Customer service requirements between UnitedHealthcare and the delegated entity (Medicare and Medicaid) - Capitation and/or delegation supplement- Capitation and/or delegation supplement - 2022 Administrative Guide

To help ensure timely support for member customer service requests, the delegated entity is responsible for working with UnitedHealthcare to address member service requirements, member/patient communication, and data sharing requests.

This includes:

  • Specific toll-free number (TFN) for service-related inquiries where you must respond with:
    • An average monthly service level at 80% or higher.
    • Average speed of answer (ASA) within 30 seconds or less.
  • When UnitedHealthcare requests data from the delegated entity requiring additional research on claim processing status and/or clarification on claim financial risk determinations and/or Utilization Management processing status, you must respond within:
    • 2 business days on escalated issues.
    • 5 business days on standard issues.
  • Providing details related to specific member/patient communication on programs offered by the delegated entity.

OptumCare CDO customer service specific requirements

The delegated entity is responsible for working with UnitedHealthcare to address member service requirements, member/ patient communication and data sharing requests.

This includes:

  • Dedicated phone line for service-related inquiries where you must respond with:
    • An average monthly service level at 80% or higher.
    • ASA within 30 seconds or less.
    • Weekly/monthly call metrics with UnitedHealthcare leadership including call volume, calls per 1,000 members, service level, ASA, transfer rate and experience (post-call survey).
  • Online chat capability between UnitedHealthcare member service advocates and OptumCare advocates.
    • Sharing online chat metrics between UnitedHealthcare and OptumCare advocates.
  • When UnitedHealthcare requests data from the delegated entity requiring additional research on claim processing status and/or clarification on claim financial risk determinations and/or utilization management processing status, you must respond within:
    • 1 day on escalated issues.
    • 2 days on standard issues.
  • Providing details related to specific member/patient communication on programs offered by the delegated entity including outbound call campaigns.