UNICARE Ancillary Professional Operations Manual
Included in this section:
This section explains the purpose of the 2001 edition of the UNICARE Ancillary Professional Operations Manual and provides an overview of the manual as well as an introduction to UNICARE Life & Health Insurance Company, UNICARE Health Plans of the Midwest, Inc., and UNICARE Health Insurance Company of the Midwest, collectively referred to throughout the manual as "UNICARE." This manual applies to health care professionals participating in networks established in any of these UNICARE affiliates.
Purpose
Welcome
We appreciate your participation in the UNICARE network. UNICARE is committed to working with participating health care professionals as well as our members to provide a high level of satisfaction in delivering quality care. The UNICARE Ancillary Professional Operations Manual is an integral part of this commitment.
Purpose of Manual
The UNICARE Ancillary Professional Operations Manual is a comprehensive document designed to familiarize health care professionals and their staff with the policies, procedures, and guidelines used to administer UNICARE plans. It addresses topics such as:
- Member eligibility
- Electronic claim submission
- Reimbursement and pricing
- Health care professional credentialing and recredentialing
- Medical management guidelines
- UNICARE networks and products
It also includes a directory of services and a glossary of specialized terms.
UNICARE is committed to providing our participating health care professionals with an accurate and up-to-date operations manual. However, there may be instances where new procedures or processes are not immediately reflected in the manual. These changes will generally be communicated through newsletter articles or letters and reflected in the next manual update.
Note: In those instances where information in the manual differs from that in the UNICARE ancillary professional agreement, the member benefit plan, or other UNICARE agreement, the agreement will take precedence over the manual.
Introduction to UNICARE
UNICARE is a national organization dedicated to the delivery of quality health care plans. Working together with its customers, brokers, employers, physicians, health care professionals, facilities, and hospitals, it provides managed care and specialty health care services throughout the United States. UNICARE is an operating subsidiary of WellPoint, one of the nation’s largest publicly traded managed care companies serving the health care needs of more than 9 million medical members.
UNICARE offers a comprehensive array of managed care health plans and specialty products that preserve member choice at competitive prices. We are committed to redefining the industry through a new generation of consumer-friendly products that put individuals back in control of their health and financial security.
Health care professionals that participate in UNICARE’s networks can look forward to seeing commercial members from all market sectors: individuals, small employers, large employers, and Medicare-eligible members (in selected states). As a participating health care professional in the UNICARE network, you are an essential partner in ensuring that members receive quality health care. Our networks of carefully selected primary care physicians, specialists, licensed health care professionals, and ancillary health care professionals create unique and beneficial relationships.
UNICARE is structured around a unique Market Business Unit (MBU) concept. Each MBU is organized to serve specific customers and consists of a full-service organization with sales and service functions dedicated exclusively to meeting the needs of customers in a particular segment. UNICARE’s MBUs serve the following market segments:
- Individual
- Small Employer Group (2-50 employees)
- Key Accounts (51-250)
- Major Employer Groups (251-2,000)
- Special Employer Groups (2,000+)
- Medicare-eligibles (In selected states)
The Major and Special Employer Group businesses have a national focus as a result of the multi-state needs of employers in those market segments. The other business units have a regional focus as a result of the localized nature of customers in these segments. Each UNICARE business unit is responsible for marketing, enrolling, underwriting, and servicing its specific customers and members.
Overview of Manual
The UNICARE Ancillary Professional Operations Manual is divided into the following sections:
How Can I Use This Manual (Guide to Manual)
- Defines the purpose of the manual
- Provides an introduction to UNICARE
- Provides an overview of the manual
What Does This Term Mean? (Glossary)
- Includes managed care terms used in the UNICARE ancillary professional agreement, other UNICARE agreements, and throughout this manual. These terms are used to represent various products, contracted health care professional types, organizations, specialized concepts, and services. The glossary will help you identify the meaning of these terms as used in this manual.
How Do I Find Out a Member’s Eligibility? (Member Eligibility)
- Explains policies and guidelines related to member eligibility and benefits, verification of eligibility, and termination of coverage
How Do I File A Claim? (Claims Submission)
- Explains general billing guidelines and UNICARE claim submission requirements
- Describes common situations that result in returned or rejected claims in order to assist the biller in minimizing delays in processing claims
How Do I Submit A Claim Electronically? (EDI)
- Provides information regarding electronic claims submission
How Does UNICARE Process Claims? (Reimbursement)
- Provides information on claim pricing and reimbursement including payment sources such as third party liability and coordination of benefits
- Explains the procedures used by UNICARE to seek recovery of excess claim payments, otherwise known as overpayment and recovery procedures
Is Medical Management Necessary? (Medical Management Programs)
- Explains UNICARE’s medical management programs, including utilization management, case management, precertification, and authorization
Whom Do I Call If I Have a Question? (Directory of Services)
- Provides point-of-contact personnel who are available to address inquiries
What Type of Products Does UNICARE Offer? (Product Summary)
- Describes the products offered by UNICARE for the various market segments
- Briefly describes some of the UNICARE participating health care professional’s responsibilities
- Describes the UNICARE credentialing and recredentialing processes for specified health care professional types
What If a Member Has a Grievance or Concern? (Member Issues: Grievances and Appeals)
- Describes UNICARE’s member grievance resolution policy
Where Can I Find Samples of UNICARE ID Cards? (Exhibits)
- Includes samples of UNICARE ID cards to help you identify UNICARE plans and coverages as well as providing you with a claims address, customer service phone number, and other information
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