Provider Reference Tools & Resources
Provider Manual
The "Provider Manual" is intended to be used by participating Ultimate Health Plans' (UHP) Providers and their staff.
Quick Reference Guide
Benefit Reference Guides
These reference guides were specifically designed for our providers to quickly outline the
benefits offered under each plan. For the full list of benefits and descriptions, visit our
Provider Benefit Summaries page.
Clinical Practice Guidelines
These Preventive Care Guidelines address routine health exams, diagnostic checkups, counseling and immunizations recommended for adults. Discuss these general guidelines with your doctor to stay as healthy as possible throughout the year.
Member Rights and Responsibilities and Advance Directives
Help Honor Your Patients’ Wishes.Our physicians and practitioners should discuss advance directives with their patients (as
appropriate) and file a copy of any advance directive document (e.g., living will, durable power of attorney for health care, health care
proxy or do not resuscitate (DNR) request) in a prominent place within the medical record.
Each medical record that contains an advance
directive should clearly indicate that said document is included.
Prior Authorization for Medical Care
Timeframes for Authorization Requests
Ultimate Health Plans processes authorization requests according to the following general time frames, which comply with Medicare guidelines:
- Standard- decision within 14 calendar days from the date of request.
- Expedited- decision within 72 hours from the date of the request (including weekends and holidays). Conditions meeting criteria
for expedited review include an imminent or serious threat to the health of the Member, including, but not limited to, severe pain, potential loss
of life, limb or major bodily function. Please, only submit authorizations for expedited review if you can support that the above criteria applies
to your request.
NOTE: Please ensure that your authorization request includes adequate documentation and/or information to medically support the
request. If the information submitted is not adequate, the determination will be based upon the available information and/or lack of medical
information. To expedite the process and to ensure appropriateness of the decision, it is very important that relevant clinical information be
submitted with the request.
Request for Extensions:
Ultimate may extend the decision time frame up to 14 calendar days. This extension is allowed if the enrollee requests the extension or if the
provider or Ultimate can justify a need for additional information and documents how the delay is in the best interest of the enrollee.
Pharmacy Policies and Forms
Prescription Drug Determination Requests
The Prescription Drug Determination Request Form can be used for the following:
- To request prior authorization for prescription drug that requires it.
- To request prior authorization for a drug designated as a high-risk medication.
- To request that we cover a non-formulary drug.
- To request that we waive quantity limit on a drug.
- To request that a drug be covered at a lower tier.
- To request that we waive the requirement to try an alternative drug first.
Appeals for Part D Prescription Drugs
To file an appeal (request for redetermination) for a Medicare
prescription drug denial please have your provider complete the form below:
Drug Transition Policy
Ultimate Health Plans will cover a Transition Supply for enrollees who have a level of care change. We will provide the
member with a written notice after we cover the Transition Supply. This notice will explain the steps they can take to
request an exception and how to work with their doctor to decide if they should switch to an appropriate drug that we
cover. These reference guides were specifically designed for our providers to quickly outline the benefits offered
under each plan. For the full list of benefits and descriptions, visit our
Plan Documents page.