UnitedHealthcare of the River Valley, Inc ... - UHC River Valley

UnitedHealthcare of the 

River Valley, Inc. 

Arkansas Expansion 

2010 

Confidential property of UnitedHealth Group. Do not distribute or reproduce without the express permission of UnitedHealth Group.

Agenda 

• Product Overview 

– UnitedHealthcare and UnitedHealthcare of the River 

Valley, Inc. 

• Healthcare Identification Cards 

• Provider Service Model 

• Provider Services & Online Tools 

• Care Management Overview 

• Claim Submission Guidelines 

• Questions 


Product Overview 

Payer ID 

Member website 

Member Services 

Provider Web Portal 

Provider Services 

Claims address for 

medical 

Claims address for 

pharmacy 

Pharmacy Group Number 

Inpatient Notification 

contract numbers 

UnitedHealthcare of 

the River Valley 

95378 

www.uhcrivervalley.com 

800-224-6602 

www.uhcrivervalley.com 

800-224-6602 

P.O. Box 5230 

Kingston, NY 12402-5230 

P.O. Box 5230 

Kingston, NY 12402-5230 

UVALLEY 

Phone: 800-224-6602 

Fax: 800-880-5403 

UnitedHealthcare 

87726 

www.myuhc.com 

800-357-0978 

www.unitedhealthcareonline.com 

877-842-3210 

P.O. Box, 740800 

Atlanta GA 30374-0800 

P.O. Box 14711 

Lexington, KY 40512 

UHEALTH 

Phone: 877-842-3210 

Fax: 866-756-9753 



Type of Plan 

PCP Required? 

Physician Choices 

and Referral 

Requirements 


River Valley 

Open Access Managed 

Health Plan 

No 

Complete freedom of choice 

with 

network providers. 

Non-Network providers 

require 

referral by UnitedHealthcare 

RiverValley. 


Open access within the 

network of practitioner 

No 

Members can choose any 

network physician or health 

care professional without a 

referral and without 

designating a primary 

physician. 

Choice Plus provides out-ofnetwork 

coverage 

Choice does not (except for 

emergency). 



In-Network 

Coverage 

Non-Network 

Coverage 



Providers In-Network 

benefits for care from 


RiverValley Providers, or 

UnitedHealthcare Choice 

Providers 

Non-network benefits with 

a POS option (if 

applicable) apply when 

Non-network providers 

render services. 

Network benefits apply if 

urgent, emergent, or by 

referral. 


unitedhealthcareonline.com 

Dependent on member 

benefit plan 



Notification of 

Inpatient 

Admission 



The contracted facility agrees to 

notify the River Valley Entities of 

the inpatient admission within 24 

hours of admission or on the next 

working day following a holiday 

or weekend admission. 


The contracted facility agrees to 

notify the River Valley Entities of 

the inpatient admission within 24 

hours of admission or on the next 

working day following a holiday or 

weekend admission. 

Radiology 

Notification 

N / A 

For Commercial programs, 

UnitedHealthcare requires prior 

notification for certain outpatient 

imaging procedures: 

•Phone: 866-889-8054 (direct line) 

or using the United Voice Portal 

Line at 877-842-3210 and selecting 

the Radiology Option. 

•Fax: 866-889-8061 


Health Care Identification Cards 


Health Care Identification cards 

• Member ID 

• Group Number 

• Member Name 

• Payer ID 

• Pharmacy related 

information 

• Coinsurance 

Bottom of card gives name of network and type of 

insurance. 

“Underwritten by” = Fully-Insured Business 

“Administered by” = Self-Funded Business 


Getting to know our cards 

• Date Card Was Printed 

(not effective date) 

• Swipe card technology 

standardized 

• Above line, member 

info 

• Below line, provider 

info 

UnitedHealthcare has negotiated a discounted rate for card readers. 

(will accept both old and new cards) 

www.bayscan.com 


Provider Service Model 

Self Service via 

the Provider Web 

Portal or Mail 


the United 

Voice Portal 

Assisted Service 

from a PPR 

Contact your 

Physician 

Advocate 

Three ways to contact us: 

•Online: UHCrivervalley.com Adjustment Request for 

Reconsideration link found in the Claim Status Detail page 

•Phone: 1-800-224-6602 Be sure to document the date/time of 

your call, customer care representative name, enrollee ID and 

Date of Service, and reference number. 

•Mail: Send “Request for Reconsideration” form to the claims 

address on the back of the enrollee’s ID card: 

-Use one form for each claim. 

-Use paper option to submit corrected claims, 

primary payer EOB, proof of timely filing, or 

clinical notes. 

-We must scan submissions to review evidence. 


Provider Service Model- Issue Resolution 


the Provider Web 

Portal or Mail 


the United 

Voice Portal 

Assisted Service 

from a PPR 

Contact your 

Physician 

Advocate 

•Reference numbers will be provided for online 

and phone contacts, but the format will be different 

from what you received from UnitedHealthcare. 

•If you have not received resolution to your issue 

after 30 business days, or it has not been resolved 

to your satisfaction: 

– Contact your Physician Advocate directly, 

– Or send an e-mail to 

uhc_tn_outreach@uhc.com with the 

reference number provided from your initial 

contact. 


Online Tools and Services 

Is the following 

available? 


River Valley Online 

UnitedHealthcare Online 

Eligibility and claim 

status available 

Obtain a referral 

number 

Claim cost estimator 

Yes 

No 

No 

Yes 

Yes 

Yes 



Use UHCRiverValley.com to: 

•Check eligibility & benefits. (No phone hold times!) 

–View deductibles, out-of-pocket maximums and coinsurance. 

•Check claim status, including check numbers and disallowed 

amount. 

•Submit single or multiple claim review requests. 

•Review product information and benefit summary. 

•View prior notification and authorization requirements. 

•View the UnitedHealthcare River Valley Administrative Guide. 



Provider Administrative Guide 

https://www.uhcrivervalley.com/10Provider/01Provider_Manual/ 



Provider web portal 

https://www.uhcrivervalley.com/10Provider/ 



• Resource Tools 

– Coverage Policy Library 

– Clinical Practice Guidelines 

– Demographic Change Form 

– Provider Directory 

– UnitedHealthcare Out-of-Network Referral Request – 

Southeast 

– Recoupment Request Form 

– Reconsideration Request Form 



• Provider e-Services 

– Benefits and Eligibility 

– To register: 

https://www.uhcrivervalley.com/Providers/eServices/ 


Provider Services and Online Tools 

Electronic Funds Transfer (EFT) & Remittance Advice (ERA) 

• Reduce administrative costs associated with postage and 

paper costs, eliminate lockboxes and check deposit fees and 

reduce manual work. 

• For electronic fund transfer please send an email to: 

JDHPDemo@UHC.com, enter EFT Enrollment in subject line. 

– Please give Contact Name, tax id, phone, fax and email 

address. 

– A representative will send all EFT enrollment documents 

for you to complete. 

• Questions? Call us at: 866-509-1593 


Care Management Overview 

Includes both case and disease management: 

• Case management centers on care for an individual 

member’s health and circumstances. 

• Disease management works with members’ treatment and 

services for a particular disease. 

• Care Management Model utilizes three different types of 

clinicians to meet the needs of our members: 

– Utilization Managers (UM) 

– Disease Managers (DM) 

– Care Managers (CM) 


Prior Authorization 

• Authorization must be requested and approved prior to the 

service being rendered to be considered for payment. 

• Retro Authorizations are not accepted through the prior 

authorization department. 

https://www.uhcrivervalley.com/10Provider/Preauthorization/ 


Prior Authorization - Inpatient 

• Notification - Hospitals must provide notification to 

UnitedHealthcare of the River Valley the next business day by 

5 p.m. of inpatient admissions, including maternity 

admissions. 

• Review – Clinical information must be faxed to UM nurse 

designated for that facility. 

• Physician practices are responsible for requesting prior 

authorization for elective admissions. 


Prior Authorization 

• Prior Authorization for Home Care to request home health 

care services 

– Fax: 800-340-2184 

– Mail: 


Attn: Clinical Coverage Review 

1300 River Drive, Suite 200 

Moline, IL 61265 

• Prior Authorization for Durable Medical Equipment (DME) & 

procedures requiring medical necessity 

– Fax: 888-242-9058 / 888-242-9078 

– Mail: 


Attn: Clinical Coverage Review 

1300 River Drive, Suite 200 

Moline, IL 61265 


Claim Submission Guidelines 

• Requirements for claim submissions: 

– NPI 

• Follow CMS and HIPAA guidelines for NPI and placement of 

NPI on claims. 

• If NPI not present on claim, claim may be rejected at point of 

submission or processed as a denial for incomplete 

information. 

– National Drug Code (NDC) Requirements 

• Each J-Code submitted must have a corresponding NDC on 

each claim line. 

• Not required on inpatient claims. 


Claim Submission Guidelines 

Timely Filing 

• Claims for services must be submitted in accordance with the 

timeframes outlined in your provider contract, or claim will be denied 

for timely filing. 

• If member has primary insurance coverage, you must submit the 

claim in accordance with timeframes outlined in your provider 

contract based on the date of the EOB. 

• Claims that are closed out must be resubmitted within the 

timeframes outlined in your provider contract. 

• Corrected claims submitted after reimbursement or denial must be 

submitted with documentation within the timely filing period for claim 

re-submission specified in your provider contract. 

• May request payment reconsideration within 365 calendar days of a 

partially or totally denied claim. 

• Acceptable documentation to override a timely filing denial can be 

found in the UnitedHealthcare Plan of the River Valley provider 

manual. 


Claims Status Definitions 

Two Types of Claims Status on Remittance Advices 

• Processed Claims- Claims that have been received with all 

necessary information for processing. Includes paid or denied 

claims. 

• Close Out Claims - Claims that have been received but returned for 

missing or invalid information necessary for processing. 

– Close Out claims are grouped together at the end of the 

remittance advice - “Total for Close Outs” 

**Timely filing guidelines are different for Close Out and 

Processed claims 


Thank You!

UnitedHealthcare of the River Valley, Inc ... - UHC River Valley

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