Special reporting requirements for certain claim types - Chapter 10, 2022 UnitedHealthcare Administrative Guide
For detailed instructions, refer to uhcprovider.com/policies> Commercial (or Medicare Advantage) Policies > Reimbursement Polices > Anesthesia Services.
Many benefit plan designs exclude outpatient laboratory services if they were not ordered by a participating health care provider. Our benefit plans may also cover such services differently when a portion of the service (e.g. the draw) occurs in the health care provider’s office, but a laboratory health care provider performs the analysis. A licensed health care provider must order laboratory services.
All laboratory 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. All claims for laboratory services must include the CLIA number for the servicing health care provider. We reject or deny laboratory claims that do not include the identity of the referring health care provider.
This requirement applies to claims and/or encounters for both anatomic and clinical laboratory services. It also applies to claims and/or encounters received from both participating and non-participating laboratories, unless otherwise provided under applicable law. It does not apply to claims for laboratory services done by health care providers in their offices.
Report the AMA Claim Designation code or Abbreviated Gene Name in loop 2400 or SV101-7 field for electronic claims or Box 24 for paper claims. When submitting code 81479, unlisted molecular pathology, report the Genetic Test Registry (GTR) unique ID.
Claims that have complied with notification or prior authorization requirements in UnitedHealthcare’s Genetic Testing and Molecular Prior Authorization program satisfy the policy’s requirements without further provider action, as long as they meet our GTR requirements.
Laboratory test registry protocol
In-network, freestanding and outpatient hospital laboratory claims for most laboratory testing services must contain the laboratory’s unique test code. In addition, each test code you submit on a claim must match the corresponding laboratory test registration provided in advance to UnitedHealthcare.
These requirements apply to most UnitedHealthcare commercial, Medicare Advantage and Community Plan networks. When you bill a laboratory test CPT code or HCPCS code, a corresponding test code with a matching test registration is required for each claim line you submit, or we may deny the claim.
Physical medicine and rehabilitation (PM&R) services are eligible for reimbursement if provided by a physician or therapy health care provider duly licensed to perform those services. If the rendering health care provider is not duly licensed, we do not pay for the service.
Assistant surgeons or surgical assistants claim submission requirements
The practice of using non-participating health care providers significantly increases the costs of services for our members. We require our participating health care providers to use reasonable efforts to find network providers, including network surgical assistants or assistant surgeons, for our members. The use of a non-participating assistant surgeon practice, in which our participating health care provider has an ownership interest or other financial arrangement, is prohibited unless the participating health care provider discloses that interest or arrangement to us in advance.
Submission of claims for services subject to medical claim review
We have the right to review claims to confirm a health care provider is following appropriate and nationally accepted coding practices. Health care providers must cooperate by providing access to requested claims information, all supporting documentation (such as medical records) and other related data and information that we may request, including itemized bills and manufacturer invoices. We may adjust payment to the health care provider at the revised allowable amount based on our review of this information, or if such information is not submitted following our request, we may deny the claim or adjust payment to the health care provider at a revised allowable amount as we determine appropriate.
We may pend or deny a claim and request medical records to determine whether the service rendered is covered, including medically necessary, and eligible for payment.
In these cases, we send a letter explaining what we need.
To help claim processing and avoid delays due to pended claims, resubmit only what is requested in our letter. The claim letter will state specific instructions for required information to resubmit, which may vary for each claim. You must also return a copy of our letter with your additional documents.
For MA benefit plans, if you are not eligible for payment but the service is covered, we will deny payment. You may not bill the member for the amount denied.
Erythropoietin (for commercial members)
For Erythropoietin (EPO) claims, you must submit the Hematocrit (HCT) level for us to determine coverage under the member’s benefit plan. For claims submitted by paper to UnitedHealthcare on a Form 1500, you must enter the HCT level in the shaded area of line 24a in the same row as the J-code. Enter HCT and the lab value (HCTxx).
For electronic claims, the HCT level is required in the (837P) Standard Professional Claim Transaction, Loop 2400 – Service line, segment MEA, Data Element MEA03.
Report the MEA segment as follows:
MEA01 = qualifier “TR”, meaning test results
MEA02 = qualifier “R2”, meaning hematocrit
MEA03 = hematocrit test result Example: MEA*TR*R2*33~
The following J codes require an HCT level on the claim:
J0881 Darbepoetin alfa (non-ESRD use)
J0882 Darbepoetin alfa (ESRD on dialysis)
J0885 Epoetin alfa (non-ESRD use)
J0886 Epoetin alfa, 1,000 units (for ESRD on Dialysis)
Q4081 Epoetin alfa (ESRD on dialysis)
For EPO claims submitted on a UB-04 claim form, an HCT level is not required.