Our claims process - Chapter 10, 2022 UnitedHealthcare Administrative Guide

For information on submitting claims using Electronic Data Interchange (EDI), go to UHCprovider.com/edi837.

Prompt claims processing

We know you want prompt payment. We work hard to process your claims timely and accurately. This is what you can do to help us:

1. Submit the claim to the correct payer by reviewing the member’s eligibility as outlined in Verifying eligibility, benefits and your network participation status.  
   • Note: When we give you eligibility and benefit information, we are not guaranteeing payment or coverage in any specific amount. Actual reimbursement depends on many factors, such as compliance with administrative protocols, date(s) of services rendered, and benefit plan terms and conditions. For Medicare Advantage (MA) benefit plans, reimbursement also depends on CMS guidance and claims processing requirements.
2. Follow the instructions in the How to submit advance notification/prior authorization, admission notification, discharge notification section.
3. Prepare complete and accurate claims (see Claims and Encounter Data Submissions section or use our reference guides found on uhcprovider.com/claims).
4. Submit claims electronically with EDI for fast delivery and confirmation of receipt.
   • Electronic submissions are preferred for sending claims to UnitedHealthcare. View our Claims Payer List to determine the correct Payer ID to use.
   • Our contracts generally require you to conduct business with us electronically. They contain specific requirements for electronic claim submission. Review your Agreement and follow the requirements. While some claims may require supporting information for initial review, we have reduced the need for paper attachments. We request additional information when needed.
   • For helpful resources and tips on submitting claims electronically, visit uhcprovider.com/edi.
   • Check the status of a claim using EDI 276/277 Claim Status Inquiry and Response transactions. Contact your vendor or clearinghouse if these transactions are not available or activated in your system.
   • Learn how to elevate your productivity and savings using EDI at uhcprovider.com/optimizeedi.
   • If you need assistance using EDI, visit our EDI Contacts page.
   • For EDI connectivity options, go to uhcprovider.com/ediconnect to learn more. You can use the Claim Submission tool in the UnitedHealthcare Provider Portal to submit claims online. View uhcprovider.com/claims for more information.

HIPAA claim edits and Smart Edits

When claims are submitted using EDI, HIPAA edits are applied by the clearinghouse to help ensure claims contain specific information. Any claims not meeting requirements are rejected and returned back to the care provider to make corrections and resubmit electronically.

Smart Edits are an EDI capability which auto-detects claims with potential errors. Smart Edits may also be applied to help reduce claim denials and improve the claim processing time. You have 5 calendar days to correct claims rejected by Smart Edits before they are automatically processed.

For more information on HIPAA claim edits, go to uhcprovider.com/claimedits. For more information on Smart Edits, go to uhcprovider.com/smartedits.