Contractual and Financial Responsibilities - Capitation and/or Delegation Supplement, 2018 UnitedHealthcare Administrative Guide

As an MA plan, UnitedHealthcare and its network care providers agree to meet all laws and regulations applicable to recipients of federal funds. The medical group/IPA and capitated facility acknowledge that they will be required to comply with certain laws applicable to entities and individuals to entities and individuals receiving federal funds.

An inpatient admission includes:

  • Inpatient acute care;
  • Skilled Nursing Facility (SNF);
  • Detoxification;
  • Medical rehabilitation; and
  • All related services.

If a member’s assigned care provider is partial risk at the time of admission and then changes to shared risk prior to the member’s discharge all claims related to this confinement from admission through discharge will be processed according to the partial risk DOFR in effect at the time of the admission.

If a member’s assigned care provider is shared risk at the time of admission and then changes to partial risk prior to the member’s discharge, all claims related to this confinement from admission through discharge processed according to the shared risk DOFR will be in effect at the time of the admission.

Collection of Fees
In the following instances, when a member needs one of the following forms, for other than medical reasons, you may collect a fee, in addition to the office visit copayment, for completion of these forms (unless the member’s benefit plan or applicable law dictates otherwise):

  • DMV forms;
  • Camp or school forms;
  • Employment or insurance forms;
  • Adoption form;

You cannot collect an additional fee, copayment, or surcharge for:

  • Completion of Prior Authorization form for non-formulary drugs;
  • Completion of disability forms;
  • Missed appointments/no shows or late cancellations; and
  • Member cannot pay office visit copayment at the time of visit, for basic healthcare services. In this instance, the medical group/IPA may reschedule the member’s appointment. If the member requires urgently needed care or emergency care, the medical group/IPA must render care.

You can collect copayments when professional services are rendered by a:

  • Licensed medical doctor or doctor of osteopath as defined by the state;
  • Care provider’s assistant; or
  • Nurse practitioner.

Do not collect copayments when there is no actual office visit. For example:

  • Injections administered by a nurse or medical assistant; or
  • Routine immunizations administered by a nurse or medical assistant.

UnitedHealthcare is required to monitor and track each member’s annual individual out-of-pocket/deductible maximum amount. The member’s annual individual outof-pocket/deductible maximum accumulation calculated through member’s cost share data collected from all or some of the following sources:

  • Medical group/IPA/capitated hospital encounters.
  • Prescription related encounters.
  • Behavioral Health-related encounters.
  • Claims processed by UnitedHealthcare or its delegates.

UnitedHealthcare and its capitated care providers share responsibility in monitoring the member’s individual out-ofpocket/deductible maximum. For additional information on the reporting available from UnitedHealthcare, see Chapter 10: Compensation of this guide.

When a member meets their annual individual out-of-pocket/deductible maximum, UnitedHealthcare will validate the reported cost share information and notify the member and their capitated care provider in writing that the member has met their annual individual out-of-pocket/deductible maximum.

If the member exceeds their annual individual out-ofpocket/deductible maximum due to the capitated care provider collecting member cost share amounts after the member has met their annual individual out-of-pocket/deductible maximum, the capitated care provider will be required to refund any cost share amounts collected in excess of the member’s annual individual out-of-pocket/deductible maximum amounts to the member. Additionally, we ask the capitated care provider to verify that the member has received all appropriate reimbursements.

UnitedHealthcare’s Compliance Assessment team will monitor the capitated care provider’s compliance with this annual individual out-of-pocket deductible maximum policy to help ensure all requests for reimbursement completed timely.

If necessary, UnitedHealthcare will work with the capitated care provider to help ensure that each member reimbursed for any amounts collected in excess of the member’s annual individual out-of-pocket/deductible maximum amounts as specified in the member’s benefit plan.

If the capitated care provider fails to reimburse a member for amounts collected in excess of the member’s annual individual out-of-pocket/deductible maximum, UnitedHealthcare may reimburse the member directly and recover the payment via capitation deduction as specified in your participation agreement.

  • Cost share information comes from different sources derived through claims and encounter data submissions.
  • Cost share totals are gathered from these sources.
  • Delegated entities can view cost share information on UHCprovider.com.
  • The following reports will be available to view the Member’s Cost Share accumulation:
    • EL915 M
    • EL917
    • EL918
    • IVR
    • 5010 version of the 270/271 — refer to the EDI companion guide
  • We notify members when they meet their annual out-ofpocket copayment/deductible maximums. Delegated entities can view members who have met the annual copayment/deductible maximum on the EL917.
  • The EL918 report is a daily Member Cost Share report that shows the cost share information for all active members belonging to a care provider. This report is available in both CSV and data formats.
  • Delegated entities are responsible for updating their systems to help ensure members not charged for copayments, coinsurance, and deductibles once the annual maximum is met.
  • UnitedHealthcare conducts assessments to help ensure appropriate administration of member cost share accumulation.

Annual out-of-pocket maximum is the combined total of annual deductible and annual copayment maximum, as shown on the member’s Schedule of Benefits. Cost sharing for certain types of covered services may not apply toward the annual out-of-pocket maximum. Please refer to the member’s Schedule of Benefits to determine applicability to the benefit plan.

When an individual member’s out-of-pocket expenses has reached the individual out-of-pocket maximum, the member will not owe any further cost share amounts for those services that apply to the out-of-pocket maximum.

For benefit plans with both individual and family maximums, no family member will owe further cost share amounts for those services that apply to the out-of-pocket maximum. When a family’s out-of-pocket expenses have reached their family out-of-pocket maximum benefits.

Cost sharing still applies to those plans with benefits that do not apply to the out-of-pocket maximum and for excluded benefits after the out-of pocket maximum reached.

Cost sharing is defined as amounts paid by the member such as copayments, coinsurance and deductibles according to their plan benefits.

There is no coverage for certain covered services until the member meets the annual deductible. Only amounts incurred for covered services that are subject to the deductible will count toward the deductible. Benefit plans may have an individual deductible only or both individual and family deductible amounts. No further deductible will be required for the individual member when the individual deductible amount has been satisfied for the year.

For plans with both individual and family deductibles, no further deductible will be required for all members of the family unit when members of the family unit satisfy the family deductible for the year.

As specified above, only certain covered services apply to the annual deductible. Other covered services not included in the annual deductible may incur a member cost share considered separate from and not applied to the annual deductible. The annual deductible applies to the annual out-of-pocket maximum. The amounts applied to the annual deductible based on UnitedHealthcare’s contracted rates, percentage copayments (coinsurance) and contracted rates.

Annual Out-of-Pocket Maximum
Annual out-of-pocket maximum is the total of the member’s annual copayment maximum (if any), as shown on the member’s Evidence of Coverage. Cost sharing for certain types of covered services may not apply toward the annual out-of-pocket maximum. Please refer to the member’s Evidence of Coverage to determine applicability to the benefit plan.

When an individual member’s out-of-pocket expenses has reached the individual annual out-of-pocket maximum, no further cost share amounts will be due by the member for those services that apply to the annual out of-pocket maximum. Plans with benefits that do not apply to the annual out-of-pocket maximum will still require cost sharing for those benefits after the annual out-of-pocket maximum reached.

Cost sharing is defined as amounts paid by the member such as copayments, coinsurance and deductibles according to their plan benefits.

Coinsurance Calculation
For all MA products, coinsurance is calculated as follows:

  1. For services reimbursed via a service-specific contracted rate, or on a fee-for-service basis, the coinsurance is based on the contracted rate or billed amount, whichever is less or as agreed upon in the care provider contract.
  2. For services reimbursed under a downstream capitation agreement between your organization and a care provider of the service, and where payment is not issued for each specific service rendered, coinsurance is based on the Medicare Allowable Rate for the location at which the service is rendered.

This coinsurance calculation is consistent with the definition of coinsurance as an amount a member may be required to pay as their share of the cost for services or prescription drugs. The methodology is used for all UnitedHealthcare Medicare Advantage plans nationwide.

The correct system setup and consistent coinsurance calculation will help reduce member appeals and complaints.

Professional and institutional encounter data consist of an itemization of medical group/IPA/capitated facility, capitated and sub-capitated services provided to our commercial or Medicare Advantage members.

We encourage you to submit your encounter data weekly. We welcome your encounter submissions more frequently than weekly (e.g., twice a week, or daily). Frequent encounter submissions, allows us to support various state and federal regulatory requirement for reporting.

Encounter Data Tip:

Send Encounter data sent using Electronic Data Interchange to Payer ID 95958 or check with your clearinghouse.

We continuously monitor encounter data submissions for quality and quantity. Submission levels below the monthly threshold of 100% are non-compliant. The capitated medical group/IPA or other submitting entity must correct any encounter errors identified by a clearinghouse or trading partner at least monthly. As you are processing claims on our behalf, we expect all encounter submissions to be an accurate reflection of the original claim received without exception.

All encounter data submitted to UnitedHealthcare are subject to state and/or federal audit. We have the right to perform routine medical record chart assessments on any or all of the medical group’s/IPA’s network care providers at such time or times as we may reasonably elect to determine the completeness and accuracy of encounter data ICD-10- CM and CPT coding. We notify the medical group/IPA in writing of audit results for coding accuracy.

The delegate may be subject to financial consequences if it or another submitting entity fails to submit or meet encounter data element requirements. In addition, the delegate may be required to perform a complete medical record chart review of its network care providers with notice from UnitedHealthcare.

Commercial Encounter Data Requirements

The capitated medical group/IPA, or other submitting entity, must certify the completeness and truthfulness of its encounter data submissions, as required by the state regulatory agency. The medical group/IPA, or other submitting entity, must submit all professional and institutional encounter data for UnitedHealthcare members to:

  • Comply with the Affordable Care Act for risk adjustment reporting, Essential Health Benefits (EHB), and with NCQA-HEDIS® reporting requirements;
  • Provide the medical group/IPA, or other submitting entity, with comparative data;
  • Facilitate settlement calculations if applicable, and oversight of utilization management and quality management; and
  • Report member out-of-pocket maximums.

We require capitated medical group/IPAs and capitated facilities to submit timely and compliant encounter data. The member cost share amount should be included on the encounter data submissions and based on the member’s benefit plan; not the amount the member paid at the time of service. The encounter should clearly distinguish between copayment, coinsurance and deductible amounts within the Claim Adjustment Segments (CAS) segment of Loop 2430 as indicated on the ANSI ASC X12N 837 Health Care Claims transaction for each service line of your assigned commercial members.

The Affordable Care Act dictates reporting requirements of submissions for risk adjustment. To comply with those requirements we require all contracted care providers to submit all diagnosis and procedure codes to the highest level of specificity relevant to the encounter data submission.
The Encounter Data Collection Team is your point of contact for additional questions.

Medicare Advantage (MA) Encounter Data Requirements
CMS reimburses all MA plans based on the member’s health status. They use the diagnosis codes from the MA claims and/or encounter data (inpatient, outpatient and care provider) to establish each member’s health status or Hierarchical Condition Category (HCC). CMS uses the HCC to help calculate Medicare reimbursement payments for each member.

As a result, we are required to send all adjudicated claims and capitated encounter data for MA members to CMS. These claims and encounters must pass all the edits that CMS applies to its fee-for-service HIPAA 5010 837 and CMS-1500 and UB-04 submissions.

To reduce rejected claims, delegates must process their MA claims and encounters in the same manner as their Medicare fee-for-service bills, and are subject to the specific claims submission and other requirements stated in this guide.

If the claim data does not pass the CMS edits, which our systems mirror, we let you know. You will need to resubmit the claim or encounter to us. CMS may at any time audit our submission. The medical record must support the diagnoses submitted by you. Only the care provider can change or submit new CMS- 1500 or UB-04 data, so your cooperation is required for us to submit the correct data.

We require the medical group/IPA/capitated facility or other submitting entity to submit all professional and institutional claims and/or encounter data for MA members to:

  • Comply with regulatory requirements of the CMS Balanced Budget Act (BBA), and NCQA-HEDIS reporting requirements.
  • Submit to us for risk adjustment reporting and accurate Medicare reimbursement so that we are able to make our submission to CMS.
  • Provide the submitting entity with comparative data.
  • Facilitate utilization management oversight, quality management oversight, and settlement calculation, if applicable.
  • Support Services 75 FR 19709 -Maximum Allowable Outof-Pocket Cost Amount for Medicare Parts A and B.

To comply with the CMS regulation 75 FR 19709 to report member cost sharing as well as out-of-pocket maximums,
we require contracted care providers to submit current, complete and accurate encounter data. This includes member cost sharing/revenue, to within the CAS segment of the ANSI ASC X12N 837 Health Care Claims transaction for each service line of your assigned MA members.

To comply with CMS regulation 42 CFR 422.111(b)(12) an EOB for Part C benefits must report total costs incurred by the health plans (us) for capitated and/or delegated provider services, on encounter submissions from contracted care providers processed with dates of service on or after Jan. 1, 2015.

Medicare Advantage Organizations (MAOs) are required to report the total costs incurred for capitated and/or delegated provider services. MAOs must populate dollar amounts for capitated and/or delegated providers in the “Total cost” and “Plan’s share” columns in the Monthly or Quarterly Summary EOB. The “Total cost” field on the member EOB includes what the member pays and what the health plan pays.

Medicare Managed Care Service Organizations (MSOs), capitated medical groups, facilities, and ancillary care providers must submit the payer amount paid at the claim level, the Service Line Paid Amount, and the member cost sharing which is based on the member’s benefit plan, for all professional and institutional Medicare encounter data. The payer amount paid submitted in the encounter should not be a zero unless we denied the claim.

We also refer to the payer amount paid as the contracted rate, Medicare Fee Schedule Rate, or Calculated Capitation Rate less any applicable member responsibility.

We continuously monitor encounter data submissions for quality and quantity. Submission levels below the monthly threshold of 100% are non-compliant. The capitated medical group/IPA or other submitting entity must correct any encounter errors identified by a clearinghouse or trading partner at least monthly. As you are processing claims on our behalf, we expect all encounter submissions to be an accurate reflection of the original claim received without exception.

All encounter data submitted to UnitedHealthcare are subject to state and/or federal assessment. We have the right to perform routine medical record chart assessments on any or all of the medical group’s/IPA’s network care providers at such time or times as we may reasonably elect to determine the completeness and accuracy of encounter data, ICD-10-CM and CPT coding. We notify the medical group/IPA in writing of audit results for coding accuracy.

The delegate may be subject to financial consequences if it or another submitting entity fails to submit or meet encounter data element requirements. In addition, the delegate may be required to perform a complete medical record chart review of its network care providers with notice from UnitedHealthcare.