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Claim Submission Tips - Chapter 9, 2018 UnitedHealthcare Administrative Guide

Submit your claims and encounters as an 837 EDI Transaction

  • Before submitting your EDI claims to us, refer to the member’s health care ID card for the Payer ID.
  • If no Payer ID is listed or you do not have access to the member’s ID card, refer to our Claims Payer List for the correct Payer ID number.

Do not use EDI or a paper claim form to resubmit claims that were denied or pended for additional information. Please use claimsLink.

The Payer ID is an identification number that instructs the clearinghouse where to send your electronic claims or encounters. In some cases, the Payer ID listed on our Claims Payer List may be different from the number issued by your clearinghouse. Validate any errors with your clearinghouse to avoid delays.

Submit professional and institutional claims and/or encounters electronically. We accept primary and secondary claims electronically. Find specific information about secondary claims submissions, such as Coordination of Benefits (COB) electronic claim requirements and EDI specifications, on  UHCprovider.com/EDI > Quick Tips for Claims > Secondary/COB or Tertiary Claims.

The HIPAA ANSI X1 25010 837 format is the only acceptable format for submitting claims and encounter data.

We support other HIPAA EDI transactions to assist you with your revenue cycle process. For a complete list of EDI transactions available to our care providers, see the home page of UHCprovider.com/EDI. Locate specific claims with your provider ID or a specific member’s ID. You can get a claim summary or line-item detail about claims status.

Estimating Treatment Costs

To support the discussions you may have with your patients about treatment costs, take advantage of the Claim Estimator on UHCprovider.com (not available for all products).

The Claim Estimator tool is a fast and simple way to get your commercial professional claim predeterminations through UHCprovider.com/claims > Get a Claim/Procedure Cost Estimate. With Claim Estimator, you receive an estimate on
whether a procedure will be covered, at what percentage, if any, and what the claim payment will be. Claim Estimator gives you expense information you can share with your patient before treatment.

HRA and HSA Benefit Plans Claims Submission Tips

For faster claims turnaround and more accurate reimbursement with UnitedHealthcare HRAs or HSAs, verify member eligibility and benefits coverage as an EDI 270/271 transaction, or online using eligibilityLink. You can also call the member service number on the back of your patient’s health care ID card.

For our HRA members: Once logged into the Patient Eligibility & Benefits, the “HRA Balance” field will display if the member is enrolled in any or our consumer-driven health plans. When there are funds available in an HRA account, the current balance will display. The current balance is also returned if you are using EDI.

This amount is based on the most recent information available and is subject to change. The actual balance may differ from what is displayed if there are outstanding claims or adjustments that have not yet been submitted or processed.

Balances for HSA members are not available through eligibilityLink or EDI.

Most UnitedHealthcare HRA and HSA benefit plans do not require copayments. Please do not ask those members to pay a copayment at the time of service unless indicated on their health care ID card.

Submit claims electronically as an 827 EDI transaction or UHCprovider.com/claims or to the address on the back of the member’s health care ID card.

Please wait until after a claim is processed and you receive your EOB/remittance advice before collecting funds from our members with a HRA/HSA benefit plan. This is because the member responsibility may be reimbursable through their HRA account and paid to you. The remittance advice displays any remaining member balance. We will not automatically transfer the HSA balance for payment. However, the member can pay with their HSA debit card or convenience checks linked to their account balance.

Consumer Account Cards and Qualified Medical Expenses

You may only charge our HRA or FSA consumer account cards for “qualified medical expenses” incurred by the cardholder, the cardholder’s spouse or dependent. “Qualified medical expenses” are expenses for medical care that provide diagnosis, cure, mitigation, treatment or prevention of any disease, or for affecting any structure or function of the body.

Examples of non-qualifying expenses include:

  • Cosmetic surgery/procedures (i.e., procedures directed at improving a person’s appearance that do not meaningfully promote the proper function of the body or prevent or treat illness or disease), such as:
    • Face lifts
    • Liposuction
    • Hair transplants
    • Hair removal (electrolysis)
    • Breast augmentation or reduction. Surgery or procedures necessary to improve a defect from a congenital abnormality, and reconstructive surgery following a mastectomy for cancer, may qualify.
    • Teeth whitening and similar cosmetic dental procedures
    • Advance expenses for future medical care
    • Weight loss programs (disease-specific nutritional counseling may be covered)
    • Illegal operations or procedures

An expense defined as a “qualified medical expense”, but might not be covered under a member’s benefit plan. For updated information regarding qualified medical expenses, go to: irs.gov or call the IRS at 800-TAX-FORM