UnitedHealthcare Community
Plan of New Jersey
Provider Orientation:
Adult and Pediatric Day Care
Overview
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Introduction to UnitedHealthcare Community Plan
Adult and Pediatric Medical Day Care
Prior Authorization
Utilization Management
Critical Incident Reporting
Unable to Contact/Open Care Opportunities
Claims and Appeals
Claims Billing Tips
Credentialing, Re-Credentialing, Criminal Background Checks and
Demographic Changes
Provider Advocates and Other Contacts
Link Training
Important Provider Training Concepts
Questions
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Introduction to UnitedHealthcare
Community Plan
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UnitedHealthcare Community Plan
• Serves more than 2.6 million members of government health care
programs in 24 states and the District of Columbia.
• Licensed in all 21 counties for NJ FamilyCare and Medicaid
• Pioneered 24/7 bilingual Member Services Helpline
• Emphasizes preventive health and education
• Developed the Personal Care Model
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Personal Care Model
The Personal Care Model is a holistic approach to care for members who
have chronic conditions and complex needs. Benefits include:
• Focused outreach
• Comprehensive needs assessment including clinical and socioeconomic needs
• Comprehensive treatment plan
• Health education activities
• Member evaluation that stratifies members according to diagnosis
and severity of the member’s medical and psychosocial conditions
Member Referrals
To refer a member for Personal Care Model services, please call
877-704-8871.
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Member ID Cards
To verify member eligibility, please call 888-702-2168 or go to
UnitedHealthcareOnline.com.
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Care Provider Website
UHCCommunityPlan.com provides a convenient way to work with us.
Using this website, you can:
• Review benefits and coverage limits
• Submit claims
• Check claim status
• Access capitation rosters
• View your panel roster
• Access remittance advice and review recoveries
• Review your preventive health measures report
• Submit demographic profile changes
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HIPAA Guidelines and PHI
Care provider are expected to follow Health Insurance Portability and
Accountability Act (HIPAA) guidelines, which were developed to:
• Improve the portability and continuity of health benefits
• Help ensure greater accountability for health care fraud
• Standardize both medical and non-medical codes across the health care
industry
Among other types of acceptable disclosures, providers are permitted to
disclose protected health information (PHI) to health plans for the purpose of
quality assurance, quality improvement, and accreditation activities.
No authorization is needed from the patient when both the care provider and
health plan had a relationship with the patient and the information relates to
that relationship.
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Adult and Pediatric Medical
Day Care
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Adult Medical Day Care ‒
Ages 18 and Older
• Medical day care services are limited to five days per week
• Include transportation
• Minimum five hours per day
• Maximum 12 hours per day
• Services currently in place will continue until the member has been
assessed by UnitedHealthcare Community Plan of New Jersey using
criteria provided by the state
• To request continuation of services, please call 800-262-0305.
• Once the member is assessed, services will be approved or denied
as indicated.
• Care providers will be notified of denial decisions by phone and in
writing.
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Pediatric Medical Day Care ‒
Ages 6 and Younger
• Medical day care services are limited to five days per week.
• Include physical therapy, occupational therapy, speech therapy and
transportation
• Minimum six hours per day
• Services currently in place will continue until the member has been
assessed by UnitedHealthcare Community Plan of New Jersey using
criteria provided by the state.
• To request continuation of services, please call 800-262-0305.
• Once the member is assessed, services will be approved or denied
as indicated.
• Care providers will be notified of denial decisions by phone and in
writing.
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Medical Day Care Service Codes
Service Description
New Jersey State
Medicaid Fee-forService Codes
UnitedHealthcare Community Plan of
New Jersey Codes for Participating and
Non-Participating Care Providers
Code
Unit of
Measure
Code
Unit of Measure
Adult day health services
S5102
visit
S5102
visit
Pediatric medical day care
facility visit for a technologydependent child
Z1863
visit
T1024
visit
Pediatric medical day care
facility visit for a medically
complex child
Z1864
visit
T1024
visit
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Prior Authorization
Requirements
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Prior Authorization Requirements
Prior authorization is required for all Long-Term Care (LTC) and Managed
Long Term Services and Supports (MLTSS) services ‒ regardless of
whether the care provider participates with UnitedHealthcare Community
Plan of New Jersey.
Please view the complete prior authorization list for Medicaid and
LTC/MLTSS at UHCCommunityPlan.com under Billing & Reference Guides.
To request prior authorization, please call 800-262-0305.
All members receiving MLTSS services will receive a face-to-face
assessment for evaluation of needs.
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When New Authorization Is Required
Here are examples to illustrate when a new prior authorization must be requested
after a care provider receives authorization to provide services for a member:
• During the authorized timeframe the member transfers to a new agency, then
transfers back to the original agency: The agency must obtain a new authorization to
resume services for the member.
• The member goes on vacation, then returns to the same agency: The agency does
not need a new authorization to resume services, but must notify us that the member
is on vacation to avoid an “unable to contact” issue resulting in a critical incident. The
care provider should not bill for services while the member is on vacation.
• The member enters a hospital or skilled nursing facility for less than 30 days, then
returns home to the same agency: The agency does not need a new authorization to
resume services, but must notify us. The member may require a face-to-face
assessment.
• The member enters a hospital or skilled nursing facility for 30 days or more, then
returns home to the same agency: The agency must get a new authorization for
services. The agency can continue to service the member at the previously approved
hours until a face-to-face assessment is completed.
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Utilization Management
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Utilization Management Appeals
Claim appeals based on UnitedHealthcare Community Plan’s adverse
determination regarding medical necessity, experimental or investigational
services should be processed under the Utilization Management appeal
process within 90 days from receipt of the original Utilization
Management denial letter.
Stage 1 Utilization Management appeals should include:
• Copy of the original Utilization Management denial letter
• Copy of the member’s medical record
• Additional information that supports the need for medical necessity on the
denied date of services.
Utilization Management appeals should be mailed to:
UnitedHealthcare Community Plan
Attention: Utilization Management Appeals Coordinator
P.O. Box 31364
Salt Lake City, UT 84131
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Critical Incident Reporting
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What Is a Critical Incident?
• A critical incident is any event or situation that has harmed or has the
potential to harm a member, such as:
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Abuse/neglect
Exploitation
Serious injury
Missing person
Medical errors
Suicide attempt
Any other incident that may cause harm to the member
• For a full list of reportable critical incidents required by the state, go to
UHCCommunityPlan.com > For Health Care Professionals > Select Your
State = New Jersey > Provider Administrative Manual.
• Critical incident reporting is important to help ensure the health and safety
of our members.
• Any critical incidents involving one of our members must be reported within
24 hours of discovery of the incident.
o May be submitted verbally, but must be followed up with a written report within
48 hours.
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Reporting Critical Incidents to
UnitedHealthcare Community Plan
If a critical incident is discovered, you are required to take steps within one
business day to prevent further harm to all members and respond to any of
their emergency needs. Then, report the critical incident to the state agency,
if appropriate, BEFORE reporting it to UnitedHealthcare Community Plan of
New Jersey.
• All critical incidents should be reported to UnitedHealthcare Community Plan of
New Jersey.
o To report a critical incident to UnitedHealthcare Community Plan of New Jersey, please call
888-702-2168 or complete the Critical Incident Reporting Form and fax it to 855-216-6408
within 24 hours of discovery of the incident. The form is available at
UHCCommunityPlan.com > For Health Care Professionals > Select Your State = New
Jersey > Provider Forms.
• Any verbal notification must be followed by a written report describing the incident
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and what the care provider did to resolve it. There is no required format for the
report. Fax the report to 855-216-6408.
Participating providers must conduct an internal critical incident investigation and
submit a written report within 30 calendar days after the date of the incident
advising of the root cause and what steps were taken to prevent such an incident
from reoccurring. There is no required format for the report. Fax the report to 855216-6408.
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Reporting Critical Incidents to the State
Immediately report to the appropriate agency including 911, any knowledge
of or reasonable suspicion of:
• Report abuse, neglect or exploitation of adults to New Jersey Adult
Protective Services at 800-792-8820.
• Report abuse, neglect or exploitation of members residing in nursing
homes to the New Jersey Office of the Ombudsman for the
Institutionalized Elderly at 877-582-6995.
• Report brutality, abuse or neglect of children to the Division of Child
Protection and Permanency (formerly the Division of Youth and family
Services) at 877-652-2873.
• Report abuse, neglect or exploitation of children residing in pediatric
nursing facilities to the Division of Child Protection and Permanency at
877-652-2873.
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Unable to Contact and
Open Care Opportunities
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Unable to Contact
If an LTC/MLTSS member is absent, without notification, from any
program or service offered and the LTC/MLTSS care provider is
unable to identify their location using the contact information
available, the member is considered “unable to contact”.
LTC/MLTSS care providers must take the following steps to
investigate and report “unable to contact” events:
1.Immediately contact the member using contact information on file.
2.If no response, immediately contact the member’s emergency
contact.
3.If unsuccessful, immediately notify the member’s MLTSS care
manager.
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Open Care Opportunities
For LTC/MLTSS members, an open care opportunity is the
difference between the number of hours or services scheduled in a
member’s plan of care and the hours or services that are actually
delivered to that member.
• If there is an open care opportunity, the care provider must contact
the member immediately to acknowledge and explain the open
care opportunity and provide an alternate plan to resolve it. The
care provider must also notify the member’s LTC/MLTSS care
manager about any open care opportunities.
• When care providers know about an upcoming open care
opportunity, they must contact the member before the scheduled
service to advise them that the regular caregiver will be
unavailable. The member may choose to receive the service from
a substitute caregiver, at an alternative time from the regular
caregiver or from an alternate caregiver from the member’s
informal support system.
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Claims Submission and
Appeals
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Electronic Claims Submission
Electronic Submission (Use Payer ID 86047)
Electronic Data Interchange (EDI) Support Services provides support for all electronic
transactions involving claims, electronic remittances and eligibility. For more
information, please contact EDI Support at 800-210-8315 or [email protected].
If you do not have office software and would like to submit claims directly at no cost,
submission can be done through Office Ally ‒ a secure, HIPAA-compliant solution that
offers:
• Direct connectivity
• No installation, transaction or support fees for care providers
• Ease of use for both batch and single claims
• 24-hour customer support
You can enroll at OfficeAlly.com. To learn more, please contact 866-575-4120 or
[email protected].
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Electronic Payments & Statements (EPS)
With EPS, you receive electronic funds transfer (EFT) for claim payments, plus your
explanations of benefits (EOBs) are delivered online. Regardless of your practice size
or claims volume, EPS can provide faster payment, easier reconciliation and less
paper.
• Users receive payments and EOBs five to seven days faster than with paper.
• View payments or EOBs for the last three months, or search a 13-month archive.
• Claim adjustments will not be deducted from your account.
To enroll online, please go to myservices.optumhealthpaymentservices.com.
Here’s what you’ll need:
• Bank account information for direct deposit
• A voided check or a bank letter to verify bank account information
• A copy of your practice’s W-9 form
You can download the EPS Paper Enrollment Form at UnitedHealthcareOnline.com >
Claims & Payments > Electronic Payments & Statements (EPS) and mail or fax it to the
contact listed in the form instructions.
If you plan to route payments to accounts based on your national provider identifier
(NPI), please call for enrollment assistance.
If you have questions or need help with EPS enrollment, please call
866-842-3278, option 5.
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835 Electronic Remittance Advice
If you receive 835 Electronic Remittance Advice (ERA) through a
vendor, please ask them to enroll you for the 835 through OptumInsight.
Once we receive the request from your clearinghouse or EDI vendor, it
takes about 30 days to set up delivery of the 835 ERA.
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Claim Submission – Coordination of
Benefits
New Jersey FamilyCare Managed Care Contract Guidance: Coordination of Benefits for
Medicaid Managed Care Members, effective January 2016
This guidance covers coordination of benefits/explanation of benefits (EOB) for Medicaid Managed
Care members with Medicare Parts A and B, Supplemental or Medicare Advantage coverage and/or
members with Third Party Liability (TPL) coverage.
1. Medicaid Managed Care members with Medicare Parts A and B who have Medicare
Supplemental do not require EOBs or denial for the following Medicaid services:
A. State plan services:
• Medical Day Care
• Personal Care Assistance - including Personal Preference Program
B. MLTSS Waiver services:
• Adult family care
• Assisted living
• Chore service
• Community transition services
• Home-based supportive care
• Home-delivered meals
• Medical day care
•
•
•
•
•
•
•
Non-medical transport
Nursing home custodial care
Personal care assistance, including Personal Preference
Program
Residential modifications
Respite
Social day care
Vehicle modifications
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Claim Submission – Coordination of
Benefits; continued
2. The Managed Care Organization will follow the Exceptions to the Cost Avoidance Rule
outlined in the New Jersey FamilyCare contract, effective January 2015 (Article 8.7 F
2,3) for the specified State Plan and MLTSS Waiver Services for Medicaid Managed
Care members with a Medicare Part A and Part B who also have a Medicare Advantage
Plan and/or TPL.
8.7 F: Exceptions to the Cost Avoidance Rule:
• If the Contractor knows that the third party will neither pay for nor provide the covered
service, and the service is medically necessary, the Contractor shall neither deny
payment for the service nor require a written denial from the third party.
• If the Contractor does not know whether a particular service is covered by the third party,
and the service is medically necessary, the Contractor shall contact the third party and
determine whether or not such service is covered rather than requiring the enrollee to do
so. Further, the Contractor shall require the provider or subcontractor to bill the third party
if coverage is available.
A. State plan services*
B. MLTSS Waiver services*
*A full listing of these services can be found on slide #37
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Claim Submission – Coordination of
Benefits; continued
3. For all other Medicaid State Plan and Waivers services included in New Jersey
FamilyCare member’s benefit package an EOB is required.
• If you receive an EOB indicating that the service is not covered by the primary insurer,
the NJ FamilyCare Managed Care Organization will pay for the service as the primary
payer. A new EOB should not be required for subsequent claims during the calendar year
for the same payer, care provider, and member and service code.
• Services paid by a third party carrier may become a non-paid service if the member’s
benefits are exhausted. If this happens, the care provider should submit an EOB stating
the benefit is exhausted before the managed care organization pays for the service.
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How Dual Eligible Special Needs Plans
(DSNP) Claims Process
• If the service provided is covered by Medicare, the normal coordination
of benefits occurs, as noted in the previous slides.
•
•
The claim will process against the member’s DSNP ID then automatically
move to the member’s Medicaid ID and complete processing.
You will see two claims on your EOB for the service; one where it processed
under the DSNP ID, and one where it processed under the Medicaid ID.
• If the service provided is not a covered service for Medicare, the claim
processes against the member’s DNSP ID and denies as “not a covered
service”, then automatically moves to the member’s Medicaid ID and
completes processing.
• You will see two claims on your EOB for the service, one where it processed
under the DSNP ID and one where it processed under the Medicaid ID.
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Claim Payment Appeals Process
Please follow the claim payment appeals process to resolve billing, payment
or other administrative disputes such as:
• Lost or incomplete claim forms or electronic submissions
• Requests for additional explanation as to services or treatment
rendered by a care provider
• Inappropriate or unapproved services initiated by care providers
• Any other reason for billing disputes
Claim payment disputes do not require any action by the member.
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Claims Payment Appeals Submission ‒
Informal Appeals
Please submit the Paper Claim Reconsideration Form, available at
UnitedHealthcareOnline.com > Tools & Resources > Forms, for the following claim
appeals only:
• Previously denied for additional information to process claim
• Resubmission as a corrected claim
• Resubmission with prior authorization information
• Resubmission because it was a bundled claim
• Previously denied/closed as exceeding timely filing
Please submit the form with a copy of the claim in question and any supporting
documentation within 90 days from receipt of the EOB/provider remittance advice
(PRA) to: UnitedHealthcare Community Plan
Attention: Claim Administrative Appeals
P.O. Box 5250
Kingston, NY 12402-5250
You can also submit claim appeals at UnitedHealthcareOnline.com or by calling
888-702-2168.
Submission of an informal appeal does not replace the submission of a formal
claim payment appeal.
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Claims Payment Appeals Submission ‒
Formal Appeals
Formal appeals must be submitted to UnitedHealthcare Community Plan
using the NJ Provider Appeal Form available at UnitedHealthcareOnline.com
> Tools & Resources > Forms.
• If a care provider submits a claim payment appeal using this form within
90 days following receipt of the EOB/PRA and we uphold the claim
payment denial, the care provider has the right to file an external claims
arbitration request using MAXIMUS, the state’s arbitration organization.
• If a care provider does not submit the original claim payment appeal on
the State’s HCAPPA form, the care provider does not have the right to a
claims arbitration. However, the appeal will be processed by
UnitedHealthcare Community Plan of New Jersey as an informal claim
payment appeal.
• The HCAPPA form can be found on the State’s website.
• If we uphold a claim payment denial on an informal claim payment
appeal, there is no second level of appeal and claim payment decisions
will be final.
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Claims Billing Tips
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Sample: Incorrect Medical Day Care Claim
The following example of a medical day care claim has submission errors.
The date range is
listed for multiple
dates of service.
The number of units billed exceeds
one unit. In addition, the number of
units does not match the number of
days represented in the date range
billed on the line.
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Sample: Correct Medical Day Care Claim
The following example of a medical day care claim is correct.
The date range
should be for one
date of service per
line.
Place of Service
should be 99.
Healthcare Common Procedure Coding
System (HCPCS) code billed would either
be the adult medical day care code or the
pediatric medical day care code.
Each line should be
billed with one unit to
represent one date of
service.
Provider should bill their
billed charges for each
date of service.
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Credentialing, Criminal
Background Checks and
Demographic Changes
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Credentialing
UnitedHealthcare Community Plan of New Jersey Credentialing
Requirements:
1. Complete Component Application
a) Component Attestation section must be signed and dated
2. Complete Demographic Update Information Sheet
3. Provide copy of declaration sheet and/or certificate of insurance for
current professional malpractice and comprehensive general liability
insurance policies
4. Provide W-9 Form
5. Provide current and/or renewed license from the Division of Consumer
Affairs
6. Provide current Medicaid and/or Medicare numbers
7. Provide certificate of accreditation from the following, if applicable:
• Community Health Accreditation Program
• Commission on Accreditation for Home Care, Inc.
• The Joint Commission
• National Association for Home Care/Home Care University
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Re-Credentialing
UnitedHealthcare Community Plan of New Jersey Re-Credentialing
Requirements:
1. Review and update the pre-filled Component Application with any
applicable changes.
2. Sign and date the Component Attestation page.
3. Return the application with the following current documents to the
address or fax number listed on the cover letter.
• Copy of current state license from the Division of Consumer Affairs
• Copy of certificates of accreditation, if applicable (e.g., Community
Health Accreditation Program)
• Copy of declaration sheet and/or certificate of insurance for current
professional malpractice and comprehensive general liability
insurance policies
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Care Provider Disclosures
• Care providers must submit certain disclosure statements to
participate with UnitedHealthcare Community Plan of New Jersey,
as described in the state contract.
• UnitedHealthcare Community Plan of New Jersey collects and
maintains these disclosures.
• To view the disclosures, please visit UHCCommunityPlan.com >
For Health Care Professionals > Select your state – New Jersey >
Provider Forms > Group Disclosure of Ownership and Control of
Interest Form OR Individual Disclosure of Ownership and Control of
Interest Form.
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Criminal Background Checks
All employees and/or agents of a provider or subcontractor and all
providers who provide direct care must have a criminal background
check as required by federal and state law.
All contracted care providers must conduct criminal background
checks on all prospective employees or providers who have direct
physical access to MLTSS members.
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Demographic Changes
All demographic changes must be sent to UnitedHealthcare Community
Plan of New Jersey using any of the following methods:
Fax: 877-382-9298
Mail: UnitedHealthcare
Attn: Adrienne Collins
P.O. Box 1276
Sharon Hill, PA 19079
Email: [email protected]
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Provider Advocates and
Other Resources
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Your Provider Advocate
• Serves as your primary contact
• Acts as a navigational specialist to help you deal with all areas of
•
•
UnitedHealthcare Community Plan
Communicates with your practice about critical programs and processes
within UnitedHealthcare Community Plan
Specializes in issue resolution
Provider Advocate for adult and pediatric medical day care providers:
Sharon Hopson
Phone: 952-202-2964
Email: [email protected]
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Key Contact List
UnitedHealthcare Community Plan website (newsletters, bulletins, forms):
UHCCommunityPlan.com
UnitedHealthcare provider website (claims, eligibility): UnitedHealthcareOnline.com
Provider Services for LTC: Call 888-702-2168
Prior Authorization/Intake for LTC: Call 800-262-0305
Health Services: Call 888-362-3368 or fax 800-766-2597
To identify a Care Manager for LTC: Call 800-645-9409
Member Services: Call 800-941-4647 (TTY:711); TTY/TDD call 800-852-7897
NurseLine: Call 888-433-1904
Demographic Changes: Fax 877-382-9298
Credentialing Center: Fax 877-620-3782 or email [email protected]
Medications requiring prior authorization: Call 800-310-6826 or fax 866-940-7328
Prescription Solutions for pharmacy specialty injectables: Fax 800-853-3844
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Link Training
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Link Overview
• Link is your gateway to UnitedHealthcare's online tools.
• It replaced Optum Cloud Dashboard. Link includes many of the same
applications as Optum Cloud Dashboard, but with a new interface that
can help make your work measurably faster and easier.*
• Use Link to check member eligibility and benefits, manage claims and
submit claim reconsideration requests.
• With Link, you can quickly move between UnitedHealthcare
applications and websites, and even customize your screen to put your
most common tasks just one click away.
• Later this year, we’ll introduce enhanced applications and additional
features to help make your transactions with us even faster.
* Based on ongoing usability studies using keystroke-level modeling when comparing Link to
UnitedHealthcareOnline.com and Optum Cloud Dashboard.
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Sign In to UnitedHealthcareOnline.com
to Access Link
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Use Your Optum ID
If you can’t remember your Optum ID or
password, click on Sign In, then Forgot
Username or Forgot Password.
If you don’t have an Optum ID yet, please
register for one by clicking Register Now.
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What’s on Link?
Applications on Link include:
• Eligibility & Benefits
• Claims Management
• Claims Reconsideration
Access other UnitedHealthcare
websites:
• UnitedHealthcareOnline.com
• UHCWest.com
• UHCCommunityPlan.com
• And more
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PCA-1-002644-07202016-08052016 Proprietary Information of UnitedHealth Group. Do not distribute or reproduce without express permission of UnitedHealth Group.
Eligibility & Benefits Application
Use the Eligibility & Benefits application to check member
eligibility and review detailed benefits information. You may
also submit referrals, notifications and prior authorization
requests using this application.
Features include:
• Search for covered members.
• View prior authorization/advance notification requirements, cost share
amounts and benefit coverage details.
• Submit and check status of referrals.
• View preventive care opportunities information for UnitedHealthcare
Medicare Solutions and UnitedHealthcare Community Plan members.
• View detailed benefits information for multiple plans.
• See coverage details and limits specific to each benefit plan.
• Export or print data.
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Claims Management Application
With the Claims Management application, you can get the
most up-to-date claims status and payment information
quickly and conveniently. Claims processed within the last
two years are available.
Features include:
• Search for claim submissions and access claim summaries and details
for multiple UnitedHealthcare plans in a single application.
• View payment information, remark codes and their descriptions.
• Submit additional information requested on pended claims.
• Submit appeals (only available in certain states).
• View Explanations of Benefits (EOBs) and letters for UnitedHealthcare
Commercial benefit plans.
• Select a claim for reconsideration.
• Flag claims for future viewing.
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Claims Reconsideration Application
Use the Claims Reconsideration application to quickly look
up processed claims and submit paid or denied claims as
reconsiderations with or without attachments. You will
receive a ticket number and can check the status of your
submission online.
Features include:
• Search for paid or denied claims.
• Receive instant printable confirmation of completed claim
reconsideration requests.
• Search for a claim reconsideration request to check its status or view its
history.
• Update previously submitted reconsideration requests.
• If you selected a claim for reconsideration in the Claims Management
application, it will appear as a draft that can be completed and
submitted in the Claims Reconsideration application.
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Link Resources
To learn more about Link, please visit the Link resources page at
UnitedHealthcareOnline.com > Quick Links > Link: Learn More.
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PCA-1-002644-07202016-08052016 Proprietary Information of UnitedHealth Group. Do not distribute or reproduce without express permission of UnitedHealth Group.
Link Resources (cont.)
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PCA-1-002644-07202016-08052016 Proprietary Information of UnitedHealth Group. Do not distribute or reproduce without express permission of UnitedHealth Group.
Important Training Concepts
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Online Resources
Online resources are available to assist you with providing services to
UnitedHealthcare Community Plan members, including the following
topics:
Cultural Competency Resources for providing culturally competent care to a growing number of
patients
• UHCCommunityPlan.com > For Health Care Professionals > Select your
state – New Jersey > Cultural Competency Library
Community Resources Resources to assist you in providing care to diverse patient populations
• UHCCommunityPlan.com > For Health Care Professionals > Select your
state – New Jersey > Provider Education > Managed Long-Term Care
Services and Supports (MLTSS)
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Options Counseling
Options Counseling is an interactive process where individuals
receive guidance to make informed choices about long-term supports
based on their assessed needs.
• Directed by the UnitedHealthcare member or their authorized
representative
• May include other people that the member chooses
• Options counseling includes the following steps:
•
Personal interview to discover strengths, values and preferences of the
individual and the utilization of screenings for public programs.
•
Facilitated decision support process that explores resources and service
options to help the member weigh pros and cons
•
Action steps geared toward a goal or a long term support plan, assistance
in applying for and accessing support options when requested
•
Quality assurance and follow-up to ensure supports and decisions are
working
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PCA-1-002644-07202016-08052016 Proprietary Information of UnitedHealth Group. Do not distribute or reproduce without express permission of UnitedHealth Group.
Options Counseling (cont.)
• For people of all income levels, but targeted for those with immediate
concerns, such as:
•
Those at greatest risk for institutionalization
•
Individuals looking to transition from long-term care facilities
• Helps ensure members are educated on the full range of LTSS and
offered a choice of care (institutional/home- and community-based
services) and option to choose MLTSS or Programs of All-Inclusive Care
for the Elderly (PACE), if available.
Every UnitedHealthcare MLTSS Care Manager has passed the State’s
Options Counseling training program.
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Thank You
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PCA-1-002644-07202016-08052016 Proprietary Information of UnitedHealth Group. Do not distribute or reproduce without express permission of UnitedHealth Group.