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Claims Disputes and Appeals, Capitation and/or Delegation Supplement - 2019 UnitedHealthcare Administrative Guide

Contracted care providers who have a claim dispute with a delegated medical group/IPA must make sure they have followed all the guidelines set forth by the medical group/IPA.

A request for reimbursement for any overpayment of a claim completed in compliance with state and federal regulations must:

  • Provide a clear, accurate, written explanation
  • Be issued within 365 calendar days from the last date of payment for the claim
  • Give the care provider 30 working days to send written notice contesting the request for reimbursement for overpayment

Non-Contracted Care Provider Disputes — CMS Non-Contracted Care Provider Payment Dispute Resolution Process (Applicable to Non-Contracted MA Paid Claims)
A non-contracted care provider can use the Payment Dispute Resolution (PDR) process for any decision where they contend that the amount paid by the organization, (in this instance the delegated entity), for a covered service is less than the amount which would have been paid under Original Medicare. This process also includes disagreements between a non-contracted care provider and the delegate about the delegate’s decision to pay for a different service than that billed (i.e., bundling issues, rate of payment, DRG payment dispute). You must submit a payment dispute within 120 calendar days from the date of the original claim determination. At a minimum, the delegate must have the following requirements and processes in place when handling claim payment disputes with a Medicare non-contracted care provider:

  • Well-defined internal payment dispute process that includes:
    • A system for receiving PDRs;
    • Proper identification of payment disputes. (Care providers must clearly state what they are disputing and why, supply relevant information that will help support their position, including description of the issue, copy of submitted claim, supporting evidence to demonstrate what Original Medicare would have allowed for the same service, etc.);
    • A system for tracking disputes; and
    • Monitoring their PDR claims inventory. 
  • A requirement to communicate the time frame of 120 calendar days from the original claim determination to submit a payment dispute to the non-contracted care provider at time of claim payment;
  • Information on how to submit an internal claim payment dispute to the organization communicated to the noncontracted care provider at time of claim payment, including their mailing address for submitting disputes and other dispute information (e.g., email addresses, phone numbers);
  • Requirements to process and respond (i.e., to finalize the PDR claim) to the non-contracted care provider within 30 days from the date the PDR claim is received;
  • Help ensure correct calculation of interest payments on overturned PDRs . Interest payment is required on a reprocessed non-contracted care provider clean claim if the group made an error on the original determination. Interest is only applied on the additional amount paid, and calculated from the ‘oldest receive date of the original claim’ until the ‘check mail date’ of the additional amount paid;
  • Provide a complete and clear rationale to the noncontracted care provider for upheld PDRs;
  • Ensure that the care provider Remittance Advice (PRA) or Explanation of Payment (EOP), and Uphold PDR Determination Letter contains appropriate information and meets requirements;
  • Include information on how to contract the organization in notices of upheld or overturned payment disputes if the non-contracted care provider has additional questions;
  • Include information in the notices of upheld or overturned payment disputes on how to contract the organization if the non-contracted care provider has additional questions;
  • If the root-cause of overturned PDRs is system-related, a process in place to update their claims system, if needed, so that future claims will reimburse appropriately;
  • Process in place to identify trends that contract year for any non-contracted care provider who submitted a payment dispute to help ensure that they may be paid correctly;
  • Ongoing training program in place for any piece of the internal claim PDR process to include educating all areas of the organization, such as customer service, claims, appeals, etc.;
  • Consistent monitoring of internal compliance to help ensure CMS requirements are met; and
  • End-to-end quality review process, from the time a dispute is received from the non-contracted care provider to the time when the dispute decision is sent to the noncontracted care provider.

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

  • Instances in which a member has filed an appeal and you have filed a dispute regarding the same issue. In these cases, the member’s appeal takes precedence. You can submit a care provider dispute after the member appeal decision is made. If you are appealing on behalf of the member, the appeal processes as a member appeal.
  • An Independent Medical Review initiated by a member through the Member Appeal Process.
  • Any dispute filed outside of the timely filing limit applicable to you, and for which you fail to supply “good cause” for the delay.
  • Any delegated claim issues that have not been reviewed through the delegated payer’s claim resolution mechanism.
  • Any request for a dispute, which involves reviews by the delegated medical group/IPA/payer or capitated facility/care provider and does not involve an issue of medical necessity or medical management.

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, the delegated Medical Group/IPA or other delegated payer, or the capitated facility/care provider, you are responsible for submitting your claim(s) to the appropriate entity that holds financial responsibility to process each claim.

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

Need More Information about UnitedHealthcare West Claims Disputes?

Additional information, requirements, and mailing addresses regarding claims disputes for UnitedHealthcare West members can be found in the UnitedHealthcare West Supplement, UnitedHealthcare West Bulk Claims Rework Reference Table.

All States: Utilize the most updated Medicare Advantage and Commercial Monthly Timeliness Report (MTR) you received from the Claims Delegation Oversight Department. The MTR forms are similar to the Industry Collaboration Efforts (ICE) versions that is based in California.

The most current forms must be used at all times. This applies to both Commercial and Medicare Advantage products.

All Delegated Entities must upload their Medicare Advantage CMS Universe Reports (Claims, DMRs and Dismissals) and MTR forms to the ECG Connect Portal.

Monthly MTR forms must be uploaded to the ECG Connect Portal by the 15th of each month and Medicare Advantage CMS Universes must be uploaded to the ECG Connect Portal by the 10th of each month.

California: In accordance with state regulatory requirements, UnitedHealthcare shall verify on a quarterly basis that our Delegated Entities have the administrative and financial capacity to meet contractual obligations through routine reviews of financial indicators and monitoring financial solvency deficiencies. UnitedHealthcare requires Delegated Entities to provide copies of quarterly financial statements, including a balance sheet, income statement and statement of cash flow, prepared in accordance with generally accepted accounting principles within 45 calendar days of the end of each calendar quarter.

Copies of assessed annual financial statements together with copies of all auditors’ letters to management in connection with such reviewed annual financial statements submissions are due within 150 calendar days of the end of each fiscal year. If the quarterly/annual financial statement submissions include deficiencies in financial solvency grading criteria defined by state regulations, a self-initiated Improvement Action Plan (IAP) proposal shall be submitted in an electronic format (template may be found on the website) to UnitedHealthcare within 45 calendar days of the end of the reporting period for which the deficiency was reported.

In addition, quarterly progress reports need submission to UnitedHealthcare within 45 calendar days of the end of each subsequent reporting period until compliance with all financial grading criteria achievement.

The Delegated Entity must submit financial statements and IAPs via email to UnitedHealthcare at Both UnitedHealthcare and the delegated entity are responsible to provide compliance oversight of the Delegated Entities financial reporting IAP.

Other UnitedHealthcare West Delegated States (AZ/CO/NV/OK/TX): The Delegated Entities in these states must submit the Monthly Self-Reported Timeliness Reports within 15 calendar days following the month being reported.

California Commercial NPI
The California Department of Managed Health Care (DMHC) Timely Access to Non-Emergency Health Care Services Regulation applies to California Commercial HMO membership only. The regulation establishes time elapsed standards or guidelines to make sure that members have timely and appropriate access to needed healthcare services, including a 24/7 telephonic triage or screening requirement. Health plans are required to comply with certain provisions of the regulation and provide an annual report detailing the status of the plan’s network care provider and enrollment, which includes the care provider’s NPI. To comply with this regulation, UnitedHealthcare requires all California Commercial HMO care providers to include their NPI with all care provider additions or when submitting a claim.


A delegated entity that is contractually delegated to process and adjudicate claims or approve or deny referrals for service shall establish and maintain a fair, fast and cost-effective dispute resolution mechanism to process and resolve contracted and non-contracted care provider disputes in accordance with state and federal regulations.

If the dispute request is for services payable by the delegated entity, we determine if the appropriate payer has reviewed the request for dispute. If the appropriate payer has not reviewed the dispute request, we forward the dispute request to the appropriate payer. We notify the care provider of service of the forwarding dispute request to the delegated entity for processing.

The delegated entity is accountable for submitting all required information to us and the appropriate state agency in accordance with the guidelines established by state and federal regulations. All delegated claims processing entities are required to report PDR processing compliance results quarterly in accordance with state and federal regulations. Submission of quarterly reports, are due no later than the 30th day following the end of the quarter.

We regularly conduct a compliance assessment of the PDR Process of each delegated entity. We review care providers at least annually.

As part of the compliance assessment, we request copies of Delegated Entity Provider Dispute report. The auditor reviews the reports and randomly selects finalized disputes for reviewing. The auditor also requires a copy of the delegated entity’s PDR Policy and Procedures, and evidence of the availability of the PDR mechanism. If the capitated medical group/IPA or capitated facility is found to be non-compliant with UnitedHealthcare state or federal requirements, we expect the delegated entities to develop an improvement action plan designed to bring them back into compliance.

We sanction care providers who do not achieve compliance within the established timeframes until they reach compliance. PDR processing is a delegated function that is subject to revocation. Sanctions may consist of additional/enhanced reviewing, onsite claims/PDR management, and/or revocation. There may be costs to the delegated entity depending on the sanction put in place.

If a care provider continues to have a Commercial claims dispute with the delegated entity related to medical necessity and utilization management, the care provider must forward all claim information and correspondence
between the delegated entity and the care provider to UnitedHealthcare for review. We do not begin the review until we receive the supporting documentation.

Commercial care provider claims must be processed in accordance with the agreed upon contract rates or member benefit plan and within state and federal requirements.

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

Commercial interest rates and timeframes for processing may vary, depending on the applicable state requirements. In some states, an additional penalty for late claims payments may also apply and be paid by the delegated medical group/IPA/facility.