Verifying eligibility, benefits and your network participation status - Chapter 2, 2021 UnitedHealthcare Administrative Guide

Check the member’s eligibility and benefits prior to providing care. Doing this:

  • Helps ensure that you submit the claim to the correct payer.
  • Allows you to collect copayments.
  • Determines if a referral and prior authorization or notification is required.
  • Reduces denials for non-coverage.

One of the primary reasons for claims rejection is incomplete or inaccurate eligibility information.

There are 3 easy ways to verify eligibility and benefits as shown in the Online/interoperability resources and how to contact us section in Chapter 1: Introduction.

EDI: Eligibility and Benefit Inquiry (270) and Response (271)

The EDI 270/271 transaction allows you to obtain a member’s eligibility and benefit information in real time. The HIPAA ANSI X12 270/271 format is the only acceptable format for this EDI transaction. We make enhancements to these transactions periodically. For more information, go to the Helpful Resources section at UHCprovider.com/edi270.

Eligibility grace period for Individual Exchange members

When individuals enroll in a health benefit plan through the Health Insurance Marketplace (also known as Individual Exchange), the plans are required to provide a 3-month grace period before terminating coverage. The grace period applies to those who receive federal subsidy assistance in the form of an advanced premium tax credit and who have paid at least one full month’s premium within the benefit year. Additionally, for individuals who do not receive federal subsidy assistance, plans are required to provide a grace period that is consistent with state law (typically 30 or 31 calendar days) before terminating coverage.

You can verify if the member is within the grace period when you verify eligibility.

If the date of service occurs after the “through date,” the member is in the grace period. They are at risk of retroactive termination if the premium is not paid in full at the end of the 3-month period.

Refer to the Chapter 4: Health Insurance Marketplace (Exchanges) for more information.

Understanding your network participation status

Your network status is not returned on 270/271 transactions. Know your status prior to submitting 270 transactions. As our product portfolio evolves and new products are introduced, it is important for you to confirm your network status and tier status (for tiered benefit plans) while checking eligibility and benefits on Link or by calling us at 1-877-842-3210. If you are not participating in the member’s benefit plan or are outside the network service area for the benefit plan (i.e., Compass), the member may have higher costs or no coverage. For more information about tiered benefit plans, visit UHCprovider.com/plans >  Select your state > Commercial > UnitedHealthcare Tiered Benefit Plans.