Universal Heathcare Medicare HMO

Universal is pleased to announce a new product under our Medicare HMO line of business for 2010. The name of the new product is the Medicare Masterpiece Premier HMO Plan. The member ID cards will be identified with “HR” as the prefix to the member number on the card.

One difference with this plan is that there are only a limited number of Primary Care Providers(PCPs) who will be participating in this plan. These PCPs are notated in the 2010 directory withan (*) by their name. If you are a PCP and would like to become part of the network for thePremier HMO Plan, please contact your local Universal Provider Representative for assistance.

All of our Medicare HMO specialists, hospitals, and ancillary providers are currently part of the Premier Plan. The significant difference is that Referral Authorizations are required from the member’s PCP before they can receive non-emergency services. This includes visits to specialty physicians and certain other medical service providers. Please see attached Authorization Guidelines for the Premier HMO Plan and the Medicare Authorization Request Form.

This plan develops better communication between the PCP and others providing service to the member. We encourage you to begin using the new authorization referral process through the. PCP as of January 1, 2010 to familiarize your practice with the new requirements. In order to create a smooth transition, the new authorization requirements will not be enforced until February 1, 2010.


1) ALL hospital-based procedures/services/diagnostic testing
2) Elective/non-urgent inpatient admission
3) Out-of Network Services
4) Out of area non-urgent/emergent
5) Orthotics/prosthetics, excluding basic stabilizing splints & casts applied in the office (CPT 29000-29799)
6) DME — Non-standard equipment including, but not limited to, custom wheelchairs, special mattresses, insulin pumps (See below for Standard DME services)
7) Infusions of Chemotherapy & specialty/biologic drugs, i.e., growth factors, Remicade, IVIG, Aranesp, Epogen, etc.
8) SNF admissions (Skilled Nursing Facility)
9) PT/OT/ST/Rehab at a free-standing network facility — Initial Evaluation and first 9 therapy visits do not require authorization. (Authorization is required for any re-evaluation, additional therapy visits, hospital-based therapy.)
10) Wound care - both home and at a Wound Care Center, including Hyperbaric Oxygen treatment
11) Complicated radiology — Angiography CT Angiography (CTA) MRA Nuclear stress tests • PET scans
12) Procedures performed in an ASC (Ambulatory Surgical Center)(excluding colonoscopy, sigmoidoscopy, EGD, cystoscopy, bronchoscopy, inguinal hernia repair, all biopsies)
13) ALL procedures regarding:a. Pain Managementb. Sleep Studies (split night study - CPT 95811- does NOT require authorization)c. Plastic, Cosmetic, or Convenience procedures (including MOHS surgery)d. Cardiac catheterization
14) Implantable devices, including AICD (implantable cardioverter defibrillator), pumps, and stimulators
15) EECP (Enhanced External Counterpulsation)
16) Dialysis
17) Transplants

Medicare managed care or HMO
Medical billing glossary basic
Medical billing process - Pre authorization and referral

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