UnitedHealthcare Community Plan
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ALERT

IMPORTANT NOTICE: UnitedHealthcare Dual Complete (HMO SNP) will no longer be available in New Jersey after December 31, 2013. All members in this plan will need to change their Medicare and Medicaid (NJ FamilyCare) coverage before the contract end date.

We will work with both CMS and DMAHS to help our D-SNP members through this transition. As a health care provider, we request that you continue to check eligibility for your D-SNP patients. We also recommend that you tell your UnitedHealthcare Community Plan members about other D-SNP plans you participate in to assist them in making their selection.

Please note that only those members enrolled in the UnitedHealthcare Community Plan Dual Complete product are affected. UnitedHealthcare Community Plan of New Jersey will continue to serve our Medicaid (NJ FamilyCare) members in the Temporary Assistance for Needy Families (TANF), Child Health Insurance Program (CHIP), Aged/Blind/Disabled (ABD) and Long-Term Care (LTC) programs.

For details about Medicare and Medicaid (NJ FamilyCare) coverage options, where to direct members for further assistance, and to get answers regarding administrative questions, please see: Provider FAQ (PDF 402.79 KB).

Thank you for being a valued partner of UnitedHealthcare Community Plan.

 

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Contact Us

General Postal Mailing/Correspondence:

UnitedHealthcare Community Plan
P.O. Box 200089
Newark, NJ 07102

Claims Address:

Medicaid and NJ Familycare:
UnitedHealthcare Community Plan
P.O. Box 5250
Kingston, NY 12402-5250

UnitedHealthcare Dual Complete (Medicare):

UnitedHealthcare Dual Complete
P.O. Box 5250
Kingston, NY 12402-5250

Claims Appeal Address:

Part C Appeals and Grievance Department
UnitedHealthcare Community Plan
Attn: Complaint and Appeals Department
P.O. Box 31364
Salt Lake City, UT 84131-0364

Part D Appeals and Grievance Department
Attn: CA124-0197
P.O. Box 6106
Cypress, CA 90630-9948

UM Appeals:

Medicaid and NJ Familycare:
UnitedHealthcare Community Plan
Attn: UM Appeals Coordinator
P.O. Box 31364
Salt Lake City, UT 84131

UnitedHealthcare Dual Complete (Medicare):
UnitedHealthcare Dual Complete
Attn: UM Appeals Coordinator
P.O. Box 31364
Salt Lake City, UT 84131

Provider Frequently Asked Questions (FAQs) New Jersey Medicare Advantage Dual Eligible
(PDF 402.79 KB)

PPACA PCP Medicaid Fee Increase Reimbursement - Update (PDF 47.33 KB) (New)


Informal Claim Resubmission Request & Guidelines:
NJ Single Claim Resubmission Form (PDF 318.73 KB)
NJ Claim Resubmission Reference Guide (PDF 59.77 KB)

Provider Service Center:
Monday – Friday: 8 a.m. – 6 p.m.
888-362-3368

 

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 it through a network specialty pharmacy:

Network Specialty Pharmacy

Phone Number

OptumRx

866-218-7398

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

Makena

866-827-8203

CVS Caremark Specialty Pharmacy

Enzyme Deficiency

Gaucher’s Disease

Makena

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.

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.

Disclaimer

If UHG Medical Policies conflict with provisions of a State contract or with state or federal law, the contractual / statutory / regulatory provisions shall prevail.

To see updated policy changes, select the Bulletin section at left.