Claims process, River Valley - 2021 UnitedHealthcare Administrative Guide

Electronic Data Interchange

Use electronic data interchange (EDI) to submit claims and conduct other business with us electronically. To enroll, call EDI customer service at 1-866-509-1593, or email RVITEDISolutions@uhc.com.

Claims Transmission

Tell your office software vendor that you want to begin transmitting electronic claims to the River Valley Payer ID 87726 for medical claims and 95378 for dental.

We receive all claims through our clearinghouse, OptumInsight. The clearinghouse sets up claims as commercial. Your EDI software vendor must establish connectivity to the clearinghouse. They can make sure you meet the requirements to transmit claims.

EDI acknowledgment and status reports

Your software vendor will give you a report showing an electronic claim left your office. It does not confirm we or the clearinghouse received or accepted the claim.

Clearinghouse acknowledgment reports show the status of your claims. They are given to you after each transmission. This lets you confirm whether a claim reached us, rejected because of an error or needed additional information.

We will also send you status reports providing more data on claims. These include copies of EOBs/remittance advice and denial letters that may request more information.

Carefully review all vendor reports, clearinghouse acknowledgment reports and the River Valley status reports when you receive them.

Paper and electronic claims format

Submit all medical or hospital services claims using, as applicable, the CMS 1500 or UB-04 claim forms. Or use their successor forms for paper claims and HIPAA-standard professional or institutional claim formats for electronic claims. Use black ink when completing a CMS 1500 claim form. This helps us scan the claim into our processing system.

Electronic claims submission and billing

We require you to submit claims electronically, with few exceptions. For electronic claims submission requirements, refer to Requirements for complete claims and encounter data submission section in Chapter 10: Our Claims Process.

Share this document with your software vendor. We update the Companion Guide regularly, so review it to help ensure you have the most current information about our requirements.

For more information about electronic claims, refer to UHCprovider.com/claims.

Exceptions to electronic claims submission guidelines

The following claims require attachments. This means they must be submitted on paper:

  • Claims submitted for dental pre-treatments for crown lengthening, periodontics, implants and veneers.
  • Claims submitted with unlisted procedure codes if sufficient information is not in the notes field.

Modifier 59 helps identify procedures/services commonly bundled together but may be appropriate to report separately. No special rules apply to electronic claims joined using Modifier 59 or for dental pre-treatment claims.

Special rules for electronic submission

  • Corrected Claims must include the words “corrected claims” in the notes field. Your software vendor may help you with correct placement of all notes.
  • Unlisted Procedure Code Claims must include details in the notes field. If you cannot, you must submit a paper claim.
  • Claims for Occupational Therapy, Speech Therapy, Physical Therapy, Dialysis, and Mental Health or Substance Use Services must have the date of service by line item. We do not accept span dates for these types of claims.
  • Secondary Coordination Of Benefits (COB) Claims must include the following fields:
    • Institutional: Payer Prior Payment, Medicare Total Paid Amount, Total Non-Covered Amount, Total Denied Amount.
    • Professional: Payer-Paid Amount, Line Level Allowed Amount, Patient Responsibility, Line Level Discount Amount (contractual discount amount of other payer), Patient-Paid Amount (amount that the payer paid to the member, not the care provider).
    • Dental: Payer Paid Amount, Patient Responsibility Amount, Discount Amount, Patient Paid Amount.
    • Span Dates: We require exact dates of service when the claim spans a period of time. Put the dates in Box 24 of the CMS 1500, Box 45 of the UB-04, or the Remarks field. This will prevent the need for an itemized bill and allow electronic submission.

Requirements for claims (paper or electronic) reporting revenue codes

  • We require the exact dates of service for all claims reporting revenue codes.
  • If you submit revenue code 270 by itself on an institutional claim for outpatient services, we require a valid CPT or HCPCS code or description.
  • If you report revenue code 274, describe the services or include a valid CPT or HCPCS code.
  • We require an itemized statement for claims with revenue codes 250-259 if the charges exceed $1,000.
  • All claims reporting the revenue codes on the following list require you to report the appropriate CPT and HCPCS codes

260 IV Therapy (General Classification)

261 Infusion Pump

262 IV Therapy/Pharmacy Services

263 IV Therapy/Drug/Supply Delivery

264 IV Therapy/Supplies

269 Other IV Therapy

290 DME (other than renal) (General Classification)

291 DME/Rental

292 Purchase of New DME

293 Purchase of Used DME

300 Laboratory(General Classification)

301 Chemistry

302 Immunology

303 Renal Patient (Home)

304 Non-Routine Dialysis

305 Hematology

306 Bacteriology & Microbiology

307 Urology

309 Other Laboratory

310 Laboratory-Pathology (General Classification)

311 Cytology

312 Histology

319 Other Laboratory Pathological

320 Radiology-Diagnostic (General Classification)

321 Angiocardiography

322 Arthrography

323 Arteriography

324 Chest X-Ray

329 Other Radiology-Diagnostic

330 Radiology-Therapeutic and/or Chemotherapy Administration (General Classification)

331 Chemotherapy Administration-Injected

332 Chemotherapy Administration-Oral

333 Radiation Therapy

335 Chemotherapy Administration-IV

339 Other Radiology-Therapeutic

340 Nuclear Medicine (General Classification)

341 Diagnostic Procedures

342 Therapeutic Procedures

350 CT Scan (General Classification)

351 CT-Head Scan

352 CT-Body Scan

359 CT-Other

360 Operating Room Services (General Classification)

361 Minor Surgery

362 Organ Transplant-Other Than Kidney

367 Kidney Transplant

369 Other Operating Room Services

400 Other Imaging Services (General Classification)

401 Diagnostic Mammography

402 Ultrasound

403 Screening Mammography

404 Positron Emission Tomography

409 Other Imaging Services

410 Respiratory Services (General)

412 Inhalation Services

419 Other Respiratory Services

460 Pulmonary Function (General Classification)

469 Other-Pulmonary Function

470 Audiology (General Classification)

471 Audiology/Diagnostic

472 Audiology/Treatment

480 Cardiology (General Classification)

481 Cardiac Cath Lab

482 Stress Test

483 Echocardiology

489 Other Cardiology

490 Ambulatory Surgical Care (General Classification)

499 Other Ambulatory Surgical Care

610 Magnetic Resonance Technology (MRT) (General Classification)

611 Magnetic Resonance Imaging (MRI)-Brain/Brain Stem

612 MRI-Spinal Cord/Spine

614 MRI-Other

615 Magnetic Resonance Anglogram (MRA)-Head and Neck

616 MRA-Lower Extremities

618 MRA Other

618 Other MRT

623 Surgical Dressing

624 FDA Investigational Devices

634 Erythropoietin (EPO) < 10,000 units

635 Erythropoietin (EPO) > 10,000 units

636 Drugs Requiring Detail Coding

730 EKG/ECG (Electrocardiogram) (General Classification)

731 Holter Monitor

732 Telemetry

739 Other EKG/ECG

740 EEG (Electroencephalogram) (General Classification)

750 Gastro-Intestinal (GI) Services (General Classification)

790 Extra-Corporeal Shock Wave Therapy (formerly Lithotripsy) (General Classification)

921 Peripheral Vascular Lab

922 Electromyogram

923 Pap Smear

924 Allergy Test

925 Pregnancy Test

929 Additional Diagnostic Services

940 Other Therapeutic Services (General Classification)

941 Recreational Therapy

942 Education/Training (Diabetic Education)

949 Other Therapeutic Services (HRSA-approved weight loss providers)

Claim reconsideration and appeals process and resolving disputes

Refer to Claim reconsideration and appeals process in Chapter 10: Our claims process and in the How to Contact River Valley section of this supplement.

If you have a question about a pre-service appeal, see Pre-Service Appeals in Chapter 7: Medical Management.