UNITEDHEALTHCARE OF NORTH CAROLINA
Updated 10/2000

These data reflect the most commonly purchased benefits package for each of the health plans in the year 2000.

HMO General Information
Background Information	UnitedHealthCare of North Carolina (UHC) received its HMO license from the NC Department of Insurance and commenced business on May 21, 1985. It is a for-profit corporation, owned by United HealthCare Corporation, a Minnesota corporation.
Type of HMO	UHC operates an IPA/network model HMO. That means that it contracts directly with physicians in the community or with networks of physicians.
Type of Products	UHC’s most commonly purchased HMO plan is a "open access" product. Open-access plans give members the authority to choose any PCP or specialist in the network without a referral. UHC also offers a PPO product and a point-of-service option.
Accreditation	UHC received a commendable accreditation from the National Committee for Quality Assurance (NCQA). NCQA looks at five categories in its accreditation process: access and services, qualified providers, staying healthy, getting better, and living with illness. An HMO seeking accreditation is evaluated on how well it meets NCQA’s standards in each of these areas. HMOs that fully meet NCQA’s standards receive a Commendable status. Those that meet most of NCQA standards receive an Accredited status. Provisional accreditation may be given for plans that meet some, but not all, of NCQA standards. Health plans that fail to meet NCQA’s requirements during the review will have their accreditation request Denied. A health plan’s accreditation status gives an idea of the quality of care provided by the plan as a whole. However, NCQA’s accreditation does not guarantee the quality of care provided to any individual member.
Enrollees	UHC offers HMO coverage to both large and small employer groups. It does not offer commercial HMO coverage to individuals ("non-group" coverage). UHC offers Medicare HMO coverage in the following counties: Alamance, Chatham, Durham, Forsyth, Guilford, Orange, Randolph, Rockingham, and Wake counties. In addition, UHC offers HMO coverage to Medicaid recipients in Davidson, Forsyth, Guilford, Mecklenburg and Rockingham counties.
Counties in which HMO has an Active Presence	UHC has at least 25 commercial (group) s members at the end of 1999 in the following North Carolina counties: Alamance, Alexander, Alleghany, Anson, Ashe, Avery, Beaufort, Bertie, Bladen, Brunswick, Buncombe, Burke, Cabarrus, Caldwell, Carteret, Caswell, Catawba, Chatham, Chowan, Cleveland, Columbus, Craven, Cumberland, Davidson, Davie, Duplin, Durham, Edgecombe, Forsyth, Franklin, Gaston, Gates, Granville, Greene, Guilford, Halifax, Harnett, Haywood, Henderson, Hertford, Hoke, Iredell, Jackson, Johnston, Jones, Lee, Lenoir, Lincoln, Macon, Madison, Martin, McDowell, Mecklenburg, Mitchell, Montgomery, Moore, Nash, New Hanover, Onslow, Orange, Pender, Person, Pitt, Polk, Randolph, Richmond, Robeson, Rockingham, Rowan, Rutherford, Sampson, Scotland, Stanly, Stokes, Surry, Swain, Transylvania, Union, Vance, Wake, Washington, Watauga, Wayne, Wilkes, Wilson and Yadkin.
Customer Service Number	336-545-5096 (Greensboro) 1-800-999-1147
Covered and Excluded Services and Limitations
Hospital Care
Inpatient Services	Covers: Semi-private medical room and board. Private room covered if not solely for the convenience of the member. Other inpatient services and supplies as ordered by physician. Physician services. Limits: All services must be ordered by a network physician and provided in a participating hospital or approved health care facility. Cost Sharing: Copayment may apply.
Outpatient services	Covers: Outpatient surgery performed by a network physician in a UHC hospital or freestanding facility. Also covers physicians charges, medications, lab and diagnostic tests performed in outpatient setting. Limits: Lab and diagnostic tests (except screening mammograms). Must be ordered by a participating physician. Must check with network physician to confirm if prior approval is needed. Medications cannot exceed a 24-hour supply. Cost Sharing: Copayments apply to some services. Excludes: Outpatient hospital services received during regular physician hours, unless the services are necessary because of an emergency.
Emergency care	Participating Facilities: Covers emergency services and supplies to treat an emergency medical condition at ehe nearest hospital, either within or outside the service area. Continuing or follow-up treatment must be provided in a network physician's office. Non-network facilities: In the event that a member is hospitalized at a non-network facility, UHC may request that the member be transferred to a network facility as soon as the emergency medical condition has stabilized. If the member declines to be transferred he or she will be responsible for all future charges related to that admission. Cost Sharing: Copayments may apply to all hospital admissions. If the member is admitted within 24 hours of emergency room treatment for the same illness, the inpatient hospital benefits will apply instead of the emergency room copayment. If the member receives outpatient surgical services for the same illness within 24 hours, outpatient surgery benefits will apply instead of the emergency copayment. Medications: Prescriptions may be filled at a network pharmacy but the member may be asked to pay for this prescription and submit the receipt to UHC for reimbursement. Pharmacy benefits are not covered under all UHC plans. Coverage and the copayment depend on the purchased prescription drug benefit. Notification Requirements: To ensure that the member receives proper care, UHC requests that they be notified within 48 hours (or once the member's condition is stabilized). The member benefits will not be affected if the member fails to notify UHC. Excludes: Non-emergency care provided in the emergency room.
Urgent Care	Within Service Area: Covers services and supplies provided at a network urgent care center. Cost Sharing: Copayment may apply. Outside of Service Area: Covered when the member could not have reasonably anticipated the need prior to leaving the service area and a delay in receiving services and supplies until a member could reasonably return to receive care from network providers would prove hazardous to the member's health or life. Continuation of care services outside the service area will not be covered unless the member obtains authorization in advance from UHC. Cost Sharing: Member pays 20% of the first $5000 of eligible expenses ($1000 maximum copayment). Payment of eligible expenses is subject to reasonable and customary charges. Notification requirements: To ensure that the member receives proper care, UHC requests that they be notified within 48 hours (or once the member's condition is stabilized). Note: The member's benefit will not be affected if they fail to notify UHC.
Ambulance	Covers: Emergency ground or air transportation provided by a licensed ambulance service to the nearest participating hospital for treatment of a true medical emergency. Cost Sharing: Copayment applies.
Care for Students Outside of Service Area	Covers: Emergency and urgent care only. Non-urgent care outside of service area excluded.
Professional Services
Professional Services (general)	Covers: Primary care and specialist services and supplies provided by physician in his/her office. Cost Sharing: Copayments apply to all office visits, including lab work and examinations, even if the physician is not seen. The amount of the copayment will vary depending on the type of physician or provider who provides the care. Notification requirements: For services provided outside of the service area, you should notify UHC as soon as possible to ensure coverage.
Specialty Care Services	Members do not need a referral in order to obtain specialty services. However, if the member is receiving duplicate services or drug therapies, he or she may be required to select a single network physician. All non-emergency health services must be given or directed by the coordinating network physician in order to receive coverage.
OB/GYN	Covers: OB/GYN services. Referral not required for services of network OB/GYN for care related to the female reproductive system and breasts.
Diagnostic Procedures	Covers: Diagnostic procedures when provided at an approved hospital or facility and ordered by a network physician. Screening mammograms must be provided at a network hospital or facility, but no referral is required. Cost Sharing: Copayments may apply.
Therapeutic Treatment Services	Covers: Short-term respiratory therapy provided under the direction of a network physician. Limits: Limited to 20 visits per member per calendar year per therapeutic type. Requires prior approval. Inpatient services are covered under the medical inpatient benefits. Cost Sharing: Copayments may apply. Covers: Radiation and Chemo-therapy Limits: High dose chemotherapy with autologous or allogenic bone marrow transplant is limited to one treatment per lifetime and is only covered for certain conditions.
Allergy Testing	Covers: Allergy testing by a network provider.
Preventive Services
Annual Physicals (well-baby, well-child)	Covers: Well-child care and annual routine medical and vision screenings. Cost Sharing: Copayment determined by type of physician or provider providing the care. Excludes: Physical exams or testing for purposes relating to career, education, travel, employment, sports, camp, insurance, marriage, or adoption. Also excludes exams or testing for judicial or administrative proceedings or orders; those conducted for medical research or to obtain or maintain any type of license.
Immunizations	Covered. Excludes: Immunizations relating to career education, travel, employment, insurance, marriage or adoption. Also excludes immunizations for judicial or administrative proceedings or orders; those conducted for medical research or to obtain or maintain any type of license.
Preventive Clinical Services	Covers: Pap smears, mammograms, bone mass measurement and PSA tests. Limits: Services must be provided at an approved hospital or facility and ordered by a network physician (except screening mammograms).
Other Health Promotion/Disease Prevention Activities	Covers: General patient education programs, including nutritional counseling directed by a network physician for reasons other than obesity.
Diabetic Treatment	Covers: Medically necessary services, supplies, medications, and laboratory procedures for the treatment of diabetes when ordered by a network physician or a health care professional designated by the physician. Diabetes outpatient self-management training and educational services also covered if directed by a network physician.
Conception Services
Prenatal Care and Obstetrical Services	Covers: Prenatal and obstetrical services, including a minimum of 48 hours in the hospital after vaginal delivery or 96 hours after cesarean sections. Cost Sharing: Members who require fewer than 10 visits will pay an office visit copayment for prenatal care, or $200 copayment, whichever is less. Excludes: Non-medically necessary amniocentesis.
Family Planning	Covers: Surgical insertion or removal of birth control implants under the skin performed in a network physician’s office. Specifically covers: Physical exams, related laboratory tests and medical supervision provided by network physician. Information and counseling on contraception, including prescribing a contraceptive. Insertion and removal or an intrauterine device (IUD) or a birth control device implanted under the skin, such as Norplant. Fitting a diaphragm Vasectomy. Elective tubal ligation. Limits: Limited to one insertion or removal of Norplant per 4-year period. Cost Sharing: Copayment applies.
Abortion	Covers: Elective abortions and complications. Limits: Care must be provided by a network provider. Cost Sharing: Copayment applies.
Infertility Services	Covers: Infertility testing and initial diagnosis. Limits: Limited to $1,500 lifetime maximum. Cost Sharing: Copayment applies. Excludes: Health services related to the treatment of infertility, including artificial insemination or fertilization methods such as in vivo fertilization, in vitro fertilization, embryo transfer, zygote intra fallopian transfer (ZIFT), gamete intra fallopian transfer (GIFT) and similar procedures. Also excludes hospital, professional and diagnostic services and medication that are incidental to such insemination or fertilization methods. Reversal of sterilization is also excluded.
Mental Health and Substance Abuse
Mental Health Inpatient	Covers: Semi-private room and physician services. Limits: Covered only when provided by a network provider. Treatment must be approved in advance by United Behavioral Health. Specific limitations vary according to benefits purchased. Cost Sharing: Copayments may apply. Excludes: Services which are: Beyond a short-term evaluation or crisis intervention period. For psychological testing, except when related to the evaluation and diagnosis of learning disabilities, behavioral disorders and mental retardation. Beyond the period necessary for the evaluation and diagnosis for learning disabilities, behavioral disorders and mental retardation. Marriage or family counseling. Psychoanalysis. Psychiatric or psychological examinations, testing or treatments for purposes related to career education, travel, sports, camp, employment, insurance, marriage or adoption. Also excludes exams, testing or treatments for judicial or administrative proceedings or orders or which are conducted for medical research or to obtain or maintain any type of license.
Mental Health Outpatient	Covers: Mental health evaluations, crisis intervention, diagnostic evaluation, and individual and group therapy services. Limits: Covered only when provided by a network provider. Treatment must be approved in advance by United Behavioral Health. Specific limitations vary according to benefits purchased. Cost Sharing: Copayments may apply. Excludes: Same exclusions as for mental health inpatient services.
Substance Abuse Inpatient	Covers: Semi-private room and physician services. Limits: Covered only when provided by a network provider. Treatment must be approved in advance by United Behavioral Health. Chemical dependency services are limited to an $8,000 annual maximum and a $16,000 lifetime maximum. Cost Sharing: Copayment may apply. Excludes: Nutrition-based therapy for alcoholism or other chemical dependency.
Substance Abuse Outpatient	Covers: Alcohol or chemical dependency evaluations, crisis intervention, diagnostic evaluation, individual and group therapy services, and intensive chemical rehabilitation. Intensive dependency rehabilitation includes family participation and after-care. Limits: Covered only when provided by a network provider. Treatment must be approved in advance by United Behavioral Health. Chemical dependency services are limited to an $8,000 annual maximum and a $16,000 lifetime maximum. Cost Sharing: Copayment may apply. Excludes: Nutrition-based therapy for alcoholism or other chemical dependency.
Prescription Drugs and Medical Supplies
Prescription drugs	Covers: Medications received during emergency care and outpatient surgery. Other outpatient prescription benefits are covered if purchased by a supplemental rider. UHC supplemental prescription drug benefit covers drugs listed in the UHC preferred drug list. Drugs must be prescribed by a network provider and obtained from a network pharmacist. One Tier Program: Limits: Prescriptions limited to a 34-day supply. Only covers prescription medications listed on the Preferred Drug List. Cost Sharing: Copayments apply to each supply, and to each vial of insulin. The member must pay 100% of the additional cost of any brand name prescription medication when the bio-equivalent generic product is available and listed in the preferred drug list. Three Tier Program: Limits: Prescriptions limited to a 31-day supply. Cost Sharing: Copayments apply to each supply. There are levels of copayments depending on if the prescription medication is a generic drug, brand name drug or a drug not listed on the preferred drug list. Members may purchase up to a 3 month supply at one time, of oral contraceptives for a copayment for each month's supply.
Blood	Covered.
Medical Supplies	Covers: Diabetic and ostomy supplies. Excludes: Supplies which can be purchased over-the-counter, except as specified.
Insulin and Diabetic Supplies	Covers: Medically necessary services, supplies, medications, and laboratory procedures for the treatment of diabetes when ordered by a network physician or a health care professional designated by the physician. Cost Sharing: Copayment applies. Note: Diabetic equipment, such as glucometers, is covered under the durable medical equipment benefit. Members must forward their receipts to UHC for reimbursement of the eligible portion. Copayments apply to diabetic services, medication and treatment, including a copayment charge for each vial of insulin.
Durable Medical Equipment, Prosthetics, and Orthotics
Durable Medical Equipment (DME)	Covers: Durable medical equipment ordered and supplied by a network vendor or vendor for use other than in the hospital. Includes such items as wheelchairs, hospital beds, glucometers, and oxygen. Limits: Prior approval required for any items costing more than $500. Cost Sharing: Copayments may apply. Excludes: Repair, replacement and duplicates except when a child outgrows the equipment. Also excludes equipment considered a personal comfort item (such as air conditioners, humidifiers, dehumidifiers, or special vacuum cleaners).
Prosthetic Devices	Covers: The initial purchase of artificial limbs, artificial eyes needed because of sickness or injury, and breast prostheses at all stages of a mastectomy. Cost Sharing: Copayment may apply. Excludes: Repair, replacements, and duplicates except for breast prostheses or when a child outgrows the equipment.
Orthotic Devices	Covers: Orthotic Devices covered (under the DME and Prosthetics benefits).
Rehabilitative and Habilitative Services
Physical therapy	Covers: Short-term physical therapy provided by a network provider and under the direction of a network provider. Limits: Limited to 20 visits per member per calendar year. Inpatient services are covered under the medical inpatient benefits. Cost Sharing: Copayments may apply.
Occupational therapy	Covers: Short-term occupational therapy provided by a network provider and under the direction of a network physician. Limits: Limited to 20 visits per member per calendar year. Inpatient services are covered under the medical inpatient benefits. Cost Sharing: Copayments may apply.
Speech Therapy	Covers: Short-term speech therapy provided by a network provider and under the direction of a network physician. Limits: Limited to 20 visits per member per calendar year. Inpatient services are covered under the medical inpatient benefits. Cost Sharing: Copayments may apply. Excludes: Speech therapy for children of school age as these services must be provided through the school system.
Pulmonary Therapy	Covers: Short-term pulmonary rehabilitation provided in a network hospital or approved health care facility, under the direction of a network physician. Limits: Limited to $500 maximum benefit.
Chiropractic	Covered with the purchase of a rider.
Cardiac Rehabilitation	Covers: Short-term cardiac rehabilitation services provided in a network hospital or approved health care facility, under the direction of a network physician. Limits: Limited to $500 maximum benefit.
Other Therapy Services	Covered when ordered by a network physician as long as it is not an experimental investigation or unproven therapy.
Skilled Nursing Facility	Covers: Semi-private room and services. Private room covered if necessary due to contagious situations. Limits: Limited to 90 days per member per calendar year. Care must be under the direction of a network physician for the treatment of an injury or sickness. Excludes: Services or articles for custodial, convalescent, or intermediate level care or care designed primarily to assist in activities of daily living. Also excludes care in a rest home.
Home Care Services
Home Health	Covers: Intermittent skilled services by a registered nurse, physical therapist, occupational therapist, or speech therapist from a home health agency. Home health aide services supervised by a registered nurse may be covered for short periods if the patient is homebound. Limits: Services must be provided in a member’s home for the care and treatment of an injury or sickness which otherwise might require inpatient confinement. Services will only be covered if provided by a network provider and under the direction of a network physician. Excludes: Maintenance or custodial care.
Private Duty Nursing	Covers: Private duty nursing in any location if directed by a network physician and obtained through a network provider. Limits: Limited to $5,000 per member per calendar year. Cost Sharing: Copayment applies. Excludes: Services or articles for custodial, convalescent, or care designed primarily to assist in activities of daily living.
Hospice	Covered as party of the home health care and skilled nursing facility benefits.
Transplants and Dialysis
Transplants	Covers: Inpatient hospital and related services, including room and board, travel expenses, related services and supplies provided in a designated transplant facility. High dose chemotherapy with autologous or allogenic bone marrow is covered only for the following diseases: non-Hodgkin’s lymphoma, Hodgkin’s disease, Neuroblastoma if older than one year of age, acute lymphocytic leukemia, and acute non-lymphocytic leukemia. Also covers travel expense to out-of-area transplant facilities if approved in advance by UHC. Limits: Services must be ordered, provided or arranged under the direction of a network physician. There is a lifetime limit of one high dose chemotherapy with bone marrow transplant (rescue), whether rescue is by autologous or allogenic bone marrow transplant or by peripheral stem cell transfusion. Notification requirements: Notify UHC before receiving these services so that UHC may coordinate your care and assist you with finding a designated transplant facility for your condition. Excludes: Organ transplants otherwise covered under the plan which is performed as a treatment for cancer, or transplants of two or more organs simultaneously. However, kidney/pancreas and heart/lung are covered. Also excludes expenses related to the removal of an organ for transplant purposes and expenses involving transplants or mechanical or animal organs.
Dialysis	Covered.
Other Services
Dental	Covers: Emergency services performed by a dentist for treatment of any sound natural teeth resulting from traumatic injury. To be covered the dentist must certify that sound natural teeth were injured as a result of an accident and the services must be provided within six months of the injury. Anesthesia and health services performed in a network hospital or outpatient surgical facility for children under age 9; or persons with serious mental or physical conditions; or persons with behavioral problems. Services provided by a network provider for diagnosis and treatment of TMJ.C. Limits: Accidental Dental services are limited to $1500 per calendar year. Cost Sharing: Copayments may apply. Excludes: Injury from biting or chewing or for dentures. Dental surgery, treatment or care including treatment of overbite or underbite, removal of wisdom teeth, and maxillary, mandibulary osteotomies. Dental X-rays, prescriptions, diagnostic testing, supplies, appliances (including occlusal splints). Dentures. Complications arising out of such dental surgery, treatment or care (including hospitalization).
Vision	Covers: Routine annual vision screening by netowrk physician. Cost Sharing: Copayment may apply. Excludes: Eye glasses, contact lenses or fittings for eyewear, radial keratotomy and other refractive eye surgery, and related services to correct vision.
Hearing	Excludes: Hearing aids, cochlear implants, and related services or devices to correct hearing.
Foot Care	Covers: Foot care when provided by a network provider and not solely for the convenience of the member.
Weight Loss	Excludes: Food supplements, vitamins, any diet or exercise program or any other form of weight control by surgery, including complications of surgery or any other method.
Smoking Cessation	Excludes: Services and supplies for smoking cessation programs and treatment of nicotine addiction.
Growth Hormones	Covers: Growth hormones when provided by a network physician and network facility.
Alternative Therapies	Covers: Short-term biofeedback training provided in a participating physician’s office. Limits: Coverage limited to the treatment of headache. Cost Sharing: Copayment applies. Excludes: Treatment, services and supplies related to acupuncture; psychosurgery; megavitamin therapy.
Reconstructive/Cosmetic Surgery	Covers: Services for reconstructive surgery including post mastectomy care, when provided by a network physician in the physician's office or at a network hospital. Reconstructive surgery must be incidental to an injury, sickness or congenital anomaly when the primary purpose is to restore normal physiological functioning of the involved body part. Cost Sharing: Copayments may apply. Excludes: Cosmetic procedures, including but not limited to pharmacological regimens; nutritional procedures or treatments; plastic surgery; salabrasion; chemosurgery and other such skin abrasion procedures associated with the removal of scars, tattoos, actinic changes, and/or which are performed as a treatment for acne. Replacement of an existing breast implant, if the earlier breast implant was a cosmetic procedure, unless benefits are available for the removal and replacement under the contract.
Non-emergency transportation	Covers: Transport to and from out-of-area facilities when recommended by a network physician and not solely for the convenience of the member. Also covers non-emergency ground transportation when recommended by a participating physician and with prior approval by UHC. Cost Sharing: Copayment applies.
Excluded Services
Experimental or Investigational Services	Excluded.
Services that are not considered medically necessary	Excluded.
Non-emergency services rendered in the emergency room	Excluded.
Commonly excluded services	See list of common exclusions
Definitions
Medically necessary	Follows statutory definition of medical necessity.
Experimental or Investigational	Medical, surgical, psychiatric, substance abuse or other health care services, supplies, treatments, procedures, drug therapies or devices that are determined by UHC (at the time it makes a determination regarding coverage in a particular case) to be: not generally accepted by informed health care professionals in the United States as safe and effective in treating the condition, illness or diagnosis for which its use is proposed, or not approved by the US Food and Drug Administration (FDA) to be lawfully marketed for the proposed use, or subject to federal law requiring Institutional Review Board review and approval for the proposed use, or the subject of ongoing FDA-regulated Phase I, II or III Clinical Trials, or not demonstrated through sufficient peer-reviewed medical literature to be safe and effective for the proposed use. Those medical technologies considered investigational for which acceptable research of the cost and treatment has not been established. Drugs considered experimental or investigational in the treatment of cancer: Any drug prescribed for the treatment of a type of cancer for which the drug has not been approved by the FDA shall not be excluded as experimental, investigational or unproven, provided that the prescribed drug: has been approved by the FDA, though not approvedby the FDA for the specific type of cancer; and as been proven effective and acceptable for the treatment of the specific types of cancer for which the drug has been prescribed in any one of the following reference compendia: The American Medical Association Drug Evaluations; The American Hospital Formulary Service Drug Information; or The United States Pharmacopeia Drug Information. Coverage shall not be required for any drug that the FDA has determined to be contraindicated for the treatment of the specific type of cancer for which the drug has been prescribed.
Emergency	Follows statutory definition.
Primary Care Provider, Referrals and Pre-Authorization Requirements
Types of providers who can serve as Primary Care Provider	Family practice, general internal medicine, pediatrician, OB/GYN, GYN or gynecologist. Note: since most of UHC members are covered under an open access plan, PCPs are not required to refer members to specialists.
What Happens if Member Fails to Choose a PCP?	Members are not required to select a PCP.
Process to Change PCP	Members in the open access plan are not required to select a PCP. Members are free to change their PCPs at any time.
Referrals to Specialists	UHC does not require members to have a referral to obtain services from a network specialist.
Can Specialists Serve as PCP	Members are not required to have a primary care provider under United HealthCare’s open access plan.
Non-Emergency Hospital Preauthorization requirements	The network provider is required to provide UHC with notification for inpatient confinements prior to the services being rendered. The network provider may not receive payment if they fail to notify UHC. If the network provider does not notify UHC the member is not responsible for the charges. Services must be ordered by a network provider and received in a network hospital or approved health care facility.
Appeal and Grievance Procedures
Informal Reconsideration	Requesting informal reconsideration: The member or their provider can request an Informal Reconsideration. Review process: The Informal Reconsideration will be conducted between the provider and a North Carolina licensed medical doctor designated by UHC. This process will be completed within 29 days after receipt of the request for Informal Reconsideration. This is a voluntary process, which means that instead the member may immediately request a First-Level Noncertification Appeal. Decision notification: If the Information Reconsideration decision is not in the member's favor, UHC will send written notification to the member and their provider.
First Level Non-Certification Appeal Provisions	Follows statutory definition. Note: Members or their representatives must submit first level appeal in writing to UHC following their informal reconsideration, UM or claims decision. No time limitations are specified in the Evidence of Coverage. Members will receive a response from UHC within 30 days of UHC’s receipt of the review request.
First Level Expedited Appeals	Follows statutory definition. Note: Responses to expedited appeals will be received within 4 days of the receipt of all necessary information.
First Level Grievance Hearings	Follows statutory definition. Note: Members or their representatives must submit written requests for grievance review. No time limitations are specified in the Evidence of Coverage. Members will receive a response within 30 days of the receipt of the grievance.
Second-Level Grievance Hearings (covers second- level appeals and grievances)	Follows statutory definition. Note: Requests for second level grievance hearings must be made in writing. No time limitations are specified in the Evidence of Coverage. The second level review meeting will be held within 45 days of the PCP receives a request for a second level grievance review. Member will be notified of the decision within 7 business days of the review meeting.
Second Level Expedited Appeals	Follows statutory definition. Note: Responses to expedited appeals will be received within 4 days of the receipt of all necessary information.
Other Avenues of Appeal	Members can obtain independent information about the appeals process, and seek assistance from the NC Department of Insurance and the Office of Commissioner. Call 1-800-662-7777.
Notes	Limitations of Informal and Formal Appeal and Grievance Process: The appeal and grievance process does not apply to denials rendered solely because UHC does not provide benefits for the healthcare service performed or requested. This information is outlined in the member’s Evidence of Coverage.
Enrollment Trends
Enrollment on December 31, 1999 (Financial Report, # 10)	262,712
Member months (1999) (Financial Report, #11)	2,821,517
Average 1999 monthly enrollment (member months/12)	235,126
Percentage of change in average monthly enrollment between 1998-1999	26.5%
Five year average enrollment trends	1999: 235,156 1998: 185,868 1997: 144,769 1996: 118,293 1995: 100,528
Percentage of Groups that Disenrolled (December 31, 1998-December 31, 1999)
Percentage of Members that Disenrolled (December 31, 1998-December 31, 1999)
Percentage of Primary Care Physicians who Resigned (Dec. 31, 1998 — Dec. 31, 1999)
Percentage of Primary Care Physicians who Were Terminated (Dec. 31, 1998 — Dec. 31, 1999)
Utilization Review Information
Number of reviews requested, 1999	82,955
Review rate per 1,000 members, 1999	447
Percentage of noncertifications, 1999	13.68%
Noncertification rate per 1,000 members, 1999	61.14
Appeal Rate per 1,000 Noncertifications. 1999	38.07
Percentage of appeals decided for the members, 1998	75.35%
Financial Data
Total 1999 revenues (Financial Report, #6)	$415,844,142
Average premium per member per month (1999) (Financial Report, #5 / #11)	$145.64
Five year premium per member per month trends	1999: $145.64 1998: $134.72 1997: $131.14 1996: $130.51 1995: $128.78 1994: $123.47
Medical/hospital expenses per member per month 1999 (Financial Report, #7 / #11)	$120.50
Medical Loss Ratio 1999 (% premiums spent on medical/hospital expenses) (Financial Report, #15)	83.0%
Five year medical loss ratio trends	1999: 83.0% 1998: 81.3% 1997: 80.6% 1996: 80.0% 1995: 80.0% 1994: 82.7%
Operating profit margin (Financial Report, #9 / #6)	3.0%
Five year operating profit margin trends	1999: 3.0% 1998: 4.3% 1997: 7.0% 1996: 7.9% 1995: 6.6% 1994: 6.6%
Sources of Information
Source of Information	United HealthCare of North Carolina, Inc., Certificate of Coverage, UCOC94 REV03/98; 1998 Annual Financial Report; NC DOI Managed Care and Health Benefits Division, "HMOs in North Carolina Status Reports: Analysis of 1995 Activity" January 1997; NC DOI, "1999 Managed Care Plan Handbook: A Comparison Guide for North Carolina Consumers." Data on utilization review and Appeals and Grievances from NC DOI.

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