See Claim reconsideration and appeals process found in Chapter 10: Our claims process for general appeal requirements.
Claims submission and status
To submit a claim, or verify the status of a claim, use any method outlined in the How to Contact Oxford Commercial section in this chapter.
The following information applies to health care providers but does not apply to facilities or ancillaries.
Oxford periodically asks health care providers to return overpayments due to either:
Oxford may pursue such claim overpayments as permitted by law and following the applicable statute of limitations (usually 6 years). We use random sampling, examination by external experts and reliable statistical methods to determine claim overpayments in situations involving large volumes of potentially overpaid claims.
Note: Once a health care provider is given notice, we initiate discussions and take action during the following 1 year period.
We do not pursue collection of overpayments from individual participating health care providers when overpayments are identified as isolated mistakes or where the health care provider is not at fault if the overpayments were more than 1 year before the date of notice of the overpayment or use extrapolation. Examples include overpayments related to duplicate claims, fee schedule issues, isolated situations of incorrect billing/unbundling and claims paid when Oxford was not the primary insurer.
Exception: Oxford will pursue collection of overpayments beyond 1 year and use statistical methods and extrapolation in situations where:
Our administrative procedures for members with an Oxford product require facilities, and health care providers participating in our network, to file a claim reconsideration and/or appeal before proceeding to arbitration under their contract.
See Claim reconsideration and appeals process found in Chapter 10: Our claims process for general reconsideration requirements and submission steps. Continue below for Oxford-specific requirements.
1. Pre-Appeal Claim Review
Before requesting an appeal determination, contact us, verbally or in writing, and request a review of the claim’s payment. We make every effort to clarify or explain our actions. If we determine that additional payment is justified, we reprocess the claim and remit the additional payment.
2. Who May Submit a Reconsideration or Appeal
3. Time frame for Submitting a Reconsideration or Appeal
Attn: New Jersey PICPA
50 Square Drive, Suite 210
Victor, NY 14564
Requests may be submitted by fax to 1-585-425-5296. (MAXIMUS, Inc. requests that faxes be limited to 25 pages.)
Consult your contract to determine the appropriate arbitration authority. Most such contracts provide for arbitration before the American Arbitration Association (AAA). The costs of arbitration are borne equally by the participating health care provider and Oxford, unless the arbitrator determines otherwise. The decision in such arbitration depends on the participating health care provider and Oxford, pursuant to the terms of the Agreement. To commence arbitration, the health care provider must file a statement of claim with the AAA.
If Oxford fails to provide the additional reimbursement within the 45-day review time frame, Oxford must pay to the hospital interest on the amount of the increase. The interest must be computed from the end of the 45-day period after resubmission of the additional medical record information.
Note: Neither the initial or subsequent processing of the claim by Oxford may be considered an adverse determination if it is based solely on a coding determination.
4. Method for Submitting a Reconsideration or Appeal
Find the correct mailing address on Oxford’s Participating Provider Claim(s) Review Request Form. There are separate processes for the following appeal types:
5. Appeal Decision and Resolution
Full documentation of the substance of the appeal and the actions taken will be maintained in an appeal file (paper or electronic). Written notification to the health care provider is issued by means of a letter or updated Remittance Advice (RA) statement at the time of determination of the appeal. This decision constitutes Oxford’s final internal decision. If the health care provider is not satisfied with Oxford’s decision, they may arbitrate the issue as set forth in their contract with Oxford. Refer to the Timeframe Standards for Benefit Administrative Initial Decisions policy at uhcprovider.com/policies > For Commercial Plans > UnitedHealthcare Oxford® Clinical, Administrative and Reimbursement Policies.
If the health care provider wants to file for arbitration after the first-level appeal has been completed, the health care provider must follow the terms of their participation agreement and file a statement of claim with the AAA at the following address:
American Arbitration Association
Northeast Case Management Center
950 Warren Avenue 4th Floor
East Providence, RI 02914
Health care providers located outside of New York, New Jersey and Connecticut should refer to the AAA website at adr.org for submission guidelines.
For participating health care providers and other health care professionals treating New York members, this external appeals process applies only to services provided to commercial members who have coverage by virtue of an insurance benefit plan licensed in the state of New York.
This appeals process does not apply to the self-funded line of business. Health care providers may use this process to appeal concurrent and retrospective utilization review decisions. Other external appeals require written consent from the member. In connection with retrospective decisions, if the health care provider’s Agreement includes arbitration language or alternate dispute language, the health care provider must follow that process. The external review process is no longer an option for dispute resolution.
Standard medical necessity appeals process
If members or their designees would like to file an appeal, they must hand-deliver or mail a written request within 180 days of receiving the initial denial determination notice to:
Oxford Clinical Appeals Department
P.O. Box 31388
Salt Lake City, UT 84131
Expedited medical necessity appeals process for members:
Appeals of benefit denials issued by the Clinical Services and Disease Management departments are handled by the Clinical Appeals department.
Administrative appeals without the Clinical Services department’s involvement are handled by the Member Appeals unit. If a member would like to file an appeal on a claim determination, they must mail all administrative appeals to the UnitedHealthcare Grievance Review Board. See How to Contact Oxford Commercial section for address information.
Second-level member appeals
Members have the right to take a second-level appeal* to our Grievance Review Board (GRB). If they remain dissatisfied with the first-level appeal determination, they may request a second-level appeal. Members with a Connecticut line of business do not have the option of submitting a second-level appeal request for a benefit or administrative issue. The request for appeal and any additional information must be submitted to the UnitedHealthcare GRB. See How to Contact Oxford Commercial section for address information.
New York, New Jersey and Connecticut members have the right to appeal a medical necessity determination to an external review agent. They may file a consumer complaint with one of the following applicable regulatory bodies. The applicable regulatory body is determined by the state in which the member’s certificate of coverage was issued, not where the member resides.
State of Connecticut Insurance Department
153 Market Street
P.O. Box 816
Hartford, CT 06142-0816
Division of Insurance Enforcement and Consumer Protection
20 West State Street
P.O. Box 329
Trenton, NJ 08625-0329
Consumer Protection Services Dept. of Banking and Insurance
P.O. Box 329
Trenton, NJ 08625-0329
1-800-446-7467 (in NJ)
Consumer Services Bureau
State of New York Insurance Department
25 Beaver Street
New York, NY 10004-2349
Office of Managed Care Certification and Surveillance
New York Department of Health
Corning Tower, Room 1911
Empire State Plaza
Albany, NY 12237
UnitedHealthcare immediately removes any health care provider from the network who is unable to provide health care services due to a final disciplinary action.
UnitedHealthcare may not prohibit, terminate or refuse to renew a contract with a health care provider solely for the following:
We grant health care providers and certain health care professionals the right to appeal certain disciplinary actions imposed by us.
The appeals process is structured so most appeals for terminations, not including non-renewal of the health care provider’s contract with us, may be heard before disciplinary action is implemented.
A health care provider or health care professional may request an appeal (fair hearing or review) after we take adverse action to restrict, suspend or terminate a health care provider or health care professional’s ability to provide health care services to our members for reasons relating to the professional competence or conduct that adversely affects or could adversely affect the member’s health or welfare.
A notice is provided within 30 calendar days after the adverse action is taken. It includes the following:
We will notify the health care provider or health care professional of the fair hearing or review date within 30 calendar days of our receipt of request for appeal, or within the time frame required by state law. The fair hearing or review takes place within 60 calendar days of the date we receive the request for appeal, or within the time frame required by state law.
The hearing panel will be comprised of at least 3 persons appointed by UnitedHealthcare. At least 1 person on the panel will have the same discipline or same specialty as the health care provider under review. The panel may consist of more than 3 members, provided the number of clinical peers constitutes one-third or more of the total panel membership.
The hearing panel will render a decision in a timely manner. Decisions will be provided in writing and include one of the following: