| Applies To |
All MCO Credentialed Faculty**
EXCEPT:
Pathology
**For further clarification of "All MCO Credentialed Faculty" refer to the Table of Contents.
|
| PCP Services |
N/A |
| Laboratory Services
|
Includes services performed at:
Does NOT include services performed at Aston Lab.
|
| Radiology Services
|
Includes services performed at:
- Algur H. Meadows Diagnostic Imaging Center
- Aston Radiology
- Mary Nell and Ralph B. Rogers MRI Center
|
| Participating Facilities |
- Children's Medical Center
- Parkland Health & Hospital System
- St. Paul Medical Center
- Zale Lipshy University Hospital
- UT Southwestern Clinical Procedure Center (ASC)
- Moncrief Radiation Oncology Center (MROC)
|
| Referral Requirements |
N/A |
| Authorization Requirements |
Medical Management Program
For Performance Individual or Small Group members call (800) 227-3814.
For Key or Large members call (800) 333-3304.
For Special Classic members refer to ID card.
Services requiring Authorization
(Elective procedures should be precertified at least 3 working days before admission. For emergency admissions, call within 48 hours or the next working day.)
- Inpatient hospital services
- Outpatient hospital services performed at an ambulatory surgery center.
- Skilled nursing facility services
- Home Health Care, Home Infusion Therapy, Rehab, and Hospice services (exclusive of professional services)
- Prosthetic devices
|
| Managed Care Plan |
PPO |
Identification Card
Performance
Classic |
UniCARE Insurance Company, UniCARE "Classic", UniCARE "Performance", "Affiliated" |
| FSC |
257
340 - Invoice Level Facility Billing |
| Contract Date(s) |
November 1, 1996 |
| Eligibility |
To verify eligibility, benefits, copays, deductibles, coinsurance, etc. call Customer Service at the phone number on patient’s ID card. |
| Claims Mailing Address |
UNICARE
P.O. Box 4458
Chicago, IL 60680-4458
Note: The group numbers for individual members will have 5 numeric characters and one alpa at the end, e.g. 12345K |
| Deductible/Co-Payment |
- Varies-see ID Card-this information may be verified at time of eligibility verification.
|
| Claims Submission |
- Claims should be filed within 95 days of the date-of-service.
- Claims should be filed utilizing the HCFA 1500 claim form or electronic filing (Payor #80314).
- UniCare Clean Claim Requirements
|
| Claims Payment |
- Within 45 days of receipt of a clean paper claim by Payor.
- Within 30 days of receipt of a clean electronic claim by Payor.
|
| Appeals |
Appeal requests must be submitted to payor within 180 days of the processing date on the EOB or the date of the denial letter. |
| Provider Relations |
1-888-697-3791
www.Unicare.com |
| Comments |
- Due to Unicare’s relationship with Affiliated Healthcare, Inc., members who participate in the Affiliated Healthcare network have access to providers in the Unicare PPO network.
- Unicare provider Website
http://accesspoint.unicare.com
|
