Authorization guarantee (CA Commercial only) - Capitation and/or delegation supplement - 2022 Administrative Guide

Authorization guarantee procedure

Authorization guarantee procedure limits the medical group/IPA’s risk of rendering care or incurring financial risk for services provided to ineligible members where the individual’s lack of eligibility is only determined after services are provided. It offers reimbursement to the medical group/IPA providing covered services to a member who:

  1. We identified as eligible before the date of service through our eligibility determination and verification processes and is later determined to be ineligible for benefits on the date of service.
  2. We provided an authorization to whom we confirmed as eligible prior to the date of service but later determined to have been ineligible on the date of service (“authorization guarantee”).

Authorization guarantee billing procedures

Medical group/IPA provides or arranges for health care services for an eligible member through our eligibility determination and verification processes. If authorization is provided, and the individual was not a member when the health care services were provided, medical group/IPA may seek reimbursement for such services.

The medical group/IPA must submit the following information to our health care provider dispute team for reimbursement consideration. Their address is in the UnitedHealthcare West Bulk Claims Rework Reference Table. Include:

  • Cover sheet.
  • Copy of authorization and the itemized bill for services rendered.
  • A record of any payment received from any other responsible payer.
  • Amount due based on medical group/IPA’s cost of care rate, less any payment received from any other responsible payer.

Authorization guarantee reimbursement

The medical group/IPA must follow the authorization guarantee billing procedures. Eligible services must be reimbursed within 45 business days of receipt of information. Reimbursement should be at the cost of care rates listed in the contract, no greater than the full uncollected balance. The medical group/IPA must reimburse the health care provider.