A Capitated care provider group submits semi-annual reports to UnitedHealthcare as outlined in their contract. UnitedHealthcare runs capitation reports by process month for both commercial and MA products. Typically, each month’s capitation report and payment reflects all current activity and retroactivity up to the standard six-month system window.
The participation agreement may define a non-standard eligibility window for less than the standard six-month system window. This non-standard eligibility window will override the standard six-month system window. For MA plans, the non-standard eligibility retro window will not limit the retroactivity related to premium increases/decreases from CMS.
Capitation reports and first-of-the-month eligibility reports run from the same snapshot of membership data. The actual date of this snapshot varies, but typically occurs on or around the 15th calendar day of the prior month for Commercial and during the last week of the prior month for MA.
The reports mentioned throughout this section are available online and provide detailed information regarding each care provider’s capitation payments. The types of reports available include:
- Flat File — Contains approximately 198 data elements in CSV (Comma Separated Value) format
- Image Reports — In Standard PDF format and are at both the member and summary levels
- Supplemental Care Provider Reports — Details any nonstandard deductions from capitation (i.e., claims that are the financial risk of the care provider and paid by UnitedHealthcare)
Reports are available on UHCprovider.com/reports on the date specified in your participation agreement. If the due date falls on a non-business day, the reports are available the next business day.
- Reports —View image reports in a PDF format (Adobe Acrobat is required) or download the file.
- Data Files — Download the flat file(s) from a zipped file format.
- All —Download image reports and flat file(s) in one zipped file.
Supplemental care provider Reports for Claims Withhold are available online. These reports have two capitation reporting options described below: reports and data files.
Medical Drug Benefit reports are available online. The “Claims Withhold” and “Medical Drug Benefits” reports are one month behind the current Capitation Report month.
For example, all claims on the Claims Withhold and Medical Drug Benefit reports that paid in April will process in May capitation. To reconcile May capitation, you need to view the April Claims Withhold and April Medical Drug Benefits Reports.
The “Shared Risk Claims” Report is also dated one month behind the current Capitation Report month. For example, all Shared Risk claims paid in May will process in the June capitation.
We maintain capitation reports online for the current month and the prior month. Previous reports purge from our website before new reports post.
We recommended that you complete your capitation download in a timely manner to make sure that you have complete and accurate capitation information.
CMS payments are based on the HCC Reporting. This payment methodology requires MA health plans to submit accurate diagnosis information, at the greatest level of specificity available.
We offer an alternate method of reporting CMS risk adjustment data in addition to the normal claim/encounter submission process.
All encounter submissions are required to process the 837 Claim/Encounter in a HIPAA 5010 compliant format.
To supplement a previously submitted 837 Claim/Encounter, you may submit an 837 replacement Claim/Encounter, or send additional diagnosis data related to the previously submitted 837, through the Optum ASM Operations FTP process.
If you choose to submit via ASM, you will first need to contact the Optum ASM Operations team at firstname.lastname@example.org to start the onboarding process.
Capitation is per member per month (PMPM) payment to a medical group/IPA or facility that covers contracted services for assigned members. This is an alternative to the fee-for-service arrangement. Capitation payments made whether or not the member seeks services from the capitated care provider.
- Under a shared risk arrangement, the medical group/IPA receives capitation for professional services rendered to its assigned members.
- Under a partial risk contract, the facility also receives capitation for institutional services rendered to their assigned members.
Refer to the Division of Financial Responsibility (DOFR) grid in your participation agreement for a detailed listing of capitated services. Services not specifically excluded from capitation are included in the capitation payment made to the medical group/IPA or facility.
The capitation system uses a 15/30 rule to determine whether capitation paid for the full month or not at all. If the effective date of a change falls between the first and 15th of the month, the change is effective for the current month, and capitation paid for that month. However, if the effective date falls on the 16th or later, the change reflected the first of the following month and capitation paid for the following month.
For purposes of capitation payments, we add members on the first day of the month, or terminated on the last day of the month, with the exception of newborns who are added on their dates of birth. We pay or recoup commercial capitation for full months.
A member added retroactively between the first and the 15th of the month would generate a capitation payment for the entire month. However, a member added on the 16th or later would not generate a capitation payment for that month, even though they would be considered eligible for services.
A member retroactively terminated between the first and 15th of the month would generate a capitation recoupment entry for the capitation previously paid for the entire month. However, a member retroactively terminated on the 16th or later, would not generate a capitation recoupment entry for the capitation previously paid for the entire month.
UnitedHealthcare makes monthly capitation payments to the medical group/IPAs and capitated facilities for providing and arranging covered services to our members.
Capitation payments are delivered via check or electronic funds transfer on the date specified in the participation agreement. If the due date falls on a non-banking day, the capitation payment delivered the next banking day.
To receive capitation payments via EFT, we require a signed EFT Payments form, detailing the bank account and bank routing information. The EFT initial set-up, or a change in banking information, requires three weeks processing time to take effect.
We deposit Capitation payments via EFT by the end of the banking/business day on the date specified in the participation agreement.
Note: Most financial institutions charge a per transaction fee, on electronic funds transfers.
The Authorization Agreement Payments form online at Link. You can submit completed forms on Link.
Capitation calculation methods are detailed in your participation agreement. For commercial products, there are four capitation calculation methods:
Flat Rate Calculation: A flat rate (PMPM) capitation calculated by applying the flat rate for each member to yield the standard services capitation amount. The flat rate detailed in your participation agreement. Both the flat file and the image reports display each member level transaction.
Fixed Rate Age/Gender Adjusted Calculation: Fixed rate age/gender adjusted capitation uses age/gender factors to modify the flat base rate up or down to align “standard services capitation” with age-weighted risk. The flat base rate multiplied by the age/gender factor yields the standard services capitation amount.
Age/gender factors work to weight for age/gender risk consideration with respect to the demographic population. UnitedHealthcare actuarially develops age/gender factors. The age/gender factors may vary between medical groups/IPAs and are included in the participation agreement.
We report the age/gender factors and standard services capitation amount at the member level on the flat file. Only the standard services capitation amount is reported on the image reports.
Fixed Rate Age/Gender/Benefit Adjusted Calculation: Fixed rate age/gender/benefit adjusted capitation contains three components: (1) flat base rate; (2) age/gender factor; and (3) benefit factor.
Flat base rate detailed in the participation agreement;
- Age/gender factors work to weight for age/gender risk consideration with respect to the demographic population;
- UnitedHealthcare actuarially develops age/gender factors. The age/gender factors may vary between medical groups/IPAs and are included in the participation agreement;
Fixed Rate Age/Gender/Copayment Adjusted Calculation: Copayment adjustment works to evaluate the member’s copayment made directly to the care provider. We actuarially derive the copayment adjustment for each copayment level.
- We add or subtract the copayment adjustment from the flat base rate. The sum of flat base rate +/- copayment adjustment multiplied by, the age/gender factor to yield the standard services capitation amount. We report the flat base rate, age/gender factor, copayment adjustment and standard services capitation amounts at the member level on the flat file. The image reports only show the standard services capitation amount.
The capitation source system can administer a single commercial contract with multiple rates, if the contract requires a different rate for members enrolled in a specific plan or in-network. These contracts are identified by the Primary Care Provider Network Indicator (PC PNI).
The four capitation calculation methods described above under Capitation Calculation Methods section apply. This option is available for commercial contracts. It allows you to manage your capitation under one medical group/IPA number.
Capitation transactions can be reported at both a summary and detailed levels. All individual transactions are summarized by PNI code and reported on several capitations image reports. There are also detailed care provider PNI transactions reports on both the flat file (CP7810, column U, field 21) and image reports (CP7210, CP7230). Member PNI is reported on the flat file (CP7810, column AP, field 42).
Capitation Calculation Process
For MA products, there are three capitation calculation methods:
- Flat rate — A rate is paid PMPM. We calculate the flat rate capitation by applying the flat rate for each member to give us the standard services capitation amount. The participation agreement details the flat rate. Both the flat file and image reports display each member level transaction.
- Percent of premium — The percent of CMS premium calculation begins with the premium identified from the CMS Monthly Membership Report (MMR), less any premium adjustments, and multiplied by the contracted percentage.
The net of all adjustments is the CMS premium. The flat file, (1 R record type), shows the CMS premium at the member level with the field name Cap_Premium_Gross_Cap.
Medical groups/IPAs and capitated facilities with a percentage-of-premium contract receive their contracted percentage rate of this cap premium gross cap amount as the standard services capitation amount for each member. The flat file (1 R record type), shows the standard services capitation amount at the member level by summing the fields Group_ Capitation_Amt plus Facility_Capitation_Amt. Image reports also show the standard services capitation amount at the member level.
3. Risk adjusted fixed rate —We calculate capitation using the base rate detailed in the participation agreement,
multiplied by various factors.
It contains three components:
- Base Rate — is detailed in the participation agreement
- Risk Adjusted Factor (RAF) — the score for each Medicare Advantage plan member taken directly from the Monthly Membership Report (MMR) provided by CMS. This factor is reported on the flat file and image reports.
- Health status variables are the base rate adjusted for members categorized as ESRD or Hospice by CMS on the MMR. For details on the ESRD and Hospice adjustments, please see your participation agreement.
The risk-adjusted fixed rate capitation amount will vary monthly resulting in changes in the risk adjustment factor and demographic factors for Medicare Advantage plan members for that month. Both the flat file and image reports show each member level transaction. The risk adjusted fixed rate capitation has the standard six-month system retro window. Payments made by CMS outside the six-month retroactivity window are not included.