Claims and encounter data submissions - Chapter 10, 2021 UnitedHealthcare Administrative Guide

We may pend or deny your claim if you do not list:

• Member’s name, address, gender, date of birth, relationship to subscriber (policy owner).
• Subscriber’s name (enter exactly as it appears on the member’s ID card), ID number, employer group name and employer group number.
• Rendering care provider’s name, signature or representative’s signature, address where service was rendered, “Remit to” address, phone number, NPI, taxonomy and federal TIN.
• Referring care provider’s name and NPI, as well as TIN (if applicable). All laboratory, DME, imaging and home health claims and/or encounters must include the referring care provider’s name and NPI number, in addition to the other elements of a complete claim and/or encounter, described in this guide.
• Complete service information, including date of service(s), place of service(s), number of services (day/units) rendered, current CPT and HCPCS procedure codes, with modifiers where appropriate, current ICD-10-CM diagnostic codes by specific service code to the highest level of specificity. It is essential to communicate the primary diagnosis for the service performed, especially if more than one diagnosis is related to a line item.
• Charge per service and total charges.
• Itemized bill – There may be times when we request an itemized bill to help adjudicate the claim. In an effort to avoid unnecessary delays, submit itemized bills upon request.
• Detailed information about other insurance coverage.
• Information regarding job-related, auto or accident information, if available.
• Retail purchase cost (or a total retail rental cost) greater than $1,000 for DME.
• Current National Drug Code (NDC) 11-digit number, NDC unit of measure (F2, GR, ML, UN, ME) and NDC units dispensed (must be greater than 0) for all claims submitted with drug codes. Enter the NDC information for the drug(s) administered in the 24D field of the CMS-1500 Form, field 43 of the UB-04 form, or the LIN03 and CTP04-05 segments of the HIPAA 837 Professional or institutional electronic form.
• Method of administration (self or assisted) for hemophilia claims – note the method of administration and submit with the claim form with applicable J-CODES and hemophilia factor, to enable accurate reimbursement. Method of administration is either noted as self or assisted.

Include a detailed description of the procedure or service for claims submitted with:

• Unlisted medical/surgical CPT
• “Other” revenue codes
• Experimental services
• Reconstructive services

Your claim may be pended or not processed if you do not include:

• Date and hour of admission
• Date and hour of discharge
• Member status-at-discharge code
• Type of bill code (3 digits)
• Type of admission (e.g., emergency, urgent, elective, newborn)
• Current four digit revenue code(s)
• Attending physician ID number
• For inpatient and outpatient services/procedures, the specific CPT or HCPCS codes, line item date of service, and appropriate revenue code(s) (e.g., laboratory, radiology, diagnostic or therapeutic)
• Complete box 45 for physical, occupational or speech therapy services (revenue codes 0420-0449)
• Submit claims according to any special billing instructions that are in your Agreement
• On an inpatient hospital bill type of 11x, use the actual time the member was admitted to inpatient status
• If charges are rolled to the first surgery revenue code line on hospital outpatient surgery claims, report a nominal monetary amount ($10 or $100) on all other surgical revenue code lines to assure appropriate adjudication
• Include the condition code designated by the National Uniform Billing Committee (NUBC) on claims for outpatient preadmission non-diagnostic services that occur within 3 calendar days of an inpatient admission and are not related to the admission