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Claims Processes - Capitation and/or Delegation Supplement, 2018 UnitedHealthcare Administrative Guide

We may delegate claims processing to medical groups/IPAs and facilities (collectively referred to as “delegated entities” in this section) that have requested delegation and have shown through a pre-delegation assessment that they are capable of processing claims that are compliant with applicable federal regulatory requirements.

Delegated entities must develop and maintain claims operational and processing procedures that allow for accurate and timely payment of claims. Procedures must properly apply benefit coverage, eligibility requirements, appropriate reimbursement methodology, etc. and meet all applicable federal regulatory requirements.

Care providers submit a clean claim by providing the required data elements, along with any attachments and additional elements, or revisions to data elements, of which the care provider properly notified, and any coordination of benefits or non-duplication of benefits information if applicable.

Please refer to Requirements for Complete Claims and Encounter Data Submission in Chapter 9: Our Claims Process, for further details.

A delegated medical group/IPA must implement and maintain a post-service/retrospective review process that is consistent with processes utilized by UnitedHealthcare.

We define a post-service/retrospective/medical claim review as the review of medical care treatments, medical documentation and billing after the service has been provided.

We perform a Medical Claim Review to provide fair and consistent means to review medical claims and confirm delegates meet the following criteria:

  • Medical necessity determinations;
  • Appropriateness of admission, length of stay and level of care;
  • Eligibility verification;
  • Initiation of appropriate follow-up for utilization, quality and risk issues;
  • Appropriateness of billing; and
  • Identifying and resolving claims-related issues as they relate to medical necessity and UnitedHealthcare claims payment criteria and/or guidelines. 

We also perform Medical Claim Reviews on claims that do not easily allow for additional focused or ad-hoc reviews, such as:

  • High dollar claims;
  • Claims without required authorization;
  • Claims for unlisted procedures;
  • Trauma claims;
  • Implants that are not identified on our Implant guidelines used by our Claim department;
  • Claim check or modifier edits based on our claim payment software;
  • Foreign claims; and
  • Claims with level of service (LOS) or level of care (LOC) mismatch.

The delegated medical group/IPA is accountable for conducting the post-service review of emergency department claims and unauthorized claims. A care provider shall review presenting symptoms, as well as the discharge diagnosis, for emergency services.

Consideration of emergency department claims must include:

  • Coverage of emergency services to screen and stabilize the member without prior approval where a prudent layperson, acting reasonably, would have believed that an emergency medical condition existed;
  • Coverage of emergency services if an authorized representative, acting for the organization, has authorized the provision of emergency service;
  • Appropriate care provider review of presenting symptoms, as well as the discharge diagnosis; and

Medical group/IPA shall monitor appeals and overturn rates for emergency department claims, and develop and execute improvement action plans when they identify deficient performance or processes.

We have established policies and procedures specifically designed to monitor the delegated entities’ compliance with state and federal claims processing requirements.

Our auditors will conduct claims processing compliance assessments. We review delegated entities found in compliance at least annually. Our auditors conduct additional reviews for other circumstances, such as:

  • Assessment results indicate non-compliance
  • Self-reported timeliness reports indicate noncompliance for two to three months
  • Non-compliance with reporting requirements
  • Lack of resources or staff turnover
  • Overall performance warrants a review, (claims appeal activity, claims denial letters or member and care provider claims-related complaints)
  • Allegations of fraudulent activities or misrepresentations
  • Information systems changes or conversion
  • New management company, or change of processing entity
  • Established Management Service Organization (MSO) acquires new business
  • Significant increase in members or volume of claims
  • Significant increase in claims-related complaints
  • Regulatory agency request
  • Significant issues concerning financial stability

As part of the claims processing compliance assessment, we will request copies of the delegated entity’s universal claims listing for contracted and non-contracted care providers. The auditor will review the reports accuracy and randomly select claims for examining. They tell the delegated entity which claims they selected at random from the universal claims listing. The delegated entity must be ready for the auditor at the time of assessment.

Examples of the categories assessed include:

  • Timeliness Assessment;
  • Financial Accuracy (including proper benefit application, appropriate administration of member cost share accumulation);
  • Administrative Accuracy;
  • Customer Denial Accuracy and Denial Letter Review;
  • Care Provider Denial Assessment;
  • Non-Contracted Care Provider Payment Dispute Resolution (Overturns and Upholds) Claims Assessment;
  • Fraud, Waste and Abuse Inspection.

Delegated entities found not compliant with state and/or federal regulations, as well as UnitedHealthcare standards for claims processing, will be required to provide a remediation plan describing how identified deficiencies are to be corrected.

The remediation plan should include timeframe in which the deficiencies will be corrected. Delegated entities not remediating deficiencies may be subject to additional oversight, sanction and potential dedelegation.

If the delegated entity is found to be non-compliant, we will require them to develop an Improvement Action Plan (IAP) to correct any deficiency, such as:

  • Processing timeliness issues
  • Failure to pay interest or penalties
  • Failure to submit Monthly/Quarterly Self-Reported Processing Timeliness reports
  • Canceling assessments
  • Failure to submit requested claims listings
  • Failure to have all documentation ready for a scheduled assessment
  • Failure to provide access to canceled checks or bank statements

When we put a delegated entity on an IAP we place them on a cure period. A cure period is a 90-calendar days timeframe we give to a delegated entity after a noncompliant review. They have 90 days to demonstrate compliance or remain in the cure period until they achieve compliance. We conduct frequent reviews during the cure period.

We may sanction delegated entities who do not achieve compliance within the established cure period. Claims processing is a delegated function that is subject to revocation. Sanctions may consist of additional/enhanced assessing, onsite claims management, revocation of delegated status, and/or enrollment freeze. Sanctions may result in costs to the delegated entity.

When a delegated entity receives a claim for a commercial or MA member, they must assess the claim for the following components before issuing a denial letter:

  • Member’s eligibility status with UnitedHealthcare on the date of service
  • Responsible party for processing the claim (forward to proper payer)
  • Contract status of the care provider of service or referring care provider
  • Presence of sufficient medical information to make a medical necessity determination
  • Covered benefits
  • Authorization for routine or in-area urgent services
  • Maximum benefit limitation for limited benefits
  • Prior to denial for insufficient information, the medical group/IPA/capitated facility must document their attempts to get information needed to make a determination

In instances when a member is financially responsible for a denied service, UnitedHealthcare or the delegated entity’s claims department (whichever holds the risk) must provide the member with written notification of the denial decision in accordance with federal and state regulatory standards.

The delegated entity must use the most current CMS approved Notice of Denial of Payment letter template to accurately document and issue a claim denial letter to a member. The denial letter must be sent within the appropriate regulatory timeframes.

If the member is enrolled in a benefit plan subject to ERISA, a claim denial letter issued to the member must clearly state the reason for the denial and provide proper appeal rights. The denial letter must be issued to the member within 30 calendar days of receipt of the claim.

The delegated entity remains responsible to issue appropriate denials for member-initiated, non-urgent/emergent medical services outside of their defined service area.

When the member is not financially responsible for the denied service, the member does not need to be notified of the denial. The care provider must receive notification of the denial and their financial responsibility (i.e., writing the charges off for the claims payment).

UnitedHealthcare or the delegated entity’s claims department (whichever holds the risk) is responsible for providing the notification.

The denial notice (letter, EOB, or PRA) issued to any noncontracted care provider of service must tell them:

  1. Their appeal rights.
  2. The member is not to be balance billed.

When the member has no financial responsibility for the denied service, the denial notice issued to any contracted care provider of service must clearly state that the member is not to be billed for the denied or adjusted charges. In addition, the contracted care provider notifies member of their right to dispute the decision or discuss it with a care provider reviewer.

All care providers are required to submit clean claims for reimbursement no later than the time specified in the care provider’s participation agreement or the timeframe specified in applicable laws, whichever is greater. Neither UnitedHealthcare nor the plan’s capitated provider that pays claims will impose a deadline for the receipt of a claim that is less than 90 days for contracted providers and 180 days for non-contracted providers after the date of service, except as required by any state or federal law or regulation.

If UnitedHealthcare or the capitated provider is not the primary payer under coordination of benefits, UnitedHealthcare or the capitated provider shall not impose a deadline for submitting supplemental or coordination of benefits claims to any secondary payer that is less than 90 days from the date of payment or date of contest, denial or notice from the primary payer.

If a network care provider fails to submit a clean claim within the foregoing timeframes, UnitedHealthcare reserves the right to deny payment for such claim. Claims that are denied for untimely filing, cannot be billed to a member.

We have established internal claims processing procedures for timely claims payment to our care providers, and we are committed to paying claims for which we are financially responsible within the timeframes required by state and federal law.

The claims “timely filing limit” is defined as the calendar day period between the claims last date of service or payment/denial by the primary payer, and the date by which UnitedHealthcare, or its delegate, receives the claim.

Determination of the date of UnitedHealthcare’s or its delegate’s receipt of a claim, the date of receipt shall be regarded as the calendar day when a claim, by physical or electronic means, is first delivered to UnitedHealthcare’s specified claims payment office, post office box, designated claims processor or to UnitedHealthcare’s capitated care provider for that claim.

We use the following date stamps to determine date of receipt:

  • UnitedHealthcare HMO Claims department date stamp primary payer claim payment/denial date as shown on the Explanation of Payment (EOP)
  • Delegated care provider date stamp
  • Third party administrator date stamp
  • Confirmation received date stamp that prints at the top/bottom of the page with the name of the sender

Refer to the official CMS website for additional rules and instructions on timely filing limitations.

Delegated entities must have a clearly identifiable date stamp used for the receipt of all paper claims. Electronic claims date stamps must follow federal standards.

Date of Receipt and Date of Service
“Date of receipt” means the working day when a claim, by physical or electronic means, is first delivered to either the plan’s specified claims payment office, post office box, or designated claims processor or to UnitedHealthcare’s capitated provider for that claim.

“Date of Service,” for the purposes of evaluating claims submission and payment requirements, means:

(A) For outpatient services and all emergency services and care: the date the provider delivered separately billable health care services to the member.

(B) For inpatient services: the date the member was discharged from the inpatient facility. However, UnitedHealthcare or the capitated provider must accept separately billable claims for inpatient services at least bi-weekly.

To meet legal and regulatory timeliness standards, forward misdirected claims to the proper payer following state and federal regulations. If care providers send claims to a delegated entity and we are responsible for adjudicating the claim, the delegated entity shall forward the claim to us within 10 working days of the receipt of the claim.

We identify, batch and forward misdirected claims to the appropriate delegated entity following state and federal regulations. We send the care provider of service a notice that we have forwarded the member’s claim to the appropriate delegated entity for processing.

The delegated entity must identify and track all claims received in error (either manually or systematically). Tracking must include:

  1. The name of the entity of where the claim was sent, and
  2. The date mailed.

The delegated entity must then immediately forward the claims to the appropriate payer, and follow state and federal regulatory timeframes. If they determine the member was assigned to another medical group/IPA on the date of service, the care provider should forward the claim to the appropriate delegated entity following state and federal regulatory timeframes for processing.

When the claim is adjudicated, the delegated entity must notify the care provider of service who the correct payer is, if known, using the Explanation of Payment (EOP) they give to the care provider.

Out-of-Area (OOA) Urgent or Emergent Claims
In most contractual arrangements, UnitedHealthcare has financial responsibility for urgent or emergent out-of-area medical and facility services provided to our members. We follow laws and regulations regarding payment of claims related to access to medical care in urgent or emergent situations.

If we determine the claims are not emergent or urgent, we forward the claims to the capitated/delegated care provider for further review. Medical services provided outside of the medical group/IPA’s defined service area and authorized by the member’s medical group/IPA are the medical group/IPA’s responsibility and are not considered OOA medical services.

Delegated entities must ensure appropriate reimbursement methodologies are in place for non-contracted and contracted care provider claims.

For payment of non-contracted network care provider services the letter, EOP, or PRA issued must notify them of their dispute rights if they disagree with the payment amount. You may not bill members for the difference of the billed amount and the Medicare allowed amount. MA contracted care provider claims must be processed following contract rates and within state and federal regulatory requirements.

Delegated entities are required automatically to pay applicable interest on claims according to state and federal requirements.

Delegated entities are responsible for updating their claims systems to help ensure members are not charged for copayments or coinsurance/deductibles once the annual maximum out-of-pocket expense met.

For claims falling under the Department of Labor’s ERISA regulations, you must make a decision to pay or deny within 30 calendar days.

You must issue denials within 30 calendar days of receipt of the complete claim. You must issue payments within 45 working days or within state regulation, whichever is more stringent. The legislation does not differentiate between clean, unclean, and nonparticipating claims.

Interest must be automatically paid on all uncontested claims not paid within 45 working days after receipt of the claim. Interest accrues at the rate established by state regulatory requirements, per annum, beginning with the first calendar day after the 45 working day period and must be included with the initial payment.

If interest is not included, there is an additional penalty paid to the care provider in addition to the interest payment.

Insured Services
Insured Services are those service types defined in the participation agreement to qualify for medical group/IPA reimbursement, assuming the qualifications of certain designated criteria.

The medical group/IPA is responsible to pay the claim and submit it to UnitedHealthcare per this process for reimbursement. Examples of an insured service could include eligibility guarantee, AIDS, or pre-existing pregnancy.

Indemnified Services
UnitedHealthcare may retain financial risk for services (or service categories) that cannot be submitted through the regular claims process due to operational limitations. These limitations include, but are not limited to, ambiguous coding and/or system limitations that can cause the claim to become misdirected.

Misdirected claims are a risk to both organizations in terms of meeting regulatory compliance and inflating administrative costs. Claims for insured or indemnified services qualify for payment to the capitated entity as defined in the medical group/IPA or facility agreement.

Should you have additional questions surrounding this process, please speak with your provider advocate.