entry errors and faster turnaround times.

Of the claims that University of Utah Health Plans (U of U Health Plans) receives electronically, 80% pass through our claims processing system without processor intervention. The average turnaround time for EDI claims (received date to check being received in the provider office) is 15 days.

Accepted Transactions

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

  • 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)

U of U Health Plans is a member of the Utah Health Information Network (UHIN), a non-profit coalition of payers, providers and other interested parties, including state government, in Utah. Numerous options are available for electronic claims submission through UHIN. Please visit http://www.uhin.org/ for more information. If a provider is not a member of UHIN, other options are available for sending EDI claims.

The steps in setting up EDI with UUHP are relatively simple:

    • Make contact with EDI support
    • Review information on our website- http://uhealthplan.utah.edu/EDI/
    • Fill out Trading Partner Form and return by fax, email or online.
    • Send a Test File for review and sign off
    • Once the Test File is good, the provider can move to production right away

The entire process of setting up EDI, from initial contact to production-ready, can take as little as a few days.

For more information or questions, please visit our website and/or contact:

EDI Information Coordinator Phone: (801)587-2638 or (801)587-2639

Fax: (801)281-6121

Email Address: uuhpedi@hsc.utah.edu

Website: http://uhealthplan.utah.edu/EDI/

If EDI Connection issues occur during off-hours for real-time 270/271 and 276/277 transactions please contact U of U Help Desk at 801-587-6000.

In compliance with CORE requirement, 270 U of U Health Plans uses the UHIN clearinghouse for all EDI transactions. Please view the UHIN Connectivity Companion Guide for further instructions. Connectivity Companion Guide can be located at www.uhin.org.

Trading Partner Registration

Before University of Utah Health Plans can process transactions, the submitting trading partner must obtain a trading partner ID and complete enrollment for services through UHIN. Contact by email at customerservice@uhin.com or by calling 801-466-7705.

Step 1: Contact UHIN and receive a copy of the UHIN Electronic Commerce Agreement (ECA)

Please be aware that the ECA is a legal document and it refers to clearinghouse services as “Administrative Messages.” If you want to enroll for clearinghouse services, please check the option for Administrative Messages on page 1 of the ECA.

Step 2 span class="s19">: Complete the UHIN Enrollment form

Make sure that you select all transaction types you will be exchanging (837, 835, 270, etc.).

UHIN will forward the enrollment information directly to University of Utah Health Plans to complete your set-up to submit EDI transactions electronically.

If you or your provider practice is new to EDI, you must register with UHIN and UHIN will then forward the information to University of Utah Health Plans. If you’re already registered with UHIN but not with University of Utah Health Plans and you only need to register your Trading Partner with University of Utah Health Plans, please complete the 837 Trading Partner Setup- Electronic Form or 837 Trading Partner Setup-Printable Form and return it to University of Utah Health Plans by email to uuhpedi@hsc.utah.edu or fax to (801) 281-6121.

EDI Enrollment Process for the 835 & EFT

All HIPAA-compliant transactions with University of Utah Health Plans route through the Utah Health Information Network (UHIN). A Provider must obtain an UHIN Trading Partner number to receive EDI Transactions from the University of Utah Health Plans. A Provider must be enrolled with the 837 to receive the 835 and EFT transactions. The 835 and EFT transactions are linked together by the Billing

Provider NPI and a Provider must enroll in both transactions. 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.

Provider must complete the University of Utah Health Plans 835 and Electronic Funds Transfer (EFT) Authorization Agreement Form. This form can be submitted either electronically or by paper.

Paper form can either be sent to University of Utah Health Plans by fax 801-281-6121 or by email: uuhpedi@hsc.utah.edu

Once the UUHP has received the EDI Enrollment form, UUHP will begin setting up the EDI connections. The provider will be notified by email once the setup is complete.

**If providers want transaction information from the bank, it is the provider’s responsibility to set this up with their financial institution. View a copy of a sample letter to send to your financial institution to request this: Sample Provider EFT Re-Association Letter.

Submitting Claims through UHIN

There are several different options for submitting claims through UHIN. These include the following:

  • Direct link: Provider is creating a HIPAA compliant file from their billing system and is sending the file to the UHIN HIPAA server (UHINet).
  • ProClaim: A Regence dial-up product, ProClaim is free to UHIN members.
  • UHINT: An internet-based product, UHINT is free to UHIN members.
  • uTRANSEND: Clearinghouse services

Other clearinghouses

A partial list of UHIN contracted clearinghouses appears below:

  • Relay Health/McKesson
    • Payer ID #4779 (professional claims)
    • Payer ID # 5920 (institutional claims)
  • WebMD/Emdeon = payer ID # SX155
  • Capario = Payer ID # SX155
  • Gateway EDI= Payer ID # 00179
  • Navicur
    • Payer ID # 4779 (professional claims )
    • Payer ID # 5920 (institutional claims)
  • Apex EDI = Payer ID # UHUOU
  • Ingenix = Payer ID # SX155
  • SSI Group: SX155
  • Zirmed: Z1030
  • Practice Insight: SX155
  • Med USA: HT000179-002
  • Office Ally: SX155
  • ENS Clearinghouse: SX155

*Please note - Payer ID numbers are assigned by the clearinghouse. As University of Utah Health Plans does not assign or maintain these numbers, please contact your clearinghouse for this information.

Paper Claims

There may be instances when you need to submit your claims on paper. U of U Health Plans has no plans at this time to require providers to submit claims electronically. However, UUHP would prefer that providers submit claims electronically, so if you need assistance on how to send EDI claims please contact us.

EDI Support

Phone: (801) 587-2638 or (801) 587-2639

Fax: (801) 587-6433

Email: uuhpedi@hsc.utah.edu

Attachments

The 5010 837 transaction allows for providers to submit a claim electronically while submitting attachments on paper. Elements in the file will indicate if you are sending an attachment, the type of attachment you are sending, and identification number for the attachment and the mode for sending the attachment (fax, email, etc.)

U of U Health Plans feels this is a valuable tool and would ask that providers who submit an electronic claim and also submit a paper attachment for that claim to use these fields. When sending UUHP an attachment, please verify that the identification number that was provided in the electronic file is also on the attachment so we can identify the claim that the attachment belongs to. We will pend all claims that you have indicated have an attachment until we have received that attachment.

Questions?

Member Information

Identification

For our commercial plans, U of U Health Plans will provide an identification card to members listing their name and their assigned ID number. The entire ID number must be used for billing and inquiries.

Although there may be some slight variation in where certain information appears on the ID cards, the cards typically include the following:

  • Member name, member ID number, group name
  • Summary of key member copay, deductible and coinsurance responsibilities
  • Pharmacy information
  • How to contact UUHP for eligibility, benefits, prior authorization, and utilization management
  • Claims submission information
  • Locating a participating provider

Member Portal

University of Utah Health Plan members are able to check claim status, eligibility, and out-of-pocket benefits on Member Portal

Member Eligibility

University of Utah Health Plan members are able to check claim status, eligibility, and out-of-pocket benefits on Member Portal

UUHP reimburses providers only for medically necessary and covered services rendered to eligible, enrolled members.

To ensure member eligibility, you should ask for a copy of the member ID card. If the patient does not have their member card, please contact UUHP at 801-587-6480 or 1-888-271-5870.

Please note that the member ID card does not guarantee member eligibility. Members may terminate their coverage with UUHP without surrendering their cards.

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.

Provider Complaints

UUHP recognizes that we cannot assist our members in getting the health care they need without you. As such, our goal is to provide GREAT customer service to our providers.

If something is not working, or if we’re doing a great job, please let us know.

On behalf of a Member

A complaint on behalf of a member about health plan benefits or health care services must be registered within one year of the service date.

Send a written complaint to:

  • University of Utah Health Plans Grievance Coordinator
    6053 Fashion Square Dr. Suite 110
    Murray, UT 84107

Upon receipt of your complaint, the Grievance Coordinator will then send a letter of acknowledgement to the complainant.

Regarding Health Plan Policies

A complaint about health plan policies may be submitted at any time to the provider relations department.

Please call Provider Relations at: 801-587-2838 or Toll Free at 1-888-xxx-xxxx.

  • Send a written complaint to:
    University of Utah Health Plans Provider Relations
    6053 Fashion Square Dr. Suite 110
    Murray, UT 84107

Email Provider Relations at provider.relations@hsc.utah.edu

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

Provider Responsibilities

Provision of Covered Services

Providers must be aware of benefit plans’ covered services and inform enrollees of covered services; as well as other programs and resources available to enrollees for prevention, education and treatment. Practitioners may freely communicate with patients about their treatment, regardless of benefit coverage limitations.

Provider Services

Provider Services shall be available from a provider, or from a covering provider, twenty-four hours a day, seven (7) days per week. Provider agrees that the covering provider shall be a participating provider. If provider services are rendered by any person other than a participating provider, the provider shall (i) notify U of U Health Plans prior to referring member to a non-participating provider, and (ii) use best efforts to notify such provider of utilization management requirements. In the event of an emergency, provider is not obligated to provide such prior notifications. Pertaining to participating facilities, services shall be available from participating facility twenty-four (24) hours a day, seven (7) days a week. If facility services are rendered by any facility other than a participating facility, facility shall (i) notifyU of U Health Plans' utilization management department prior to referring member to a non-participating facility, and (ii) use best efforts to notify such facility of UUHP’s utilization management requirements. In the event of an emergency, facility is not obligated to provide such prior notifications.

Service Delivery / Non-Discrimination

Providers are required contractually to render covered services to University of Utah Health Plan 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. To arrange translation services please contact the UUHP member services at (801) 587-6480, option 1. Practitioners and Providers may openly discuss with members all appropriate or medically necessary treatment options, regardless of benefit coverage limitations including alternative treatments that may be self-administered.

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, ethnicity, national origin, religion, gender, age, mental or physical disability, sexual orientation, genetic information, or source of financial assistance. Additionally, the 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 833-981-0213, option 1and ask to speak with our Civil Rights Coordinator.

Doctors are not rewarded for denying care

U of U Health Plans reminds our practitioners/providers that decisions about utilization management (effective use of services) are based only on whether care is appropriate and whether a Member has coverage. U of U Health Plans does not reward doctors or others for denying coverage or care. UM decisions are based only on appropriateness of care and service and existence of coverage. U of U Health Plans does not reward practitioners/providers or other individuals for issuing denials of coverage or service care, and UM decision-makers do not receive financial incentives.

Physical Facilities

Providers shall maintain physical facilities that are clean/sanitary, accessible to disabled members in accordance with the ADA, have adequate fire and safety features, adequate waiting and exam room space, equipped with the appropriate medical equipment, devices, and supplies commensurate with the type of services offered, and the appropriate, secure storage of medical records and other PHI. Providers must write prescriptions on tamper-resistant prescription pads, in accordance with Section 7002(b) of the U.S. Troop Readiness, Veterans’ Care, Katrina Recovery, and Iraq Accountability Appropriations Act of 2007.

Record Keeping 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

Providers must make records available to U of U Health Plans upon request for the purposes of:

  • Advance determinations of coverage
  • Plan coverage
  • Medical necessity
  • Proper billing
  • Quality reporting
  • Fraud and abuse investigations
  • Risk adjustment activities

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.

All provision of medical records must be consistent with HIPAA privacy statue and regulations (see hhs.gov/ocr/privacy).

Patient records should be maintained for at least seven years.

Patient Confidentiality & HIPAA

Providers, their employees, and business associates agree to safeguard the privacy and confidentiality of the University of Utah Health Plan 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 the member for all uses and disclosures of Protected Health Information (PHI) EXCEPT uses and disclosures for Treatment, Payment and Health Care 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 family or friends who care, or will be caring for a UUHP member,
  • Providing the necessary information to UUHP for processing and payment claims, and or authorizations,
  • Complying with UUHP’s QA/QI activities, HEDIS reporting and/or other UUHP programs centered on the improvement and measurement of patient care.

UUHP is responsible to ensure members’ privacy and also adhere to stringent confidentiality regulations as required by Federal law. This means that the identity of any caller purporting to be a member must be verified before any information concerning the member is given. This will be accomplished by obtaining the member's identification number and date of birth. Failing that, the member will be required to provide social security number, date of birth and address to ensure the member is actually on the line.

NOTE: Providers must supply Tax ID Number (TIN) and NPI when requesting patient information.

For more detailed information on HIPAA, please see CMS website at, http://health.utah.gov/hipaa/

Compliance with UUHP Policies and Procedures

Provider shall comply and participate with all UUHP Utilization Management Programs, Quality Improvement Programs, Credentialing & Recredentialing activities, and Complaint/Grievance Policies and Procedures. Providers agree to allow UUHP to use their performance data. In addition, Provider shall abide by policies and procedures related to covered services, billing of enrollees, emergency services, and other Policies and Procedures as defined by University of Utah Health Plans with respect to each plan Provider participates in. To request a copy of a Medical Policy, please contact Provider Relations at 801-587-2838 Option 1.

Compliance with State & Federal Regulations (Medicaid)

Provider shall comply with all State & Federal Medicaid regulations in providing services to enrollees in such plans.

Licensure & Insurance

Provider shall maintain current licensure, malpractice liability insurance, specialty board certification when applicable, hospital privileges, malpractice history, and other credentials, and releasing this information upon University of Utah Health Plans’ request.

Notification of Changes

Provider shall notify University of Utah Health Plans Provider Relations in writing immediately upon a change in status: address, malpractice, licensure, hospital privileges, Medicare / Medicaid sanctions and/or other disciplinary actions or other changes in your credentials.

Updates can be sent to provider.relations@hsc.utah.edu or you can complete the online form at on the website

Complaint Resolution

Cooperate with UUHP personnel to resolve any complaints identified by University of Utah Health Plan members, other providers or State Health Medicaid Program Representatives.

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

Please take the time to share this information, today.

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 888-271-5870, 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.

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.

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 website at http://uhealthplan.utah.edu/for-providers/forms.php

UM Requests can be submitted electronically. Visit our website for the information on how to submit the requests http://uhealthplan.utah.edu/for-providers/pdf/howto-box.pdf

Key Program Components

Key components of the Utilization / Care Management program include pre-payment review, demand management, comprehensive case management, link to disease management, and outcome analysis. Utilization / Care Management requires the comprehensive coordinated care of a patient along the care continuum. This supports the role of the primary care physician in organizing and coordinating the managed care for his or her patients through multi-disciplinary resources. This also encourages and supports the development of effective alternatives to traditional modes of medical practice without compromising the quality of care rendered to UUHP patients.

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:

  • Develop and operate a clinical management process that assures appropriate, timely and cost-effective application of services. (Utilization Management)
  • Encourage and facilitate the development of quality improvement processes. (Participate in QI initiatives)
  • Serve as a resource for medical review (Pre-payment, Pre-existing reviews, Medical necessity)
  • Educate providers about effective utilization review to assure appropriate patient access to, and use of medical care resources. (Participate in provider profiling)
  • Consistently review data and processes for improvement opportunities. (Analyze trends, HEDIS, benchmarking)
  • Provide a collaborative process which assesses, plans, implements, coordinates, monitors and evaluates options and services to meet a specific individual’s health needs. (Care Management)
  • Provide a collaborative process which identifies, promotes self-education, and assess for case management opportunities based on disease-specific indicators (Links to Disease Management)

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:

  • Pre-payment Review
  • Concurrent Review
  • Discharge Planning
  • Expedited Review
  • Second Opinion Program
  • Case Management
  • Demand Management
  • Disease Management
  • Data Capture / Tracking / Trending of clinical indicators
  • Outcomes Analysis (identification of patterns of care)

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

Pre-Payment Review

The basic elements of pre-payment review include eligibility verification, benefit interpretation, and medical necessity review. Services are reviewed, and determinations are

made by Utilization Management licensed professional staff and Medical Directors. Only the Medical Director can deny a service for reasons of medical appropriateness or necessity.

The following Healthy U services will be reviewed for medical necessity prior to paying claims:

  • Abortion services
  • Cosmetic Procedures
  • Durable medical equipment: over $5,000 of billed charges
  • Home Health Care
  • Hysterectomies and sterilization procedures inclusive of abdominal, vaginal or laparoscopic-assisted
  • Implants
  • Inpatient Services over $50,000 or a length of stay over 30 days.
  • Orthotics / Prosthetics
  • Skilled Nursing Facility (please notify the plan when admitted)
  • Synagis Immunization
  • Transplant services: lung heart, liver, kidney, bone marrow, etc. Admission and Concurrent Review (including discharge planning)

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

All reviews are conducted by a licensed health professional and referred to the Medical Director as necessary.

Any quality of care issues will be reported to the Quality Improvement Specialist.

There is a mechanism in place to provide utilization management/discharge planning functions seven days per week.

Any extensions and/or denials will be documented with supporting data.

Acute care hospital review requirements:

  • Plan eligibility shall be identified at time of admission
  • Urgent/emergent admissions shall be reviewed based on criteria standards and layperson definition.
  • Aberrant days will be assigned as appropriate.
  • 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 Individual and Family Plans

Healthy Premier Individual Plan is offered to eligible members on or off the Health Insurance Exchange Marketplace. The information provided in this section is designed to assist Healthy Premier 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) 587-6480 opt. 1 or (888) 271-5870 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, 6053 South Fashion Square Dr., Suite 110, 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: http://uhealthplan.utah.edu/for-providers/forms.php

>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) 587-6480 opt. 1 or (888) 271-5870 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, 6053 South Fashion Square Dr., Suite 110, 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 patients. The information provided in this section is designed to assist Healthy U providers in recognizing Medicaid patients and the services that must be accessible to Medicaid patients.

Fee Schedule Updates

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’s July fee schedule is defined as August 1st.

Service Area

Healthy U is available to eligible Medicaid enrollees throughout the state of Utah.

Use of Primary Care Providers

All Healthy U enrollees are encouraged to choose a Primary Care Provider (PCP) to manage and coordinate all of their care. A PCP is defined as a generalist in any of the following areas:

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

A PCP can be a Medical Doctor (MD), Doctor of Osteopathic Medicine (DO), Nurse Practitioner, Resident or Physician Assistant. The enrollee may also select a Clinic to act as their PCP.

Receiving Care

Referrals – Healthy U members may consult a specialist without obtaining a referral from their primary care provider.

Use of Provider Network – Except in the case of an emergency, enrollees must obtain covered services in the following manner:

  • Members must receive ALL services from a Healthy U PARTICIPATING provider in order to receive coverage. Services rendered by a NON-PARTICIPATING provider will be DENIED with no payment.
  • Facility services from a PARTICIPATING facility only. Services rendered by a NON_PARTICIPATING facility will be DENIED with no payment.
  • Urgent Care Centers. Providers shall be reimbursed at 100% of the prevailing Medicaid Rate.

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

at http://uhealthplan.utah.edu/healthyU .

Directories are also made available to State Medicaid Health Program Representatives, and to participating providers upon request. Since information in the directory is subject to change, Healthy U encourages members to check provider’s participating status prior to obtaining services.

Care Management

Patients are identified at the earliest possible point for care management intervention. The mechanism for identification may be through enrollment, claims, utilization trending, medical history, survey tool or notification by provider and/or State Medicaid Representative (HPR). HIGH-RISK patients may be identified through primary care referral, specific diagnosis ICD-9 clustering, emergency room logs, referral requests, payer personnel and specialty provider contracts.

Each patient identified may be assigned a care manager from the CM Department, and followed by their case manager across the continuum of care; both in inpatient and ambulatory settings. Services may also be coordinated among social and community services, family, or specialty and primary care providers. Coordination is achieved via phone, e-mail, fax or through case conferences.

All complex case management patients, pending open and closed cases are reported to the Healthy U UM Committee on a quarterly basis.

Care Coordination will be provided through our Case Management Department for the following:

  • Healthy U-Restricted patients – Please notify Healthy U if services are not provided by the Primary Care Provider (PCP)
  • Obstetrical Patients - Contact U Baby Care at 801- 587-6480 and notify the plan when admitted for delivery.
  • Out of area non-emergent care.
  • Patients identified, by referral, from physician, patient or utilization patterns where Case Management assistance is needed.
  • Patients with complex needs related to physical health and/or psychosocial issues.

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 referral has been obtained from the plan. If you have a question about whether a service or supply is covered, please contact Healthy U. You may also refer to the Utah Medicaid Provider Manual for more detailed information on covered services, including applicable definitions, regulations and limitations.

Please note: Please reference our website for current plan information.

Non-Covered Services

This list is not inclusive of all Medicaid non-covered services and supplies, but rather is intended to provide basic guidelines for determining non-covered services. Please refer to the Utah Medicaid Provider Manual for detailed information on non-covered services or contact a Healthy U Representative.

General Exclusions:

  • Services rendered during a period the client 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, urgent care services, or where a referral was not obtained from Healthy U.
  • Covered services for illnesses and injuries sustained directly from a catastrophic occurrence or disaster, including but not limited to, earthquakes or acts of war. The effective date of excluding such covered services will be the date specified by the Federal Government or the State of Utah that a Federal or State emergency exists or disaster has occurred.
  • Elective services requested or provided solely due to the patient’s personal preference. Provider must notify patient in writing that service(s) is not covered and that financial responsibility will be the patient’s if the elective services are performed.
  • Services for which a third party payer is primarily responsible. Healthy U will make a partial payment up to the plan’s allowable amount if the limit has not been reached by the third party.
  • Services that are fraudulently claimed.
  • Services that represent abuse or overuse.
  • Services rejected or disallowed by Medicare for any of the reasons listed above.
  • When a procedure or service is not covered for the above listed reasons or is disallowed by Healthy U, all related services and supplies, including institutional costs will be excluded for the standard post-operative recovery period.
  • Cosmetic, reconstructive or plastic surgery procedures, including all services, supplies and institutional costs related to services which are elective or desired for primarily personal, psychological reasons or as a result of the aging process.
  • Removal of tattoos.
  • Hair transplants.
  • Breast augmentation or reduction mammoplasty.
  • Panniculectomy and body sculpturing procedures.
  • Rhinoplasty unless there is evidence of recent accidental injury resulting in significant obstruction of breathing.
  • Procedures related to trans-sexualism.
  • Surgical procedures to implant prosthetic testicles or provide penile implants.
  • Family planning services which are not covered include:
  • Surgical procedures for the reversal of previous elective sterilization, both male and female
  • Infertility studies
  • In-vitro fertilization
  • Artificial insemination
  • Surrogate motherhood, including all services, tests and related charges.
  • Abortion, except when the life of the mother would be endangered or when the pregnancy is the result of rape or incest.
  • Certain services are excluded from coverage because medical necessity, appropriate utilization and cost-effectiveness of the service cannot be assured. No specific therapy or treatment is identified except for those that border on behavior modification, experimental or unproven practices. These services include:
  • Sleep apnea, sleep studies, or both
  • Pain management and pain clinic services
  • Eating disorders.
  • An inpatient admission for 24 hours or more solely for observation or diagnostic evaluation is not a covered Medicaid service.
  • Miscellaneous supplies, dressings, durable medical equipment and drugs to be used as take-home supplies from an inpatient stay or outpatient service are not separately covered services.
  • Surgical procedures, unproven or experimental procedures, medications for appetite suppression, or educational, nutritional support programs for the treatment of obesity or weight control are non-covered Medicaid services.

Verification of Eligibility

It is important for all Healthy U patients to show their Medicaid Identification Card BEFORE receiving any type of service. Providers must verify that the patient is eligible for Medicaid on the date of service and whether the patient is enrolled in an HMO, in a Prepaid Mental Health Plan, in the Restriction Program, or has a Primary Care Provider. This information is printed on the Medicaid Identification Card, and the information is also available through UUHP Member Services.

Since eligibility of a Medicaid member can change frequently, the provider’s office should request a copy of the member’s Medicaid Identification Card upon each visit and prior to rendering services

Provider’s offices may contact UUHP member services to verify eligibility information: Salt Lake County: 801-587-6480

Toll Free: 888-271-5870

Or providers may utilize the Medicaid Hotline: Salt Lake County: 801-538-6155

Toll Free: 800-662-9651

Lock-in or Medicaid Restriction Program

When a Medicaid recipient uses their Medicaid services unwisely, they are placed on the 'lock-in' or Restriction Program. An example of misuse includes seeing a provider or seeing several physicians in an attempt to have pain medications prescribed. 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. Healthy U conducts an in-person orientation with the Restricted Medicaid member to ensure the member understands the limitations and requirements.

The Member’s Medicaid Identification Card will identify if the member is in the Restriction Program as well as list the primary care provider, hospital and pharmacy they are restricted to

use. Questions regarding this program should be directed to University of Utah Health Plans Utilization Management at 801-587-6480, option 2.

For the duration of the “Lock-in” they are required to contact the State Department of Health Restriction Program to have their primary care provider, hospital or pharmacy changed.

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. All services rendered outside the members PCP without a referral will be denied for payment.

Direct Billing of Services

Generally, health providers who agree to treat Medicaid patients are prohibited by Federal law from billing Medicaid patients directly for covered services. As such, the Provider is prohibited from billing and/or collecting from the member, except for State mandated patient responsibilities (such as co-payments & coinsurance) and/or non-covered services (see below for instructions on billing for non-covered services), any amount due to Provider by UUHP (Refer to Provider Agreement for further details), and Provider must accept Healthy U’s payment as payment in full. Failure to abide by State billing rules and regulations, and/or the Policies and Procedures of Healthy U may result in the claim(s) being denied for payment. In such cases, the Provider is prohibited from billing the member.

Healthy U members are responsible for presenting 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. Please refer to the Medicaid Provider Manual for additional rules and regulations.

Non-Covered Services: A provider may be reimbursed for the provision of Non-covered services if one of the two conditions are met:

  • A benefit exception is obtained from Healthy U. To obtain a benefit exception, please 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 that the services to be rendered are not covered under their Medicaid benefits, informs them of the total charges for which they would be liable for, and obtains the members authorization signature prior to the services being rendered. (Note – This must be done each time a non-covered service is to be rendered. A single, one-time statement covering all future services is not acceptable.)

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 Case Management Department for questions on medical necessity.

Emergency Services

Emergency Services means those services provided in a hospital, clinic, office, or other facility that is equipped to furnish the required care, after the sudden onset of a medical condition

manifesting itself by acute symptoms of sufficient severity (including severe pain) such that a prudent layperson, who possesses an average knowledge of health and medicine, could reasonably expect that the absence of immediate medical attention to 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. Members with non-emergent conditions should be referred to their primary care physician for treatment and follow-up care.

The initial screening examination to make a clinical determination whether an actual medical emergency exits will be covered by the plan with a triage fee. All services required to stabilize the enrollee with an emergency medical condition will be covered by the 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 emergency services being rendered.

If the initial screening examination determines that the enrollee’s condition is not an emergency nor of an urgent nature, the patient should be referred to his or her Primary Care Physician for further treatment. Healthy U will reimburse a triage fee to the emergency department and attending physician for this initial assessment. If the emergency room provider provides treatment for the patient even after determining the condition is not for a medical emergency, only a triage fee for the initial screening examination will be covered by the plan.

Out-of-network

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

  • Medical necessary services that were unavailable through the Healthy U network of participating providers and are approved by the plan through the referral process.
  • 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.

Translation Services

For a list of contracted translations agencies, call the Customer Service number for the member's benefits plan.

Customer Service Phone Numbers


Type of Plan  Local Phone Number Toll-Free Phone Number
Healthy U Medicaid 801-213-4104 833-981-0212
U of U Health Plans– Commerical  801-213-4008 833-981-0213
U of U Health Plans– Individual  801-213-4111 833-981-0214

Women’s Services

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

“U Baby Care”

Healthy U requires provider notification on all pregnant members.

The “U Baby Care” program is provided 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 case management services. Every member who completes the “U Baby Care” program receives a gift.

When Healthy U is notified (state report, provider notification, member notification, hospital admit) of a pregnant member, a welcome letter, risk survey, and education materials are mailed to the member. When the member returns the risk survey and has indicated a pregnancy risk, the “U Baby Care” coordinator forwards the information to the case manager (RN). The case manager contacts the member and completes a risk assessment, scoring the member low, medium, or high risk. Medium and high-risk members qualify for case management.

Healthy U offers Enhanced Services for pregnant members, including perinatal care coordination, prenatal and postnatal home visits, group prenatal and postnatal education such as Lamaze classes, nutritional assessment and counseling, and prenatal and postnatal psychosocial counseling. Providers may refer members for any of these services. Please call Healthy U’s Utilization Management Department for questions concerning enhanced services.

Information about HIV and sexually transmitted infections are provided to members of the “U Baby Care” program.

Healthy U requires providers to conduct a risk assessment on every pregnant member. Providers are encouraged to contact the “U Baby Care” case manager (RN) with any information that is pertinent to the member for coordination of care.

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 C-Section.

For additional information please visit the University of Utah website at

http://www.dol.gov/ebsa/newsroom/fsnmhafs.html

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.

Cervical Cancer Screening

Healthy U recommends and covers Cervical Cancer Screening (pap test) for all female members on a yearly basis. Chlamydia Screening is also recommended and covered by Healthy U.

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 he or she is not a Healthy U provider.

Birth control services include information and instructions related to birth control pills, including emergency contraceptive pills; Depo Provera; IUDs; the birth control patch, the ring (Nuvaring), spermicides, barrier methods including diaphragms, male and female condoms; and cervical caps; vasectomy or tubal ligations. Office calls, examinations and counseling related to contraceptive devices are also covered and must be made available to Healthy U patients. The removal of Norplant is also a covered benefit.

Please note that elective tubal ligations and vasectomies must have the Medicaid sterilization consent form signed 30 days prior to the procedure. The form expires 180 days after consent form is signed.

Providers are expected to be familiar with the Utah “Minor’s Consent to Treatment” Law. Providing family planning services and certain other treatments for minors without parents’ consent is legal and expected of Healthy U providers. The “Minor’s Consent to Treatment” Law outlines when a provider may treat a minor without getting the consent of the minor’s parents.

The complete text of the “Minor’s Consent to Treatment” Law and forms are included in the appendix of this handbook for your convenience.

Note: Any provider participating with Healthy U who does not wish to offer family planning services because of religious or personal reasons should contact Healthy U Provider Relations at 801-587-6602, or 801-587-6480 so patients can be directed to an alternate provider.

Foster Children

A special population served by the Healthy U Health Plan is children in the custody of the State of Utah Department of Human Services. This group includes both 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 will be made to ensure that child continues his or her care with that provider.

There are specific guidelines that must be adhered to when scheduling provider visits for children in State custody because of suspected abuse or neglect. In cases where the DCFS child protective caseworker suspects physical and/or sexual abuse it is the responsibility of Healthy U providers to ensure that the child have 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 determine the selection of a suitable placement for the child. There are occasions when a child is placed with the State and must be examined and have medical treatment before a Medicaid case is opened for the child.

Child Health Evaluation and Care (CHEC)

CHEC is the Utah Medicaid version of the federally mandated Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) with three main components: Outreach and Education, Expanded Services, and Screening and Prevention. This section of the provider manual includes information on each component, other CHEC services, and reimbursement.

Outreach and Education

Families of Medicaid eligible children are encouraged to seek early and repeated well-child health care visits beginning ideally at birth, and continuing through the child's 20th birthday. 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 CHEC Medicaid program. For more information about outreach education, please call Case Management at (801) 587-6480 or 800-271-5870, option 2.

Expanded Services for Medically Necessary Health Care

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

Please contact the University of Utah Healthy U Case Management at (801) 587-6480 or 800- 271-5870, option 2, with any coverage questions, or for a medical necessity review.

Screening and Prevention Services

  • Comprehensive Health History:
  • Health history includes an assessment of both physical and mental development obtained from the parent, guardian, or other responsible adult who is familiar with the child’s history. The Health history should include:
  • Developmental History: following developmental screening tools are recommended for children up to 6 years of age:
  • Child Development Review (CDR) - http://www.childdevrev.com/.
  • Infant Development Inventory (IDI) - http://www.childdevrev.com/.
  • Ages and Stages Questionnaire (ASQ) - http://www.brookespublishing.com/.
  • Communication and Symbolic behavior Scales Development Profile – Infant and Toddler (CSBSDP) - http://www.brookespublishing.com/.
  • Parents’ Evaluation of Developmental Status (PEDS) - http://www.developmentalscreening.org/screening_tools/peds.htm
  • Nutritional History: Use to identify nutritional deficiencies or unusual eating/feeding habits.
  • Dental History

Comprehensive Physical Examination:

A comprehensive physical examination includes:

  • Physical Examination: A standardized physical examination with an assessment of all body systems and a complete oral inspection of the mouth, teeth and gums during each CHEC screening.
  • Measurement of Length, Height, and Weight: Measure and lot these items (and the occipital frontal head circumference of each child two years of age and younger) on the 2000 CDC growth charts (available at http://www.cdc.gov/growthcharts/).

Vision Screening

Services include diagnosis and treatment for defects in vision, including eyeglasses. When needed, refer the child to the appropriate specialist. Further evaluation and proper follow-up is recommended for the following vision problems:

  • Infants and children who show evidence of enlarged or cloudy cornea, cross eyes, amblyopia, cataract, excessive blinking, or other eye normality.
  • A child who scored abnormally on the fixation test, the pupillary light reflex test, alternate cover test, or corneal light reflex in either eye.
  • A child with unequal distant visual acuity (a two-line discrepancy or greater).
  • A child under age five years of age with distant visual acuity of 20/50 or worse, or a child five years of age or older with distant visual acuity of 20/40 or worse.

Note: A table with the recommended vision screening protocols and intervals is available in the Utah Medicaid Provider Manual (Section 2 – CHEC Services) at http://health.utah.gov/medicaid/pdfs/chec.pdf.iv)

Hearing Services

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 CHEC exam and perform at each periodic visit if indicated by historical findings or the presence of risk factors. When indicated, Infants require screening every six months until three years of age. When needed, refer the child to an appropriate specialist.

Age-appropriate hearing screening intervals, protocols, and procedures, and screening indicators are available in the Medicaid Provider Manual (Section 2 – CHEC Services) at http://health.utah.gov/medicaid/pdfs/chec.pdf.

Speech and Language Development

Screen for appropriate development and to identify developmental delays. The CHEC program recommends using the following landmarks for screening:

  • At six months a child babbles and initiates social approach through vocalization.
  • At one year a child says 'mama' and 'dada' specifically and engages in vocal play.
  • At two years a child begins connecting words for a purpose, such as 'me go' and ‘want cookie’.
  • At three years a child holds up her fingers to show her age and has a vocabulary of 500- 1,000 words. She will use an average of three to four words per utterance.
  • At four years a child's speech should be 90% intelligible. They may make some articulation errors with letters s, r, l, and v. They should use a minimum of four to five words in a sentence.
  • Refer the child for a speech and hearing evaluation if you observe one or more of the following:
  • Child is not talking at all by age 18 months.
  • You suspect a hearing impairment.
  • Child is embarrassed or disturbed by his own speech.
  • Child's voice is monotone, extremely loud, largely inaudible, or of poor quality.
  • A noticeable hypernasality or lack of nasal resonance.
  • Child fails the screening tests.
  • Recurrent otitis media.
  • Speech is not understandable at age four years, especially in cases of suspected hearing impairment or severe hypernasality.
  • Blood Pressure Measurements
  • Measure at each exam and compare against age-specific percentiles for all children three years and older.
  • Age-appropriate Immunizations
  • Assess whether the child’s immunizations are up-to-date. Provide all appropriate immunizations according to the schedule in Appendix B of the Medicaid Provider Manual at http://www.immunize-utah.org/ , or on the CDC web site at http://www.cdc.gov/vaccines/.
  • You may also refer the child to the local health department.
  • Laboratory Testing
  • Determine the applicability of specific tests for each child. Perform the following laboratory tests at the time of the CHEC screening using the recommendations of the American Academy of Pediatrics to determine the specific periodicity of each of the following tests:
    • Newborn Metabolic Disease Screening.
    • Hematocrit or Hemoglobin Screening.
    • Tuberculin Screening with annual testing for the following high risk groups:
    • American Indian and Alaskan native children.
    • Children living in neighborhoods where the case rate is higher than the national average.
    • Children from Asia, Africa, the Middle East, Latin America or the Caribbean (or children whose parents have emigrated from these locations).
    • Children in households with one or more cases of tuberculosis.
  • 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 CHEC 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 CHEC screening. Beginning at 6 months of age, a verbal risk assessment must be performed at every CHEC visit. At a minimum, the following questions must be asked to determine the child’s risk for lead exposure:
    • Does the child live in or regularly visit a house built before 1978? Was his/her child care center or preschool/babysitter’s home built before 1978? Does the house have peeling or chipping paint?
    • Does the child live in a house built before 1978 with recent, ongoing or planned renovation or remodeling?
    • Do any of the child’s siblings or playmates have lead poisoning?
    • Does the child frequently come in contact with an adult who works with lead? (Examples are construction, welding, pottery, or other trades practiced in your community.)
    • Does the child live near a lead smelter, battery recycling plant, or other industry likely to release lead? (Give examples in your community.)
    • Do you or anyone give the child home or folk remedies that may contain lead?
    • Does the child live near a heavily traveled major highway where soil and dust may be contaminated with lead?
    • Does the home the child live in have lead pipes or copper with lead solder joints? Scoring the Verbal Risk Assessment:
    • Low Risk for Lead Exposure: If the answers to all questions are negative, a child is considered low risk and must receive a blood lead test at 12 and 24 months.
    • High Risk for Lead Exposure: If the answer to any question is positive, a child is considered high risk, and a blood lead level test must be obtained regardless of the child’s age. Subsequent verbal risk assessments can change a child’s risk category. If a previously low-risk child is re-categorized as high risk, that child must be given a blood lead level test.
    • Complete a blood lead level testing 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 may be capillary or venipuncture. However, 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.

Other Tests

Please 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.

Health Education:

This is a CHEC 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 Appendix C of Utah Medicaid Provider Manual at http://health.utah.gov/medicaid/pdfs/chec2_0104.pdf.

Mental Health:

Services that support young children’s healthy mental development can reduce the prevalence 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 mental 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, and
  • be accurate enough to avoid mislabeling many children.
  • Screen the child for possible mental health needs. You may use 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 can play an important role in linking children with and at-risk for developmental problems with appropriate interventions.

Please refer children with suspected mental health needs for mental health assessment.

Healthy U does not cover mental health services. Services are covered by the Prepaid Mental Health Program. For information, please call the General Medicaid Program at (801) 538-6155 or 800-662-9651. Healthy U and Medicaid encourage providers to refer children with suspected mental health needs to the mental health provider listed on the Medicaid Identification card. If no provider is listed on the Medicaid card, refer the child to a Medicaid Mental Health Provider in the child’s home area. Mental Health Services, at a minimum, include diagnosis and treatment for mental health conditions. Refer to the Utah Medicaid Provider Manual for Mental Health Services, Section 2, for policy on services.

Dental Services

Dental services are not covered by Healthy U. Services are covered by the General Medicaid Program at (801) 538-6155 or 800-662-9651. The state 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.

Reimbursement for CHEC Services

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

Please use the Preventive Medicine codes listed in the table below each time you complete a CHEC exam. Use these codes even if the child presents with a chronic illness and/or other health problem. Please avoid billing CHEC exams using Evaluation and Management codes. If you do use an Evaluation and Management code, it should be accompanied by the appropriate ICD-9 V code in the table below to identify it as a CHEC exam.

Codes for Preventative Medicine Services

New Patient

99381 Infant – less than 1 year of age.

99382 Early childhood – age 1 through 4 years.

99383 Late childhood – age 5 through 11 years.

99384 Adolescent – age 12 through 17 years.

99385 Young adult – age 18 through 20 years.

Established Patient

99391 Infant – less than 1 year of age.

99392 Early childhood – age 1 through 4 years.

99393 Late childhood – age 5 through 11 years.

99394 Adolescent – age 12 through 17 years.

99395 Young adult – age 18 through 20 years.

Other

99431 History and examination for new born infant

99432 Normal newborn care in other than hospital or birthing room setting.

To bill for a CHEC 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/CHEC. On a paper claim, enter the procedure code in box 24-D and enter a Y in box 24-H EPSDT/CHEC.

For additional information regarding the latest in Pediatric Health, please visit the University of Utah Website at http://healthcare.utah.edu/womenshealth/ or www.ped.med.utah.edu.

Utilization Management

Prior Authorizations

University of Utah Health Plans (U of U Health Plans) will require prior authorization for inpatient admissions except healthy maternity and healthy newborns beginning June 1, 2017.

Selected services will be reviewed prior to payment for medical necessity. Although Healthy U does not require prior authorization, Providers still may call to review medical necessity prior to the services being rendered.

Services will be paid according to Medicaid benefits and medical necessity. The following services will be reviewed for medical necessity prior to paying claims:

Services Reviewed for Medical Necessity
Abortion Services Orthotics & Prosthetics
Cosmetic Procedure Outpatient Speech Therapy
Durable Medical Equipment over $5,000 in Billed charges Skilled Nursing Facility (Notification required upon admission)
Home Health Care Services Synagis Immunizations
Hysterectomies and sterilization procedures inclusive of abdominal, vaginal or laparoscopic Transplant Services: Lung, Heart, Kidney, Bone Marrow, Cornea, etc.
Implants Any service where Medicaid criteria is available.
Inpatient Services (Prior authorization is required)

Services provided that are not medically necessary may result in the provider writing off the charges.

Services deemed ‘medically necessary’ do not guarantee payment if coverage terminates, benefits change, or benefit limits are exhausted.

Notification does not guarantee payment if coverage terminates, benefits change, or services provided are not medically necessary.

Utilization review means a review and confirmation program that determines medical necessity of any care service or treatment. In general, all covered benefits are based on medical necessity and utilization review is not limited to the above list.

The UM department will actively review cases such as organ transplants, special health care needs patients, major catastrophic illnesses, highly complex case management cases, high cost cases (i.e., neonate), any referrals out of the provider network and cases involving risk management issues.

Requests are forwarded to the UM department for review. If approved, as medically necessary, the UM Department will assign a reference number. Reference notification will be sent to the provider, facility and enrollee.

If the request is denied, the UM department will send written notice via mail or fax to the requesting provider or facility and enrollee. If the requesting provider or enrollee finds the reasons given for denial insufficient, they may file an appeal to Healthy U for review (Please refer to Appeal Policy).

Medical necessity review requests can be sent to UUHP UM department via fax or mail. Internal University of Utah provider offices may send requests via EPIC.

Submit Medical Necessity Review Requests to: University of Utah Health Plans

Attn: UM Department

Box 45180

Salt Lake City, Utah 84145

Turn-around time frames for Medical Necessity review are:

  • Urgent request -Same day, (weekends, holidays and off-hours will be processed the next working day)
  • Routine- 3-4 business days

Medical Appeals Process

The Healthy U policy and process is as follows:

  • Clinical Appeals (i.e., appeals for pre-service denials) must be received within 30 calendar days from the date on the Notice of Action letter.
  • For Clinical Appeals, you must obtain the member's consent to appeal.
  • For Appeals (or State Fair Hearing requests) related to termination, suspension, or reduction of a previously authorized Medicaid-covered service (if the previous authorization is not expired):
    • Healthy U will mail a notice of action at least 10 days before the proposed date of the action, including the date the action will occur.
    • If the member/provider would like the service to continue during the appeal process, the appeal needs to be filed within 10 days of the proposed termination, suspension or reduction in the service.
    • If the member decides to continue the service, and the appeal decision is not in the members favor, the member may have to pay for the service.
  • If the member's immediate health or life is in danger, you may request an Expedited Appeal. If Healthy U determines that the members immediate health or life is in danger, we will review the request within 3 working days. If additional information is needed, we may request a 14-day extension, to complete the review. If the member's immediate health or life is not in danger, Healthy U will transfer the Expedited appeal request, to a routine appeal request. We will call you and send a letter, if we decide the request is not urgent.
  • Non-clinical appeals (e.g., timely filing) must be received within 60 calendar days from the date notice of action.

An appeal is a request for review of an Action. Action means:

  • The denial or limited authorization of a requested service, including the type or level of service, including Restricted status;
  • The reduction, suspension, or termination of a previously authorized service;
  • The denial, in whole or in part, of payment for a service;
  • The failure to provide services in a timely manner, as defined by the state;
  • The failure of Healthy U (ACO) to act within the timeframes provided in §438.408(b)

All appeals will be reviewed within 30 calendar days. Once we have made a decision, we will mail you an Appeal Resolution Letter, and call you if you requested an expedited appeal. If we need more time to review an appeal, we will request a 14-day extension to make our decision.

Medicaid appeals may be submitted by phone by calling Customer Service at (801) 213-4104 or 833-981-0212.

We will accept appeals by mail, fax, or orally. You can also submit an appeal request online.

Grievance Process

A Grievance is a complaint about something that is not an Action. Members have the right to file a complaint against their plan, service, or provider. Healthy U will assist members in filing appeals, grievances, or State Fair Hearings.

Filing a Grievance

Members, providers, or another authorized person may submit a Grievance on behalf of a member, either orally or written. Grievances will be accepted by completing a complaint form on our website uhealthplan.utah.edu, by mail, by fax (801) 281-6121 or over the phone. Member Services is available to help file a complaint; call (801) 587-6480 or 1 (888) 271-5870, option 1.

Assistance will be provided to enrollees, upon request, in completing the required steps to file a complaint (e.g., interpreter services, TTY).

To file a written Grievance, please fax to (801) 281-6121, or mail it to: Healthy U

Grievance Committee Chairperson
6053 Fashion Square Drive
Suite 110
Murray, UT 84107
Fax Number: 801-587-9958 (Appeals and Complaints Only)

Healthy U Medicaid benefits won’t stop because of filing a Grievance. The Grievance Committee Chairperson will follow up with a decision, in writing, within 45 calendar days after receiving the Grievance. Healthy U will send a request for an extension of 14 days, if necessary.

State Fair Hearing Process

When a Healthy U Medicaid member, provider, or other authorized party is dissatisfied with an action taken by Healthy U Medicaid, and they have completed the appeal process with Healthy U Medicaid, they may file a request for a State Fair Hearing with the Office of Administrative Hearings. The “Request for Hearing/Agency Action” form must be filed within 120 calendar days of the “Notice of Appeal Resolution” letter, from Healthy U Medicaid.

When a provider wishes to appeal a payment reflected by an Explanation of Benefits (EOB), or other remittance document issued by Healthy U Medicaid, and they have completed the appeal process with Healthy U Medicaid, they may file a request for a State Fair Hearing with the Office of Administrative Hearings.

The “Request for Hearing/Agency Action” form must be filed within 120 calendar days of the “Notice of Appeal Resolution” letter, from Healthy U Medicaid. (speaking to a service representative or other Healthy U Medicaid employee, exchanging e-mails, or having any other contact with Healthy U Medicaid about the claim or issue cannot extend or fulfill the 120 calendar day requirement).

Of note, Healthy U Medicaid “Notice of Appeal Resolution” letters are sent by mail or fax and contain information about filing a State Fair Hearing, including the time within which a hearing must be filed, and a State Fair Hearing Form.

State Fair Hearing Forms may also be obtained on the Utah Medicaid website at https://medicaid.utah.gov/Documents/pdfs/Forms/HearingRequest2015.pdf

or request a copy from our office by calling (801) 587-6480 or 1 (888) 271-5870.

The form must be filled out and mailed or faxed to:

Mailing Address:

Office of Administrative Hearings DIVISION OF MEDICAID AND HEALTH FINANCING

DIRECTOR'S OFFICE/FORMAL

HEARINGS BOX 143105

SALT LAKE CITY, UT 84114-3105

Street Address:

Office of Administrative Hearings DIVISION OF MEDICAID AND HEALTH FINANCING

DIRECTOR'S OFFICE/FORMAL HEARINGS288 NORTH 1460 WEST SALT LAKE CITY, UT 84114-3105 Fax: (801) 536-0143

If the member is currently receiving a service that has been reduced or denied, they may continue to receive the service, if they file a hearing request within 10 days from the date on the “Notice of Appeal” Resolution” letter. If the member decides to continue to get the service and the decision about their service/s is not in the member’s favor, the member may have to pay for the service.

The member has a right to have an attorney or other person, familiar with their case, at the hearing.

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. The following options are provided by the University Neuropsychiatric Institute (UNI) 24 hours per day, 7 days a week:

UNI CrisisLine – 833-995-1295 – Crisis intervention and suicide prevention

UNI WarmLine – Triaged through the CrisisLine – Non-crisis support by Certified Peer Specialists offering engagement, a sense of hope, and self-respect

UNI Receiving Center - Triaged through the CrisisLine – Therapeutic crisis management, assessment, and discharge planning in a short-term setting (up to 23 hours)

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. Billing & Refer to 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.

Advantage U (Medicare Advantage PPO)

Starting in January 2021, University of Utah Health Plans will offer Advantage U Signature (PPO), a Medicare Advantage product in addition 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. At this time, Advantage U Signature will be available to Medicare beneficiaries living in Davis, Salt Lake, Tooele, Utah, and Weber counties.

Note:As this is a new product offering, information that is yet to come is denoted in red as [In Development]. We will consistently update this section of the Provider Manual as more information is available.

Network Name

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

Advantage U Fee Schedule

Advantage U fee schedule rates are based on published Medicare rates. In the event CMS makes a change to their published rates, U of U Health Plans will implement the updated rate within 45 days of the CMS publication. No retroactive adjustments will be made to claims payments in response to the updated rate.

Medicare Advantage Administrative Partner

University of Utah Health Plans has delegated Cognizant® TMG HealthSM to perform the following administrative functions for the Advantage U network and our Advantage U Signature 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
Medical Management and Prior Authorizations Phone: 888-605-0858 | 801-587-3003
Website: https://uhealthplan.utah.edu/providers/policy-forms.php
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
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
6053 Fashion Square Dr. Suite 110
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 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 (coming June, 2021) 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 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.

  • 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 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 & 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,
  • and Site Audits and Ensuring Appropriate Physical Facilities

Record Retention

For Advantage U Signature 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 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 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 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 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.

Pharmacy

Advantage U has contracted with CVS Caremark® to administer pharmacy benefits for Advantage U Signature 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 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.

Questions about Plans?