Claims recovery, appeals, disputes and grievances, Oxford - 2021 UnitedHealthcare Administrative Guide

The following information applies to care providers but does not apply to facilities or ancillaries. Oxford periodically asks care providers to return overpayments due to either:

• Administrative reasons: Duplicate payments, payments relating to fee schedules or billing/bundling issues, payments made where Oxford was not the primary insurer).
• Behavioral issues: Upcoding, misrepresentation of service provided, services not rendered at all, frequent waiver of member financial responsibility.

Oxford may pursue such claim overpayments as permitted by law and following the applicable statute of limitations (usually 6 years). We use random sampling, examination by external experts, and reliable statistical methods to determine claim overpayments in situations involving large volumes of potentially overpaid claims.

Note: Once a care provider is given notice, we initiate discussions and take action during the following 1 year period.

We do not pursue collection of overpayments from individual participating care providers when overpayments are identified as isolated mistakes or where the care provider is not at fault if the overpayments were more than one year before the date of notice of the overpayment or use extrapolation. Examples include overpayments related to duplicate claims, fee schedule issues, isolated situations of incorrect billing/unbundling, and claims paid when Oxford was not the primary insurer.

Exception: Oxford will pursue collection of overpayments beyond one year and use statistical methods and extrapolation in situations where:

1. Oxford has a reasonable suspicion of fraud or a sustained or high level of billing errors related to:
   • Extensive or systemic upcoding.
   • Unbundling.
   • Misrepresentation of services or diagnosis.
   • Services not rendered.
   • Frequent waiver of member financial responsibility.
   • Misrepresentation of care provider rendering the services or licensure of such care provider, and similar issues.
2. A care provider affirmatively requests additional payment on claims or issues older than one year.
3. The Centers for Medicare & Medicaid Services (CMS) makes a retroactive change to enrollment or to primary versus secondary coverage of a Medicare benefit plan member.

Our administrative procedures for members with an Oxford product require facilities, and care providers participating in our network, to file a claim reconsideration and/or appeal before proceeding to arbitration under their contract.

See Claim reconsideration and appeals process found in Chapter 10: Our claims process for general appeal requirements.

1. Pre-Appeal Claim Review 2021uhcprovideradminguide

Before requesting an appeal determination, contact us, verbally or in writing, and request a review of the claim’s payment. We make every effort to clarify or explain our actions. If we determine that additional payment is justified, we reprocess the claim and remit the additional payment.

2. Who May Submit a Reconsideration or Appeal

1. Participating care providers appealing a decision on their own behalf, according to the terms of their Agreement with us.
2. Any care provider or practitioner when appealing on behalf of the member, with signed member consent. You must follow the process for member administrative claims appeals. Refer to the Member Administrative Grievance & Appeal (Non UM) Process & Time frames policy at OxfordHealth.com > Providers or Facilities > Tools & Resources > Medical Information > Medical & Administrative Policy Index or UHCprovider.com/policies-protocols > Commercial Policies > UnitedHealthcare Oxford Clinical, Administrative and Reimbursement Policies. Refer to the back of the member’s ID card for the applicable website.

3. Time frame for Submitting a Reconsideration or Appeal

a. Claim Reconsideration and Appeal Process

If you disagree with the way a claim was processed, or need to submit corrected information, you must file your reconsideration and/or appeal request of an administrative claim determination within 12 months (or as required by law or your Agreement) from the date of the original Explanation of Benefits (EOB) or Provider Remittance Advice (PRA). You must include all relevant clinical documentation, along with a Participating Provider Review Request Form. The two-step process described here allows for a total of 12 months for timely filing – not 12 months for step one and 12 months for step two. If an appeal is submitted after the time frame has expired, Oxford upholds the denial. Exceptions: There are separate processes for New Jersey Participating Providers and Unilateral Coding Adjustments for New York Hospitals. Refer to the New Jersey Participating Provider Appeal Process and Unilateral Coding Adjustments for New York Hospitals sections for additional information.

1.    Step One – Reconsideration Level: The request must include the Claim Reconsideration Form located on UHCprovider.com/claims > Submit a Claim Reconsideration and all supporting documentation. If after reconsideration, we do not overturn our decision, the EOB or response letter includes next-level rights and where to submit a request for further review. 

2.    Step Two – Appeal Level: Participating care provider and practitioner appeals must be submitted in writing within the same 12 month time frame. The appeal must include all relevant documentation, including a letter requesting a formal appeal and a Participating Provider Review Request Form. If the appeal does not result in an overturned decision, the care provider must review their contract for further dispute resolution steps.

b.  New Jersey Participating Provider Appeal Process

New Jersey (NJ) participating care providers are subject to the NJ state-regulated appeal process. If a NJ participating care provider has a dispute relating to payment of a claim involving a NJ commercial member, the dispute is eligible for an individual two-step process.

1.    First Level: The first-level appeal is made through Oxford’s internal appeal process. A written request for appeal must be submitted by the Health Care Provider Application to Appeal a Claims Determination Form created by the NJ Department of Banking and Insurance. This appeal must be submitted within 90 days of the date on Oxford’s initial determination notice to:

UnitedHealthcare Attn: Provider Appeals
P.O. Box 29136
Hot Springs, AR 71903

We conduct the review and communicate the results to the care provider in a written decision within 30 calendar days of receipt of all material necessary for such appeal.

2.    Second Level: The second-level appeal must be made through the external dispute resolution process. If a NJ participating care provider completed the internal appeal process and is not satisfied with the results of that internal appeal, the care provider has the right under their contract to arbitrate the dispute with Oxford. Care providers should submit their request to:

MAXIMUS, Inc.
Attn: New Jersey PICPA 50 Square Drive, Suite 210
Victor, NY 14564

Requests may be submitted by fax to 1-585-425-5296. (MAXIMUS, Inc. requests that faxes be limited to 25 pages.)

Consult your contract to determine the appropriate arbitration authority. Most such contracts provide for arbitration before the American Arbitration Association (AAA).The costs of arbitration are borne equally by the participating care provider and Oxford, unless the arbitrator determines otherwise. The decision in such arbitration depends on the participating care provider and Oxford, pursuant to the terms of the Agreement. To commence arbitration, the care provider must file a statement of claim with the AAA.

c.    Unilateral Coding Adjustments for New York Hospitals

If a New York hospital receives a remittance advice/payment indicating that Oxford adjusted payment based on a particular coding (i.e., assignment of diagnosis and or CPT/HCPCS or other procedure code), the hospital has the right to resubmit the claim, along with the related medical record supporting the initial coding of the claim, within 30 days of receipt/notification of payment. Oxford must review the medical records within the normal review time frames (45 days). If Oxford’s initial determination:

• Remains unchanged, the insurer’s decision must be accompanied by a statement providing the specific reasons why the initial adjustment was appropriate.
• Changes, and the payment is increased based on the information submitted by the hospital, Oxford must provide the additional reimbursement within the 45-day review time frame.

If Oxford fails to provide the additional reimbursement within the 45-day review time frame, Oxford must pay to the hospital interest on the amount of the increase. The interest must be computed from the end of the 45-day period after resubmission of the additional medical record information.

Note: Neither the initial or subsequent processing of the claim by Oxford may be considered an adverse determination if it is based solely on a coding determination.

4.    Method for Submitting a Reconsideration or Appeal

Find the correct mailing address on Oxford’s Participating Provider Claim(s) Review Request Form. There are separate processes for the following appeal types:

• Internal and external claims payment appeals for NJ participating care providers who treat NJ commercial members.
• The appeal of unilateral coding adjustments made to New York hospital claims.

5.     Appeal Decision and Resolution

Full documentation of the substance of the appeal and the actions taken will be maintained in an appeal file (paper or electronic). Written notification to the care provider is issued by means of a letter or updated Remittance Advice (RA) statement at the time of determination of the appeal. This decision constitutes Oxford’s final internal decision. If the care provider is not satisfied with Oxford’s decision, they may arbitrate the issue as set forth in their contract with Oxford. Refer to the Time frame Standards for Benefit Administrative Initial Decisions policy at OxfordHealth.com > Providers or Facilities >   Tools & Resources > Medical and Administrative Policies > Medical & Administrative Policy Index or UHCprovider.com/policies-protocols > Commercial Policies > UnitedHealthcare Oxford Clinical, Administrative and Reimbursement Policies. Refer to the back of the member’s ID card for the applicable website.

6.     Arbitration

If the care provider wants to file for arbitration after the first-level appeal has been completed, the care provider must file a statement of claim with the AAA at the following address:

American Arbitration Association Northeast Case Management Center
950 Warren Avenue 4th Floor
East Providence, RI 02914

Phone: 1-800-293-4053

Care providers located outside of New York, New Jersey and Connecticut should refer to the AAA website ar adr.org for submission guidelines.

• Participating care providers appealing an adverse determination are entitled under their care provider contract to bring the issue before the AAA. They have this right only under the following circumstances:

1. The first-level internal grievance process has been completed.
2. The appeal is on their own behalf (not on behalf of the member).

• Participating hospitals and ancillary facilities also have arbitration rights, but those rights vary depending on contracts. If a hospital or ancillary facility calls to inquire about arbitration rights, they should be referred to their contract for the specific arbitration entity. Hospitals and ancillary facilities still must use the first-level internal appeal process.

For participating care providers and other health care professionals treating New York members, this external appeals process applies only to services provided to commercial members who have coverage by virtue of an insurance benefit plan licensed in the state of New York.

This appeals process does not apply to the self-funded line of business. Care providers may use this process to appeal concurrent and retrospective utilization review decisions. Other external appeals require written consent from the member. In connection with retrospective decisions, if the care provider’s Agreement includes arbitration language or alternate dispute language, the care provider must follow that process. The external review process is no longer an option for dispute resolution.

Standard Medical Necessity Appeals Process

If members or their designees would like to file an appeal, they must hand-deliver or mail a written request within 180 days of receiving the initial denial determination notice to:

Oxford Clinical Appeals Department
P.O. Box 29139
Hot Springs, AR 71903

Expedited medical necessity appeals process for members:

• Members have the right to request an expedited appeal.
• To request an expedited appeal, the member or care provider or other health care professional must state specifically that the request is for an expedited appeal.
• The Clinical Appeals department determines whether or not to grant an expedited request.
• If the Clinical Appeals department determines the request does not meet expedited criteria set by the Clinical Appeals department, the member is notified.

Appeals of benefit denials issued by the Clinical Services and Disease Management departments are handled by the Clinical Appeals department.

Administrative appeals without the Clinical Services department’s involvement are handled by the Member Appeals unit. If a member would like to file an appeal on a claim determination, they must mail all administrative appeals to the UnitedHealthcare Grievance Review Board. See How to Contact Oxford Commercial section for address information.

Second-level member appeals

Members have the right to take a second-level appeal* to our Grievance Review Board (GRB). If they remain dissatisfied with the first-level appeal determination, they may request a second-level appeal. Members with a Connecticut line of business do not have the option of submitting a second-level appeal request for a benefit or administrative issue. The request for appeal and any additional information must be submitted to the UnitedHealthcare Grievance Review Board. See How to Contact Oxford Commercial section for address information.

New York, New Jersey and Connecticut members have the right to appeal a medical necessity determination to an external review agent. They may file a consumer complaint with one of the following applicable regulatory bodies. The applicable regulatory body is determined by the state in which the member’s certificate of coverage was issued, not where the member resides.

UnitedHealthcare immediately removes any health care provider from the network who is unable to provide health care services due to a final disciplinary action.

UnitedHealthcare may not prohibit, terminate or refuse to renew a contract with a care provider solely for the following:

• Advocating on behalf of a member.
• Filing a complaint against UnitedHealthcare.
• Appealing a decision made by UnitedHealthcare.
• Providing information or filing a report per PHL4406- c regarding prohibitions.
• Requesting a hearing or review.

We grant care providers and certain health care professionals the right to appeal certain disciplinary actions imposed by us.

The appeals process is structured so most appeals for terminations, not including non-renewal of the care provider’s contract with us, may be heard before disciplinary action is implemented.

A care provider or health care professional may request an appeal (fair hearing or review) after we take adverse action to restrict, suspend or terminate a care provider or health care professional’s ability to provide health care services to our members for reasons relating to the professional competence or conduct that adversely affects or could adversely affect the member’s health or welfare.

A notice is provided within 30 calendar days after the adverse action is taken. It includes the following:

1. UnitedHealthcare determined an adverse action is necessary, and the final action will be reported to the National Practitioner Data Bank, Healthcare Integrity and Protection Data Bank and appropriate state licensing board.
2. A description of and reason for the action.
3. Right to request an appeal in writing within 30 calendar days after receipt of the notice. Failure to file such request shall constitute a waiver of all rights to the appeal process, unless such a right is provided under state law.
4. A summary of the care provider’s or health care professional’s appeal rights provided.

We will notify the care provider or health care professional of the fair hearing or review date within 30 calendar days of our receipt of request for appeal, or within the time frame required by state law. The fair hearing or review takes place within 60 calendar days of the date we receive the request for appeal, or within the time frame required by state law.

The hearing panel will be comprised of at least 3 persons appointed by UnitedHealthcare. At least one person on the panel will have the same discipline or same specialty as the care provider under review. The panel may consist of more than 3 members, provided the number of clinical peers constitutes one-third or more of the total panel membership.

The hearing panel will render a decision in a timely manner. Decisions will be provided in writing and include one of the following:

1. Reinstatement.
2. Provisional reinstatement with conditions set forth by us.
3. Termination.