Claims and encounter data submissions - Chapter 10, 2022 UnitedHealthcare Administrative Guide

You must submit a claim and/or encounter for your services, regardless of whether you have already collected the copayment, deductible or coinsurance from the member. If you have questions about submitting claims to us, call us at the phone number listed on the member’s ID card.

It is important to accurately code the claim because a member’s level of coverage under their benefit plan may vary for different services. To help correctly code your claims, use Claim Estimator in the UnitedHealthcare Provider Portal. It includes a feature called Professional Claim Bundling Logic. This helps you determine allowable bundling logic and other commercial claims processing edits for a variety of procedure codes. This is not available for all products.

Pricing and payment calculations for professional commercial claims are available under the Pre-Determination of Benefits option. Allow 45 calendar days for us to process your claim, unless your Agreement says otherwise. Check claims in the UnitedHealthcare Provider Portal before sending second submissions or tracers. If you do need to submit a second submission or a tracer, submit the claim electronically no sooner than 45 days after original submission.

Complete claims by including the information listed under the Requirements for complete claims and encounter data submission section. We prefer to receive claims electronically, but we do accept claims submitted on paper. Send the completed and appropriate forms to the claims address listed on the back of the member’s ID card.

If we receive a claim electronically with missing information or invalid codes, we may reject the claim, not process it or, if applicable, not submit it to CMS for consideration in the risk adjustment calculation.

If we receive a similar claim using the paper form, we may pend it to get the correct information. We may also require additional information for particular types of services or based on particular circumstances or state requirements.

To order CMS 1500 and CMS-1450 (also known as UB-04) forms, contact the U.S. Government Printing Office at 1-866-512-1800, local printing companies in your area, and/or office supply stores.

Simplify your administrative workflow with

Claims in the UnitedHealthcare Provider Portal

Get the most up-to-date claims status and payment information, and submit your claim reconsideration and appeal requests.

  • View claims information for multiple UnitedHealthcare® plans
  • Access letters, remittance advice documents and reimbursement policies
  • Submit additional information requested on pended claims
  • Flag claims for future viewing
  • Submit claim reconsideration and appeal requests
  • Receive instant printable confirmation for your submissions

Learn more:
For more information — including quick reference guides and videos — go to > Menu > Resource Library > UnitedHealthcare Provider Portal.

UnitedHealthcare Web Support
1-866-842-3278, Option 1, Monday – Friday, 7 a.m. – 9 p.m. CT

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We may pend or deny your claim if you do not list:

  • Member’s name, address, gender, date of birth, relationship to subscriber (policy owner).
  • Subscriber’s name (enter exactly as it appears on the member’s ID card), ID number, employer group name and employer group number.
  • Rendering health care provider’s name, signature or representative’s signature, address where service was rendered, “Remit to” address, phone number, NPI, taxonomy and federal TIN.
  • Referring health care provider’s name and NPI, as well as TIN (if applicable). All laboratory, DME, imaging and home health claims and/or encounters must include the referring health care provider’s name and NPI number in addition to the other elements of a complete claim and/or encounter described in this guide.
  • Complete service information, including date of service(s), place of service(s), number of services (day/units) rendered, Current Procedural Terminology (CPT) and Healthcare Common Procedure Coding System (HCPCS) procedure codes, with modifiers where appropriate, current ICD-10-CM diagnostic codes by specific service code to the highest level of specificity. You must communicate the primary diagnosis for the service performed, especially if more than one diagnosis is related to a line item.
  • Charge per service and total charges.
  • Itemized bill – There may be times when we request an itemized bill to help adjudicate the claim. In an effort to avoid unnecessary delays, submit itemized bills upon request.
  • Detailed information about other insurance coverage.
  • Information regarding job-related, auto or accident information, if available.
  • Retail purchase cost (or a total retail rental cost) greater than $1,000 for DME.
  • Current National Drug Code (NDC) 11-digit number, NDC unit of measure (F2, GR, ML, UN, ME) and NDC units dispensed (must be greater than 0) for all claims submitted with drug codes. Enter the NDC information for the drug(s) administered in the 24D field of the CMS-1500 Form, field 43 of the UB-04 form, or the LIN03 and CTP04-05 segments of the HIPAA 837 Professional or institutional electronic form.
  • Method of administration (self or assisted) for hemophilia claims – note the method of administration and submit with the claim form with applicable J-CODES and hemophilia factor, to enable accurate reimbursement. Method of administration is either noted as self or assisted.

Include a detailed description of the procedure or service for claims submitted with:

  • Unlisted medical/surgical CPT.
  • “Other” revenue codes.
  • Experimental services.
  • Reconstructive services.

Your claim may be pended or not processed if you do not include:

  • Date and hour of admission.
  • Date and hour of discharge.
  • Member status-at-discharge code.
  • Type of bill code (3 digits).
  • Type of admission (e.g., emergency, urgent, elective, newborn).
  • Current 4 digit revenue code(s).
  • Attending physician ID number.
  • For inpatient and outpatient services/procedures, the specific CPT or HCPCS codes, line item date of service and appropriate revenue codes (e.g., laboratory, radiology, diagnostic or therapeutic).
  • Complete box 45 for physical, occupational or speech therapy services (revenue codes 0420-0449).
  • Any special billing instructions that are in your Agreement.
  • On an inpatient hospital bill type of 11x, use the actual time the member was admitted to inpatient status.
  • If charges are rolled to the first surgery revenue code line on hospital outpatient surgery claims, report a nominal monetary amount ($10 or $100) on all other surgical revenue code lines to assure appropriate adjudication.
  • Include the condition code designated by the National Uniform Billing Committee (NUBC) on claims for outpatient preadmission non-diagnostic services that occur within 3 calendar days of an inpatient admission and are not related to the admission.

Timely Filing

Your claim must be filed within your timely filing limits or it may be denied. If you disagree with a claim that was denied due to timely filing, you will be asked to show proof you filed the claim within your timely filing limits.

Timely filing limits vary based on state requirements and contracts. Refer to your internal contracting contact or Agreement for your specific timely filing requirements.