UCare’s Payment Policies Website contains Payment Policies that assist in administering payment for UCare benefits under UCare’s health benefit plans. Payment Policies are intended to serve only as a general reference resource regarding UCare’s administration of health benefits and are not intended to address all issues related to payment for health care services provided to UCare members.
Payment Policies are provided for informational purposes and do not constitute coding or compliance advice. Providers are responsible for submission of accurate and compliant claims.
UCare reserves the right, in its sole discretion, to modify its Policies and Guidelines as necessary and to administer payments in a manner other than as described by UCare Payment Policies when necessitated by operational or regulatory considerations.
Payment Policies are published on-line and available to members, providers and the general public at www.ucare.org.
In addition to Payment Policies, UCare also uses tools developed by third parties, such as the Current Procedural Terminology (CPT®*), InterQual guidelines, Centers for Medicare and Medicaid Services (CMS) and Minnesota Department of Human Services (DHS) guidance, Minnesota Administrative Uniformity Committee (AUC) guides or other coding guidelines, to assist in administering health benefits. References to CPT or other sources in UCare Payment Policies are for definitional purposes only and do not imply any right to payment. Other UCare Policies and Guidelines may also apply.
How Payment Policies Are Developed
UCare’s Payment Policies are based on available regulatory and coding guidance and, where applicable, community standards. Payment Policies are revised and updated annually; however, Policies may be reviewed prior to their scheduled review date if new guidance or standards, that would alter the Policy criteria, become available sooner.
How Payment Policies Are Used
When making payment determinations, UCare staff will identify member eligibility, federal and state legislation or regulatory guidance regarding claims submission, UCare provider participation agreement contract terms, and the member-specific Evidence of Coverage (EOC) or other benefit document. In the event of a conflict, the enrollee’s specific benefit document and federal and state legislation and regulatory guidance supersede the Payment Policies. In the absence of regulatory guidance that governs payment for the service, procedure or treatment, or when the member’s EOC document is silent or not specific, Payment Policies help to clarify how UCare will pay for certain healthcare services.
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