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Care Provider Claims Appeals and Disputes - UnitedHealthcare West Supplement, 2018 UnitedHealthcare Administrative Guide

Claims Research and Resolution (Applies to Commercial in Oklahoma & Texas)

The Claims Research & Resolution (CR&R) process applies:

  • If you do not agree with the payment decision after the initial processing of the claim; and
  • Regardless of whether the payer was UnitedHealthcare West, the delegated medical group/IPA or other delegated payer, or the capitated hospital/provider, you are responsible for submitting your claim(s) to the appropriate entity that holds financial responsibility to process each claim.

UnitedHealthcare West researches the issue to identify who holds financial risk of the services and abides by federal and state legislation on appropriate timelines for resolution. We work directly with the delegated payer when claims have been misdirected and financial responsibility is in question. If appropriate, care provider-driven claim payment disputes will be directed to the delegated payer Provider Dispute Resolution process.

Claim Reconsideration Requests (Does Not Apply in California)

You may request a reconsideration of a claim determination. These rework requests typically can be resolved with the appropriate documents to support claim payment or adjustments (e.g., sending a copy of the authorization for a claim denied for no authorization or proof of timely filing for a claim denied for untimely filing). All rework requests must be submitted within 365 calendar days following the date of the last action or inaction, unless your participation agreement contains other filing guidelines. The most efficient way to submit your requests is through the claimsLink app. Learn more on UHCprovider.com > Service Links > Link Self-Service Tools. You can submit your request to us in writing by using the Paper Claim Reconsideration Form on UHCprovider.com/claims.

Please refer to the UnitedHealthcare West Provider Rework or Dispute Process Reference Table at the end of this section for the address to which your request should be sent.

Submission of Bulk Claim Inquiries

The Claims Project Management (CPM) team handles bulk claim inquiries. Contact the CPM team at the address below to initiate a bulk claim inquiry:

Arizona

UnitedHealthcare
Attn: WR Claims Project Management
P.O. Box 52078
Phoenix, AZ 85072-2078

Notes: Submit requests for 20 or more claims.

California

Claims Research Projects CA120-0360
P.O. Box 30968
Salt Lake City, UT 84130-0968

Notes: Submit requests for 19 or more claims.

Colorado

Medicare Advantage Claims Department
Attn: Colorado Resolution Team
P.O. Box 30983
Salt Lake City, UT 84130-0983

Notes: Submit requests for 20 or more claims.

Nevada

For Medicare Advantage claims:

UnitedHealthcare
Attn: WR Claims Project Management Claims
Research Projects
P.O. Box 95638
Las Vegas, NV 89193-5638

Notes:

  • The Nevada delegated payer handles bulk claim inquiries received from providers of service. The provider of service should submit the bulk claims with a cover sheet indicating “Appeal” or “Review” to the Claims Research Department at the designated address to initiate a bulk claim inquiry.
  • Submit requests for 10 or more claims.

Oklahoma

Claims Research Projects
P.O. Box 30967
Salt Lake City, UT 84130-0967

Notes: Submit requests for 20 or more claims.

Oregon

Claims Research Projects
P.O. Box 30968
Salt Lake City, UT 84130-0968

Notes: Submit requests for 10 or more claims.

Texas

Claims Research Projects
P.O. Box 30975
Salt Lake City, UT 84130-0975

Notes: Submit requests for 20 or more claims.

Washington

Claims Research Projects
P.O. Box 30968
Salt Lake City, UT 84130-0968

Notes: Submit requests for 10 or more claims.

UnitedHealthcare West’s Response

We respond to issues as quickly as possible.

  • Reworks/disputes requiring clinical determination: Individuals with clinical training/background who were not previously involved in the initial decision review all clinical rework/dispute requests. We send a letter to you outlining our determination and the basis for that decision.
  • Reworks/disputes requiring claim process determination: Individuals not previously involved in the initial processing of the claim review the rework/dispute request.
  • Response details: If claim requires an additional payment, the EOP serves as notification of the outcome on the review. If the original claim status is upheld, you are sent a letter outlining the details of the review.

California: If a claim requires an additional payment, the EOP does not serve as notification of the outcome of the review. We send you a letter with the determination. In addition, payment must be sent within five calendar days of the date on the determination letter. We respond to you within the applicable time limits set forth by federal and state agencies. After the applicable time limit has passed, call Provider Relations at 877-847-2862 to obtain a status.

Care Provider Dispute Resolution (CA, OR, and WA Commercial Plans)

If you disagree with our claim determination, you may initiate a care provider dispute. You must submit a care provider dispute, in writing, and with additional documentation for review. All disputes must be submitted within 365 calendar days following the date of the last action or inaction, unless your participation agreement or state law dictate otherwise. This time frame applies to all disputes regarding contractual issues, claims payment issues, overpayment recoveries and medical management disputes.

The PDR process is available to provide a fair, fast and costeffective resolution of care provider disputes, in accordance with state and federal regulations. We do not discriminate, retaliate against or charge you for submitting a care provider dispute. The PDR process is not a substitution for arbitration and is not deemed as an arbitration.

What to Submit

As the care provider of service, you should submit the dispute with the following information:

  • Member’s name and health care ID number
  • Claim number
  • Specific item in dispute
  • Clear rationale/reason for contesting the determination and an explanation why the claim should be paid or approved
  • Your contract information

Disputes are not reviewed if the supporting documentation is not submitted with the request.

Where to Submit

State-specific addresses and other pertinent information regarding the PDR process may be found in the UnitedHealthcare West Provider Rework or Dispute Process Reference Table at the end of this section.

Accountability for Review of a Care Provider Dispute

The entity that initially processed/denied the claim or service in question is responsible for the initial review of a PDR request. These entities may include, but are not limited to, UnitedHealthcare West, the delegated medical group/IPA/payer or the capitated hospital/care provider.

Excluded From the PDR Process

The following are examples of issues excluded from the PDR process:

  • A member has filed an appeal, and you have filed a dispute regarding the same issue. In these cases, the member’s appeal is reviewed first. You can submit a care provider dispute after we make a decision on the member’s appeal. If you are appealing on behalf of the member, we treat the appeal as a member appeal.
  • An Independent Medical Review initiated by a member through the member appeal process.
  • Any dispute you file beyond the timely filing limit applicable to you, and you fail to give “good cause” for the delay.
  • Any delegated claim issue that has not been reviewed through the delegated payer’s claim resolution mechanism.
  • Any request for a dispute which has been reviewed by the delegated medical group/IPA/payer or capitated hospital/care provider and does not involve an issue of medical necessity or medical management.

Arizona

PacifiCare of Arizona
Attn: Claims Resolution Team
P.O. Box 52078
Phoenix, AZ 85072-2078

Notes:

  • First Review: Request for reconsideration of a claim is considered a grievance. Physicians and health care professionals are required to notify us of any request for reconsideration within one year from the date the claim was processed.
  • Second Review: Request for reconsideration of a grievance determination is also considered a grievance. You are required to notify us of any second level grievance within one year from the date the first level grievance resolution was communicated to the care provider.

California

UnitedHealthcare West
Provider Dispute Resolution
P.O. Box 30764
Salt Lake City, UT 84130-0764

Notes: UnitedHealthcare of California acknowledges receipt of paper disputes within 15 business days and within two business days for electronic disputes. If additional information is required, the dispute is returned within 45 business days. A written determination is issued within 45 business days.

Colorado

Medicare Advantage
Claims Department
Attn: Colorado Resolution Team
P.O. Box 30983
Salt Lake City, UT 84130-0983

Notes:

  • Upon receipt of a dispute, Colorado Resolution Team:
  • Acknowledges receipt of the dispute within 30 calendar days of the receipt of the dispute;
  • Conducts a thorough review of your dispute and all supporting documentation;
  • Acknowledges receipt, including the specific rationale for the decision, within 60 calendar days of receipt of the dispute;
  • Processes payment, if necessary, within five business days of the written determination;
  • Replies to the care provider of service within 30 calendar days if additional information is required.
  • If additional information is required, we will hold the dispute request for 30 additional calendar days.

Nevada

For Medicare Advantage claims:

UnitedHealthcare
P.O. Box 95638
Las Vegas, NV 89193-5638

Notes: All Nevada Medicare Advantage HMO claims are processed by a delegated payer. Therefore, care provider appeals are reviewed primarily by the delegated payer.

Oklahoma

UnitedHealthcare West
Provider Dispute Resolution
P.O. Box 30764
Salt Lake City, UT 84130-0764

Oregon

UnitedHealthcare West
Provider Dispute Resolution
P.O. Box 30764
Salt Lake City, UT 84130-0764

Notes:

  • UnitedHealthcare of Oregon allows at least 30 calendar days for you to initiate the dispute resolution process.
  • We render a decision on care provider or facility complaints within a reasonable time for the type of dispute.
  • In the case of billing disputes, we render a decision within 60 calendar days of the complaint.

Texas

UnitedHealthcare West
Claims Department
P.O. Box 400046
San Antonio, TX 78229

Washington

UnitedHealthcare West
Provider Dispute Resolution
P.O. Box 30764
Salt Lake City, UT 84130-0764

Notes:

  • UnitedHealthcare of Washington allows at least 30 calendar days for care providers to initiate the dispute resolution process.
  • We render a decision on care provider or facility complaints within a reasonable time for the type of dispute.
  • In the case of billing disputes, we render a decision within 60 calendar days of the complaint.