OptumHealth Care Solutions, LLC Provider Operations Manual
OptumHealth Care Solutions, LLCProvider Operations ManualPhysical Health EditionOptumHealthCare Solutions, Inc. omPhysical Health* EditionRevised: March 2020Provider Services Web Site: www.myoptumhealthphysicalhealth.comNot sure the disclosure is correct?*OptumHealth Care Solutions - Physical Health includes OptumHealth Care Solutions, Inc., ACN Optumis p IPA of New York, Inc.,ManagedNetwork,and ACN Group Careof California,Inc.LLC, ACN Group IPA of New York, Inc., ManagedBrandchangesPhysical Health of California.Physical Network, Inc., ACN Group of California, Inc. d/b/aOptumHealthrjoh145 10/7/13 9:40 AMDeleted: Health
Provider Operations ManualProvider Operations Manual Contents(Click on the topic to directly view information on each topic)Welcome To Optum. 3About Optum . 3Terminology. 4Provider Resources. 6Online Provider Information and Tools. 6Plan Summaries. 7Clinical Appeals Process . 8Patient Satisfaction Data . 9Clinical Support Program. 10Overview. 10Review Process. 10Submission Process. 11Response Process. 12Reconsiderations. 12Network Tiering Overview. 14Accessing Your Tier Letter. 14Network Tiering Criteria. 14Data Sharing Resources. 14Claims Process. 15Claims Submission and Status. 15Contracted Rate/Fee Schedules. 16Payment and Remittance Advice . 16Coordination of Benefits. 18Patient Financial Responsibility. 19Fraud and Abuse. 20Fraud and Abuse. 20Provider Obligations. 21Credentialing and Recredentialing. 21Office Operation Expectations. 22Notices & Information Updates. 26Medical Records. 27Termination of Participation. 28OptumHealth Physical Health of California (Optum). 29Language Assistance program. 29Member Grievances. 30Member Grievance Form. 35Insurance Benefit Plans. 38Provider Dispute Resolution. 39All information, documents, software and other materials furnished by Optum, including this ProviderOperations Manual, policies and/or procedures, proprietary software, lists, copyright, service marks, trademarksand trade secrets are and remain the property of Optum. Such information is only to be used for the specificpurpose as determined by Optum and the provider must not disclose or use any proprietary informationfor his or her own benefit, now or in the future.
Provider Operations ManualWelcome to Optum About OptumCongratulations, and welcome to OptumHealth Care Solutions, LLC (Optum). Optum is anational leader in providing physical medicine solutions to the health care market.As an Optum participating provider, you are part of a growing network of health careprofessionals dedicated to providing consumers with access to quality, affordable health careservices. Visit our corporate Web site at optum.com for more information on our scope ofservices and products.Through most of our communication to you, we identify ourselves as Optum. This nameunites our program with other quality programs and products under the UnitedHealthGroup , parent company. In all legal documentation, to include Optum Provider Agreements,we will identify ourselves as Optum.Upon acceptance into the Optum network, you should have received a welcome letterwith important information to get you started. It identifies the health plans whose enrolleesyou are able to treat as an in-network Optum provider, and also includes Plan Summariesand fee schedules for each health plan. In addition, the welcome letter provides informationabout our online provider portal and the process to obtain an exclusive provider loginidentification number (ID) and password that you can use to: Access WebAssist, (the Optum online provider Web sitemyoptumhealthphysicalhealth.com) Submit claims electronically through myoptumhealthphysicalhealth.com Submit a Patient Summary Form (PSF) electronically through myoptumhealthphysicalhealth.comThe Optum Plan Summaries provide procedural information specific to each contractedhealth plan. We encourage you, and your office staff, to carefully review your OptumProvider Agreement, Plan Summaries, and this Provider Operations Manual. Used inconjunction with each other, these documents will give you information you need toeffectively interact with Optum.This Provider Operations Manual contains important information including policies andprocedures to be followed when working with Optum, and/or members covered by healthplans managed by Optum. These provisions apply to all providers under contract withOptum and/or its affiliated companies. California specific language set forth in grayThe obligations of the provider under the Optum Provider Agreement, Plan Summaries,this Provider Operations Manual and other such policies and/or procedures, apply equallyto the provider and to the provider’s office staff. Please communicate important aspectsof these obligations to your staff to help ensure successful participation as a provider inthe Optum network.3
Provider Operations ManualTerminologyThe following terms listed below have been provided for your information. Please referencethis list if you have questions as to how these terms should be interpreted in this ProviderOperations Manual.Benefit ContractThe Benefit Contract defines the coverage the member hasavailable and is a document of the health plan that is madeaccessible to each member by the health plan. BenefitContracts are also known as Evidence of Coverage (EOC),or may be known as the Summary Plan Descriptions (SPD).Covered ServicesCovered services are the health care services coveredby the member’s benefit contract.Claims ProcessingTypically, claims and clinical support services are coupledtogether for the most effective tracking of the health careepisode. Receipt of the claim, or claims data, allows usto develop provider profile information in addition togenerating proper payment to the provider for appropriateservices. It is important to pay close attention to thePlan Summary to determine the proper procedures forclaim processing.Clinical SubmissionClinical information submitted to Optum at or near thebeginning of care or at the extension of care. Summarizeddata derived from clinical submissions is made availablethrough a variety of data-sharing resources.Clinical SubmissionResponseA response supplied to the provider by Optum once anevaluation of the provider’s clinical submission has been made.Coordination ofBenefits (COB)Coordination of Benefits (COB) is a contract provisionthat applies when a person is covered under more thanone group medical program. It requires that payment ofbenefits be coordinated by all programs to eliminate overinsurance or duplication of benefits. (The primary planpays first; the difference is paid by the secondary plan.)Eligibility Verification/Benefit InformationMost Plans offer automated forms of eligibility verificationthrough the Internet, the Plan’s Web site or automatedtelephone systems. These systems are generally the mosteffective method of obtaining current eligibility information.The Plan Summary identifies eligibility verification optionsthat may be used for each Plan. Regardless of the methodof eligibility verification, it is important to verify patienteligibility. (Any reference to ID card includes both a physicalor digital card.) Obtaining this coverage informationwill help you determine the correct clinical submissionprocedure and will allow you to clearly communicate withthe patient regarding the patient’s financial responsibility.For referral-based plans, the provider should verify that thepatient has a valid referral, or that the patient is aware ofthe benefit impact of seeking care without a referral.Please be aware that the Payer will make the finaldetermination of eligibility at the time of claim payment.Eligibility may change retroactively when: The Payer, or Optum, receives information that anindividual is no longer eligible; or The individual’s Benefit Contract has been terminated; or The individual decides not to purchase continuationcoverage; or The eligibility information received is later determinedto be false.4
Provider Operations ManualNetwork AccessThis arrangement provides a member with access to anetwork of participating providers. Network access maybe provided to a Plan on a standalone basis; however, itmay be combined with additional services to provide amore robust array of services.Patient Summary Form(PSF)The PSF is a standardized health record including valid andreliable public domain outcomes-assessment instrumentsfor documenting and submitting data regarding thedemographic, diagnostic and historical attributes of allpatients treated and the outcomes of treatment.PayerThe entity or person that has financial responsibility forpayment of covered services. Payer may be Optum, Planor other entity as designated by Optum or Plan.PlanAs referenced in this Provider Operations Manual, “Plan”refers to the entity that has been authorized by Optum toaccess its network of providers. A Plan generally has theresponsibility for issuance and administration of themember’s benefit contract.Public SectorPublic Sector includes Medicaid, Medicare, or any otherlocal, state, and federal government-sponsored programs.Service LevelDefined as the number of passive modality/therapyCurrent Procedural Terminology (CPT) units.Support CliniciansThese are licensed peers that perform utilization review(UR) and clinical outreach.Tier 1 ProviderProviders that meet a minimal patient volume and haveclinical decision-making consistently aligned with currentevidence and community standards. Tier 1 providersparticipate in a minimal UR process.Following two consecutive years as a Tier 1 provider, whilemeeting a minimal patient volume, the provider movesto a no UR process (Tier 1 Advantage). Tier 1 Advantageproviders, with minor plan exceptions, are no longerrequired to submit PSFs.Tier 2 ProviderProviders that are new to the network, have not meta minimum patient volume or have clinical decisionmaking not aligned with current evidence and communitystandards in one or more areas. Tier 2 providers participatein a comprehensive UR process.TransparencyAll contracted providers have 24/7 access to acomprehensive set of administrative, demographic,case mix, and clinical outcomes data key performanceindicators. This data is made available to contractedproviders via secure web-enabled applications.5
Provider Operations ManualProvider ResourcesOnline Provider Information and ToolsOptum WebAssist, myoptumhealthphysicalhealth.com, is a valuable resource for providersand their administrative support staff. Access to this secure Web site is obtained through yoursix-digit Optum login ID and unique password which you have obtained from our ProviderServices Department. If you have misplaced your login ID and/or your password or have anyother questions, please contact the Optum Provider Service Department at (800) 873-4575.The Optum WebAssist feature includes:Data Submission Quick and easy access. PSF Submissions A confirmation of receipt. Claim Submission There is no need to re-enter patient demographicinformation for returning patients as it is stored Patient Status Reportselectronically. Simply select the patient’s name fromthe “My Patients” list.Status Checks Clinical SubmissionsResponse Claims It is the same information as provided on your faxed ormailed Clinical Submission Response. It is a preferred method since you have the ability toprint results instantly from your printer. The Web site is updated frequently giving the mostup to date information. Clinical submissions can generally be viewed on theWeb site within two days of receipt. Claims can generally be viewed on the Web site withinfive to 10 days of receipt.Clinical Informationand Tools Provides immediate access to the most currenteducational materials, clinical Web links, printablepatient exercise templates, clinical guidelines, providernewsletters, and articles.Provider Profiles Updated monthly. You may choose a variety of report types to viewyour data. You may also choose the time period; annually,semiannually, or quarterly.Provider Tier Letters Posted annually, providing access to your mostcurrent tier letter. You have the ability to view and print the letter.AdministrativeResources Provides real time access to current documentseliminating the wait on mail delivery. Provider Operations Manual. Plan Summaries and fee schedules.6
Provider Operations ManualPlan Summaries How to identify members/enrollees of a specific health plan How to verify eligibility Malpractice requirements Where and when to submit claims The form of clinical submission required and the designated process Where and when to submit required clinical documentation Regional office addresses, telephone and fax numbers Where to find online assistanceThe following represents a typical Plan Summary format.HEALTH PLANProgram Effective Datexx/xx/xxxx[Specialty] Plan SummaryRevision Date: xx/xx/xxxxValid for the State of xxxxxxyELMPSA7
Provider Operations ManualClinical Appeals ProcessOptum recognizes that providers may desire a review of a clinical decision made by Optum.To process these requests, we have created a Clinical Appeals Process. Prior to initiating aformal appeal of a clinical decision, the provider may choose to request reconsideration.Issues of a nonclinical nature, such as reimbursement, coding or administrative denialsare not handled under the Clinical Appeals Process and should be handled as directed inthe “Clinical Support Program” section or the “Claims Process” section of this ProviderOperations Manual.Clinical appeal requests may be made either by telephone or in writing. Written requestsare preferred and can be submitted to the attention of the Service Operations Department.Include the following in your request: Reference number from initial determination Patient name A clear statement of the denied services that you are appealing The basis for your appeal Any additional information that may have a bearing on the decisionA clinical peer not previously involved in the initial determination and not a subordinateto the initial reviewer will conduct the review. If the provider is not satisfied with the resultsof this review, there are, in many cases, additional appeal procedures available to theprovider. This may include a second level appeal request to Optum and/or a review by anindependent review organization, if required by state regulations. If Optum upholds itsinitial determination, the provider will be informed of subsequent appeal rights in ourresponse letter.The patient has appeal rights as well; the process and timeframes are generally differentthan those for providers as they vary based upon state regulations and/or the specific healthplan’s process. The rights and information concerning the process are communicated to thepatient at the time of the determination.8
Provider Operations ManualPatient Satisfaction DataThere are a variety of market dynamics highlighting the need to make patient satisfactiondata regarding health care services more transparent to consumers. In response toconsumers’ interest, Optum has undertaken a significant initiative to collect patientsatisfaction data and make that information available online.Patient satisfaction data is collected through a survey administered by an independent surveyvendor utilizing the Consumer Assessment of Healthcare Providers and Systems (CAHPS )survey tool. The survey tool was developed by the Agency for Healthcare Research andQuality (AHRQ) for a multi-year initiative to support and promote the assessment ofconsumers’ experience with health care. The CAHPS survey is utilized nationally and focuseson four key components of the consumer experience in your office: ease of getting anappointment, communication skill of the treating health care provider, courtesy andhelpfulness of staff, and an overall rating of the treating health care provider.As consumers assume greater financial responsibility for their care, it’s important for them,when selecting a provider to be able to compare the differences between providers.Patient satisfaction data may be used in two ways. First, your clinic data is reported back toyou for your review through the Optum provider Web site. With this data, you candetermine the level of satisfaction among your patients; uncover areas of opportunity basedon patient feedback and compare patient satisfaction against other health care professionals.Second, once sufficient data is collected, results may be published on a consumer-facingprovider lookup portal.The following steps describe how to access and learn more about the goals, chosen providerperformance measures, measurement
*OptumHealth Care Solutions - Physical Health includes OptumHealth Care Solutions, Inc., ACN Group IPA of New York, Inc., Managed Physical Network, Inc., and ACN Group of California, Inc. Brand changes rjoh145 10/7/13 9:40 AM Deleted: Health OptumHealth Care Solutions, LLC Provider Operations Manual
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are the vehicle by which a provider reports critical case elements and communicates these and the treatment plan for a patient to OptumHealth. The change in a patient's status as a result of treatment is the outcome from treatment. From a patient's perspective, this is the benefit of care. Treatment goals are important in that they represent
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