Member and provider complaints/fraud and abuse reports. During this time you may experience longer wait times on our phone lines. When needed, refer the child to an appropriate specialist. 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. (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). Were here to help. UUHP will review and provide notification of decisions to the member for first-level, second-level, and expedited appeals. Professional care: Except in the case of an emergency, enrollees must obtain covered services from a contracted Healthy U Behavioral network provider. Members may have an in-network out-of-pocket maximum that is separate from the out-of-network out-of-pocket maximum. Please refer children with suspected mental health needs for mental health assessment. Other sources of information may be considered as appropriate and relevant at the sole discretion of the Credentialing Committee members. U of U Health Plansis 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. Refer the child to a dentist as follows: Make the initial referral for most children beginning at age one year and yearly thereafter. 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. Since our inception, we have grown our Healthy U membership, and have added several lines of business. At one year a child says 'mama' and 'dada' specifically and engages in vocal play. If you would like to learn more about U Link, please contact Provider Relations at 801-587-2838 or provider.relations@hsc.utah.edu. https://mychart.med.utah.edu/mychart/default.asp. Add/edit phone number, email and mailing address. I live in the USA I live outside of the USA Molina Health Plan of UT Breast Pump Coverage Requirements If you have Molina Health Plan of UT, you qualify for a pump and supplies for every baby you have. The adequacy of the Utilization / Care Management protocols and systems will be monitored to assure quality outcomes as well as appropriate utilization by providers. Denials with solutions in Medical Billing, Denials Management Causes of denials and solution in medical billing, CO 4 Denial Code The procedure code is inconsistent with the modifier used or a required modifier is missing, CO 5 Denial Code The Procedure code/Bill Type is inconsistent with the Place of Service, CO 6 Denial Code The Procedure/revenue code is inconsistent with the patients age, CO 7 Denial Code The Procedure/revenue code is inconsistent with the patients gender, CO 15 Denial Code The authorization number is missing, invalid, or does not apply to the billed services or provider, CO 17 Denial Code Requested information was not provided or was insufficient/incomplete, CO 19 Denial Code This is a work-related injury/illness and thus the liability of the Workers Compensation Carrier, CO 23 Denial Code The impact of prior payer(s) adjudication including payments and/or adjustments, CO 31 Denial Code- Patient cannot be identified as our insured, CO 119 Denial Code Benefit maximum for this time period or occurrence has been reached or exhausted, Molina Healthcare Phone Number claims address of Medicare and Medicaid, Healthfirst Customer Service-Health First Provider Phone Number-Address and Timely Filing Limit, Kaiser Permanente Phone Number Claims address and Timely Filing Limit, Amerihealth Caritas Phone Number, Payer ID and Claim address, ICD 10 Code for Sepsis Severe Sepsis and Septic shock with examples, Anthem Blue Cross Blue Shield Timely filing limit BCBS TFL List, Workers Compensation Insurances List of United States, Workers Compensation time limit for filing Claim and reporting in United States. Contact Information | Medicaid Need mental health help? Please note: Please reference our website for current plan information. CoverMyMeds automates the prior authorization (PA) process making it the fastest also light way to review, complete and track PA requests. Does the home the child live in have lead pipes or copper with lead solder joints? Unable to take your feedback now, Please try again later. University of Utah Health Plans requires that Advanced Practice Professionals (APP), including PAs, complete credentialing. If a previously low-risk child is re-categorized as high risk, that child must be given a blood lead level test. Coordination is achieved via phone, e-mail, fax or through case conferences. Members have 180 days to appeal from Notice of Action Letter/EOB. 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. 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. Breast augmentation or reduction mammoplasty. Expedited Appeals within 72 hours of receipt of the request. U of U Health Plans will assist members in filing appeals, grievances, or an external level of appeal. 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. Coordination of care by primary as well as specialty providers will be augmented by use of ancillary health care and community social services. 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. 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. Nutritional History: Use to identify nutritional deficiencies or unusual eating/feeding habits. UUHP honors the Newborns and Mothers Health Protection Act of 1996. If something is not working, or if were doing a great job, please let us know. 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. Medical Director, Behavioral Health (ID/UT) - LinkedIn Surgical procedures to implant prosthetic testicles or provide penile implants. Appeals may be received via mail, in-person delivery, fax, or orally. 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, 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. PDF JUST THE FAX - Molina Healthcare To bill for a CHEC screening electronically, enter the procedure code in loop 2400 - service line. By using our website, you consent to our use of cookies in accordance with our Privacy Policy. If you would like to speak to someone at EDI our help line is 866-409-2935 and/or email edi.claims@molinahealthcare.com. When there is question about whether a service or item is covered under the members Advantage U Signature benefits, contact Advantage U Customer Service. 99383 Late childhood age 5 through 11 years. A Grievance is a complaint about something that is not an Action. Providers may refer members for any of these services. 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. 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. We appreciate your feedback about our website. Getting the right health care is about: Having regular checkups to stay healthy Seeking help when you are sick Being able to visit a provider you trust with all your health care needs Find a Molina Healthcare Provider Near You Today You can find our providers in hospitals and clinics near you. U of U Health Plans group product offerings include PPO, EPO, HSA, and QHDHP. 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. 99392 Early childhood age 1 through 4 years. The Voluntary External appeals must be requested within 180 days of the member receipt of the notice of the prior adverse decision. An Action is a denial, reduction, suspension, or termination of requested or previously requested service or payment of service. Information about HIV and sexually transmitted infections are provided to members of the U Baby Care program. You may also refer to the Utah Medicaid Provider Manual for more detailed information on covered services, including applicable definitions, regulations and limitations. If youre 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, Any EDI enrollment questions can be sent to, https://mychart.med.utah.edu/mychart/default.asp, http://uhealthplan.utah.edu/for-providers/prov_update_form.php, "Advance Directives Sharing your wishes when you cant speak for yourself.". ) We recommend the following social-emotional screening tools for screening infants 0-12 months: Ages and Stages Questionnaire: Social-Emotional (ASQ:SE), Parents Evaluation of Developmental Status (PEDS), Temperament and Atypical Behavior Scale (TABS). The Organizational Provider Credentialing Application is available here. Restricted members are required to obtain medical services from their PCP. 99431 History and examination for new born infant. Services rendered by non-contracted facilities will be denied with no payment. 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. Healthy U also conducts education sessions for primary care physicians offices to keep them up-to-date with the CHEC Medicaid program. These coding edits are developed based on procedures referenced in the American Medical Associations (AMA) Current Procedural Terminology (CPT) Manual and the Healthcare Common Procedure Coding System (HCPCS) Manual. Be familiar with and ask questions about their health benefits, plan requirements, covered services, and contact information. Care Managers will also coordinate care and pharmacy services for Medicaid Restricted members. For unfavorable decisions, providers may consult the Practitioner Appeal Rights in the Credentialing Policy found on the UUHP website. It is important for all Healthy U patients to show their Medicaid Identification Card BEFORE receiving any type of service. 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. 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 childs history. 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. 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. Molina understands that communication with our network providers is essential. 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. Learn more. Healthy U will make a partial payment up to the plans allowable amount if the limit has not been reached by the third party. 99385 Young adult age 18 through 20 years. MIDVALE, UT ZIP 84047 Phone: (888) 562-5442 Fax: (562) 499-6191 Get Directions Mailing Address 200 OCEANGATE STE 100 LONG BEACH, CA ZIP 90802 The phone number is, 801-587-6480, option 1. 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/). Communication and Symbolic behavior Scales Development Profile Infant and Toddler (CSBSDP) - http://www.brookespublishing.com/. Pay their premiums and co-payments as required by their health care coverage. Billing & Refer to the Billing & Claims Payment section of this manual for specifics of how to submit claims and receive payment. If we need more time, we will send you a letter telling you why. 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. Provider must notify patient in writing that service(s) is not covered and that financial responsibility will be the patients if the elective services are performed. Subsequent verbal risk assessments can change a childs risk category. 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. Services that meet the definition of emergency services or urgent care services. If the Policyowner elects to discontinue this Policy, provide a written notice 30 days in advance of the requested termination date. Do any of the childs siblings or playmates have lead poisoning? PDF 2023 UT Medicaid Provider Manual - Molina Healthcare 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. Please follow the instructions below for your provider type. The Compliance Hotline is available 24 hours a day, 7 days a week. Coverage for Dependent Child Due to Court or Administrative Order. By using our website, you consent to our use of cookies in accordance with our Privacy Policy. 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. 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: Standard Medicare Coordination of Benefits (COB) guidelines apply to Advantage U Signature claims. Please use the appropriate Customer Service phone number for the member's benefits plan. This coordination may be facilitated by phone, email, or case conferences. PDF New Provider Orientation - MeetMolina Continue enrollment in their selected plan without regard to adverse changes in health or medical condition. Screen for appropriate development and to identify developmental delays. 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. 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). U of U Health Plans is currently accepting the following HIPAA-compliant transactions: EFT (Electronic funds transfer) in conjunction with the 835, 270/271 0051010X279A1 Eligibility Request/Response (real-time), 276/277 Claim status inquiry/response (real-time). 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. No specific therapy or treatment is identified except for those that border on behavior modification, experimental or unproven practices. Healthy U members may consult a specialist without obtaining a referral from their primary care provider. Refer to the members ID card. Member Services; Call us at (844) 236-0894 and we'll update your contact information for you. View Medicare Outpatient Observation Notice for details and a sample copy of the form. Please contact the Healthy U Case Management Department for questions on medical necessity. The IRO will make a decision within 45 days after receipt of the request. 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. 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. Services that fail to meet the existing standards of professional practice are investigational or experimental. Paper form can either be sent to University of Utah Health Plans by fax 801-281-6121 or by email: uuhpedi@hsc.utah.edu. Services rendered during a period the client was ineligible with the Healthy U Medicaid Plan. Although the member may choose any provider there are advantages to choosing network providers. 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. Applicants are notified of these rights in the Provider Manual and website: www.uhealthplan@hsc.utah.edu. If you have a question on processing or payment of a claim, please contact a UUHP Member Service Representative. Providing family planning services and certain other treatments for minors without parents consent is legal and expected of Healthy U providers. (Examples are construction, welding, pottery, or other trades practiced in your community. 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. As such, our goal is to provide GREAT customer service to our providers. Emergency Medical Services/Do Not Resuscitate: a directive alerting emergency workers that the person does not want CPR or life-saving techniques. View our FAQs for answers to some commonly Services obtained out-of-network that are not emergency services, urgent care services, or where a referral was not obtained from Healthy U. 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. All premium, any charges or fees for this Policy (hereinafter referred to as premium) must be paid to us. 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. 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). U of U Health Plans is committed to ensuring that its members have timely access to the services they need. If compensation is recovered from a third-party payer, the provider is expected to refund any amounts paid byU of U Health Plansfor covered medical services. Healthy U Medicaid: The timely filing for both primary and secondary claims is 365 days from the date of service. 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 parents policy; Is not claimed as a dependent on the parents federal tax return; or. 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. We are flexible and effective in benefit design and provider network combinations. If the initial screening examination determines that the enrollees 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. See their medical record. Providers may contact the agencies above for additional prevention, detection, and resource information. The Voluntary External appeals must be requested within 180 days of the member receipt of the notice of the prior adverse decision. Healthy U is a managed care health plan exclusively for Medicaid patients. Any EDI enrollment questions can be sent to uuhpedi@hsc.utah.edu. 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. For a list of contracted translations agencies, call the Customer Service number for the member's benefits plan. 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. use. U of U Health Plans has policies and procedures for claim appeals. Inpatient Services (Prior authorization is required). Expanded Services for Medically Necessary Health Care. A high-deductible health plan (HDHP) is a health insurance plan with lower premiums and higher deductibles than a traditional health plan. We welcome your comments and suggestions on how we can better serve you and your staff. Medicaid members may also contact Utah Legal Services at (801) 328-8891. Provider shall comply with all State & Federal Medicaid regulations in providing services to enrollees in such plans. The steps in setting up EDI with UUHP are relatively simple: Review information on our website- http://uhealthplan.utah.edu/EDI/. The information communicated in this manual does not take the place of the physician service agreement signed by the contracted or employed 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. All covered services must be medically necessary and meet all Healthy U Behavioral plan requirements for services to be reimbursed. Contact Number Email Address ; California Hospital Systems ; Deletha Foster ; 909-577-4351 : Deletha.Foster@molinahealthcare.com : Los Angeles : Clemente Arias ; 562-517-1014 : Clemente.Arias@molinahealthcare.com : . 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. Please contact appeal coordinators at (801) 587-6480 or (888) 271-5870. consent from a Healthy U or commercial member, to appeal on their behalf, for denied claims or referrals, relating to clinical services. Please note that elective tubal ligations and vasectomies must have the Medicaid sterilization consent form signed 30 days prior to the procedure. 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). There clearinghouses, in turn, connect to UHINet. Determine the applicability of specific tests for each child. 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.