Jul 2, 2019

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Special Reporting Requirements for Certain Claim Types - Chapter 9, 2019 UnitedHealthcare Administrative Guide

Special Reporting Requirements for Certain Claim Types

Anesthesia Services

For detailed instructions, view our Policies section > Commercial (or Medicare Advantage) Policies > Reimbursement Polices > Anesthesia Services.

Laboratory Claims

Many benefit plan designs exclude outpatient laboratory services if they were not ordered by a participating care provider. Our benefit plans may also cover such services differently when a portion of the service (e.g., the draw) occurs in the care provider’s office, but a laboratory care provider performs the analysis. A licensed care provider must order laboratory services.

All laboratory claims and/or encounters must include the name of the referring care provider and NPI number of the referring care provider, in addition to the other elements of a complete claim and/or encounter described in this guide. We reject or deny laboratory claims that do not include the identity of the referring care provider. 

This requirement applies to claims/or encounters for both anatomic and clinical laboratory services. It also applies to claims and/or encounters received from both participating and non-participating laboratories, unless otherwise provided under applicable law. It does not apply to claims for laboratory services done by care providers in their offices. Please also refer to the Laboratory Services Protocol, in Chapter 8: Specific Protocols.

Physical Medicine and Rehabilitation Services

Physical Medicine and Rehabilitation (PM&R) services are eligible for reimbursement if provided by a physician or therapy care provider duly licensed to perform those services. If the rendering care provider is not duly licensed, we do not pay for the service. 

Assistant Surgeons or Surgical Assistants Claim Submission Requirements

The practice of using non-participating care providers significantly increases the costs of services for our members. We require our participating care providers to use reasonable efforts to find network care providers, including network surgical assistants or assistant surgeons for our members.

Submission of Claims for Services Subject to Medical Claim Review

We have the right to review claims to confirm a care provider is following appropriate and nationally accepted coding practices. We may adjust payment to the care provider at the revised allowable amount. Care providers must cooperate by providing access to requested claims information, all supporting documentation and other related data. 

We may pend or deny a claim and request medical records to determine whether the service rendered is covered and eligible for payment.

In these cases, we send a letter explaining what we need.

To help claim processing and avoid delays due to pended claims, please resubmit only what is requested in our letter. The claim letter will state specific instructions for required information to resubmit, which may vary for each claim. You must also return a copy of our letter with your additional documents.

For Medicare Advantage benefit plans, if you are not eligible for payment but the service is covered, we will deny payment. You may not bill the member for the amount denied.

Erythropoietin (For Commercial Members)

For Erythropoietin (EPO) claims, you must submit the Hematocrit (Hct) level for us to determine coverage under the member’s benefit plan. For claims submitted by paper to UnitedHealthcare on a Form 1500, you must enter the Hct level in the shaded area of line 24a in the same row as the J-code. Enter Hct and the lab value (Hctxx).

For electronic claims, the Hct level is required in the (837P) Standard Professional Claim Transaction, Loop 2400 – Service line, segment MEA, Data Element MEA03.

Report the MEA segment as follows: 

  • MEA01 = qualifier “TR”, meaning test results
  • MEA02 = qualifier “R2”, meaning hematocrit
  • MEA03 = hematocrit test result 
    • Example: MEA*TR*R2*33~

The following J codes require an Hct level on the claim:

  • J0881 Darbepoetin alfa (non-ESRD use)
  • J0882 Darbepoetin alfa (ESRD on dialysis) 
  • J0885 Epoetin alfa (non-ESRD use) 
  • J0886 Epoetin alfa, 1,000 units (for ESRD on Dialysis) 
  • Q4081 Epoetin alfa (ESRD on dialysis)

For EPO claims submitted on a UB-04 claim form, an Hct level is not required.