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Claims Process - Mid-Atlantic Regional Supplement, 2018 UnitedHealthcare Administrative Guide

Please refer to Chapter 9: Our Claims Process for detailed information about our claims process.

All claims that can be submitted electronically must be submitted to payer ID 87726.

Reconsideration and Appeals Processes

For claim reconsiderations for M.D. IPA and Optimum Choice, please submit your request online using claimsLink.

Captation Reports to PCPs 

UnitedHealthcare of the Mid-Atlantic region provides Capitation Reports to PCPs, as described below:

7030-A01: Capitation Analysis Summary – Provider Medical Group Report

High-level capitation information by current and retro periods for each care provider.

7010-A01: Capitation Paid ECap – Provider Medical Group Report – Summary

A contract-level report that summarizes the capitation paid by current and retro periods.

The three sections of the report include amounts for:

  1. Standard services
  2. Supplemental benefits and capitated adjustments
  3. Non-capitated adjustments and withholds

7010-A02: Capitation Paid ECap – Primary Care Provider Report - Detail

A PCP-level report that summarizes the capitation paid by current and retro periods.

The three sections of the report include amounts for:

  1. Standard services
  2. Supplemental benefits and capitated adjustments
  3. Non-capitated adjustments and withholds

7210-A01: Capitation Details – Primary Care Provider Report for Standard Services- (PMG)

Detailed capitation information for each current member assigned to a PCP.

7240-A01: Member Changes Capitation Details – Primary Care Provider Report for Standard Services-(PMG)

Detailed retroactive change information on added, changed and terminated members.

The three sections of the report include information on:

  1. Member adds
  2. Member demographic changes
  3. Member terms

7290-A01: Capitation Adjustment Details – Primary Care Provider Report-(PMG)

Capitation adjustment details for Member and provider-level guide adjustments.

The two sections of the report include information on:

  1. Current period
  2. Retro period

The PCP practice should reconcile the capitation payment and report upon receipt. Any requests for an adjustment or reconciliation of the capitation payment must be made within 60 calendar days of receipt.

If the PCP/medical group (practice) does not request reconsideration of the capitation payment within 60 days, the capitation payment provided is accepted as payment in full (as per contract). 

Copies of the reports above can be obtained by calling Provider Services at 877-842-3210.

Bill Above

In addition to the capitation payments, certain covered services are eligible for reimbursement. To obtain a copy of this information, please contact your Network Representative.

To locate your Network Representative, please go to UHCprovider.com > Support and Privacy > Contact Us > Find a Network Management Contact > Select your state.