Claims Process - UnitedHealthcare West Supplement, 2018 UnitedHealthcare Administrative Guide

Claims and Encounters

EDI is the preferred method of claim submission for participating physicians and health care providers. Submit all professional and institutional claims and/or encounters electronically for UnitedHealthcare West and Medicare Advantage HMO product lines

Quick Tip

Instructions and quick tips for EDI can be found on UHCprovider.com/edi.

The payer ID is an identification number that instructs the clearinghouse where to send your electronic claims and encounters. In some cases, the payer ID listed on UHCprovider.com/edi may be different from the numbers issued by your clearinghouse. To avoid processing delays, you must validate with your clearinghouse for the appropriate payer ID number or refer to your clearinghouse published Payer Lists.

Please refer to our online Companion Guides for the data elements required for these transactions found on UHCprovider.com/edi.

For information on EDI claim submission methods and connections, go to EDI 837: Electronic Claims.

OptumInsight Connectivity Solutions, UnitedHealthcare’s managed gateway, is also available to help you begin submitting and receiving electronic transactions. For more information, call 800-341-6141.

Submit your claims and encounters and primary and secondary claims as EDI transaction 837.

For UnitedHealthcare West encounters, the payer ID is 95958. For claims, the payer ID is 87726. For a complete list of payer IDs, refer to the Payer List for Claims at UHCprovider.com/edi.

Do not resubmit claims that were either denied or pended for additional information using EDI or paper claims forms. Use the ClaimsLink application on Link.

Electronic Funds Transfer

Now you can enroll or make changes to Electronic Funds Transfer (EFT) and ERA/835 for your UnitedHealthcare West claims using the UnitedHealthcare West EFT Enrollment app. Enrollment in UnitedHealthcare West EFT currently applies to payments from SignatureValue and MA plans only. You’ll continue to receive checks by mail until you enroll in UnitedHealthcare West EFT. View our Payer List for ERA to determine the correct payer ID to use for ERA/835 transactions.

To access the UnitedHealthcare West EFT Enrollment app, UHCprovider.com/eps, then click on the UnitedHealthcare West EFT Enrollment App.

For more information go to UHCprovider.com/claims, scroll down to “Enroll or Change Electronic Funds Transfer (EFT) for UnitedHealthcare West,” and open the UnitedHealthcare West EFT Enrollment App Overview document.

Claims Adjudication

We use industry claims adjudication and/or clinical practices, state and federal guidelines, and/or our policies, procedures and data to determine appropriate criteria for payment of claims. To find out more, please contact your network account manager, physician advocate or hospital advocate or visit UHCprovider.com/claims.

Complete Claims

We follow the Requirements for Complete Claims and Encounter Data Submission, as found in Chapter 9: Our Claims Process.

National Provider Identification

We are able to accept the National Provider Identification (NPI) on all HIPAA transactions, including the HIPAA 837 professional and institutional (paper and electronic) claim submissions. A valid NPI is required on all covered claims (paper and electronic) in addition to the TIN. For institutional claims, please include the billing provider National Uniform Claim Committee (NUCC) taxonomy. We will accept NPIs submitted through any of the following methods:

  • Online: UHCprovider.com/mypracticeprofile.
  • Phone: 877-842-3210 through the United Voice Portal, select the “Health Care Professional Services” prompt. State “Demographic changes.” Your call will be directed to the Service Center to collect your NPI, corresponding NUCC Taxonomy Codes, and other NPIrelated information.

Level-of-Care Documentation and Claims Payment

Claims are processed according to the authorized level of care documented in the authorization record, reviewing all claims to determine if the billed level of care matches the authorized level of care.

If the billed level of care is at a higher level than the authorized level of care, we pay you the authorized level of care. You may not bill the member for any charges relating to the higher level of care. If the billed level of care is at a lower level than authorized, we pay you based on the lower level of care, which was determined by you to be the appropriate level of care for the member.

Level of Specificity — Use of Codes

To track the specific level of care and services provided to its members, we require care providers to utilize the most current service codes (i.e., ICD-10-CM, UB and CPT codes). We also require that you make sure the documented bill type is appropriate for the type of service provided.

Member Financial Responsibility

You can verify the eligibility of our members before you see them and obtain information about their benefits, including required copayments and any deductibles, out-of-pockets maximums or coinsurance that are the member’s responsibility.

No Balance Billing

You may not balance bill our members. You may not collect payment from the member for covered services beyond the member’s copayment, coinsurance, deductible, and for non-covered services the member specifically agreed on in writing before receiving the service. In addition, you shall not bill a UnitedHealthcare West member for missed office visit appointments.

Claims Status Follow-up

We can provide you with an Explanation of Payment (EOP). If you don’t get one, you can follow-up on the status of a claim using one of the following methods:

Claims Submission Requirements

You can mail paper CMS 1500 or UB-04s to the address listed on the member’s health care ID card. Refer to the Prompt Claims Processing section of Chapter 9: Our Claims Process, for more information about electronic claims submission and other EDI transactions. If your claim is the financial responsibility of a UnitedHealthcare West delegated entity (e.g., PMG, MSO, Hospital), then bill that entity directly for reimbursement.

Claims Submission Requirements for Reinsurance Claims for Hospital Providers

If covered services fall under the reinsurance provisions set forth in your agreement with us, follow the terms of the agreement to make sure:

  • The stipulated threshold has been
  • Only covered services are included in the computation of the reinsurance threshold;
  • Only those inpatient services specifically identified under the terms of the reinsurance provision(s) are used to calculate the stipulated threshold rate;
  • Applicable eligible member copayments, coinsurance, and/or deductible amounts are deducted from the reinsurance threshold computation;
  • The stipulated reinsurance conversion reimbursement rate is applied to all subsequent covered services and submitted claims;
  • The reinsurance is applied to the specific, authorized acute care confinement; and
  • Claims are submitted in accordance with the required time frame, if any, as set forth in the agreement. In addition, when submitting hospital claims that have reached the contracted reinsurance provisions and are being billed in accordance with the terms of the agreement and/or this supplement, you shall:
    • Indicate if a claim meets reinsurance criteria; and
    • Make medical records available upon request for all related services identified under the reinsurance provisions (e.g., ER face sheets).

If a submitted hospital claim does not identify the claim as having met the contracted reinsurance criteria, we process the claim at the appropriate rate in the agreement. An itemized bill is required to compute specific reinsurance calculations and to properly review reinsurance claims for covered services.

Interim Bills

We adjudicate interim bills at the per diem rate for each authorized bed day billed on the claim and reconcile the complete charges to the interim payments based on the final bill.

The following process will increase efficiencies for both us and the Hospital/SNF business offices

  • 112 Interim – First Claim: Pay contracted per diem for each authorized bed day billed on the claim (lesser of billed or authorized level of care, unless the contract states otherwise).
  • 113 Interim – Continuing Claim: Pay contracted per diem for each authorized bed day billed on the claim (lesser of billed or authorized level of care, unless the contract states otherwise).
  • 114 Interim – Last Claim: Review admits to discharge and discharge and apply appropriate contract rates, including per diems, case rates, stop loss/outlier and/ or exclusions. The previous payments will be adjusted against the final payable amount.

Reciprocity Agreements

You shall cooperate with our participating care providers and our affiliates and agree to provide services to members enrolled in benefit plans and programs of UnitedHealthcare West affiliates and to assure reciprocity with providing health care services.

If any member who is enrolled in a benefit plan or program of any UnitedHealthcare West affiliate, receives services or treatment from you and/or your subcontracted care providers (if applicable), you and/or your subcontracted care providers (if applicable), agree to bill the UnitedHealthcare West affiliate at billed charges and to accept the compensation provided pursuant to your agreement, less any applicable copayments and/ or deductibles, as payment in full for such services or treatment.

You shall comply with the procedures established by the UnitedHealthcare West affiliate and this agreement for reimbursement of such services or treatment.

Overpayments

Please follow the instructions as indicated in the Overpayments section of Chapter 9: Our Claims Process.

End-Stage Renal Disease

If a member has or develops end-stage renal disease (ESRD) while covered under an employer’s group benefit plan, the member must use the benefits of the plan for the first 30 months after becoming eligible for Medicare due to ESRD. After the 30 months elapse, Medicare is the primary payer. However, if the employer group benefit plan coverage were secondary to Medicare when the member developed ESRD, Medicare is the primary payer, and there is no 30-month period.

Medicaid (Applies Only to MA) Please follow the instructions as indicated in the Member Financial Responsibility section of Chapter 10: Compensation.

The calendar day we receive a claim is the receipt date, whether in the mail or electronically. The following date stamps may be used to determine date of receipt:

  • Our Claims Department date stamp
  • Primary payer claim payment/denial date as shown on the EOP
  • Delegated provider date stamp
  • TPA date stamp
  • Confirmation received date stamp that prints at the top/ bottom of the page with the name of the sender

Note: Date stamps from other health benefit plans or insurance companies are not valid received dates for timely filing determination.

Time Limits for Filing Claims

You are required to submit to clean claims for reimbursement no later than 1) 90 days from the date of service, or 2) the time specified in your participation agreement, or 3) the time frame specified in the state guidelines, whichever is greater.

If you do not submit clean claims within these time frames, we reserve the right to deny payment for the claim(s). Claim(s) that are denied for untimely filing cannot be billed to a member.

We have claims processing procedures to help ensure timely claims payment to care providers. We are committed to paying claims for which we are financially responsible within the time frames required by state and federal law.