Contractual and financial responsibilities - Capitation and/or delegation supplement - 2022 Administrative Guide

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As an MA plan, UnitedHealthcare and its network providers agree to meet all laws and regulations applicable to recipients of federal funds. The medical group/IPA and capitated facility acknowledge they must comply with certain laws applicable to entities and individuals receiving federal funds.

An inpatient admission includes:

  • Inpatient acute care.
  • SNF.
  • Detoxification.
  • Medical rehabilitation.
  • All related services.

If a member’s assigned health care provider is partial risk at the time of admission and then changes to shared risk prior to the member’s discharge, all claims related to this confinement from admission through discharge are processed according to the partial risk DOFR in effect at the time of the admission.

If a member’s assigned health care provider is shared risk at the time of admission and then changes to partial risk prior to the member’s discharge, all claims related to this confinement from admission through discharge processed according to the shared risk DOFR will be in effect at the time of the admission.

Collection of fees

When a member needs one of the following forms for reasons other than medical reasons, you may collect a fee, in addition to the office visit copayment, for completion of these forms (unless the member’s benefit plan or applicable law dictates otherwise):

  • DMV forms
  • Camp or school forms
  • Employment or insurance forms
  • Adoption form

You cannot collect an additional fee, copayment, or surcharge for:

  • Completion of Prior Authorization form for non-formulary drugs.
  • Completion of disability forms.
  • Missed appointments/no shows or late cancellations.
  • Times when a member cannot pay office visit copayment at the time of visit for basic health care services. The medical group/IPA may reschedule the member’s appointment. If the member requires urgently needed care or emergency care, the medical group/IPA must render care.

You can collect copayments when professional services are rendered by a:

  • Licensed medical doctor or doctor of osteopath as defined by the state.
  • Physician assistant.
  • Nurse practitioner.

Do not collect copayments when there is no actual office visit. For example:

  • Injections administered by a nurse or medical assistant.
  • Routine immunizations administered by a nurse or medical assistant.

We are required to monitor and track each member’s annual individual out-of-pocket/deductible maximum amount. The member’s annual individual out-of-pocket/deductible maximum accumulation is calculated through the member’s cost-share data collected from all or some of the following sources:

  • Medical group/IPA/capitated hospital encounters
  • Prescription related encounters
  • Behavioral health-related encounters
  • Claims processed by UnitedHealthcare or its delegates

UnitedHealthcare and its capitated health care providers share responsibility to monitor the member’s individual out-of-pocket/ deductible maximum. For additional information on reporting available from UnitedHealthcare, see Chapter 11: Compensation of this guide. When a member meets their annual individual out-of-pocket/deductible maximum, UnitedHealthcare notifies the member’s capitated health care provider. Capitated health care providers are responsible for updating their claims systems within 2 business days of receiving the notification. They must help ensure members are not charged for copayments or coinsurance/deductibles once the annual maximum out-of-pocket expense is met.

If the member exceeds their annual individual out-of-pocket/deductible maximum due to the capitated health care provider collecting member cost-share amounts after the member has met their annual individual out-of-pocket/deductible maximum, the capitated health care provider must:

  • Re-process the member claims to adjust the cost-share amounts and confirm transactions with UnitedHealthcare within 7 days.
  • Submit the corrected encounter data to UnitedHealthcare within 16 days.
  • Refund the member any cost-share amounts collected in excess of the member’s annual individual out-of-pocket and deductible maximums.
  • Verify the member received all appropriate reimbursements.

UnitedHealthcare monitors the capitated health care provider’s compliance with this policy to help ensure all requests for claims reprocessing and member reimbursement are completed timely.

If necessary, we work with the capitated health care provider to help ensure each member is reimbursed for any amounts collected in excess of the member’s annual individual out-of-pocket/deductible maximum amounts as specified in the member’s benefit plan.

If the capitated health care provider fails to reimburse a member for amounts collected in excess of the member’s annual individual out-of-pocket/deductible maximum, we may reimburse the member directly and recover the payment by capitation deduction as specified in your Agreement.

  • Cost-share information comes from different sources derived through claims and encounter data submissions.
  • Delegated entities can view up-to-date cost-share information including various reports that they can download on uhcprovider.com. Reach out to your health care provider advocate for further details.
  • Delegated entities can contact oop@uhc.com for any member out-of-pocket inquiries.
  • Delegated entities are responsible for updating their systems within 2 business days of receiving the notification from UnitedHealthcare that a member met their maximum out-of-pocket costs. This helps ensure members not charged for copayments, coinsurance and deductibles once the annual maximum is met.

Delegated entities must work with UnitedHealthcare to address member issues related to out-of-pocket balances. This includes:

  • Responding to a UnitedHealthcare request for data on care services provided to a member:
    • Within 2 business days on escalated issues.
    • Within 5 business days on standard issues.
  • For claims identified by UnitedHealthcare to be re-processed by the delegated entity:
    • Within 7 days, adjusting cost-share amounts, reprocessing the claims and confirming transactions with UnitedHealthcare.
    • Within 16 days, submitting the corrected encounter data.

To help ensure timely processing of service health care provider claims, delegated entities are responsible for working with UnitedHealthcare to address financial risk dispute issues. This includes:

  • When UnitedHealthcare requests data from the delegated entity on claim processing status and/or clarification on claim financial risk determinations, you must respond within:
    • 2 business days on escalated issues.
    • 5 business days on standard issues.
  • When UnitedHealthcare identifies claims to be re-processed by the delegated entity to resolve service health care provider or member issues:
    • Reprocess the claims and confirm transactions with UnitedHealthcare within 7 business days.
    • Submit the corrected encounter data within 16 days.

Failure to comply with these requirements may result in an improvement action plan that may lead to financial penalties and loss of delegation if not addressed appropriately. Please refer to the Compliance assessments section for further information on the policies and procedures in place to help ensure health care provider compliance with contractual state and federal claims processing requirements. Please refer to the Non-compliant assessments section for further information on the improvement action plan.

Professional and institutional encounter data consist of an itemization of medical group/IPA/capitated facility, capitated and sub-capitated services provided to our commercial or MA members.

We require you to transmit your encounter data on a weekly basis, at a minimum. We also welcome your encounter submissions more frequently. Frequent encounter submissions allows us to support various state and federal regulatory requirements for reporting, such as risk adjustment reporting for Medicare reimbursement from CMS, member out-of-pocket costs, STARS reporting and NCQA and HEDIS reporting. One of our performance goals is to receive 90% of encounters within 90 days from the date of service. We have an additional performance goal to receive encounters no later than 16 calendar days from the delegate’s adjudication date to the logged date at UnitedHealthcare.

Encounter Data Tip:

We request that you use one of our preferred clearinghouses to transmit your encounters. Contact encountercollection@uhc.com for this information.

We continuously monitor encounter data submissions for quality and quantity. Submission levels below the monthly threshold of 100% are non-compliant. The medical group/IPA or other submitting entity must correct any encounter errors identified by a clearinghouse or trading partner at least weekly. Our performance goal is not to exceed 500 outstanding edits based on weekly reporting provided by our clearinghouses. As you are processing claims on our behalf, we expect all encounter submissions to accurately reflect the original claim received without exception. Delegates are required to send replacement or void encounters for both commercial and MA lines of business, if applicable. Delegates send a replacement encounter when information on the original logged encounter at UnitedHealthcare needs to be corrected. A void submission is required to eliminate a previously submitted logged encounter at UnitedHealthcare. Delegates should not send replacements and voids when the original encounter is rejected by a clearinghouse.

For examples of when a replacement or void encounter should be submitted and the required details on submitting them within the 837P and 837I ASC X12 EDI format, refer to section 6.1 of the Electronic Claim Submission Guidelines in the UnitedHealthcare Companion Guides or contact encountercollection@uhc.com. All encounter data submitted to UnitedHealthcare are subject to state and/or federal audit. We have the right to perform routine medical record chart assessments on any or all of the medical group’s/IPA’s network providers at such time or times as we may reasonably elect to determine the completeness and accuracy of encounter data ICD-10- CM and CPT coding. We notify the medical group/IPA in writing of audit results for coding accuracy.

The delegate may be subject to the implementation of an IAP and/or financial consequences if it or another submitting entity fails to submit or meet encounter data element requirements. In addition, the delegate may be required to perform a complete medical record chart review of its network providers with notice from UnitedHealthcare.

System/software upgrades, change in claims platforms, change to new clearinghouse

When system/software upgrades occur, you may be required to test your encounter files. Changes/modifications to the platforms and applications used to process claims and encounters will be required to complete testing with your clearinghouse.

If changing to a new clearinghouse, there is special advance setup required at UnitedHealthcare and your new clearinghouse for encounters to be transmitted and processed successfully at UnitedHealthcare. Please include your UnitedHealthcare provider advocate and encounter data business analyst in your 120-day advance notification to UnitedHealthcare. Following these guidelines will ensure your data is 837 5010 EDI compliant and reduce gaps in your weekly encounter submissions.

Refer to the Notification of Platform Transitions or Migrations section for more information.

Commercial encounter data requirements

The capitated medical group/IPA, or other submitting entity, must certify the completeness and truthfulness of its encounter data submissions as required by the state regulatory agency. The medical group/IPA, or other submitting entity, must submit all professional and institutional encounter data for UnitedHealthcare members to:

  • Comply with the Affordable Care Act for Essential Health Benefits (EHB) and NCQA-HEDIS® reporting requirements.
  • Enhance member and health care provider service quality.
  • Provide the medical group/IPA, or other submitting entity, with comparative data.
  • Facilitate settlement calculations if applicable, and oversight of utilization management and quality management.
  • Report member out-of-pocket maximums.

We require capitated medical group/IPAs and capitated facilities to submit timely and compliant encounter data. Include the member cost-share amount on the encounter data submissions based on the member’s benefit plan, not the amount the member paid at the time of service. The encounter should clearly distinguish between copayment, coinsurance and deductible amounts within the Claim Adjustment Segments (CAS) segment of Loop 2430, as indicated on the ANSI ASC X12N 837 Health Care Claims transaction for each service line of your assigned commercial members.

Check with your clearinghouse to verify the appropriate Payer ID to use to send your encounters to them, or contact encountercollection@uhc.com.

The Affordable Care Act dictates reporting requirements. To comply with those requirements, we require all contracted health care providers to submit all diagnosis and procedure codes to the highest level of specificity relevant to the encounter data submission. If the encounters do not include specific information, or data elements are invalid or missing, the clearinghouse will reject them.

For more information on UnitedHealthcare encounter data submission requirements, refer to the UnitedHealthcare’s EDI Companion Guides or email encountercollection@uhc.com.

MA encounter data requirements

CMS reimburses all MA plans based on the member’s health status. They use the diagnosis codes from the MA claims and/ or encounter data (inpatient, outpatient and health care provider) to establish each member’s health status or Hierarchical Condition Category (HCC). CMS uses the HCC to help calculate Medicare reimbursement payments for each member.

As a result, we are required to send all adjudicated claims and capitated encounter data for MA members to CMS.

These claims and encounters must pass all the edits CMS applies to its fee-for-service HIPAA 5010 837 and CMS-1500 and UB- 04 submissions.

To reduce rejected claims, delegates must process MA claims and encounters in the same manner as their Medicare fee-for- service bills. Delegates are subject to the specific claims submission and other requirements stated in this guide.

CMS may at any time audit our submissions. The medical record must support the diagnoses you submit. Only the health care provider can change or submit new CMS-1500 or UB-04 data, so your cooperation is required for us to submit the correct data.

We require the medical group/IPA/capitated facility or other submitting entity to submit all professional and institutional claims and/or encounter data for MA members to:

  • Comply with regulatory requirements of the CMS Balanced Budget Act (BBA), and NCQA-HEDIS reporting requirements.
  • Enhance member and health care provider service quality.
  • Submit to us for risk adjustment reporting and accurate Medicare reimbursement so we can submit to CMS.
  • Provide the submitting entity with comparative data.
  • Facilitate utilization management oversight, quality management oversight and settlement calculation, if applicable.
  • Support Services 75 FR 19709 -Maximum Allowable Out-of-Pocket Cost Amount for Medicare Parts A and B.

To comply with the CMS regulation 75 FR 19709 to report member cost-sharing as well as out-of-pocket maximums, we require contracted health care providers to submit current, complete and accurate encounter data. This includes member cost-sharing/ revenue, within the CAS segment of the ANSI ASC X12N 837 Health Care Claims transaction for each service line of your assigned MA members. Check with your clearinghouse to verify the appropriate Payer ID to use to send your encounters to them, or contact encountercollection@uhc.com.

CMS requires EOBs for Part C benefits to report total costs incurred by the health plans (UnitedHealthcare) for capitated and/or delegated health care provider services.

Medicare Advantage organizations (MAOs) are required to report the total costs incurred for capitated and/or delegated health care provider services. MAOs must populate dollar amounts for capitated and/or delegated health care providers in the “Total cost” and “Plan’s share” columns in the monthly EOB. The “Total Cost” field on the member EOB includes what the member pays (“Your Share” on the EOB) and what the health plan (“Plan Paid” on the EOB) pays.

The MAOs, capitated medical groups, facilities, and ancillary health care providers must submit the payer amount paid at the claim level, the Service Line Paid Amount, and the member cost-sharing for all professional and institutional Medicare encounter data. The payer amount paid submitted in the encounter should not be a zero unless the claim was denied.

We also refer to the payer amount paid as the contracted rate, Medicare Fee Schedule Rate, or Calculated Capitation Rate less any applicable member responsibility.

For more information on CMS EOB requirements, refer to cms.gov > Medicare > Health Plans.

All encounter data submitted to UnitedHealthcare are subject to state and/or federal assessment. We have the right to perform routine medical record chart assessments on any or all of the medical group’s/IPA’s network providers at such time or times as we may reasonably elect to determine the completeness and accuracy of encounter data, ICD-10-CM and CPT coding. We notify the medical group/IPA in writing of audit results for coding accuracy.

For further details on UnitedHealthcare encounter data submission requirements, refer to the UnitedHealthcare EDI Companion Guides or email encountercollection@uhc.com.