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

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

IMPORTANT UPDATE

Attention Providers 

The Ohio Department of Medicaid has recently changed its policy on record retention per OAC 5160-26-06.  The UnitedHealthcare Community Plan Provider Agreement has changed for the retention of all records, including medical records and financial documents. 

The healthcare industry is preparing for monumental changes as it transitions toward implementing the International Classification of Diseases, Tenth Revision, also known as ICD-10. Please click here (PDF 236.55 KB) for Q & A about ICD-10.
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Please choose your topic of interest, by selecting one of the navigation buttons on the left-hand side of the page, or select one of the topics or products below to reveal our Contact Information, Provider Administrative Manuals and Forms.

Contact Us

 

Provider Call Center

 

 

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

 

Postal Mailing Address

 

 

UnitedHealthcare Community Plan
9200Worthington Road, 3rd Floor
Westerville, OH 43082

 

Claims Mailing Address

 

 

UnitedHealthcare Community Plan
P.O. Box 8207
Kingston, NY 12402

 

Utlization Management Appeals Address   

 

 

UnitedHealthcare Community Plan
Attn: Complaint and Appeals Department
P.O. Box 31364
Salt Lake City, UT 84131
Fax: (801) 994-1082

 

Claims Appeals Mailing Address

 

 

UnitedHealthcare Community Plan
Attn: Complaint and Appeals Department
P.O. Box 31364
Salt Lake City, UT 84131
Fax: (801) 994-1082

 

UHC Connected™ For MyCare
Ohio Appeals Mailing Address

 

 

Part C Appeals or Grievances:
UnitedHealthcare Community Plan
Attn: Complaint and Appeals Department
P.O. Box 31364
Salt Lake City, UT 84131
Fax: (801) 994-1082

Medicare Part D Grievances:
UnitedHealthcare Community Plan
Attn: Complaint and Appeals Department
P.O. Box 31364
Salt Lake City, UT 84131
Fax: (801) 994-1082

Medicare Part D Appeals:
UnitedHealthcare Community Plan
Attn: Part D Standard Appeals
P.O. Box 6103
Cypress, CA 90630-9998
Fax: (877) 960-8235

 

Provider Administrative Manual

Medicaid
Medicaid OH Provider Administrative Manual (PDF 657.55 KB)

UnitedHealthcare ConnectedTM for MyCare Ohio Medicare-Medicaid Product 

Provider Administrative Manual (PDF 888.15 KB)

UnitedHealthcare Dual Complete (SNP)
UnitedHealthcare Dual Complete OH Provider Administrative Manual

Forms


EPSDT / Healthchek

Use these forms for appointments related to Early Periodic Screening, Diagnosis, and Treatment (EPSDT) / Healthchek.

Other Forms

Case Rate Agreement Letter (PDF 38.52 KB)
Obstetrical Needs Assessment (PDF 271.79 KB)
Coordination of Care (PDF 110.78 KB)
Botulinum Toxins Prior Authorization Form
(PDF 576.51 KB)

Prior Authorization Forms

Prior Authorization Form (PDF 157.92 KB)

Prior Authorization Fax Request (PDF 113.7 KB)

Quick Reference Guides

Ohio Par Quick Reference Guide (PDF 495.83 KB)
Ohio Non-Par Quick Reference Guide (PDF 509.55 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 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.

Medical Injectibles

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.

 

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.