As an MA plan, UnitedHealthcare and its network care providers agree to meet all laws and regulations applicable to recipients of federal funds. The medical group/IPA and capitated facility acknowledge they must comply with certain laws applicable to entities and individuals receiving federal funds.
An inpatient admission includes:
If a member’s assigned care provider is partial risk at the time of admission and then changes to shared risk prior to the member’s discharge, all claims related to this confinement from admission through discharge are processed according to the partial risk DOFR in effect at the time of the admission.
If a member’s assigned care provider is shared risk at the time of admission and then changes to partial risk prior to the member’s discharge, all claims related to this confinement from admission through discharge processed according to the shared risk DOFR will be in effect at the time of the admission.
Collection of fees
When a member needs one of the following forms for reasons other than medical reasons, you may collect a fee, in addition to the office visit copayment, for completion of these forms (unless the member’s benefit plan or applicable law dictates otherwise):
You cannot collect an additional fee, copayment, or surcharge for:
You can collect copayments when professional services are rendered by a:
Do not collect copayments when there is no actual office visit. For example:
We are required to monitor and track each member’s annual individual out-of-pocket/deductible maximum amount. The member’s annual individual out-of-pocket/deductible maximum accumulation calculated through member’s cost-share data collected from all or some of the following sources:
UnitedHealthcare and its capitated care providers share responsibility to monitor the member’s individual out-of-pocket/ deductible maximum. For additional information on reporting available from UnitedHealthcare, see Chapter 11: Compensation of this guide. When a member meets their annual individual out-of-pocket/deductible maximum, UnitedHealthcare tells the member’s capitated care provider in writing. Capitated care providers are responsible for updating their claims systems within 2 business days of receiving the notification. They must help ensure members are not charged for copayments or coinsurance/ deductibles once the annual maximum out-of-pocket expense is met.
If the member exceeds their annual individual out-of-pocket/deductible maximum due to the capitated care provider collecting member cost-share amounts after the member has met their annual individual out-of-pocket/deductible maximum, the capitated care provider must:
UnitedHealthcare monitors the capitated care provider’s compliance with this policy to help ensure all requests for claims reprocessing and member reimbursement are completed timely.
If necessary, we work with the capitated care provider to help ensure each member is reimbursed for any amounts collected in excess of the member’s annual individual out-of-pocket/deductible maximum amounts as specified in the member’s benefit plan.
If the capitated care provider fails to reimburse a member for amounts collected in excess of the member’s annual individual out-of-pocket/deductible maximum, we may reimburse the member directly and recover the payment by capitation deduction as specified in your Agreement.
Delegated entities must work with UnitedHealthcare to address member issues related to out-of-pocket balances. This includes:
To help ensure timely processing of service provider claims, delegated entities are responsible for working with UnitedHealthcare to address financial risk dispute issues. This includes:
Professional and institutional encounter data consist of an itemization of medical group/IPA/capitated facility, capitated and sub-capitated services provided to our commercial or MA members.
We encourage you to submit your encounter data weekly. We welcome your encounter submissions more frequently. Frequent encounter submissions allows us to support various state and federal regulatory requirements for reporting, such as risk adjustment reporting for Medicare reimbursement from CMS, member out-of-pocket costs, STARS reporting and NCQA and HEDIS reporting. Our performance goal is to receive 90% of encounters within 90 days from the date of service
We continuously monitor encounter data submissions for quality and quantity. Submission levels below the monthly threshold of 100% are non-compliant. The capitated medical group/IPA or other submitting entity must correct any encounter errors identified by a clearinghouse or trading partner at least weekly. As you are processing claims on our behalf, we expect all encounter submissions to accurately reflect the original claim received without exception. Delegates are required to send replacement or void encounters for both commercial and MA lines of business, if applicable. Delegates send a replacement encounter when information on the original logged encounter at UnitedHealthcare was not previously sent or needs to be corrected. A void submission is required to eliminate a previously submitted logged encounter at UnitedHealthcare. Delegates should not send replacements and voids when the original encounter is rejected by a clearinghouse.
For examples of when a replacement or void encounter should be submitted and the required details on submitting them within the 837P and 837I ASC X12 EDI format, refer to section 6.1 of the Electronic Claim Submission Guidelines in the UnitedHealthcare Companion Guides or contact email@example.com. All encounter data submitted to UnitedHealthcare are subject to state and/or federal audit. We have the right to perform routine medical record chart assessments on any or all of the medical group’s/IPA’s network care providers at such time or times as we may reasonably elect to determine the completeness and accuracy of encounter data ICD-10- CM and CPT coding. We notify the medical group/IPA in writing of audit results for coding accuracy.
The delegate may be subject to financial consequences if it or another submitting entity fails to submit or meet encounter data element requirements. In addition, the delegate may be required to perform a complete medical record chart review of its network care providers with notice from UnitedHealthcare.
Commercial encounter data requirements
The capitated medical group/IPA, or other submitting entity, must certify the completeness and truthfulness of its encounter data submissions as required by the state regulatory agency. The medical group/IPA, or other submitting entity, must submit all professional and institutional encounter data for UnitedHealthcare members to:
We require capitated medical group/IPAs and capitated facilities to submit timely and compliant encounter data. Include the member cost-share amount on the encounter data submissions based on the member’s benefit plan, not the amount the member paid at the time of service. The encounter should clearly distinguish between copayment, coinsurance and deductible amounts within the Claim Adjustment Segments (CAS) segment of Loop 2430, as indicated on the ANSI ASC X12N 837 Health Care Claims transaction for each service line of your assigned commercial members.
The Affordable Care Act dictates reporting requirements. To comply with those requirements, we require all contracted care providers to submit all diagnosis and procedure codes to the highest level of specificity relevant to the encounter data submission.
If you have other questions, email the Encounter Data Collection Team at firstname.lastname@example.org.
MA encounter data requirements
CMS reimburses all MA plans based on the member’s health status. They use the diagnosis codes from the MA claims and/ or encounter data (inpatient, outpatient and care provider) to establish each member’s health status or Hierarchical Condition Category (HCC). CMS uses the HCC to help calculate Medicare reimbursement payments for each member.
As a result, we are required to send all adjudicated claims and capitated encounter data for MA members to CMS.
These claims and encounters must pass all the edits CMS applies to its fee-for-service HIPAA 5010 837 and CMS-1500 and UB- 04 submissions.
To reduce rejected claims, delegates must process MA claims and encounters in the same manner as their Medicare fee-for- service bills. Delegates are subject to the specific claims submission and other requirements stated in this guide.
If the claim data does not pass the CMS edits, which our systems mirror, we let you know. You will need to resubmit the claim or encounter to us. CMS may at any time audit our submission. The medical record must support the diagnoses you submit. Only the care provider can change or submit new CMS- 1500 or UB-04 data, so your cooperation is required for us to submit the correct data.
We require the medical group/IPA/capitated facility or other submitting entity to submit all professional and institutional claims and/or encounter data for MA members to:
To comply with the CMS regulation 75 FR 19709 to report member cost-sharing as well as out-of-pocket maximums, we require contracted care providers to submit current, complete and accurate encounter data. This includes member cost- sharing/revenue, within the CAS segment of the ANSI ASC X12N 837 Health Care Claims transaction for each service line of your assigned MA members. Send encounter data using current ASC X12 format to Payer ID 95958 or check with your clearinghouse.
CMS requires EOBs for Part C benefits to report total costs incurred by the health plans (us) for capitated and/or delegated provider services.
Medicare Advantage organizations (MAOs) are required to report the total costs incurred for capitated and/or delegated provider services. MAOs must populate dollar amounts for capitated and/or delegated providers in the “Total cost” and “Plan’s share” columns in the Monthly or Quarterly Summary EOB. The “Total cost” field on the member EOB includes what the member pays and what the health plan pays.
The MAOs, capitated medical groups, facilities, and ancillary care providers must submit the payer amount paid at the claim level, the Service Line Paid Amount, and the member cost-sharing for all professional and institutional Medicare encounter data. The payer amount paid submitted in the encounter should not be a zero unless the claim was denied.
We also refer to the payer amount paid as the contracted rate, Medicare Fee Schedule Rate, or Calculated Capitation Rate less any applicable member responsibility.
For more information on CMS EOB requirements, refer to CMS.gov > Medicare > Health Plans.
We continuously monitor encounter data submissions for quality and quantity. Submission levels below the monthly threshold of 100% are non-compliant. The capitated medical group/IPA or other submitting entity must correct any encounter errors identified by a clearinghouse or trading partner weekly. As you are processing claims on our behalf, we expect all encounter submissions to be an accurate reflection of the original claim received, including provider billing information, along with all adjudication details.
All encounter data submitted to UnitedHealthcare are subject to state and/or federal assessment. We have the right to perform routine medical record chart assessments on any or all of the medical group’s/IPA’s network care providers at such time or times as we may reasonably elect to determine the completeness and accuracy of encounter data, ICD-10-CM and CPT coding. We notify the medical group/IPA in writing of audit results for coding accuracy.
The delegate may be subject to financial consequences if it or another submitting entity fails to submit or meet encounter data element requirements. In addition, the delegate may need to perform a complete medical record chart review of its network care providers with notice from UnitedHealthcare.
For further details on UnitedHealthcare encounter data submission requirements, refer to the UnitedHealthcare Companion Guides at UHCprovider.com/edi > EDI Companion Guides.
Send Encounter data using current ASC X12 format to Payer ID 95958 or check with your clearinghouse.