It's Your Choice 2013 - Decision Guide (ET-2128d-13) - ETF

UnitedHealthcare of Wisconsin Northeast
(800) 357-0974 or (866) 873-3903 during the Enrollment Period
myuhc.com
Overall Quality Rating
See Report Card section
What’s New for 2013
Each member who completes the online
health risk assessment with biometric
screening will receive a $75 gift card.
Innovative resources such as: the health
care cost estimator tool, myHCE, to assist in
decisions with more than 120 care paths; a
new Health & Wellness tab personalized for
individual goals and support; also check out
our new Health4me App for access on the
go!
Provider Directory
Go to welcometouhc.com/state, Find a
doctor/hospital. Call customer service at
(800) 357-0974 (current member) or (866)
873-3903 for a paper copy.
Referrals and Prior Authorizations
You do not need a referral to see a
physician/hospital in the network. If a
specific covered health service is not
available from a network physician/
hospital, your network physician must notify
UnitedHealthcare (UHC) Care Coordination
to request a “Network Gap Exception.” In
addition, you are responsible for notifying
UHC’s Care Coordination before obtaining
services for dental/oral surgery or within
24 hours (or as soon as possible) of an
emergency admission to a non-network
hospital. You and your physician will be
notified in writing of UHC’s decision and
coverage determination.
Care Outside Service Area
For emergency or urgent care, contact UHC
at (800) 357-0974 as soon as possible. Care
other than emergency or urgent care is not
covered outside of the service area. Followup
care will need to be completed back
in the service area with your participating
provider (see map at
right).
Mental and Behavioral
Health Services
Members must call
United Behavioral
Health (UBH) at (800)
851-5188 for an initial
assessment and for
authorization for any
Qualified Plan
and all services with
Non-Qualified Plan
network providers. See Glossary for definitions
Please note: After
standard business hours,
UBH can only manage inpatient benefits
and authorizations.
Dental Benefits (Contact plan for full details.)
Preventive Services: Covered at 100%:
exams two times per calendar year, bitewing
X-rays, cleanings, fluoride treatments
and sealants, complete series or panorex
X-rays.
Restorative Services: Covered at 50% after
deductible ($50 individual/$100 family):
amalgam and composite resin restorations,
general anesthesia and space retainers. No
coverage for major restorative services.
Annual Benefit Maximum: $1,000 per person
per calendar year.
Orthodontics: Covered at 50% for
dependents younger than age 19; up to an
individual orthodontic lifetime maximum of
$1,200.
Dental Network: Open dental network to
allow members to go to a dentist of their
choice. Charges are payable up to UHC’s
maximum allowable fee schedule.
Health Risk Assessment Information for Enrolled Members at:
myuhc.com, log on, then select “Health Risk Assessment” or call one of the numbers above
Decision Guide Page 51