We have compiled a list of evidence-based clinical guidelines and where they can be found for our quality and health management programs.
We respect the expertise of the physicians and other health care professionals in our network and appreciate your help as we work together to offer our members better quality, better health outcomes and better cost.
If you have questions, please contact your Physician Advocate or call the number on the back of the member’s ID card.
Deficit Reduction Act/False Claims – New Jersey-specific policy
This policy requires employees (and employees of applicable contractors and agents of the company) to comply with the federal False Claims Act, state False Claims Acts, and similar state and local laws and applicable agency policy.
Health Insurance Portability and Accountability Act (HIPAA) information
HIPAA standardized both medical and non-medical codes across the health care industry and under this federal regulation, local medical service codes must now be replaced with the appropriate HCPCS and CPT-4 codes.
Integrity of claims, reports, and representations to the government
UnitedHealth Group requires compliance with the requirements of federal and state laws that prohibit the submission of false claims in connection with federal health care programs, including Medicare and Medicaid.
Disclaimer
If UnitedHealthcare policies conflict with provisions of a state contract or with state or federal law, the contractual/statutory/regulatory provisions shall prevail.
UnitedHealthcare has developed medical policies and medical benefit drug policies to assist us in administering health benefits. These policies and guidelines are provided for informational purposes, and do not constitute medical advice.
For reimbursement guidance for Community Plan members, view the current UnitedHealthcare Community Plan Reimbursement Policies
For policy guidance for Medicare Advantage plan members, view the UnitedHealthcare Medicare Advantage medical policies, medical benefit drug policies and corresponding policy update bulletins.