Our Claims Process
Topics in this Section
- Electronic Payments and Statements (EPS)
- Claims and Encounter Data Submissions
- Risk Adjustment Data - Medicare Advantage (MA) and Commercial
- National Provider Indentification (NPI)
- Medicare Advantage Claim Processing Requirements
- Claim Submission Tips
- Pass-Through Billing / CLIA Requirements / Reimbursement Policy
- Special Reporting Requirements for Certain Claim Types
- Subrogation and Coordination of Benefits
- Claim Correction and Resubmission
- Claim Reconsideration, Appeals Process and Resolving Disputes
- Resolving Disputes - Concern or Complaint
- Member Appeals, Greivances or Complaints
- Medical Claim Review
Claims Tools to Prepare, Submit and Manage Your Claims
You can learn more about the many tools available to help you prepare, submit and manage your UnitedHealthcare claims including: Claim Estimator with bundling logic, training tools and resources including Frequently Asked Questions (FAQs), Quick References, Step-by-Step instructions and tutorials.
Prompt Claims Processing
We know that you want prompt payment. We work hard to process your claims timely and accurately. This is what you can do to help us:
1. Submit the claim to the correct payer by reviewing the member’s eligibility as outlined in Verifying Eligibility, Benefits, and Your Network Participation Status.
Note: Member Eligibility & Benefit Information and Submitting Claims
When we give you eligibility and benefit information, we are not guaranteeing payment or coverage in any specific amount. Actual reimbursement depends on many factors, such as compliance with administrative protocols, date(s) of services rendered, and benefit plan terms and conditions. For Medicare Advantage (MA) benefit plans, reimbursement also depends on CMS guidance and claims processing requirements.
Follow the instructions in the How to Submit Advance or Admission Notifications/Prior Authorizations section.
4. Submit claims electronically for fast delivery and confirmation of receipt.
a. Electronic submissions are preferred for sending claims to UnitedHealthcare. View our Claims Payer List to determine the correct Payer ID to use.
b. Our contracts generally require you to conduct business with us electronically. They contain specific requirements for electronic claim submission. Please review your Agreement and follow the requirements. While some claims may require supporting information for initial review, we have reduced the need for paper attachments. We request additional information when needed.
c. Visit our EDI section for helpful resources and tips on submitting claims electronically.
d. Check the status of a claim using EDI 276/277 Claim Status Inquiry and Response transactions. Contact your vendor or clearinghouse if these transactions are not available or activated in your system.
f. If you need assistance using EDI, visit our EDI Contacts page.
g. If you don't have electronic data interchange (EDI) capabilities, you can use the Claim Submission tool on Link. Go to UHCProvider.com/claims for more information.
HIPAA Claim Edits and Smart Edits
When claims are submitted using EDI, HIPAA edits are applied by the clearinghouse to help ensure claims contain specific information. Any claims not meeting requirements are rejected and returned back to the care provider to make corrections and resubmit electronically.
Smart Edits are an EDI capability which auto-detects claims with potential errors. set of Smart Edits may also be applied to help reduce claim denials and improve the claim processing time. You’ll have five calendar days to correct claims that reject due to Smart Edits before they are automatically processed.
For more information on claim edits, go to HIPAA Claim Edits and Smart Edits.