UnitedHealthcare is implementing a laboratory and pathology services protocol with Connecticut and Maryland participating (network) providers. Under the protocol, network providers are required to tell their UnitedHealthcare/UnitedHealthcare Oxford patients if they are recommending, involving or referring to an out-of-network laboratory or pathologist in the member’s care.
What is changing?
A consent form has been created and will be made available to participating providers for use beginning June 1, 2019. The provider is required to discuss the form with the member and explain the options for where and how the member receives the services, as well as the financial consequences of using an out-of-network provider. After reading the form, the member should be asked to sign it as confirmation of his or her choice of a provider when laboratory or pathologist services are needed. The signed form also indicates the member’s understanding of the financial impact of his or her decision. The conversation and form is required to be used in the following circumstances:
- Member is instructed to go to anylaboratory or pathologist for blood or specimen collection and Analysis is done outside of the doctor’s office (this includes a freestanding laboratory facility).
- The doctor collects blood or a specimen in the office and sends it to an out-of-network provider.
Note: The protocol requires network providers to follow the member’s instructions on the form beforereferring the member for services.
Claims will be processed as follows:
- In-network laboratory and pathology services claims for members will be processed using the member’s network benefits.
- Out-of-network laboratory and pathology services claims for members will be processed out-of-network. This means:
The claim will be paid out-of-network if the member has a plan with out-of-network benefits (out-of-network cost-shares will apply); or
The claim will be denied, if the member does not have a plan with out-of-network benefits (the member will be responsible for 100 percent of the out-of-network laboratory or pathologist provider bill).
Please inform your UnitedHealthcare and UnitedHealthcare Oxford clients of this protocol. Also, let them know that their covered employees may receive a letter from UnitedHealthcare about the protocol.
Why is this change occurring?
At UnitedHealthcare, our mission is helping people live healthier lives™. We strive to make health care simpler and easier for our members to understand. Going out-of-network usually means greater out-of-pocket costs for the member. The Participating Provider Laboratory and Pathology protocol is intended to help make members aware of their choice of providers and the financial implications of involving out-of-network providers in their care.
Employers: News of the protocol will be included in an upcoming issue of the Customer Connection e-newsletter.
Providers: The new protocol and consent form will be posted to uhcprovider.com and oxhp.com and an article was included in the March Network e-Bulletin for providers.
For more information, please contact your UnitedHealthcare sales representative.
For Maryland Only
The Participating Provider Laboratory & Pathology Protocol does not apply to members of MAMSI Life and Health Insurance Company, MD-Individual Practice Association, Inc. and Optimum Choice, Inc.