What if services are performed or referrals are written for a member without the eligibility being confirmed?
A PCP will run the risk of not being capitated for the member, nor having any fee-for-service payments covered. Services provided to an ineligible member will result in non-payment to the specialist and billing of services directly to the member. Ultimately, this will cause unnecessary issues for the member, your office, our site and the HMO. Always check eligibility!
How do you prepare and submit referral requests?
Once eligibility has been verified, authorization for all services must be provided that are performed outside of the primary care physicians office. Further, some of those services require pre-approval from the HMO itself. You simply complete the UPN request for referral form and fax to 847-676-6982 or you can complete the electronic version on this website.
How long do referrals take to be processed?
All non-urgent requests are processed within 3-5 business days, if urgent-same day-stat, then within 4 hours of receipt of request with supporting information.
Who do you use for laboratory work?
Quest diagnostics is UPN’s exclusive laboratory vendor offering specimen pick-up’s, conveniently located testing facilities and flexible appointment scheduling times. If you need to be set-up with quest, please call UPN for information at 847-763-1700.
What are the necessary documents to expedite my pre-certification request?
The national medical criteria used by UPN requires proper documentation including PCP progress notes pertinent to the case, related test results and any consultative notes from the evaluating specialist physician.
The patient was sent to a specialist for evaluation and treatment. Why haven’t you received a pre-cert number from UPN?
Pre-certification can only be given once confirmation of an actual procedure is received. If a member is referred for an evaluation and treatment, the evaluation must first be performed before a decision for further services can be entertained. It would be more appropriate if the initial consult did not include “treat” as part of the initial referral. See question 6 for more information.
UPN has denied a referral request and the member is upset. What should the member do?
Access to the appeal process is open to the member or physician representative. The member should be instructed to contact the UPN member services department. An appeal initiated by the PCP will require you to telephone UPN medical management requesting reconsideration. Written appeals are also acceptable. Once a service is denied, a denial letter will be sent to the member and the PCP. This letter clearly delineates the process for appeal and member’s rights and responsibilities.
The patient is out of the service area and is in need of medical attention. What should you do?
Typically, UPN cannot determine approval and coverage of out of area services; it is up to the HMO. If your office is contacted by a member who is seeking medical attention outside the service area, advise the member to call the HMO out of area benefit line- the number is located on the reverse side of the members i/d card. UPN should then be notified so that the services are properly documented. This information will assist with coordination of care within the service area once the member returns. You may notify us via the admission notification line at 847-763-7280. A paper referral is not required.
How do you verify member eligibility?
Remember, eligibility of all health plan members should be verified prior to any services being provided to a member! Eligibility can be verified through several methods: one, every month your office receives a capitation check along with an eligibility listing. Two, you can contact UPN at 847-763-1700. Three, you can use this secure website’s portal to check on your assigned members eligibility.
The patient received a bill in the mail and is asking you to write a referral to cover the services. Is this acceptable?
Retroactive referrals (those written for services already provided) are not allowed. If your office inadvertently caused the error, such as sending the member without a referral, you should contact UPN regarding the situation. Your office is not responsible for approving services that were not originally directed by the PCP. You should direct the member to UPN member services for further education.