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Claims Process - UnitedheatlhOne Individual Plans Supplement, 2018 UnitedHealthcare Administrative Guide

We know that you want to be paid promptly for the services you provide. This is what you can do to help promote prompt payment:

  • Notify us, in accordance with the notification requirements set forth in this supplement.
  • Prepare a complete and accurate claim form. For facility (UB-04/8371) claims see number five below.
  • Submit electronic claims using the electronic payer ID on the health care ID card, or submit paper claims to the address listed on the member’s health care ID card. GRIC payer ID is 37602.
  • Requirements for claims (paper or electronic) reporting revenue codes:
    • All claims reporting revenue codes require the exact dates of service if they are span dates.
    • If you report revenue code 274, you are required to provide a description of the services or a valid CPT or HCPCS codes.
    • All claims reporting the revenue codes on the following list require that you report the appropriate CPT and HCPCS codes.
  • 260 IV Therapy (General Classification)
  • 261 Infusion Pump
  • 262 IV therapy/pharmacy services
  • 263 IV therapy/drug/supply delivery
  • 264 IV Therapy/Supplies
  • 269 Other IV therapy
  • 290 Durable Medical Equipment (DME) (other than renal) (General Classification)
  • 291 DME/Rental
  • 292 Purchase of new DME
  • 293 Purchase of used DME
  • 300 Laboratory (General Classification)
  • 301 Chemistry
  • 302 Immunology
  • 303 Renal Patient (Home)
  • 304 Non-Routine Dialysis
  • 305 Hematology
  • 306 Bacteriology & Microbiology
  • 307 Urology
  • 309 Other Laboratory
  • 310 Laboratory-Pathology (General Classification)
  • 311 Cytology Histology
  • 312 Other Laboratory Pathological
  • 319 Radiology–Diagnostic (General Classification)
  • 320 Angiocardiography
  • 321 Arthrography
  • 322 Arteriography
  • 323 Chest X-Ray
  • 324 Other Radiology-Diagnostic
  • 329 Radiology-Therapeutic and/or Chemotherapy Administration (General Classification)
  • 330 Chemotherapy Administration-Injected Chemotherapy Administration-Oral Radiation Therapy
  • 331 Chemotherapy Administration-Injected
  • 332 Chemotherapy Administration-Oral
  • 333 Radiation Therapy
  • 335 Chemotherapy Administration-IV
  • 339 Other Radiology-Therapeutic
  • 340 Nuclear Medicine (General Classification)
  • 341 Diagnostic Procedures
  • 342 Therapeutic Procedures
  • 350 CT Scan (General Classification)
  • 351 CT-Head Scan
  • 352 CT-Body Scan
  • 359 CT-Other
  • 360 Operating Room Services (General Classification)
  • 361 Minor Surgery
  • 362 Organ Transplant-Other Than Kidney Transplant
  • 367 Other Operating Room Services
  • 369 Other Imaging Services (General Classification)
  • 400 Diagnostic
  • 401 Mammography
  • 402 Ultrasound
  • 403 Screening Mammography
  • 404 Positron Emission
  • 409 Tomography Other Imaging Services
  • 410 Respiratory Services (General)
  • 412 Inhalation Services
  • 419 Other Respiratory Services
  • 460 Pulmonary Function (General Classification)
  • 469 Other-Pulmonary Function
  • 470 Audiology (General Classification)
  • 471 Audiology/Diagnostic
  • 472 Audiology/Treatment
  • 480 Cardiology (General Classification)
  • 481 Cardiac Cath Lab
  • 482 Stress Test
  • 483 Echocardiology
  • 489 Other Cardiology
  • 490 Ambulatory Surgical Care (General Classification)
  • 499 Other Ambulatory Surgical Care
  • 610 Magnetic Resonance Technology (General Classification)
  • 611 MRI-Brain/Brain Stem
  • 612 MRI-Spinal Cord/Spine
  • 614 MRI-Other
  • 615 MRA-Head and Neck
  • 616 MRA-Lower Extremities
  • 618 MRA Other
  • 618 Other MRT
  • 623 Surgical Dressing
  • 624 FDA Investigational Devices
  • 634 Erythropoietin (EPO) < 10,000 units
  • 635 Erythropoietin (EPO) > 10,000 units
  • 636 Drugs Requiring Detail Coding
  • 730 EKG/ECG (Electrocardiogram) (General Classification)
  • 731 Holter Monitor
  • 732 Telemetry
  • 739 Other EKG/ECG
  • 740 EEG (Electroencephalogram) (General Classification)
  • 750 Gastro-Intestinal (GI) Services (General Classification)
  • 790 Extra-Corporeal Shock Wave Therapy (formerly Lithotripsy) (General Classification)
  • 921 Peripheral Vascular Lab
  • 922 Electromyogram
  • 923 Pap Smear
  • 924 Allergy Test
  • 925 Pregnancy Test
  • 929 Additional Diagnostic Services
  • 940 Other Therapeutic Services (General Classification
  • 941 Recreational Therapy
  • 942 Education/Training (Diabetic Education)
  • 949 Other Therapeutic Services (HRSA)

Note: Use the payer ID number on the member’s health care ID card. The electronic claims submission number does vary. The claim will reject if the correct payer ID is not used.

Claim Adjustments

If you believe your claim was processed incorrectly, please call the number on the back of the member’s health care ID card and request an adjustment as soon as possible, in accordance with applicable statutes and regulations. If you or our staff identifies a claim where you were overpaid, send us the overpayment within 30 calendar days from the date of your identification of the overpayment or of our request.

If you disagree with our determination regarding a claim adjustment, you can appeal the determination.

Claim Reconsideration, Appeals and Disputes

If you disagree with a claim payment determination, send a letter requesting a review to the following address:

Grievance Administrator
P.O. Box 31371
Salt Lake City, UT 84131-0370
Standard Fax: 801-478-5463
Phone: 800-657-8205

If you feel your situation is urgent, request an expedited (urgent) appeal orally, by fax or in writing at:

Grievance Administrator
3100 AMS Blvd.
Green Bay, WI 54313
Expedited Fax: 866-654-6323
Phone: 800-657-8205

Your appeal must be submitted within 12 months from the date of payment shown on the EOB, unless your agreement with us or applicable law provide otherwise.

Please refer to Claim Reconsideration, Appeals Process and Resolving Disputes section in Chapter 9: Our Claims Process.

If you disagree with the outcome of the claim appeal, you may file an arbitration proceeding as described in your participation agreement.

Claim reconsideration does not apply to some states based on applicable state legislation (e.g. Arizona, California, Colorado, New Jersey, Texas). For states with applicable legislation, any request for dispute will follow the state specific process.

New Jersey Care Provider Dispute Process

Disputes involving New Jersey (NJ) commercial members are subject to the NJ state-regulated care provider dispute process.

The state regulated provider dispute process does not apply in the following situations:

  • Our determination involves a utilization management (UM) denial. UM denials are refusals to pay a claim or to authorize a service or supply because we have determined that the service or supply is:
    • Not medically necessary;
    • Experimental or investigational;
    • Cosmetic;
    • Dental rather than medical; or
    • Treatment of a pre-existing condition.

You can appeal a UM denial by going through the Internal UM Appeals Process described under the Member Complaints and Grievances section. You must submit a completed Consent to Representation in Appeals of Utilization Management Determinations and Authorization for Release of Medical Records in UM Appeals and Independent Arbitration of Claims form to begin the UM appeal process.

  • Our determination indicates we denied the service or supply as not covered under the terms of the plan or because the person is not our member.
  • The dispute is due to coordination of benefits.
  • We have provided you notice that we are investigating this claim (and related ones, as appropriate) for possible fraud.

The process does apply for the following situation:

  • The claim was not paid for any reason other than previously listed;
  • The claim was paid at a rate you did not expect based on your network contract between or the terms of the plan;
  • The claim was paid at a rate you did not expect because of differences in our treatment of the codes in the claim from what you believe is appropriate;
  • We required additional substantiating documentation to support the claim, and you believe the required information is inconsistent with our stated claims handling policies and procedures or is not relevant to the claim;
  • You believe we failed to adjudicate the claim, or an uncontested portion of a claim, in a timely manner consistent with law and the terms of your network contract, if any;
  • Our denial was due to lack of appropriate authorization, but you believe you obtained appropriate authorization from us or another carrier for the services;
  • You believe we failed to appropriately pay interest on the claim;
  • You believe our statement that we overpaid on one or more claims is erroneous or that the amount we have calculated as overpaid is erroneous;
  • You believe we have attempted to offset an inappropriate amount against a claim because of an effort to recoup for an overpayment on prior claims.

If the dispute is eligible the following process will apply:

A written request for appeal must be submitted using the Health Care Provider Application to Appeal a Claims Determination Form created by the New Jersey Department of Banking and Insurance. This request must be submitted within 90 days following receipt of our initial determination notice to:

UnitedHealthcare Oxford Navigate Individual
Grievance Administrator
P.O. Box 31371
Salt Lake City, UT 84131-0371
Standard Fax: 801-478-5463

The review will be conducted, and a decision will be communicated to you in writing within 30 calendar days of receipt of the form.

If you are not satisfied with the results of the internal dispute, you may initiate the New Jersey Program for Independent Claims Payment Arbitration (PICPA) process. Submit your requests to Maximus, Inc. within 90 calendar days from receipt of the internal dispute decision. A dispute is eligible if the payment amount in dispute is $1,000 or more. The arbitration decision is binding.