Eligibility/Authorization Gaurantee - Capitation and/or Delegation Supplement, 2018 UnitedHealthcare Administrative Guide

Medical Group/IPA’s Responsibility to Monitor Eligibility (CA Commercial Only)

We periodically send each medical group/IPA an eligibility list of all your assigned members. We make current eligibility information available through the Enterprise Voice website, care provider portal, and member service center. You and/or your network of care providers are responsible for checking eligibility within two business days prior to the date of service for individuals for who/whom services are provided or authorized through the Enterprise Voice Portal, care provider website or toll-free phone number. If the medical group/IPA checked and confirmed eligibility within two business days prior to the date of service, it is eligible for reimbursement under the Eligibility Guarantee and Authorization Guarantee programs. This program applies to services authorized by the medical group/IPA or UnitedHealthcare or provided by the medical group/ IPA prior to the receipt of updated eligibility, showing an individual is no longer eligible.

Eligibility/Authorization Guarantee Procedure

Eligibility/Authorization Guarantee provides an opportunity for reimbursement to the medical group/IPA for covered services provided to an individual whom:

  1. UnitedHealthcare identified as eligible one or two business days before the date of service through our eligibility determination and verification processes and
  2. Is later determined to be ineligible for benefits on the date of service, but no authorization has been provided (“Eligibility Guarantee”); and
  3. UnitedHealthcare provided an authorization and who we confirmed as eligible on or two business days prior to the date of service but who is later determined to have been ineligible on the date of service (“Authorization guarantee”).

The Eligibility Guarantee and Authorization Guarantee procedures are designed to limit the medical group/IPA’s risk of rendering care or incurring financial risk for services provided to ineligible members where the individual’s lack of eligibility is only determined after the services are
provided.

Eligibility Guarantee Billing Procedures (No Authorization Provided)

Medical group/IPA provides or arranges for health care services for an individual identified as an eligible member through our eligibility determination and verification processes. If no authorization is required or provided, and it is later determined that the individual was not a member at the time the health care services were provided, medical group/IPA may seek reimbursement for such services by following the procedure set forth below.

  • Submit the claim to the member or the responsible payer for fee-for-service reimbursement in two consecutive billing cycles, no less than 30 calendar days apart. The responsible payer may be another health plan or insurer or it may be a government payer, such as Medicare when determined primary.
  • If neither the member nor the responsible payer pays the claim within 30 business days following the submission of the second bill, the medical group/IPA must submit the following information to our care provider Dispute Team for reimbursement consideration using the address included in the UnitedHealthcare West Bulk Claims Rework Reference Table, in the Appeals section of the UnitedHealthcare West Supplement in is guide:
    • Cover sheet;
    • Copy of the itemized bill for services rendered;
    • Proof of eligibility verification within two business days prior to the date of service through the Enterprise Voice Portal, online care provider portal or toll-free phone number or care provider attestation letter;
    • Proof of billing the member or responsible payer twice - no less than 30 calendar days apart;
    • A record of any payment received from any other responsible payer; and
    • Amount due based on medical group/IPA’s cost of care rate, less any payment received from any other responsible payer.

Eligibility Guarantee Reimbursement

Verification of the medical group/IPA’s compliance with the eligibility guarantee billing procedures with reimbursement to the medical group/IPA for services which are eligible under the eligibility guarantee policy, within 45 business days of receipt of the information stated above at the cost of care rates defined in the contract but no greater than 100% of the uncollected balance. Medical group/IPA shall be responsible for reimbursing the care provider of service if it is financially responsible for issuing payment for the applicable service under its contract with us.