UnitedHealthcare Community Plan
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Welcome to the UnitedHealthcare Community Plan Health Professionals area for Delaware providers!

Here you will find the information, forms, manuals and links you need to conduct business with UnitedHealthcare Community Plan.


Note: UnitedHealthcare Community Plan's Portal will be a historic portal only and will display claims and eligibility for dates of services prior to 3/1/14.  If you are looking for details on Member Eligibility or Claim Status for dates of service on or after 3/1/14, please use UnitedHealthcare Online. If you do not already have access to UnitedHealthcare Online, you will need to register as a new user. 

Note: DMAP is now accepting attestations from Delaware providers eligible to receive the PPACA increase for certain E&M and VFC fees.  Providers attesting before June 30 will be eligible for retroactive payments at the Medicare Part B rate back to January 1, 2013.  Attestations completed after July 1 will authorize increase payments as of the effective date only. Click here for more information.

Attention Providers: Some phone numbers for UHC staff members have changed. Click "Contact Us" for the updated information.

Contact Us

Provider Call Center

 

(800) 600-9007
Monday-Friday, 8 a.m. – 5 p.m. 

Postal Mailing Address

UnitedHealthcare Community Plan
4051 Ogletown Road
Suite 200
Newark, DE   19713

Claims Mailing Address

UnitedHealthcare Community Plan
PO Box 8207
Kingston, NY  12402

 

Utilization Management Appeals Address   

UnitedHealthcare Community Plan
1001 Brinton Road
Pittsburgh, PA 15221
 

Claims Appeals (and other Correspondence)
Mailing Address

UnitedHealthcare Community Plan
P. O. Box 31364
Salt Lake City, UT 84131-0364
 

Behavioral Health Providers For inquiries related to credentialing,
demographic updates, or adding a
new provider to your practice,
please contact OPTUM HEALTH
at (877) 614-0484.


Interactive Voice Response Line (IVR) 24/7 (verify member eligibility)
(888) 586-4766

 

Credentialing
Skilled Service Providers Contact:
National Credentialing Center (877) 842-3210

Non-skilled Service Providers Contact:
Provider Services (800) 600-9007

 

Long Term Care (LTC) Care Management Team

Debby Pecoraro, RN
Manager, Care Management
New Castle County
Phone: 302-319-1907
Email: Debby.Pecoraro@uhc.com

Patty Winward, RN
Manager, Care Management
Kent/Sussex Counties
Phone: 302-354-7198
Email: Patricia.Winward@uhc.com

Temika Carter, RN, BSN
Manager, Care Management
New Castle County
Phone: 302-300-0564
Email: Temika.Carter@uhc.com

Member Advocates

Erica Kearse
Member Advocate
Medicaid and Delaware Healthy Children Program (DHCP)
Phone: (302) 781-6729
Email: erica.kearse@uhc.com

 

Tracy Sprague
Member Advocate
Diamond State Health Plan Plus (DSHP-Plus)
Phone: (302) 781-6745
Email: tracy.sprague@uhc.com

 

Quality Management Department

Desiree Dowling
Sr. Quality Analyst
Phone: (302) 781-6728
Email: Desiree.Dowling@uhc.com

 

Christine Puckett
Health Educator
Phone:  302-781-6727
Email: Christine_Puckett@uhc.com

Paul Fransisco, RN
Clinical Quality Analyst
Phone: 302-284-4064
Email: Paul.Fransisco@uhc.com

Manuals and Forms

Provider Administrative Manuals
 

Forms

Provider Education

Asthma Triggers (PDF 96.83 KB)
Blood Sugar (PDF 159.13 KB) 
Hemoglobin A1c (PDF 178.36 KB)
Branding Article July 2011 (PDF 60.9 KB)
Disease Management Information (PDF 135.11 KB)
Healthy First Steps (PDF 1.76 MB)
Online Prior Authorization Request Tool Instructions (PDF 115.98 KB)
Provider Portal Application Authorization Status Inquiry Instruction Sheet (PDF 179.5 KB)
Transportation Benefits (PDF 20.41 KB)
United Behavioral Health FAQ (PDF 184.12 KB)

Bulletins
Rebranding Bulletin (PDF 131.6 KB)

EDI Category
EDI Fact Sheet (PDF 1.53 MB)
ERA and EFT Fact Sheet (PDF 660.45 KB)
Getting Connected with EDI, EFT and ERA (PDF 147.57 KB)

Medical Injectables

To review the clinical criteria/guidelines used to conduct medical necessity reviews, please use this link: https://www.unitedhealthcareonline.com/b2c/CmaAction.do?channelId=ca174ccb4726b010VgnVCM100000c520720a____

 

Medical Injectables

Specialty pharmacy medications covered on the Medical Benefit may be provided through a variety of channels – home infusion provider, outpatient facility, physician, or specialty pharmacy.

For physicians who do not want to buy-and-bill a specialty pharmacy medication that is covered on the Medical Benefit, they may choose to source through a network specialty pharmacy: 

Network Specialty Pharmacy

Phone Number

BioScrip (offers nursing services)

 v also a National Home Infusion Provider for Medical Benefit medications

866-788-7710

The following specialty pharmacies may also provide specific categories of specialty pharmacy medications: 

Network Specialty Pharmacy

Medication Category

Phone Number

Accredo (offers nursing services)

Enzyme Deficiency

Gaucher’s Disease

Immune Globulin

Pulmonary Hypertension

888-296-4513

Walgreens Infusion Services (offers nursing services)

Cardiovascular/Heart Failure

Enzyme Deficiency

Gaucher’s Disease

Hemophilia

Immune Globulin

866-827-8203

CVS Caremark Specialty Pharmacy

Enzyme Deficiency

Gaucher’s Disease

Pulmonary Hypertension

800-237-2767

Coverage of the requested drug is dependent on the member’s benefits, and the availability of a specific drug from a network specialty pharmacy may vary.

The Specialty Pharmacy can deliver the medication to the healthcare practitioner’s office or another site (ex. patient’s home) upon request, and the Specialty Pharmacy will bill the patient’s health plan directly.

 

Helpful Links & Information

UnitedHealthcare Community Plan received NCQA New Health Plan Accreditation on July 7, 2010. NCQA’s mission is to improve the quality of health care, and participating in their accreditation process is voluntary. NCQA’s New Health Plan Accreditation Program applies to health plans that are less than 36 months old. The program is distinct from NCQA’s MCO Accreditation Program. NCQA Accreditation is a nationally recognized evaluation that purchasers, regulators, and consumers can use to assess managed care plans.

Medical Policies and Coverage Determination Guidelines for Community Plans

Medical Policies and Coverage Determination Guidelines for Community Plans

Please read the terms and conditions below carefully.

UnitedHealthcare has developed Medical Policies and Coverage Determination Guidelines to assist us in administering health benefits. These policies and guidelines are provided for informational purposes, and do not constitute medical advice. Treating physicians and health care providers are solely responsible for determining what care to provide to their patients. Enrollees should always consult their physician before making any decisions about medical care.

Our Medical Policies express our determination of whether a health service (e.g., test, device or procedure) is proven to be effective based on the published clinical evidence. They are also used to decide whether a given health service is medically necessary. Services determined to be experimental, investigational, unproven, or not medically necessary by the clinical evidence are typically not covered.

Coverage Determination Guidelines are used to determine whether a service falls within a benefit category or is excluded from coverage. Coverage Determination Guidelines may address such matters as whether services are skilled versus custodial, or reconstructive versus cosmetic.

Benefit coverage for health services is determined by the enrollee's specific benefit plan document, such as a Certificate of Coverage, Schedule of Benefits, or Summary Plan Description, and applicable laws that may require coverage for a specific service. The enrollee's benefit plan document identifies which services are covered, which are excluded, and which are subject to limitations. In the event of a conflict, the enrollee's specific benefit document supersedes these policies and guidelines.

Medical Policies and Coverage Determination Guidelines are developed as needed, are regularly reviewed and updated, and are subject to change. They represent a portion of the resources used to support UnitedHealthcare coverage decision making. The information presented in these policies and guidelines is believed to be accurate and current as of the date of publication, and is provided on an "AS IS" basis. Additionally, UnitedHealthcare may use tools developed by third parties, such as the MCGTM Care Guidelines, to assist us in administering health benefits. The MCGTM Care Guidelines are intended to be used in connection with the independent professional medical judgment of a qualified health care provider and do not constitute the practice of medicine or medical advice.

Medical Policies and Coverage Determination Guidelines are the property of UnitedHealthcare. Unauthorized copying, use and distribution of this information are strictly prohibited. The MCGTMCare Guidelines are proprietary to MCGTM and are not published on this website.

When these medical policies are used to determine medical necessity, clinical guidelines will be applied in the following order:

1) State/Federal Guidelines and Contract Requirements
2) UnitedHealthcare Community Plan Medical Policies and Coverage Determination Guidelines
3) Milliman Care Guidelines

For UnitedHealthcare Community Plan Medical Policies and Coverage Determination Guidelines, please click here.

 

Integrity of Claims, Reports, and Representations to the Government

UnitedHealth Group requires compliance with the requirements of federal and state laws that prohibit the submission of false claims in connection with federal health care programs, including Medicare and Medicaid. Click here (PDF 38.15 KB) to download our policy.