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Capitation, Mid-Atlantic Supplement - 2019 UnitedHealthcare Administrative Guide

Capitation

Capitation payment will be paid to the practice for covered services on a per member per month (PMPM) basis. The PCP receives separate capitation payments for members of M.D. IPA and Optimum Choice monthly, on the fifth day of each month.

The PMPM is calculated by multiplying the fixed monthly rates (detailed in the Capitation Rate Schedule contained in your agreement) by the number of members who have selected or been assigned to a PCP within the practice.

Payment Rules

The capitation payment for a given month is calculated based on the 15/30 rule. This rule is used to determine whether a capitation payment is made for the full month or not at all. If the effective date of member change falls between the first and 15th of the month, the change is effective for the current month. If the effective date of the member change falls on or after the 16th of the month, the capitation adjustment is reflected on the first of the following month. As such, retroactive adjustments to capitation payments may be made based on the member’s eligibility on the 15th of the month.

15/30 Rule

For purposes of capitation payments, members are added on the first day of the month or terminated on the last day of the month, with the exception of newborns, which are added on the date of their birth(s). Capitation is paid for full months, and conversely recouped for full months if appropriate. For example:

Retroactive Add

A member added retroactively on the 14th of the month would generate a capitation payment for the entire month. However, a member added on the 16th or later would not generate a capitation payment, even though the member would be considered eligible for services. To help you identify these members, the member’s standard services capitation is reported as $0.

Retroactive Term

A member retroactively terminated between the first and 14th of the month would generate a capitation recoup entry for the capitation previously paid for the entire month. However, a member retroactively terminated on the 16th or later would not generate a capitation recoup entry for the capitation previously paid for the entire month.

UnitedHealthcare of the Mid-Atlantic region provides Capitation Reports to PCPs, as described below:

High-level capitation information by current and retro periods for each care provider.

A contract-level report that summarizes the capitation paid by current and retro periods. The three sections of the report include amounts for:

  1. Standard services
  2. Supplemental benefits and capitated adjustments
  3. Non-capitated adjustments and withholds

A PCP-level report that summarizes the capitation paid by current and retro periods. The three sections of the report include amounts for:

  1. Standard services
  2. Supplemental benefits and capitated adjustments
  3. Non-capitated adjustments and withholds

Detailed capitation information for each current member assigned to a PCP.

Detailed retroactive change information on added, changed and terminated members. The three sections of the report include information on:

  1. Member adds
  2. Member demographic changes
  3. Member terms

Capitation adjustment details for Member and provider-level guide adjustments. The two sections of the report include information on:

  1. Current period
  2. Retro period

The PCP practice should reconcile the capitation payment and report upon receipt. Any requests for an adjustment or reconciliation of the capitation payment must be made within 60 calendar days of receipt.

If the PCP/medical group (practice) does not request reconsideration of the capitation payment within 60 days, the capitation payment provided is accepted as payment in full (as per contract). 

You may obtain copies of the reports above by calling Provider Services at 877-842-3210.

Bill Above

In addition to the capitation payments, certain covered services are eligible for reimbursement. To obtain a copy of this information, please contact your Network Representative. To locate your Network Representative, go to Find a Network Contact and then select your state