Contracted care providers who have a claim dispute with a delegated medical group/IPA must make sure they have followed all guidelines set forth by the medical group/IPA.
A request for reimbursement for any overpayment of a claim completed in compliance with state and/or federal regulations must:
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 CMS non- contracted care provider Payment Dispute Resolution (PDR) process for any decision where they contend the amount paid by the organization (i.e., the delegated entity) for a covered service is less than the amount which would have been paid under Original Medicare. This PDR 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). The care provider 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 an MA non- contracted care provider:
The following are examples of issues excluded from the PDR process:
Use the most updated Medicare Advantage and Commercial Monthly Timeliness Report (MTR) you received from the Claims Delegation Oversight Department.
If the due date for the PDR falls on a weekend or holiday, provide the following business day.
Delegated entities must complete an Action Improvement Plan (IAP) and submit it to the health plan for submitting untimely reports containing inaccurate or incomplete information.
All delegated entities must upload their MA CMS Universe Reports (Claims, DMRs and Dismissals) and MTR forms to the ECG Connect Portal.
Upload monthly MTR forms to the ECG Connect Portal by the 15th of each month. Upload MA CMS Universes to the ECG Connect Portal by the 10th of each month.
CA: Based on 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. Prepare these based on generally accepted accounting principles within 45 calendar days of the end of each calendar quarter.
Submit copies of assessed annual financial statements together with copies of all auditors’ letters to management in connection with such reviewed annual financial statements submissions within 150 calendar days of the end of each fiscal year. If these financial statement submissions have deficiencies in financial solvency grading criteria defined by state regulations, submit a self-initiated Improvement Action Plan (IAP) proposal in an electronic format (template may be found on the Iceforhealth.org website) to UnitedHealthcare within 45 calendar days of the end of the reporting period for which the deficiency was reported. In addition, submit quarterly progress reports to UnitedHealthcare within 45 calendar days of the end of each subsequent reporting period until compliance with all financial grading criteria achievement.
Email financial statements and IAPs to UnitedHealthcare at firstname.lastname@example.org.
Both UnitedHealthcare and the delegated entity must provide compliance oversight of the delegated entity’s 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.
CA 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 members have timely and appropriate access to needed health care services, including a 24/7 telephonic triage or screening requirement. Health plans must 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.
The CR&R process applies:
UnitedHealthcare will research the issue to identify who holds financial risk for the services. We will abide by federal and state legislation on appropriate timelines for resolution. We 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.
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.
A delegated entity that is contractually delegated to process claims or approve referrals for service must have a fair, fast and cost-effective dispute resolution mechanism. This process must help manage contracted and non- contracted care provider disputes based on 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 must submit all required information to us and the appropriate state agency based on state and federal regulations. All delegated claims processing entities are required to report PDR processing compliance results quarterly based on state and federal regulations. Submit quarterly reports 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 non-compliant with UnitedHealthcare state or federal requirements, the delegated entities must develop an improvement action plan IPA 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 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 you continue to have a commercial claims dispute with the delegated entity related to medical necessity and utilization management, forward all claim information and correspondence between the delegated entity and you to UnitedHealthcare for review. We do not begin the review until we receive the supporting documentation.
Commercial care provider claims must be processed based on 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.