Claims process, UnitedHealthOne- 2021 UnitedHealthcare Administrative Guide

We know you want to be paid promptly for your services. To help prompt payment:

  1. Notify us based on the notification requirements in this supplement.
  2. Prepare a complete and accurate claim form. For facility (UB-04/8371) claims, see number four below.
  3. Submit electronic claims using the electronic Payer ID on the health plan ID card or submit paper claims to the address listed on the member’s ID card. GRIC Payer ID is 37602.
  4. Requirements for claims (paper or electronic) reporting revenue codes:
    • All claims reporting revenue codes require the exact dates of service if they are span dates.
    • If you report revenue code 274, you are required to provide a description of the services or a valid CPT or HCPCS codes.
    • All claims reporting the revenue codes on the following list require that you 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 Durable Medical Equipment (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 Histology

312 Other Laboratory Pathological

319 Radiology–Diagnostic (General Classification)

320 Angiocardiography

321 Arthrography

322 Arteriography Revenue codes requiring CPT® and HCPCS codes

323 Chest X-Ray

324 Other Radiology-Diagnostic

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

330 Chemotherapy Administration-Injected Chemotherapy Administration-Oral Radiation Therapy

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 Transplant

367 Other Operating Room Services

369 Other Imaging Services (General Classification)

400 Diagnostic

401 Mammography

402 Ultrasound

403 Screening Mammography

404 Positron Emission

409 Tomography 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 (General Classification)

611 MRI-Brain/Brain Stem

612 MRI-Spinal Cord/Spine

614 MRI-Other

615 MRA-Head and Neck

616 MRA-Lower Extremities

618 MRA Other

618 Other MRT

623 Surgical Dressing Revenue codes requiring CPT® and HCPCS codes

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)

Note: Use the Payer ID number on the member’s ID card. The

electronic claims submission number does vary. The claim

will reject if the correct Payer ID is not used.

Claim adjustments

If you believe your claim was processed wrong, call the number on the back of the member’s ID card. Request an adjustment as soon as possible, in accordance with applicable statutes and regulations. If you identify a claim overpayment, or we notify you of an overpayment, send us the overpayment within 30 calendar days from the date of identification or notification.

Claim reconsideration, appeals and disputes

If you disagree with a claim payment determination or adjustment, you may appeal. Request a review by mail, fax or phone:

Grievance Administrator
P.O. Box 31371
Salt Lake City, UT 84131-0371

Standard Fax: 1-801-478-5463
Phone: 1-800-657-8205

If you feel your situation is urgent, request an expedited (urgent) appeal by mail, fax or phone:

Grievance Administrator
3100 AMS Blvd.
Green Bay, WI 54313

Expedited Fax: 1-866-654-6323
Phone: 1-800-657-8205

Your appeal must be submitted within 12 months from the date of payment shown on the EOB, unless your Agreement with us or applicable law provide otherwise.

Refer to Claim reconsideration and appeals process section in Chapter 10: Our Claims Process.

If you disagree with the outcome of the claim appeal, you may file an arbitration proceeding as described in your Agreement.

Claim reconsideration does not apply to some states based on applicable state law (e.g. Arizona, California, Colorado, New Jersey, Texas). For states with applicable law, dispute requests will follow the state-specific process.

New Jersey care provider dispute process

Disputes involving New Jersey (NJ) commercial members are subject to the NJ state-regulated care provider dispute process. The state-regulated care provider dispute process does not apply in the following situations:

  • Our determination involves a utilization management (UM) denial. UM denials are refusals to pay a claim or to authorize a service or supply because we have determined the service or supply is one of the following:
    • Not medically necessary
    • Experimental or investigational
    • Cosmetic
    • Dental rather than medical
    • Treatment of a pre-existing condition.

UM denials include prescription quantity limit denials and requests for in-plan exception denials. You may appeal a UM denial by going through the Internal UM Appeals Process described under the Member Complaints and Grievances section. You must submit a completed Consent to Representation in Appeals of Utilization Management Determinations and Authorization for Release of Medical Records in UM Appeals and Independent Arbitration of Claims form to begin the UM appeal process.

  • Our determination indicates we denied the service or supply as not covered under the terms of the plan or because the person is not our member.
  • The dispute is due to coordination of benefits.
  • We have provided you notice that we are investigating this claim (and related ones, as appropriate) for possible fraud. The process does apply for the following situations:
  • The claim was not paid for any reason other than previously listed.
  • The claim was paid at a rate you did not expect based on your network contract or the terms of the plan.
  • The claim was paid at a rate you did not expect because of differences in our treatment of the codes in the claim from what you believe is appropriate.
  • We required additional substantiating documentation to support the claim, and you believe the required information is inconsistent with our stated claims handling policies and procedures or is not relevant to the claim.
  • You believe we failed to adjudicate the claim, or an uncontested portion of a claim, in a timely manner consistent with law and the terms of your network contract, if any.
  • Our denial was due to lack of appropriate authorization, but you believe you obtained appropriate authorization from us or another carrier for the services.
  • You believe we failed to appropriately pay interest on the claim.
  • You believe our statement that we overpaid on one or more claims. a claim is erroneous or the amount we calculated as overpaid is erroneous.
  • You believe we have attempted to offset an inappropriate amount against a claim because of an effort to recoup for an overpayment on prior claims.

If the dispute is eligible, the following process will apply:

Submit a written request for appeal using the Health Care Provider Application to Appeal a Claims Determination Form created by the New Jersey Department of Banking and Insurance. Submit the request within 90 days following receipt of our initial determination notice to:

UnitedHealthcare Oxford Navigate Individual
Grievance Administrator
P.O. Box 31371
Salt Lake City, UT 84131-0371

Standard Fax: 1-801-478-5463

We will review the request and tell you our decision in writing within 30 calendar days of receipt of the form.

If you are not satisfied with the decision, you may initiate the New Jersey Program for Independent Claims Payment Arbitration (PICPA) process. Submit your requests to Maximus, Inc. within 90 calendar days from receipt of the internal dispute decision. A dispute is eligible if the payment amount in dispute is $1,000 or more. The arbitration decision is binding.