2011 Member Handbook English UHCCPforAdults NY

N E W YO R K
UnitedHealthcare Community Plan

Medicaid Member Handbook
ACNY10MC3283503_000
938-1011 12/10
Telephone Numbers/Translation Services

Member Services Department (open 24 hours a day, 7 days a week) . . . . . . . . . . . . 1-800-493-4647 TDD/TTY (for the hearing impaired) . . . . . . . . . . . 1-800-662-1220 Your Primary Care Physician . . . . . . . . . . . See Your UnitedHealthcare Community Plan ID Card New York State Health Dept. (complaints) . . . . . . . . 1-800-206-8125 Upstate County Departments of Social Services Cayuga County Department of Social Services . . . . . . 1-315-253-1011 Herkimer County Department of Social Services . . . . . 1-315-867-1291 Madison County Department of Social Services . . . . . . 1-315-366-2211 Oneida County Department of Social Services . . . . . . . 1-315-798-5632 Onondaga County Department of Social Services . . . . 1-315-435-2928 Oswego County Department of Social Services . . . . . . 1-315-963-5000 New York City and Long Island Nassau County Department of Social Services . . . . . . 1-516-227-8000 New York City Human Resources Administration . . . . . 1-718-557-1399 New York City Human Resources Administration (within the 5 boroughs) . . . . . . . . . . . . . . . . . . . . . . . . . . 1-877-472-8411 New York Medicaid CHOICE . . . . . . . . . . . . . . . . . . . . . 1-800-505-5678 Suffolk County Department of Social Services Hauppauge . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1-631-853-8730 Riverhead . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1-631-852-3710 Ronkonkoma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1-631-854-9700
Website www .uhccommunityplan .com
Other Health Provider(s)

Name: ____________________________________ Phone: ___________________________________ Name: ____________________________________ Phone: ___________________________________ Emergency Room: __________________________ Phone: ___________________________________ Pharmacy: _________________________________ Phone: ___________________________________ 2 Medicaid Member Handbook
Table of Contents
Welcome to UnitedHealthcare Community Plan Managed Care Program . . . . . . . . . How Managed Care Works . . . . . . . . How to Use This Handbook . . . . . . . . Help From Member Services . . . . . . . Your Health Plan ID Card . . . . . . . . . . Part II Your Benefits and Plan Procedures . . . . . . . . . . . . . . Benefits . . . . . . . . . . . . . . . . . . . . . . . . Services Covered by UnitedHealthcare Community Plan . . . . Benefits You Can Get From UnitedHealthcare Community Plan or With Your Medicaid ID Card . . . . . . Benefits Using Your Medicaid Card Only . Services NOT Covered by Medicaid orUnitedHealthcare Community Plan . . Service Authorization and Actions . . . . . . Prior Authorization and Timeframes . . . . . Retrospective Review and Timeframes . . How Our Providers Are Paid . . . . . . . . . You Can Help With Plan Policies . . . . . . Information From Member Services . . . . . Keep Us Informed . . . . . . . . . . . . . . . . . Disenrollment and Transfers . . . . . . . . . . Action Appeals . . . . . . . . . . . . . . . . . . . External Appeals . . . . . . . . . . . . . . . . . . Fair Hearings . . . . . . . . . . . . . . . . . . . . Complaint Process . . . . . . . . . . . . . . . . How to File a Complaint . . . . . . . . . . . . . What Happens Next . . . . . . . . . . . . . . . Complaint Appeals . . . . . . . . . . . . . . . . Member Rights and Responsibilities . . . . Advance Directives . . . . . . . . . . . . . . . . Notice of Privacy Practices . . . . . . . . . . . . 16 . . 17 . 17 . . 21 . . 22 . . . . . . . . . . . . . . . . . . . . 24 . 25 . 26 . 28 . 28 . 28 . 29 . 29 . 30 . 32 . 35 . 37 . 38 . 38 . 38 . 40 . 41 . 43 . 44
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Part I First Things You Should Know How to Choose Your PCP . . . . . . . . . . . . How to Get Care . . . . . . . . . . . . . . . . . . . Get These Services From UnitedHealthcare Community Plan Without a Referral . . . . . . . . . . . . . . . . Emergencies . . . . . . . . . . . . . . . . . . . . . . Urgent Care . . . . . . . . . . . . . . . . . . . . . . We Want to Keep You Healthy . . . . . . . . .
. . 7 . . 8 . 10 . 12 . 14 . 14 . 15
New York
Welcome to UnitedHealthcare Community Plan Managed Care Program

We are glad that you chose UnitedHealthcare Community Plan. We want to be sure you get offto a good start as a new member. In order to get to know you better, we will be in touch with you in the next two or three weeks. You can ask us any questions you have or get help making appointments. If you need to speak with us before we call on you, however, just call usat 18004934647.
How Managed Care Works

The Plan, Our Providers andYou
No doubt you have seen or heard about the changes in health care. Many consumers now get their health benefits through managed care. Many counties in New York State, including New York City, offer their consumers a choice of managed care health plans. In some counties, people with Medicaid must join a health care plan. Such counties operate a mandatory managed care program. Other counties allow their consumers to choose whether they want to join managed care. These counties operate a voluntary Medicaid managed care program. Both programs allow for some people to keep getting care through regular Medicaid. UnitedHealthcare Community Plan members who live in New York City, Nassau, Suffolk, Cayuga, Madison, Oneida, Onondaga, Oswego and Herkimer counties are in a mandatory Medicaid managed care program. UnitedHealthcare has contracts with the State Department of Health and the New York City Department of Health and Mental Hygiene to meet the health care needs of people with Medicaid. In turn, we choose a group of
health care providers to help us meet your needs. These doctors and specialists, hospitals, labs and other health care facilities make up our provider network. Youll find a list in our provider directory. If you dont have a provider directory, call 1-800-493-4647 to get a copy. When you join UnitedHealthcare, one of our providers will take care of you. Most of the time that person will be your primary care provider (PCP). If you need to have a test, see a specialist or go to the hospital, your PCP will arrange it. Your PCP is available to you every day, day and night. If you need to speak to him or her after hours or weekends, leave a message and how you can be reached. Your PCP will get back to you as soon as possible. Even though your PCP is your main source for health care, in some cases you can selfrefer to certain doctors for some services. See page 12 for details.
How to Use This Handbook

Whether you have to join or choose to join a managed care plan, this handbook will help. Itwill tell you how your new health care system will work and how you can get the most from UnitedHealthcare. This handbook
is your guide to health services. It tells you the steps to take to make the plan work for you. The first several pages will tell you what you need to know right away. The rest of the handbook can wait until you need it. Use it for reference or check it out a bit at atime. When you have a question, check this handbook or call our Member Services unit. You can also call the managed care staff at your local Department of Social Services. Please see the front inside cover for a list of local Department of Social Services telephone numbers. If you live in New York City, Cayuga, Madison, Nassau or Suffolk counties, you can call the New York Medicaid CHOICE Help Line at 18005055678. Member Services is available 24 hours a day, 7days a week at 18004934647. If you have trouble hearing, call AT&T TDDRelay Service at 18006621220.
your newborn child is in a group that cannot join managed care. You should call us and your local social services office right away if you become pregnant, and let us help you to choose a doctor for your newborn baby before he or she is born. We offer free sessions to explain our health plan and how we can best help you. Its a great time for you to ask questions and meet other members. If youd like to come to one of the sessions, call us to find a time and place that works best for you. If you do not speak English, we can help. Wewant you to know how to use your health care plan, no matter what language you speak. Just call us and we will find a way to talk to you in your own language. We have agroup of people who can help. We will also help you find a PCP who can serve you in yourlanguage. For people with disabilities: If you use a wheelchair, are blind, or have trouble hearing or understanding, call us if you need extra help. We can tell you if a particular providers office is wheelchair accessible or is equipped with special communication devices. Wealso offer the following services: TY machine (our TTY phone number T is18004211220 or 18006621220) nformation in large print, Braille or on I audio tape Case management Help making or getting to appointments ames and addresses of providers who N specialize in your disability
Help From Member Services

There is someone to help you at Member Services 24 hours a day, 7 days a week. Just call 18004934647. If you have trouble hearing, call AT&T TTY/TDD Relay Service at 18006621220. You can call to get help any time you have a question. You may call us to choose or change your primary care provider, ask about benefits and services, replace a lost ID card, report the birth of a new baby or ask about any change that might affect you or your familys benefits. If you are or become pregnant, your child will become part of UnitedHealthcare on the day he or she is born. This will happen unless
New York
Your Health Plan ID Card

After you enroll, well send you a welcome letter. Your UnitedHealthcare Community Plan ID card should arrive within 14 days CUSTDIAMOND_KEY5 CUSTDIAMOND_KEY4 CUSTDIAMOND_KEY3 J10 CUSTDIAMOND_KEY2 HCAC/Rxonly CUSTDIAMOND_KEY1 KIMORA MAILSET_NUMBER 0000021 NAME RUSH DOC_SEQ_ID 0000021 90100 DOC_ID UHG_TYPE 20100907 00100224059 CLIENT_NUMBER 003115 DATA_SEQ_NO 0000001 ,KIMORA RUN_DATE DIG1CARD18:45:57 after your enrollment date. Your card has your PCPs name and phone number on it. It will also have your Client Identification Number (CIN). If anything is wrong, call us right away. Carry your ID card at all times and show it each time you go for care. If you need care before the card comes, your welcome letter is proof that you are a member. You must keep your Medicaid benefit card. You will need that card to get Medicaid services that UnitedHealthcare does not cover, such as pharmacy benefits. If you live in Cayuga, Madison, Herkimer, Oneida, Onondaga or Oswego counties, you will need your Medicaid card for dental services.
>000021 9901477 001 003115
Were glad to have you as a member. We recently changed our name. AmeriChoice by UnitedHealthcare is now UnitedHealthcare Community Plan. Dont worry, only our name has changed. We still have the same quality service, local knowledge and commitment to your needs..
Bienvenido(a) a UnitedHealthcare Community Plan Nos complace tenerlo como miembro. Recientemente, cambiamos nuestro nombre. AmeriChoice by UnitedHealthcare ahora se llama UnitedHealthcare Community Plan. No se preocupe, lo nico que cambiamos fue nuestro nombre. El servicio de calidad, el conocimiento local y el compromiso que tenemos para satisfacer sus necesidades sigue igual.
This is your new Memeber ID Card. Please carry it with you at all times. You should present this card when you go to doctor appointments or get covered services from other health care providers.
In an emergency go to nearest emergency room or call 911.
Printed: 10/04/10
Health Plan (80840)
911-87726-04
Group Number: Payer ID: 87726
Member ID: 999999999 Member: JOHN DOE EMPLOYEE BROWN AB12375C CIN#: ED57975K PCP Name: HEALER, PRIMARY PCP Phone: (999)555-9999
99999
This card does not guarantee coverage. For coordination of care call your PCP. To verify bene ts or to nd a provider, visit the website www.uhccommunityplan.com or call.
For Members:
800-493-4647 888-291-2506
TDD 800-662-1220 TDD 800-486-7914
Mental Health:
For Providers : 866-362-3368 www.uhccommunityplan.com Medical Claims: PO Box 5240, Kingston, NY, 12402-5240
0501
UnitedHealthcare Community Plan for Families Administered by UnitedHealthcare of New York, Inc.
sta es su nueva tarjeta de identificacin del miembro. Srvase llevarla consigo en todo momento. Debe presentar esta tarjeta cuando vaya a sus citas con el mdico o cuando reciba servicios cubiertos de otros proveedores de atencin mdica.
Welcome to UnitedHealthcare Community Plan
EMPLOYEE BROWN 9999 ANYOLE ST BAYSHORE NY 11706
We've changed our name. AmeriChoice by UnitedHealthcare is now UnitedHealthcare Community Plan.
UNITEDHEALTHCARE COMMUNITY PLAN 14TH FLOOR 77 WATER STREET NEW YORK NY 10005
03115 9901477 0000 0000021 0000021 251 0 111
Part I First Things YouShould Know

How to Choose Your PCP How to Get Regular Care How to Get Specialty Care Get These Services From UnitedHealthcare Without a Referral Emergencies Urgent Care We Want to Keep You Healthy
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How to Choose Your PCP
You may have already picked your PCP to serve as your regular doctor. This person could be a doctor or a nurse practitioner. If you have not chosen a PCP for you and your family, you should do so right away. If you do not choose a doctor within 30 days, we will choose one for you. Each family member can have a different PCP, or you can choose one PCP to take care of the whole family. A pediatrician treats children. Family practice doctors treat the whole family. Internal medicine doctors treat adults. Member Services can help you choose aPCP. With this handbook, you should have a provider directory. This is a list of all the doctors, clinics, hospitals, labs and others who work with UnitedHealthcare. It lists the addresses, phone numbers and special training of the doctors. The provider directory will show which doctors and providers are taking new patients. You should call their offices to make sure they are taking new patients at the time you choose aPCP.
Women can also choose one of our OB/GYN doctors or midwives to deal with womens health issues. You never need a referral for family planning, wellwoman care or care during pregnancy. Women can have routine checkups (twice a year), followup care if there is a problem and regular care duringpregnancy. We also contract with several federally qualified health centers (FQHC). All FQHCs give primary and specialty care. Some consumers want to get their care from FQHCs because the centers have a long history in the neighborhood. Maybe you want to try them because they are easy to get to. You should know that you have a choice. Youcan choose one of our providers. Or you can sign up with a primary care physician at one ofthe FQHCs that we work with, listed in the provider directory. Call Member Services at 18004934647 forhelp.
You may want to find a doctor:

Who you have seen before Who understands your health problems Who is taking new patients Who can serve you in your language Who is easy to get to
In almost all cases, your doctors will be UnitedHealthcare providers. In some cases you can continue to see another doctor that you had before you joined UnitedHealthcare, even if he or she does not work with our plan. You can continue to see your doctor if: ou are more than 3 months pregnant Y when you join and you are getting prenatal care. In that case, you can keep your doctor until after your delivery and followupcare. t the time you join, you have a A lifethreatening disease or condition that gets worse with time. In that case, you can ask to keep your doctor for up to 60 days. In both cases, however, your doctor must agree to work with UnitedHealthcare. If you have a longlasting illness, like HIV/AIDS or other longterm health problems, you may be able to choose a specialist to act as your PCP. Please call Member Services to request a specialist as your PCP. If you need to, you can change your PCP in the first 30 days after your first appointment with your PCP. After that, you can change your PCP three times during the year without cause or more often if you have a good reason. You can also change your OB/GYN or health care specialist.
If your provider leaves UnitedHealthcare, we will tell you within 15 days from when we know about this. If you wish, you may be able to see that provider if you are more than three months pregnant or if you are receiving ongoing treatment for a condition. If you are pregnant, you may continue to see your doctor for up to 60 days after delivery. If you are seeing a doctor regularly for an ongoing condition, you may continue your present course of treatment for up to 90days. Your doctor must agree to work with UnitedHealthcare during this time. If any of these conditions apply to you, check with your PCP or call MemberServices at 1-800-493-4647 forhelp.
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How to Get Care
Regular Care
Regular care means exams, regular checkups, shots or other treatments to keep you well, give you advice when you need it and recommend you to a hospital or a specialist when needed. It means you and your PCP will be working together to keep you well or to see that you get the care you need. Day or night, your PCP is only a phone call away. Be sure to call him or her whenever you have a medical question or concern. If you call after hours or on weekends, leave a message and where or how you can be reached. Your PCP will call you back as quickly as possible. Remember, your PCP knows you and knows how the health plan works. Your care must be medically necessary. Theservices you get must be needed: To prevent, or diagnose and correct, what could cause more suffering, To deal with a danger to your life, To deal with a problem that could cause illness, or o deal with something that could limit T your normal activities Your PCP will take care of most of your health care needs, but you must have an appointment to see your PCP. If ever you cant keep an appointment, call to let your PCP know. As soon as you choose a PCP, call to make a first appointment. If you can, prepare for your first appointment. Your PCP will need to know as much about your medical history as you can tell him or her. Make a list of your medical background, any problems you have now and the questions you want to
ask your PCP. In most cases, your first visit should be within three months of your joining theplan. If you need care before your first appointment, call your PCPs office to explain the problem. He or she will give you an earlier appointment. (You should still keep the first appointment.)
Specialty Care
Sometimes you may have a health problem that your PCP will not treat because you need special medical attention. When that happens, your PCP will send you to a specialist, a doctor who is an expert in the care and treatment of certain medical problems. There are some treatments and services that your PCP must ask UnitedHealthcare to approve before you can get them. You are not responsible for any of the costs except any copayments as described in this handbook. Here are some examples of specialists: Cardiologist heart doctor Dermatologist skin doctor Hematologist doctor for blood problems Podiatrist foot doctor Ophthalmologist eye doctor When your PCP sends you to see a specialist, he or she will give you the name of the specialist and may help you make an appointment. Your PCP may give you a note on his or her letterhead or on a prescription form with the specialists name and any important information the specialist needs to have when he or she sees you.
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If the specialist is not in the UnitedHealthcare network, your PCP must call UnitedHealthcares Prior Authorization Department at 18666043267 to get authorization for you to go to a specialist that is not part of the UnitedHealthcare network. The specialist has to agree to work with UnitedHealthcare and accept our payments as payment in full. This permission is called prior authorization. Your PCP will explain all of this to you when he or she sends you to a specialist. Please refer to the Service Authorization and Actions section for more information on what documentation your request for a nonparticipating provider shouldinclude. If UnitedHealthcare determines that we do not have a specialist in our plan who can give
you the care you need, we will get you the care you need from a specialist outside of our network. Of course, you will not pay for this care when approved. If you have a longterm disease or a disabling illness that gets worse over time, your PCP may be able to arrange for: Your specialist to act as your PCP ou to go to a specialty care center that Y deals with the treatment of your problem. You can also call Member Services for help in getting access to a specialty care center If you ever want to see a different specialist, talk to your PCP or call Member Services at1-800-493-4647.
Use the following list as an appointment guide for our limits on how long you may have to wait after your request for an appointment:
dult baseline and routine physicals: within 12 weeks A Urgent care: within 24 hours Non-urgent sick visits: within 3 days Routine, preventive care: within 4 weeks irst prenatal visit: within 3 weeks during 1st trimester, 2 weeks during 2nd F and1week during 3rd irst newborn visit: within 2 weeks ofhospital discharge F irst family planning visit: within 2weeks F ollow-up visit after mental health/substance abuse ER or inpatient visit: 5days F on-urgent mental health or substance abuse visit: 2 weeks N
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Get These Services From UnitedHealthcare Without a Referral

You Can Get These Womens Services If:
You are pregnant You need OB/GYN services You need family planning services You want to see a midwife You need to have a breast or pelvic exam We can provide you with information on how the infection is spread, how to protect yourself if you do not have the infection and how to protect others if you do have the infection. Wecan also provide you with information on how to get tested and receive counseling for you and your partner. There are many doctors who specialize in the care of people with HIV. If you want more information about HIV prevention and how UnitedHealthcare can assist you, call 18662195159 during regular business hours. UnitedHealthcare also has a special program designed to assist members who have HIV. If you would like information about how this program may help you, call the Case Management Department Hotline at 18662195159 during regular business hours. ou can get HIV testing and counseling Y any time you have family planning services. You do not have to tell your PCP. Just make an appointment with one of our family planning providers. r if youd rather not see one of O UnitedHealthcares providers, you can use your Medicaid card to see a family planning provider outside UnitedHealthcare. For help in finding either a UnitedHealthcare Community Plan provider or a Medicaid provider for family planning services, call Member Services at 18004934647. f you want HIV testing and counseling I but not as part of a family planning service, your PCP can arrange it for you. Or you can visit an anonymous HIV testing and counseling site. For information, call the New York State HIV Counseling Hotline at 18008722777 or 1800541AIDS. Medicaid Member Handbook
Family Planning
You can get the following family planning services: advice for birth control, pregnancy tests, sterilization or a medically necessary abortion to protect your health. If you have Medicaid in New York City, you may have an abortion for any reason. During your visits for this care, you can also get tests for sexually transmitted infections, a breast cancer exam or a pelvic exam. You can choose where to get these services. You can use your UnitedHealthcare Community Plan ID card to see one of UnitedHealthcares family planning providers. Check the plans provider directory or call Member Services for help finding a provider. Or you can use your Medicaid card if you want to go to a doctor or clinic outside UnitedHealthcare. Ask your PCP or call Member Services at 18004934647 for a list of places to go to get these services. You can also call the New York State Growing Up Healthy Hotline (18005225006) for the names of family planning providers near you.
HIV Counseling andTesting

UnitedHealthcare wants to promote HIV/AIDS prevention. There is information available for people who are at risk for HIV. 12
f you need HIV treatment after the I testing and counseling service, your PCP will help you get followup care.
Eye Care
The covered benefits include the needed services of an ophthalmologist, optometrist and an ophthalmic dispenser, and include an eye exam and pair of eyeglasses, if needed. Generally, you can get these once every two years, or more often if medically needed. Enrollees diagnosed with diabetes may selfrefer for a dilated eye (retinal) examination once in any 12month period. You just choose one of our participating vision providers listed in the provider directory. New eyeglasses (with Medicaidapproved frames) are usually provided once every two years. New lenses may be ordered more often, if, for example, your vision changes more than /2 diopter. Ifyou break your glasses, they can be repaired. Lost eyeglasses, or broken eyeglasses that cant be fixed, will be replaced with the same prescription and style of frames. If you need to see an eye specialist for care of an eye disease or defect, your PCP can recommend one.
inpatient detoxification, inpatient rehabilitation or outpatient detoxification services in any 12month period. If you need more care, your chemical dependence or detoxification program will work with UnitedHealthcare. If you want a chemical dependence assessment for any alcohol and/or substance abuse outpatient treatment services, except outpatient detoxification services, you must use your Medicaid benefit card to go to any provider that takes Medicaid.
Case Management
UnitedHealthcare has a special case management program designed to assist members with serious and complex medical conditions, including: HIV/AIDS Kidney Failure High Blood Pressure Emphysema (COPD) Diabetes Asthma Sickle Cell Anemia Congestive Heart Failure Heart Disease Hemophilia Cancer High-Risk Pregnancy If you would like information about how these programs may help you, call the Case Management Department at 18662195159 during regular business hours. If you have endstage renal disease (ESRD) or are a longterm resident of a skilled nursing facility, you may be eligible to disenroll from our health plan.
Mental Health Chemical Dependence (Including Alcohol and Substance Abuse)

You may go for 1 mental health assessment in any 12month period. You must use a UnitedHealthcare Community Plan provider, but you do not need an OK from your PCP. If you need more visits, your mental health provider will arrange them with UnitedHealthcare. You may also go for 1 chemical dependence assessment for all New York
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Emergencies
Remember
You do not need prior approval for emergency services. Use the emergency room only if you have an emergency. The emergency room should not be used for problems like the flu, sore throats or ear infections. If you have questions, callyour PCP or UnitedHealthcare at 18004934647.
You are always covered for emergencies.

An emergency means a medical or behavioral condition: That comes on all of a sudden, and That has pain or other symptoms This would make a person with an average knowledge of health fear that someone will suffer serious harm to body parts or functions or serious disfigurement without care right away. Examples of an emergency are: A heart attack or severe chest pain Bleeding that wont stop or a bad burn Broken bones Trouble breathing, convulsions or loss of consciousness When you feel you might hurt yourself or others If you are pregnant and have signs like pain, bleeding, feveror vomiting Examples of nonemergencies are: colds, sore throat, upset stomach, minor cuts and bruises, or sprained muscles.
Urgent Care
You may have an injury or an illness that is not an emergency but still needs prompt care. is could be a child with an Th earache who wakes up in the middle of the night and wont stopcrying. t could be a sprained ankle, or a I bad splinter you cant remove. You can get an appointment for an urgent care visit for the same or next day. Whether you are at home or away, call your PCP any time, day or night. If you cannot reach your PCP, call us at 1800493647 forassistance.
If you have an emergency, heres what to do:

If you believe you have an emergency, call 911 or go to the emergency room. You do not need your plans or your PCPs approval before getting emergency care, and you are not required to use our hospitals or doctors. If you are not sure, call your PCP or UnitedHealthcare. Theywill: Tell you what to do at home Tell you to come to the PCPs office ell you to go to the nearest emergency room T If you are out of the area when you have an emergency: Go to the nearest emergency room
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We Want to Keep You Healthy
Besides the regular check ups and the shots you and your family need, here are some other ways to keep you in good health:
Classes for you and your family Stop-smoking classes Prenatal care and nutrition Grief/Loss support Breast-feeding and baby care Stress management Weight control Cholesterol control Diabetes counseling and self-management training Asthma counseling and self-management training
Call Member Services at 1-800-493-4647 to find out more and get a list of services.
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Part II Your Benefits andPlan Procedures

The rest of this handbook is for your information when you need it. It lists both covered and non-covered services. Ifyou have a complaint, the handbook tells you what to do. The handbook has other information you may find useful. Keep this handbook handy for when you need it.
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Benefits
Medicaid managed care provides a number of services you can get in addition to those you get with regular Medicaid. UnitedHealthcare will provide or arrange for most services that you will need. You can get a few services, however, without going through your PCP. These include emergency care; family planning/HIV testing and counseling; and specific selfreferral services, including those you can get from within the plan and some that you can choose to go to any Medicaid provider of the service.
Services Covered by UnitedHealthcare Community Plan

You must get these services from the providers who are in UnitedHealthcare. All services must be medically necessary.
Regular Medical Care

Office visits with your PCP Specialist visits Vision/hearing exams
Maternity Care
Pregnancy care Doctors/midwife and hospital services Newborn nursery care moking cessation counseling for S pregnantwomen
Preventive Care
Well-baby care Well-child care Regular checkups hots for children from birth S throughadolescence Access to Early and Periodic Screening, Diagnosis and Treatment (EPSDT) services for enrollees from birth until age 21 years
Home Health Care

t least 2 visits for high-risk A infants(newborns) isit for women who stay in the hospital V less than 48 hours after birth isit for women who stay in the hospital V less than 96 hours after a cesarean birth ther home health care visits as needed O and ordered by your PCP/specialist 17
New York
Services Covered by UnitedHealthcare Community Plan (cont .)

Dental Care
UnitedHealthcare covers dental services in New York City, Nassau and Suffolk counties. UnitedHealthcare believes that providing you with good dental care is important to your overall health care. We offer dental care through contracts with individual dentists and group practices who are experts in providing highquality dental services. Covered services include regular and routine dental services such as preventive dental checkups, cleanings, Xrays, fillings and other services to check for any changes or abnormalities that may require treatment and/or followup care for you. You do not need a referral from your PCP to see adentist.
Vision Care
Services of an ophthalmologist, ophthalmic dispenser and optometrist, and coverage for contact lenses, polycarbonate lenses, artificial eyes, and/or replacement of lost or destroyed glasses, including repairs, when medically necessary. Artificial eyes are covered as ordered by a plan provider Eye exams, generally every two years, unless medically needed more often Glasses (new pair of Medicaid-approved frames every two years, or more often if medically needed) Low-vision exam and vision aids ordered by your doctor Specialist for eye diseases or defects
How to Access Dental Services

You do not need to select a primary care dentist as part of UnitedHealthcare. If you live in New York City, Nassau or Suffolk counties, you can choose any participating dentist by selecting a dentist listed in the provider directory, or you can call Member Services at 18004934647. Please present your UnitedHealthcare Community Plan ID card whenever you receive dental services. If you live in Cayuga, Madison, Herkimer, Oneida, Onondaga or Oswego counties and need to visit a dentist, make an appointment with any dentist that takes regular Medicaid. You will need to use your Medicaid card to pay for the visit.
Hospital Care
Inpatient care, such as surgery, inpatient physician visits, anesthesia and medically necessary services Outpatient care, such as ambulatory surgery, anesthesia, physician services and medically necessary services Lab, X-ray and other tests
Emergency Care
Emergency care services are procedures, treatments or services needed to evaluate or stabilize an emergency After you have received emergency care, you may need other care to make sure you remain in stable condition. Depending on the need, you may be treated in the emergency room, in an inpatient hospital Medicaid Member Handbook
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room or in another setting. This is called poststabilization services For more about emergency services, see page 14
Mental Health/ Chemical Dependence (Including Alcohol and Substance Abuse)

All inpatient mental health and chemical dependence services (including alcohol and substance abuse) Most outpatient mental health services (contact the plan for specifics) Medicaid recipients who receive SSI or who are certified blind or disabled get mental health and chemical dependence (including alcohol and substance abuse) services from any Medicaid provider by using their Medicaid benefit card. Detoxification services, however, are covered by the plan as abenefit
When the stay in the nursing home is not determined permanent by your LDSS (or HRA for New York City) Covered nursing home services include medical supervision, 24hour nursing care, assistance with activities of daily living, physical therapy, occupational therapy and speechlanguage pathology
Transportation
Emergency
If you need emergency transportation, pleasecall 911.
Non-Emergency Transportation
UnitedHealthcare wants to make sure that you get the medical care you need. That means making sure you are able to get to your medical appointments. We offer nonemergency transportation for our members living in Manhattan, Bronx, Kings, Queens, Richmond, Nassau, Suffolk and Onondagacounties.
Specialty Care
Includes the services of other practitioners, including: Occupational, physical and speech therapists and audiologists Midwives
Members Who Live in New York City

If you live in New York City, we will provide a Metro Card for you to get to and from your appointment the Metro Card will be mailed to you. Please request your Metro Card at least 10 days in advance of your appointment and we will send it to you on time for your appointment. Ifyou need to schedule an urgent medical appointment and are unable to tell us 10days before, call us as soon as you know about the appointment and we will either overnight a Metro Card to you, send it to you as reimbursement for your outofpocket transportation expense or 19
Residential Health Care Facility Care (Nursing Home)

When ordered by your physician and authorized by UnitedHealthcare
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Services Covered by UnitedHealthcare Community Plan (cont .)

arrange for another form of transportation. To be eligible for a Metro Card, the providers office must be 10blocks or more from where you live. If you have a disability or medical condition that prevents you from taking public transportation, we will arrange for car service, ambulette or stretcher transportation for you. Your PCP or other health care provider will be asked to document the medical reason why you are unable to use public transportation. If you are approved for car service, ambulette or stretcher transportation, you should request this form of transportation at least 3 days prior to your appointment. If you require an attendant to go with you to your doctors appointment or if your child is the member of the plan, transportation is also covered for the attendant or parent or guardian. If your child requires a car seat or booster seat, you must bring your own car seat or booster with you. We do not provide car seats or boosters. condition you have that requires these forms of transportation. If you require an attendant to go with you to your doctors appointment or if your child is the member of the plan, transportation is also covered for the attendant or parent or guardian. If your child requires a car seat or booster seat, you must bring your own car seat or booster with you. We do not provide car seats or boosters. Member Services is available to assist you with transportation needs 24 hours a day, 7daysaweek.
Members Who Live in Cayuga, Herkimer, Madison, Oneida and Oswego Counties
If you live in Cayuga, Herkimer, Madison, Oneida or Oswego counties, UnitedHealthcare does not provide nonemergency transportation in these counties. Please contact your local Department of Social Services to arrange for transportation. Phone numbers can be found on the inside cover of this handbook.
Members Who Live in Nassau, Onondaga and Suffolk Counties

For members who live in Nassau, Onondaga or Suffolk counties, we will provide car service to get you to and from your medical appointment. You should request transportation at least 3 days before your scheduled appointment so we can make arrangements for you. If you require special transportation like ambulette or stretcher transportation, your PCP may be asked to explain the medical
Other Covered Services

Durable medical equipment (DME)/ hearing aids/prosthetics/orthotics Court-ordered services Case management Social support services (help in getting community services) FQHC or similar services Podiatry for children and persons with special health problems (e.g., diabetes)
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Benefits You Can Get From UnitedHealthcare or With Your Medicaid ID Card
For some services, you can choose where to get the care. You can get these services by using your UnitedHealthcare Community Plan membership card. You can also go to providers who will take your Medicaid benefit card. Call us if you have questions at 18004934647.
Family Planning
You can go to any doctor or clinic that takes Medicaid and offers family planning services. You can visit one of our family planning providers as well. Either way, you do not need a referral from your PCP.
TB Diagnosis and Treatment

You can choose to go either to your PCP or to the county public health agency for diagnosis and/or treatment. You do not need a referral to go to the county public health agency.
HIV Testing and Counseling

You can get these services from UnitedHealthcare doctors if you talk to your PCP first. When you get these services as part of a family planning visit, you can go to any doctor or clinic that takes Medicaid and offers family planning services. You do not need a referral when you get this service as part of a family planning visit. You can also go to anonymous counseling and testing clinics offered by the state and local health departments. To get more information about these sites, call the New York State HIV Counseling Hotline at 18008722777 or 1800541AIDS.
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Benefits Using Your Medicaid Card Only
There are some services UnitedHealthcare does not provide. You can get these services from anyprovider who takes Medicaid by using your Medicaid benefit card.
Pharmacy
You can get prescriptions, overthecounter medicines, enteral formulas and some medical supplies from any pharmacy that takes Medicaid. A copayment may be required for some people, for some medications and for pharmacy items. Certain medications may require that your doctor get prior authorization from Medicaid before writing your prescription. Getting prior authorization is a simple process for your doctor and does not prevent you from getting medications that you need.
Hotline at 18005412831, and they will send you a list of dentists in your neighborhood.
Transportation
If you live in Cayuga, Herkimer, Madison, Oneida or Oswego counties, please contact your local Department of Social Services to arrange for transportation. Phone numbers can be found on the inside cover of this handbook.
Mental Health
Intensive psychiatric rehab treatment Day treatment Intensive case management Partial hospital care Rehab services to those in community homes or in familybased treatment Clinic services for children with a diagnosis of serious emotional disturbance (SED), at mental health clinics certified by the State Office of Mental Health Continuing day treatment All covered mental health services for people who receive SSI or who are certified blind or disabled are available by using the Medicaid benefit card
Dental Services
If you live in Cayuga, Herkimer, Madison, Oneida, Onondaga or Oswego counties, you can get dental care using your Medicaid benefit card. Medicaid covers regular and routine dental services such as preventive dental checkups, cleanings, Xrays, fillings and other services to check for any changes or abnormalities that may require treatment and/or followup care for you.
How to Access DentalServices

You can go to any dentist who acceptsMedicaid. If you need help finding a dentist or a dental clinic that is run by an academic dental center, call the New York State 22
Mental Retardation and Developmental Disabilities

Long-term therapies Day treatment Housing services Medicaid Service Coordination (MSC)program Services received under the Home and CommunityBased Services Waiver Medical Model (Care-at-Home) Waiverservices
Other Medicaid Services

Personal care services Preschool and school services programs (early intervention) Early start programs Comprehensive Medicaid Case Management (CMCM) program TB therapy/DOT Adult day treatment for persons withHIV Hospice services
Alcohol and Substance Abuse Services

Methadone treatment Outpatient substance abuse treatment Outpatient alcohol rehab Outpatient alcohol clinic services Chemical dependence (including alcohol and substance abuse) services covered by your LDSS (or HRA for New York City) Outpatient chemical dependence for youthprograms Chemical dependence (including alcohol and substance abuse) services ordered by the Human Resources Administration All covered alcohol and substance abuse services (except detoxification) are available for people who receive SSI or who are certified blind or disabled by using their Medicaid benefit card. Detoxification services are available using your UnitedHealthcare Community Plan IDcard New York 23
Services NOT Covered by Medicaid or UnitedHealthcare Community Plan

These services are not covered by UnitedHealthcare Community Plan or Medicaid. If you get any of these services, you may have to pay the bill. You will also have to pay the bill if you agree to pay privately for services. Theseservicesinclude: Cosmetic surgery if not medically needed Routine foot care for those 21 years and older (there are some exceptions) Personal and comfort items Infertility treatments Services of a provider that is not part of UnitedHealthcare (unless UnitedHealthcare authorizes you to go to that provider) Services for which you need an authorization (approval) in advance and you did not get it Chiropractic care (for those 21 years andolder) Services delivered outside the continental United States Immigration examination and immunization Except for medical emergencies as defined in this handbook, services received outside of the plans service area as described in this handbook. Youare covered for emergency and urgent care in the UnitedStates, Canada, the American territories of Puerto Rico, the Virgin Islands, Guam, Northern Mariana Islands, American Samoa and American territorialwaters You may have to pay for any service that your PCP or specialist does not approve. Also, if you agree to be a private pay or selfpay patient before you receive services, you will have to pay for these services. This includes: Non-covered services (listed above) Unauthorized services Services provided by providers not part ofUnitedHealthcare If you have any questions, call MemberServices at1-800-493-4647.
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Service Authorization and Actions
Prior Authorization
There are some treatments and services that you need to get approval for before you receive them or in order to be able to continue receiving them. This is called prior authorization. You or someone you trust can ask for this. Your health care provider can ask for this on your behalf. The following treatments and services must be approved before you get them: Admissions to inpatient facilities (example:hospital, except for maternity) Home health care services Durable medical equipment (DME) over$500 Prosthetic and orthotic devices over $500 Cosmetic and reconstructive surgery Gastric bypass evaluations and surgery Hospice services, inpatient and outpatient Advanced radiology services including MRI, MRA and PET scans Accidental dental services Experimental or investigational health care services Out-of-network or out-of-state services Mental health or substance abuse services Physical, occupational and speech therapy after the 6th visit Transplant evaluations Asking for approval of a treatment or service is called a service authorization request. To get approval for these treatments or services, your doctor or health care provider must call UnitedHealthcares Prior Authorization New York
Department at 18666043267, or your physician or health care provider may send a request in writing or by fax at 18007717507. Written physician or health care provider requests can be sent to: UnitedHealthcare Community Plan NewYork 9700 Bissonnet Street, Suite 2700 Houston, TX 77036-8000 You will also need to get prior authorization if you are getting one of these services now, but need to continue or get more of the care. This includes a request for home health care while you are in the hospital or after you have just left the hospital. This is called concurrentreview. Home health care (HHC) services that follow an inpatient hospital admission are evaluated and determined in the same manner as if you are already getting the service now, but need to continue or get more of the care (concurrentreview).
What Happens After We Get Your Service AuthorizationRequest

The health plan has a review team to be sure you get the services that are covered by our plan if medically necessary. Doctors and nurses are on the review team. Their job is to be sure the treatment or service you asked for is medically needed and right for you. They do this by checking your treatment plan against medically acceptable standards.
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Service Authorization and Actions (cont .)
Any decision to deny a service authorization request or to approve it for an amount that is less than requested is called an action. These decisions will be made by a qualified health care professional. If we decide that the requested service is not medically necessary, the decision will be made by a clinical peer reviewer, who may be a doctor or may be a health care professional who typically provides the care you requested. You or someone you trust can request the specific medical standards, called clinical review criteria, used to make the decision for actions related to medical necessity. After we get your request, we will review it under a standard or expedited process. You or your doctor can ask for an expedited review if it is believed that a delay will cause serious harm to your health. If your request for an expedited review is denied, we will tell you and your case will be handled under the standard review process. If you are in the hospital or have just left the hospital and we received a request for home health care, we will handle the request as a fast track review. In all cases, we will review your request as fast as your medical condition requires us to do so, but no later than mentioned below. We will tell you and your provider both by phone and in writing if your request is approved or denied. We will also tell you the reason for the decision. We will explain what options for appeals or fair hearings you will have if you dont agree with our decision.
Timeframes for Prior Authorization Requests

Standard review: We will make a decision about your request within 3working days of when we have all the information we need, but you will hear from us no later than 14 days after we receive your request. We will tell you by the 14th day if we need more information. Fast track review: We will make a decision and you will hear from us within 3 working days. We will tell you by the 3rd working day if we need more information. We will tell attempt to tell you our decision by phone and send a written notice later.
Timeframes for Concurrent Review Requests

Standard review: We will make a decision within 1 working day of when we have all the information we need, but you will hear from us no later than 14days after we received your request. Wewill tell you by the 14th day if we need moreinformation. With respect to requests for home health care (HHC) immediately following an inpatient hospital admission, we will make a decision within 1 working day of when we have all the information we need, but you will hear from us no later than 14 days after we received your request or within 72 hours of receipt of the necessary information when the day after the request date falls on a weekend orholiday. Medicaid Member Handbook
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Fast track review: We will make a decision within 1 working day of when we have all the information we need. However, if you are in the hospital or have just left the hospital, and you ask for home health care on a Friday or day before a holiday, we will make a decision no later than 72 hours of when we have all the information we need. In all cases you will hear from us no later than 3 working days after we received your request. We will tell you by the 3rd working day if we need moreinformation. We will attempt to tell you our decision by phone and send a written notice later. If we need more information to make either a standard or fast track decision about your service request, we will: Write and tell you what information is needed. If your request is in a fast track review, we will call you right away and send a written notice later Tell you why the delay is in your bestinterest Make a decision no later than 14 days from the day we asked for more information You, your provider or someone you trust may also ask us to take more time to make a decision. This may be because you have more information to give the plan to help decide your case. This can be done by calling 18004934647 or by fax at 18007717507.
Written physician or health care provider requests can be sent to: UnitedHealthcare Community Plan NewYork 9700 Bissonnet Street, Suite 2700 Houston, TX 77036-8000 You or someone you trust can file a complaint with the plan if you dont agree with our decision to take more time to review your request. You or someone you trust can file a complaint with the New York State Department of Health by calling 18002068125. We will notify you of our decision by the date our time for review has expired. But if for some reason you do not hear from us by that date, it is the same as if we denied your service authorization request. If you are not satisfied with this answer, you have the right to file an action appeal with us. See the Action Appeal section later in this handbook.
Other Decisions About Your Care

Sometimes we will do a concurrent review on the care you are receiving to see if you still need the care. We may also review other treatments and services you have already received. This is called retrospective review. We will tell you if we take these other actions.
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Service Authorization and Actions (cont .)
Timeframes for Notice of Other Actions

In most cases, if we make a decision to reduce, suspend or terminate a service we have already approved and you are now getting, we must tell you at least 10 days before we change the service. If we are checking care that has been given in the past, we will make a decision about paying for it within 30 days of receiving necessary information for the retrospective review. If we deny payment for a service, we will send a notice to you and your provider the day the payment is denied. You will not have to pay for any care you received that was covered by the plan or by Medicaid even if we later deny payment to the provider.
How Our Providers ArePaid

You have the right to ask us whether we have any special financial arrangement with our physicians that might affect your use of health care services. You can call Member Services at 18004934647 if you have specific concerns. If our PCPs work in a clinic or health center, they probably get a salary. The number of patients they see does not affectthis. Our PCPs who work from their own offices may get a set fee each month for each patient for whom they are the patients PCP. The fee stays the same whether the patient needs one visit or many or even none at all. This is calledcapitation. Providers may also be paid by feeforservice. This means they get a planagreedupon fee for each service theyprovide.
You Can Help With Plan Policies

We value your ideas. You can help us develop policies that best serve our members. If you have ideas, tell us about them. Maybe youd like to work with one of our member advisory boards or committees. Call Member Services at 18004934647 to find out how you canhelp.
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Information From Member Services
Here is information you can get by calling Member Services at 18004934647: A list of names, addresses and titles of UnitedHealthcares Board of Directors, officers, controlling parties, owners andpartners A copy of the most recent financial statements/balance sheets, summaries of income and expenses A copy of the most recent individual direct pay subscriber contract Information from the State Insurance Department about consumer complaints about UnitedHealthcare How we keep your medical records and member information private In writing, we will tell you how UnitedHealthcare checks on the quality of care to our members We will tell you which hospitals our health providers work with
If you ask us in writing, we will tell you the guidelines we use to review conditions or diseases that are covered byUnitedHealthcare If you ask in writing, we will tell you the qualifications needed and how health care providers can apply to be part ofUnitedHealthcare If you ask, we will tell you: 1) whether our contracts or subcontracts include physician incentive plans that affect the use of referral services, and, if so, 2) information on the type of incentive arrangements used, and 3) whether stoploss protection is provided for physicians andphysiciansgroups Information about how our company is organized and how it works Please send all written requests to: Member Services UnitedHealthcare Community Plan NewYork 77 Water Street, 14th Floor New York, NY 10005
Keep Us Informed
Call Member Services whenever these changes happen in your life: You change your name, address or telephone number You have a change in Medicaid eligibility You are pregnant You give birth There is a change in insurance for you or your children
If you no longer get Medicaid, check with the Human Resources Administration or your Local Department of Social Services. You may be able to enroll your children in Child Health Plus, even if you lose Medicaid. Adults age 19 to 64 may be able to get Family Health Plus coverage. New York 29
Disenrollment and Transfers
When Your County Requires You to Joina Medicaid Health Plan (aMandatory County)
You can try us out for 90 days. You may leave UnitedHealthcare and join another health plan at any time during that time. If you do not leave in the first 90 days, however, you must stay in UnitedHealthcare for nine more months, unless you have a good reason (goodcause). Some examples of good cause include: Our health plan cannot provide a suitable primary care provider for you within acceptable travel times (if providers are routinely within 30 minutes or 30 miles from where you live) Our health plan does not meet New York State requirements and members are harmed because of it You move out of our service area You, the plan and your local Department of Social Services (HRA in New York City) all agree that disenrollment is best for you You are or become exempt or excluded from managed care We do not offer a Medicaid managed care service that you can get from another health plan in your area You need a service that is related to a benefit we have chosen not to cover and getting the service separately would put your health at risk We have not been able to provide services to you as we are required to under our contract with the state 30
When your county lets you decide to join a Medicaid health plan or not (a voluntary county), you can ask to leave the plan at any time for any reason.
To Disenroll or Change Plans

Call the managed care staff at your local Department of Social Services. The phone numbers are listed in this handbook. InNewYork City, Cayuga, Madison, Nassau or Suffolk counties, call New York Medicaid CHOICE at 18005055678 to change healthplans. It will take between 2 and 6 weeks to process your request, depending on when it is received. You can ask for faster action if you believe the timing of the regular process will cause added damage to your health. You can also ask for faster action if you have complained because you did not agree to the enrollment. Just call your local Department of Social Services or New York MedicaidCHOICE. If you have to be in managed care, you will have to choose another health care plan. Callthe managed care unit of your local Department of Social Services or New York Medicaid CHOICE to get a transfer or disenrollment packet. Be sure to let them know you are disenrolling from UnitedHealthcare and if you want to reenroll in a new plan. You will get a notice that the change will take place by a certain date. In most cases, we will provide the care you need until then.
You Could Become Ineligible forMedicaid Managed Care

You or your child may have to leave UnitedHealthcare if you or the child: Moves out of the county or service area Changes to another managed care plan Joins an HMO or other insurance plan through work Joins a long-term home health careprogram Goes to prison Becomes a permanent resident of a nursinghome Your child may have to leave UnitedHealthcare if he or she: Joins a physically handicapped childrensprogram Is placed in foster care (voluntarily by parent/guardian or by a decision of the local Social Services Commissioner) In some cases, you may be guaranteed coverage by UnitedHealthcare. That means we will not drop you as a member during the first 6months of your enrollment in our plan even if you are no longer eligible for Medicaid and your Medicaid case is closed. The reasons for losing eligibility must not be related to death, moving out of state or incarceration. During this time you can get the services that UnitedHealthcare covers. You can also get pharmacy and family planning care using your Medicaid card. Guaranteed coverage does not apply if you choose to leave UnitedHealthcare.
We Can Ask You to Leave UnitedHealthcare

You can also lose your UnitedHealthcare Community Plan membership if you often: Refuse to work with your PCP in regard to your care Dont keep appointments Go to the emergency room for nonemergency care Dont follow UnitedHealthcares rules Do not fill out forms honestly or do not give true information (commit fraud) Cause abuse or harm to plan members, providers or staff Act in ways that make it hard for us to do our best for you and other members even after we have tried to fix the problems
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Action Appeals
There are some treatments and services that you need to get approval for before you receive them or in order to be able to continue receiving them. This is called prior authorization. Askingfor approval of a treatment or service is called a service authorization request. This process is described earlier in this handbook. Any decision to deny a service authorization request or to approve it for an amount that is less than requested is called an action appeal. If you are not satisfied with our decision about your care, steps to request a review of an action include provider reconsideration and an action appeal.
Your Provider Can Ask forReconsideration

If we made a decision that your service authorization request was not medically necessary or was experimental or investigational and we did not talk to your doctor, your doctor may ask to speak with the plans medical director. The medical director will talk to your doctor within 1 working day.
You Can File an ActionAppeal

If you are not satisfied with an action we took or what we decide about your service authorization request, you have 60working days from the date of our letter/notice to you to file an action appeal. You can do this yourself or ask someone you trust to file the action appeal for you. You can call Member Services at 18004934647 if you need help filing an action appeal. We will not treat you any differently or act badly toward you because you filed an action appeal.
The action appeal can be made by phone or in writing. If you make an action appeal by phone, it must be followed up in writing. You must also sign the written action appeal that you send to us. You or your designee must sign the written action appeal. You can ask someone you trust (such as a legal representative, a family member or friend) can request an action appeal for you. If you need our help because of a hearing or vision impairment, if you need translation services, or if you need help filling out the forms, we can help you. We will not make things hard for you or take any action against you for filing an action appeal. Please send all written appeals to: Member Complaints, Grievances andAppeals UnitedHealthcare Community Plan NewYork P.O. Box 31364 Salt Lake City, UT 84131-0364
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Your Action Appeal Will Be Reviewed Under the Fast Track Process If:
If you or your doctor asks to have your action appeal reviewed under the fast track process. Your doctor would have to explain how a delay will cause harm to your health. If your request for fast track is denied, we will tell you and your action appeal will be reviewed under the standardprocess. If your request was denied when you asked to continue receiving care that you are now getting or need to extend a service that has been provided. If your request was denied when you asked for home health care after you were in thehospital. Fast track action appeals can be made by phone and do not have to be followed up inwriting.
What Happens After We Get Your Action Appeal

Within 15 days, we will send you a letter to let you know we are working on your action appeal. Action appeals of clinical matters will be decided by qualified health care professionals who did not make the first decision, at least one of whom will be a clinical peer reviewer. Non-clinical decisions will be handled by persons who work at a higher level than the people who worked on your first decision.
Before and during the action appeal you or your designee can see your case file, including medical records and any other documents and records being used to make a decision on your case. You can also provide information to be used in making the decision in person or in writing. Call Member Services at 18004934647 if you are not sure what information to give us. If you are appealing our decision that the outofnetwork service you asked for was not different from a service that is available in our network, ask your doctor to send us: 1. A written statement that the service you asked for is different from the service we have in our network; and 2. 2 pieces of medical evidence (published articles or scientific studies) that show the service you asked for is better for you, and will not cause you more harm than the service we have in our network. You will be given the reasons for our decision and our clinical rationale, if it applies. If you are still not satisfied, any further appeal rights will be explained or you or someone you trust can file a complaint with the New York State Department of Health at 18002068125.
Time Frames for ActionAppeals

Standard action appeals: If we have all the information we need, we will tell you our decision within 30 days from your action appeal. A written notice of our decision
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Action Appeals (cont .)
will be sent within 2 working days from when we make the decision. Fast track action appeals: If we have all the information we need, expedited appeal decisions will be made within 2 working days from your action appeal. We will tell you in 3 working days after giving us your action appeal, if we need more information. We will tell you our decision by phone and send a written notice as well. If we need more information to make either a standard or fast track decision about your action appeal, we will: Write you and tell you what information is needed. If your request is in a fast track review, we will call you right away and send a written notice later. Tell you why the delay is in your bestinterest. Make a decision no later than 14 days from the day we asked for more information. You, your provider or someone you trust may also ask us to take more time to make a decision. This may be because you have more information to give the plan to help decide your case. This can be done by calling 18004934647 or in writing. Please send written requests to: UnitedHealthcare Community Plan NewYork P.O. Box 31364 Salt Lake City, UT 84131-0364 You or someone you trust can file a complaint if you dont agree with our decision to take more time to review your request. You can file
this complaint with the health plan by calling Member Services at 18004934647 (you have trouble hearing, call the TDD Relay Service at 18006621220), or contact the NewYork State Department of Health by calling 18002068125. If your original denial was because we said the service was not medically necessary, the service was experimental or investigational, orthe outofnetwork service was not different from a service that is available in our network and we do not tell you our decision about your action appeal on time, the original denial of service will be reversed. This means your service authorization request will be approved.
Aid to Continue While Appealing a Decision About Your Care

In some cases you may be able to continue the services while you wait for your action appeal case to be decided. You may be able to continue the services that are scheduled to end or be reduced if you ask for a fair hearing: Within 10 days from being told that your request is denied or care is changing By the date the change in services is scheduled to occur If your fair hearing results in another denial, you may have to pay for the cost of any continued benefits that you received. Thedecision you receive from the fair hearing officer will be final.
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External Appeals
If the plan decides to deny coverage for a medical service you and your doctor asked forbecause the service not medically necessary, the service was experimental or investigational, or the out of-network service was not different from a service that is available in our network you can ask New York State for an independent external appeal. This is called an external appeal because it is decided by reviewers who do not work for the health plan or the state. These reviewers are qualified people approved by New York State. The service must be in the plans benefit package, or be an experimental treatment, clinical trial or treatment for a rare disease. You do not have to pay for an external appeal. Before you appeal to the state: 1. You must file an action appeal with the plan and get the plans final adverse determination; or 2. If you had an fast track action appeal and are not satisfied with the plans decision, you can choose to file a standard action appeal with the plan or go directly to an external appeal; or 3. You and the plan may agree to skip the plans appeals process and go directly to external appeal.
You have 45 days after you receive the plans final adverse determination to ask for an external appeal. If you and the plan agreed to skip the plans appeals process, then you must ask for the external appeal within 45 days of when you made that agreement. Additional appeals to your health plan may be available to you if you want to use them. However, if you want an external appeal, you must still file the application with the State Department of Insurance within 45 days from the time the plan gives you the notice of final adverse determination or when you and the plan agreed to waive the plans appeal process. You will lose your right to an external appeal if you do not file an application for an external appeal on time. To ask for an external appeal, fill out an application and send it to the State Insurance Department. You can call Member Services at 18004934647 if you need help filing an appeal. You and your doctors will have to give information about your medical problem. The external appeal application says what information will be needed. Here are some ways to get an application: Call the State Insurance Department at 18004008882 Go to the State Insurance Departments website at www.ins.state.ny.us Contact the health plan at 18004934647
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External Appeals (cont .)
Your external appeal will be decided in 30days. More time (up to 5 working days) may be needed if the external appeal reviewer asks for more information. You and the plan will be told the final decision within 2 days after the decision is made. You can get a faster decision if your doctor says that a delay will cause serious harm to your health. This is called an expedited external appeal. The external appeal reviewer will decide an expedited appeal in 3 days or fewer. The reviewer will tell you and the plan the decision right away by phone or fax. Later, a letter will be sent that tells you thedecision. You may also ask for a fair hearing if the plan decided to deny, reduce or end coverage for a medical service. You may request a fair hearing and ask for an external appeal. If you ask for a fair hearing and an external appeal, the decision of the fair hearing officer will be the one that counts.
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Fair Hearings
In some cases you may ask for a fair hearing from New York State if: You are not happy with a decision your local Department of Social Services (HRAfor NYC) or the State Department of Health made about your staying or leaving UnitedHealthcare. You are not happy with a decision we made about medical care you were getting. You feel the decision limits your Medicaid benefits or that we did not make the decision in a reasonable amount of time. You are not happy about a decision we made that denied medical care you wanted. You feel the decision limits your Medicaid benefits. You are not happy with a decision your doctor would not order services you wanted. You feel the doctors decision stops or limits your Medicaid benefits. You must file a complaint with UnitedHealthcare. If UnitedHealthcare agrees with your doctor, you may ask for a State fair hearing. The decision you receive from the fair hearing officer will be final. In some cases you may be able to keep getting care the same way while waiting for your fair hearing. If the services you are now getting are scheduled to end, you can choose to ask to continue the services your doctor ordered while you wait for your case to be decided. However, if you choose to ask for services to be continued and the fair hearing is decided against you, you may have to pay the cost for the services you received while waiting for adecision.
You can use one of the following ways to request a fair hearing: 1.By phone: 18003423334 (tollfree) 2. By fax: 15184736735 3. By Internet: www.otda.state.ny.us/oah/forms.asp 4. By mail: Fair Hearing Section NYS Office of Temporary and DisabilityAssistance P.O. Box 1930 Albany, NY 12201 Remember, you can file a complaint any time to the New York State Department of Health by calling 18002068125.
New York
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Complaint Process
Complaints
We hope our plan serves you well. Most problems can be solved right away. If you have a problem or dispute with your care or services, you can file a complaint with the plan. Problems that are not solved right away over the phone and any complaint that comes in the mail will be handled according to our complaint procedure described below.
How to File a Complaint With the Plan

If you have a problem, please call MemberServices at 18004934647 so they can assist you. If you want to file a complaint after discussing the problem with Member Services, Member Services can help you do so. Or you can write to us at: Member Complaints, Grievances andAppeals UnitedHealthcare Community Plan NewYork P.O. Box 31364 Salt Lake City, UT 84131-0364 You can ask someone you trust (such as a legal representative, family member or friend) to file the complaint for you. If you need our help because of a hearing or vision impairment, or if you need translation services, we can help you. We will not make things hard for you or take any action against you for filing a complaint. You also have the right to contact the New York State Department of Health about your complaint at 18002068125, or write to NewYork State Department of Health, Division of Managed Care, Bureau of Managed Care Certification and Surveillance, Room 1911 Corning Tower ESP, Albany,NY12237. You may also contact
your local Department of Social Services with your complaint at any time. You may call the New York State Insurance Department at 18003423736 if your complaint involves a billing problem.
What Happens Next

If we dont solve the problem right away over the phone or after we get your written complaint, we will send you a letter within 15working days. The letter will tell you: Who is working on your complaint How to contact someone at the plan about your complaint If we need more information Your complaint will be reviewed by one or more qualified people. If your complaint involves clinical matters, your case will be reviewed by one or more qualified health careprofessionals.
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After We Review Your Complaint

We will let you know our decision in 45days of when we have all the information we need to answer your complaint, and you will hear from us in no more than 60 days from the day we get your complaint. We will write to you and will tell you the reasons for our decision. When a delay would risk your health, we will let you know our decision in 48hours of when we have all the information we need to answer your complaint, and you will hear from us in no more than 7days from the day we get your complaint. Wewill call you with our decision or try to reach you to tell you. You will get a letter to follow up our communication in 3workingdays. You will be told how to appeal our decision if you are not satisfied, and we will include any forms you may need. If we are unable to make a decision about your complaint because we dont have enough information, we will send a letter and let you know.
New York
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Complaint Appeals
If you disagree with a decision we made about your complaint, you or someone you trust can file a complaint appeal with the plan.
How to Make a ComplaintAppeal

If you are not satisfied with what we decide, you have 60 working days from the date of our letter/notice to you to file anappeal You can do this yourself or ask someone you trust to file the appeal for you The appeal must be made in writing. Ifyou make an appeal by phone, it must be followed up in writing. After your call, we will send you a form that is a summary of your phone appeal. If you agree with our summary, you must sign and return the form to us. You can make any needed changes before sending the form back to us. Please send all written correspondenceto: Complaint Appeals UnitedHealthcare Community Plan New York 77 Water Street, 14th Floor New York, NY 10005
Your complaint appeal will be reviewed by one or more qualified people at a higher level than those who made the first decision about your complaint. If your complaint appeal involves clinical matters, your case will be reviewed by one or more qualified health professionals, with at least one clinical peer reviewer, that were not involved in making the first decision about your complaint. After we get all the information we need, we will let you know our decision within 2working days when a delay would risk your health. For all other complaint appeals, we will let you know our decision in 30 days. We will give you the reasons for our decision and our clinical rationale, if it applies. If you are still not satisfied, you or someone on your behalf can file a complaint at any time with the New York State Department of Health at 18002068125; or you can write to the NYS Department of Health, Division of Managed Care, Bureau of Managed Care Certification and Surveillance, Room 1911 Corning Tower ESP, Albany, NY 12237.
What Happens After We Get Your Complaint Appeal

After we get your complaint appeal we will send you a letter within 15 working days. The letter will tell you: Who is working on your complaint appeal How to contact someone at UnitedHealthcare about your complaintappeal If we need more information
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Member Rights and Responsibilities
Your Rights
As a member of UnitedHealthcare, you have a right to: Be cared for with respect, without regard for health status, sex, race, color, religion, national origin, age, marital status or sexual orientation. Be told where, when and how to get the services you need from UnitedHealthcare. Be told by your PCP what is wrong, what can be done for you, and what will likely be the result in language you understand. Get a second opinion about your care. Give your OK to any treatment or plan for your care after it has been fully explained to you. Refuse care and be told what you may risk if you do. Get a copy of your medical record and talk about it with your PCP, and to ask that your medical record be amended or corrected, if needed. Be sure that your medical record is private and will not be shared with anyone except as required by law, contract or with yourapproval. Use the UnitedHealthcare complaint system to settle any complaints, or you can complain to the New York State Department of Health or the local Department of Social Services any time you feel you were not fairly treated.
Use the State Fair Hearing system. Appoint someone (relative, friend, lawyer, etc.) to speak for you if you are unable to speak for yourself about your care andtreatment. Receive considerate and respectful care in a clean and safe environment free of unnecessary restraints.
If You Get a Bill

UnitedHealthcare provides a full range of health care services at no cost to you. You never have to pay your PCP or any other UnitedHealthcare participating provider anything. You should not be charged for any approved services offered through UnitedHealthcare when you get them from a UnitedHealthcare Community Plan provider. If you are asked to pay for services by a UnitedHealthcare Community Plan provider, remind the office that you are covered by UnitedHealthcare and present your UnitedHealthcare Community Plan member ID card. You can also call Member Services at 18004934647 for help. You may be asked to pay for services that are not covered by Medicaid or UnitedHealthcare. You cannot be charged for any such service unless you understood and agreed before the care was given that you would pay for it.
New York
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Member Rights and Responsibilities (cont .)
If you get a medical bill, call Member Services at 18004934647, and a representative will help you straighten out the problem. Most bills should include a billing number you can call to give them your UnitedHealthcare Community Plan member ID number and ask them to bill UnitedHealthcare. If you are asked to pay for a service and you are not sure whether it is covered, call Member Services at 18004934647 before paying for the service. If you paid a bill and you are seeking reimbursement, call Member Services at 18004934647 and a representative will assistyou.
Your Responsibilities
As a member of UnitedHealthcare, you agreeto: Work with your PCP to guard and improve your health Find out how your health care systemworks Listen to your PCPs advice and ask questions when you are in doubt Call or go back to your PCP if you do not get better, or ask for a second opinion Treat health care staff with the respect you expect yourself Tell us if you have problems with any health care staff. Call Member Services Keep your appointments. If you must cancel, call as soon as you can Use the emergency room only for real emergencies Call your PCP when you need medical care, even if it is after hours
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Advance Directives
There may come a time when you cant decide about your own health care. By planning in advance, you can arrange now for your wishes to be carried out. First, let family, friends and your doctor know what kinds of treatment you do or dont want. Second, you can appoint an adult you trust to make decisions for you. Be sure to talk with your PCP, your family or others close to you so they will know what you want. Third, it is best if you put your thoughts in writing. The documents listed below can help. You do not have to use a lawyer, but you may wish to speak with one about this. You can change your mind and these documents at any time. We can help you understand or get these documents. They do not change your right to quality health care benefits. The only purpose is to let others know what you want if you cant speak for yourself. Health Care Proxy With this document, you name another adult that you trust (usually a friend or family member) to decide about medical care for you if you are not able to do so yourself. If you do this, you should talk with the person so they know what you want. CPR and DNRYou have the right to decide if you want any special or emergency treatment to restart your heart or lungs if your breathing or circulation stops. If you do not want special treatment, including cardiopulmonary resuscitation (CPR), you should make your wishes known in writing.
Your PCP will provide a DNR (Do Not Resuscitate) order for your medical records. You can also get a DNR form to carry with you and/or a bracelet to wear that will let any emergency medical provider know about yourwishes. Organ Donor Card This walletsized card says that you are willing to donate parts of your body to help others when you die. Also, check the back of your drivers license to let others know if and how you want to donate your organs.
New York
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Privacy Notice
Medical Information
Effective January 1, 2010. This says how medical information about you may be used and shared. It says how you can get access to this information. Read it carefully. We1 must by law protect the privacy of your health information. We must send you this notice. Ittells you: How we may use your health information. When we can share your health information with others. What rights you have to your health information. We must by law follow the terms of this notice. Health information in this notice means information that can be used to identify you. And it must relate to your health or health care. We have the right to change our privacy practices. If we change them, we will mail a notice within 60 days. We will post the new notice on our website www.uhccommunityplan.com. We have the right to make changes apply to health information that we have and future information that we may receive.
We have the right to use and share health information for your treatment, to pay for care and to run our business. For example, we may use and share it: To pay premiums, determine coverage and process claims. This also may include coordinating benefits. For example, we may tell a doctor you have coverage. We may tell a doctor how much of the bill may be covered. For treatment or managing care. For example, we may share your health information with providers to help them give you care. For health care operations related to your care. For example, we may suggest a disease management or wellness program. We may study data to see how we can improve our services. To tell you about health programs. This may be other treatments or products and services. These activities may be limited by law as of February 17, 2010. For reminders on benefits or care. Such as appointment reminders. We may use or share your health information as follows: As stated by law. To persons involved with your care. This may be to a family member. This may happen if you are unable to agree or object, such as in an emergency or when you agree or fail to object when asked. If you are not able to object, we will use our best judgment.
How We Use or Share Information

We must use and share your health information if asked for by: You or your legal representative. The Secretary of the Department of Health and Human Services to make sure your privacy is protected.
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For public health activities. This may be to prevent disease outbreaks. For reporting abuse, neglect or domestic violence. We may only share with entities allowed by law to get this health information. This may be a social or protective service agency. For health oversight activities to an agency allowed by the law to get the health information. This may be for licensure, audits and fraud and abuse investigations. For judicial or administrative proceedings. Such as to answer a court order orsubpoena. For law enforcement. Such as to find a missing person or report a crime. For threats to health or safety. This may be to public health agencies or law enforcement. Such as in an emergency ordisaster. For government functions. This may be for military and veteran use, national security, or the protective services. For workers compensation. To comply with labor laws. For research. Such as to study disease or disability, as allowed by law. To give information on descendants. This may be to a coroner or medical examiner. Such as to identify the deceased, find a cause of death or as stated by law. We may give health information to funeraldirectors. For organ transplant. To help get bank or transplant organs, eyes or tissue.
To correctional institutions or law enforcement. For persons in custody: (1)To give health care. (2) To protect your health and the health of others. (3) For the security of the institution. To our business associates if needed to give you services. Our associates agree to protect your health information. They are not allowed to use health information other than as per our contract with them. As of February 17, 2010, our associates will be subject to federal privacy laws. To notify of a data breach. To give notice of unauthorized access to your health information. We may send notice to you. Other restrictions. Federal and state laws may limit the use and sharing of highly confidential health information. This may include state laws on HIV/AIDS, mental health, genetic tests, alcohol and drug abuse, sexually transmitted diseases and reproductive health, or child/adult abuse, neglect or sexual assault. If stricter laws apply, we try to meet those laws. Attached is a summary of federal and state laws. Except as stated in this notice, we use your health information only with your written consent. If you allow us to share your health information, we do not promise that the person who gets it will not share it. You may take back your consent, unless we have acted on it. To find out how, call the phone number on the back of your ID card.
New York
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Privacy Notice (cont .)
Your Privacy Rights

You have a right: To ask us to limit use or sharing for treatment, payment, or health care operations. You can ask to limit sharing with family members or others involved in your care or payment for it. We may allow dependents to ask for limits. We will try to honor your request, but we do not have to do so. To ask a provider not to send health information to us if you paid for the care in full. To ask to get confidential communications in a different way or place. (For example, at a P.O. Box instead of your home.) We will agree to your request when a disclosure could endanger you. We take verbal requests. You can change your request. This must be in writing. Mail it to the address below. To see or get a copy of health information that we use to make decisions about you. You must ask in writing. Mail it to the address below. We may send you a summary. We may charge for copies. We may deny your request. If we deny your request, you may have the denial reviewed. As of February 17, 2010, if we keep an electronic record, you may ask for an electronic copy to be sent to you or a third party. We may charge a fee for this. To ask to amend. If you think your health information is wrong or incomplete you can ask to change it. You must ask in writing. You must give the reasons for the
change. Mail this to the address below. If we deny your request, you may add your disagreement to your health information. To get an accounting of health information shared in the six years prior to your request. This will not include any health information shared: (i) Prior to April 14, 2003. (ii) For treatment, payment, and health care operations. (iii) With you or with your consent. (iv) With correctional institutions or law enforcement. This will not list disclosures if federal law does not make us keep track of them. To get a paper copy of this notice. You may ask for a copy at any time. Even if you agreed to get this notice electronically, you have a right to a paper copy. You may also get a copy at our website: www.uhccommunityplan.com. Using Your Rights To ask privacy questions: Call Member Services at 18004149025. To submit a written request: mail to: UnitedHealthcare Community Plan PSMG Privacy Office MN006W800 P.O. Box 1459 Minneapolis, MN 55440 To file a complaint: if you think your privacy rights have been violated, you may send a complaint at the address above. You may also notify the Secretary of the U.S. Department of Health and Human Services. We will not take any action against you for filing a complaint.
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Financial Information
Effective January 1, 2010. This notice says how your financial information may be used and shared. It says how you can get access to this information. Review it carefully. We2 protect your personal financial information. This is nonhealth information about an enrollee or an applicant obtained to provide coverage. It is information that identifies the person and is not public.
Your Right to Access and Correct Information

You have a right to ask for access to your financial information. You can ask: For the source of the financial information. For a list of disclosures made in the two years before your request. To view and copy your financial information in person. For a copy to be sent. We may charge afee. For corrections, amendments or deletions. Follow these directions: To access your financial information: Send a request in writing with your name, address, social security number, phone number and the financial information you want to access. State if you want access in person or a copy sent. When we get your request, we will contact you within 30 business days. To correct, amend, or delete any of your financial information: Send a request in writing with your name, address, social security number, phone number, the financial information in dispute and the identity of the document or record. Upon receipt of your request, we will contact you within 30 business days. We will tell you if we have made the correction, amendment or deletion. Or we will tell you we refuse to do so and the reasons why. You may challenge this. Send requests to: UnitedHealthcare Community Plan Customer Service Privacy Unit PO Box 740815 Atlanta, GA 303740815 47
Information We Collect
We get financial information about you from: Applications or forms. This may be name, address, age and social security number. Your transactions with us or others. This may be premium payment data.
Sharing of Financial Information

We do not share financial information about our enrollees or former enrollees, except as required or permitted by law. To run our business, we may share financial information without your consent to our affiliates. This is to tell them about your transactions, such as premium payment.
Confidentiality and Security

We limit access to your financial information to our employees and providers who manage your coverage and provide services. We have physical, electronic and procedural safeguards per federal standards to guard your financial information. We do regular audits to ensure secure handling. New York
Privacy Notice (cont .)
This Medical Information Notice of Privacy Practices applies to the following health plans that are affiliated with UnitedHealth Group: ACN Group of California, Inc.; All Savers Insurance Company; All Savers Insurance Company of California; American Medical Security Life Insurance Company; AmeriChoice of Connecticut, Inc.; AmeriChoice of Georgia, Inc.; AmeriChoice of New Jersey, Inc.; AmeriChoice of Pennsylvania, Inc.; Arizona Physicians IPA, Inc.; Arnett HMO, Inc.; Dental Benefit Providers of California, Inc.; Dental Benefit Providers of Illinois, Inc.; Evercare of Arizona, Inc.; Evercare of New Mexico, Inc.; Evercare of Texas, LLC; Golden Rule Insurance Company; Great Lakes Health Plan, Inc.; Health Plan of Nevada, Inc.; IBA Health and Life Assurance Company; MAMSI Life and Health Insurance Company; MD Individual Practice Association, Inc.; Midwest Security Life Insurance Company; National Pacific Dental, Inc.; Neighborhood Health Partnership, Inc.; Nevada Pacific Dental; Optimum Choice, Inc.; Oxford Health Insurance, Inc.; Oxford Health Plans (CT), Inc.; Oxford Health Plans (NJ), Inc.; Oxford Health Plans (NY), Inc.; Pacific Union Dental, Inc.; PacifiCare Behavioral Health of California, Inc.; PacifiCare Behavioral Health, Inc.; PacifiCare Dental; PacifiCare Dental of Colorado, Inc.; PacifiCare Insurance Company; PacifiCare Life and Health Insurance Company; PacifiCare Life Assurance Company; PacifiCare of Arizona, Inc.; PacifiCare of California; PacifiCare of Colorado, Inc.; PacifiCare of Nevada, Inc.; PacifiCare of Oklahoma, Inc.; PacifiCare of Oregon, Inc.; PacifiCare of Texas, Inc.; PacifiCare of Washington, Inc.; Sierra Health & Life Insurance Co., Inc.; Spectera, Inc.; U.S. Behavioral Health Plan, California; Unimerica Insurance Company; Unimerica Life Insurance Company of New York; Unison Family Health Plan of Pennsylvania, Inc.; Unison Health Plan of Delaware, Inc.; Unison Health Plan of Ohio, Inc.; Unison Health Plan of Pennsylvania, Inc.; Unison Health Plan of South Carolina, Inc.; Unison Health Plan of Tennessee, Inc.; Unison Health Plan of the Capital Area, Inc.; United Behavioral Health; UnitedHealthcare Insurance Company; UnitedHealthcare Insurance Company of Illinois; UnitedHealthcare Insurance Company of New York; UnitedHealthcare Insurance Company of the River Valley; UnitedHealthcare Insurance Company of Ohio; UnitedHealthcare of Alabama, Inc.; UnitedHealthcare of Arizona, Inc.; UnitedHealthcare of Arkansas, Inc.; UnitedHealthcare of Colorado, Inc.; UnitedHealthcare of Florida, Inc.; United HealthCare of Georgia, Inc.; UnitedHealthcare of Illinois, Inc.; UnitedHealthcare of Kentucky, Ltd.; United HealthCare of Louisiana, Inc.; UnitedHealthcare of MidAtlantic, Inc.; UnitedHealthcare of the Midlands, Inc.; UnitedHealthcare of the Midwest, Inc.; United HealthCare of Mississippi, Inc.; UnitedHealthcare of New England, Inc.; UnitedHealthcare of New York, Inc.; UnitedHealthcare of North Carolina, Inc.; UnitedHealthcare of Ohio, Inc.; UnitedHealthcare of Tennessee, Inc.; UnitedHealthcare of Texas, Inc.; United HealthCare of Utah; UnitedHealthcare of Wisconsin, Inc.; UnitedHealthcare Plan of the River Valley, Inc. For purposes of this Financial Information Privacy Notice, we or us refers to the entities listed in footnote 1, plus the following UnitedHealthcare affiliates: ACN Group IPA of New York, Inc.; ACN Group, Inc.; Administration Resources Corporation; AmeriChoice Health Services, Inc.; Behavioral Health Administrators; Behavioral Healthcare Options, Inc.; DBP Services of New York IPA, Inc.; DCG Resource Options, LLC; Dental Benefit Providers, Inc.; Disability Consulting Group, LLC; HealthAllies, Inc.; Innoviant, Inc.; MAMSI Insurance Resources, LLC; Managed Physical Network, Inc.; Mid Atlantic Medical Services, LLC; Midwest Security Care, Inc.; National Benefit Resources, Inc.; OneNet PPO, LLC; OptumHealth Bank, Inc.; Oxford Benefit Management, Inc.; Oxford Health Plans LLC; PacifiCare Health Plan Administrators, Inc.; PacificDental Benefits, Inc.; ProcessWorks, Inc.; RxSolutions, Inc.; Sierra HealthCare Options, Inc.; Sierra Nevada Administrators, Inc.; Spectera of New York, IPA, Inc.; UMR, Inc.; Unison Administrative Services, LLC; United Behavioral Health of New York I.P.A., Inc.; United HealthCare Services, Inc.; UnitedHealth Advisors, LLC; United Healthcare Service LLC; UnitedHealthcare Services Company of the River Valley, Inc.; UnitedHealthOne Agency, Inc.
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2011 Member Handbook English UHCCPforAdults NY

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2011 Member Handbook English UHCCPforAdults NY

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N E W YO R K

UnitedHealthcare Community Plan

Telephone Numbers/Translation Services

Website www .uhccommunityplan .com

Other Health Provider(s)

Welcome to UnitedHealthcare Community Plan Managed Care Program

How Managed Care Works

How to Use This Handbook

Medicaid Member Handbook

Help From Member Services

Your Health Plan ID Card

In an emergency go to nearest emergency room or call 911.

Health Plan (80840)

TDD 800-662-1220 TDD 800-486-7914

Medicaid Member Handbook

Welcome to UnitedHealthcare Community Plan

EMPLOYEE BROWN 9999 ANYOLE ST BAYSHORE NY 11706

03115 9901477 0000 0000021 0000021 251 0 111

Part I First Things YouShould Know

How to Choose Your PCP

You may want to find a doctor:

Medicaid Member Handbook

How to Get Care

Medicaid Member Handbook

Get These Services From UnitedHealthcare Without a Referral

HIV Counseling andTesting

Mental Health Chemical Dependence (Including Alcohol and Substance Abuse)

You are always covered for emergencies.

If you have an emergency, heres what to do:

Medicaid Member Handbook

We Want to Keep You Healthy

Part II Your Benefits andPlan Procedures

Medicaid Member Handbook

Services Covered by UnitedHealthcare Community Plan

Regular Medical Care

Home Health Care

Services Covered by UnitedHealthcare Community Plan (cont .)

How to Access Dental Services

Mental Health/ Chemical Dependence (Including Alcohol and Substance Abuse)

Members Who Live in New York City

Residential Health Care Facility Care (Nursing Home)

Services Covered by UnitedHealthcare Community Plan (cont .)

Members Who Live in Nassau, Onondaga and Suffolk Counties

Other Covered Services

Medicaid Member Handbook

TB Diagnosis and Treatment

HIV Testing and Counseling

Benefits Using Your Medicaid Card Only

How to Access DentalServices

Medicaid Member Handbook

Mental Retardation and Developmental Disabilities

Other Medicaid Services

Alcohol and Substance Abuse Services

Services NOT Covered by Medicaid or UnitedHealthcare Community Plan

Medicaid Member Handbook

Service Authorization and Actions

What Happens After We Get Your Service AuthorizationRequest

Service Authorization and Actions (cont .)

Timeframes for Prior Authorization Requests

Timeframes for Concurrent Review Requests

Other Decisions About Your Care

Service Authorization and Actions (cont .)

Timeframes for Notice of Other Actions

How Our Providers ArePaid