Claim reconsideration does not apply in some states, such as MD, based on applicable state law. Refer to Care provider dispute resolution (CA delegates, OR HMO claims, OR and WA commercial plans) section for more information on similar prohibitions in those jurisdictions.
Note: For Non-Network Care Providers Claim Appeals and Dispute Process, refer to UHCprovider.com/plans > Choose your state > Medicare > Select plan name >Tools & Resources > Non-Contracted Care Provider Dispute and Appeal Rights.
You must submit both your reconsideration and appeal to us within 12 months (or as required by law or your Agreement), from the date of the EOB or PRA. The 2-step process, as outlined below, allows for a total of 12 months for timely submission for both steps (Step 1: Reconsideration and Step 2: Appeals).
If you disagree with the outcome of a processed claim (payment, correction or denial), you can appeal the decision by first submitting a Claim Reconsideration Request.
Submit claims on Link. For more information and necessary forms, visit UHCprovider.com/claims.
Submit your reconsideration request by mail by sending the Single Payer Claim Reconsideration Form to the applicable address listed on the EOB or PRA. The address may differ based on product. Include a copy of the original EOB or PRA. See applicable benefit plan supplement for specific contact information. If your request does not include the reason for reconsideration, we may deny your claim as a duplicate.
Call the number on the back of the member’s ID card to request an adjustment to a claim that does not require written documentation.
If you are submitting medical documentation we requested for a pended claim, use Claims on Link -OR- complete the Claim Reconsideration Request Form and check “Previously denied/closed for additional information” as your reason for request. Include the following on the form to prevent processing delays:
If you disagree with the outcome of the claim reconsideration decision in Step 1, you may use the following claim appeal process.
Attach all supporting materials to the appeal request, including member-specific treatment plans or clinical records. We make our decision based on the materials available at the time of formal appeal review.
Mail the claim appeal request and all supporting materials to the specific contact address in the applicable benefit plan supplement.
If you have a request to reconsider 20 or more paid or denied claims for the same administrative issue (and attachments are not required), you may submit these in bulk online. Use the Claims Research Project tool on Link.
If you are submitting medical documentation we requested for a pended claim:
Use Claims on Link to submit a Claim Reconsideration Request for a claim denied because filing was not timely. Provide one of the following documents:
All proof must include documentation that the claim is for the right patient and the correct date of service. For electronic claims, include confirmation that we received and accepted your claim
If the claim then requires an additional payment, the EOB or PRA will serve as notification of the outcome on the review. If the original claim status is upheld, you will be sent a letter outlining the details of the review.
If a claim requires an additional payment, the EOB or PRA itself does not serve as notification of the outcome of the review. We will send you a letter with the determination. In addition, you must send payment within 5 calendar days of the date on the determination letter. We will respond to you within the time limits set forth by federal and state law. After the time limit has passed, contact Provider Relations at 1-877-842-3210 to obtain a status.
If you are disputing a refund request that you received from us, refer to the Audit findings section in Chapter 11.
If a member has authorized you to appeal a clinical or coverage determination on the member’s behalf, such an appeal will follow the process governing member appeals as outlined in the member’s benefit contract or handbook.
Eligibility under a benefit plan may change retroactively if:
If you have submitted a claim affected by a retroactive eligibility change, a claim reconsideration may be necessary, unless otherwise required by state and/or federal law. We list the reason for the claim reconsideration on the EOB or PRA. If you are enrolled in Electronic Payment System, you will not receive an EOB. However, you will be able to view the transaction online or in the electronic file. If we implement a claim reconsideration and request refund, we notify you at least 30 business days prior to any adjustment, or as required by law or your Agreement.
MA members who are hospital inpatients have the statutory right to request an immediate review by the Quality Improvement Organization (QIO) when UnitedHealthcare and the hospital, with physician concurrence, determine that inpatient care is no longer necessary. The QIO notifies the facility and UnitedHealthcare of an appeal.
The facility will fax a copy of the DND to the QIO and UnitedHealthcare. If the MA member fails to make a timely request to the QIO for immediate review and remains in the hospital, they may ask for an expedited reconsideration (appeal) by UnitedHealthcare.