Health care provider claims appeals and disputes, UnitedHealthcare West - 2022 UnitedHealthcare Administrative Guide

Claims research and resolution (OK and TX commercial plans)

The Claims Research & Resolution (CR&R) process applies:

• If you do not agree with the payment decision after the initial processing of the claim.
• Regardless of whether the payer was UnitedHealthcare West, the delegated medical group/IPA or other delegated payer, or the capitated hospital/provider, you are responsible for submitting your claim(s) to the appropriate entity that holds financial responsibility to process each claim.

UnitedHealthcare West researches the issue to identify who holds financial risk of the services and abides by federal and state legislation on appropriate timelines for resolution. We work directly with the delegated payer when claims have been misdirected and financial responsibility is in question. If appropriate, health care provider-driven claim payment disputes will be directed to the delegated payer Provider Dispute Resolution process.

Claim reconsideration requests (does not apply to capitated/delegated claims in California)

You may request a reconsideration of a claim determination. These rework requests typically can be resolved with the appropriate documents to support claim payment or adjustments (e.g., sending a copy of the authorization for a claim denied for no authorization or proof of timely filing for a claim denied for untimely filing). All rework requests must be submitted within 365 calendar days following the date of the last action or inaction, unless your Agreement contains other filing guidelines. Submit your requests in the UnitedHealthcare Provider Portal. Learn more at uhcprovider.com/portal. You may submit your request to us in writing by using the Paper Claim Reconsideration Form on uhcprovider.com/claims.

To mail your request, refer to the chart titled UnitedHealthcare West Provider Rework or Dispute Process Reference Table at the end of this section.

Submission of bulk claim inquiries

The Claims Project Management (CPM) team handles bulk claim inquiries. Contact the CPM team at the address below to initiate a bulk claim inquiry:

UnitedHealthcare West Bulk Claims Rework Reference Table

UnitedHealthcare West’s response

We respond to issues as quickly as possible.

• Reworks/disputes requiring clinical determination: Individuals with clinical training/background who were not previously involved in the initial decision review all clinical rework/dispute requests. We send a letter to you outlining our determination and the basis for that decision.
• Reworks/disputes requiring claim process determination: Individuals not previously involved in the initial processing of the claim review the rework/dispute request.

Response details: If claim requires an additional payment, the EOP serves as notification of the outcome on the review. If the original claim status is upheld, you are sent a letter outlining the details of the review.

California: If a claim requires an additional payment, the EOP does not serve as notification of the outcome of the review. We send you a letter with the determination. In addition, payment must be sent within 5 calendar days of the date on the determination letter. We respond to you within the applicable time limits set forth by federal and state agencies. After the applicable time limit has passed, call Provider Relations at 1-877-847-2862 to obtain a status.

Health care provider dispute resolution (CA delegates, OR HMO claims, OR and WA commercial plans)

If you disagree with our claim determination, you must initiate and complete the PDR process before commencing arbitration on a claim. You must submit a PDR in writing and with additional documentation for review. All disputes must be submitted within 365 calendar days following the date of the adverse payment determination on the claim, unless your Agreement or state law dictate otherwise. This time frame applies to all disputes regarding contractual issues, claims payment issues, overpayment recoveries and medical management disputes.

The PDR process is available to provide a fair, fast and cost-effective resolution of health care provider disputes, in accordance with state and federal regulations. We do not discriminate, retaliate against or charge you for submitting a health care provider dispute. The PDR process is not a substitution for arbitration and is not deemed as an arbitration.

What to submit

As the health care provider of service, submit the dispute with the following information:

• Member’s name and health plan ID number
• Claim number
• Specific item in dispute
• Clear rationale/reason for contesting the determination and an explanation why the claim should be paid or approved
• Your contract information

Disputes are not reviewed if the supporting documentation is not submitted with the request.

Where to submit

State-specific addresses and other pertinent information regarding the PDR process may be found in the UnitedHealthcare West Provider Rework or Dispute Process Reference Table at the end of this section.

Accountability for review of a health care provider dispute

The entity that initially processed/denied the claim or service in question is responsible for the initial review of a PDR request. These entities may include, but are not limited to, UnitedHealthcare West, the delegated medical group/IPA/payer or the capitated hospital/health care provider.

Excluded from the PDR process

The following are examples of issues excluded from the PDR process:

• A member has filed an appeal, and you have filed a dispute regarding the same issue. In these cases, the member’s appeal is reviewed first. You may submit a health care provider dispute after we make a decision on the member’s appeal. If you are appealing on behalf of the member, we treat the appeal as a member appeal.
• An Independent Medical Review initiated by a member through the member appeal process.
• Any dispute you file beyond the timely filing limit applicable to you, and you fail to give “good cause” for the delay.
• Any delegated claim issue that has not been reviewed through the delegated payer’s claim resolution mechanism.
• Any request for a dispute which has been reviewed by the delegated medical group/IPA/payer or capitated hospital/health care provider and does not involve an issue of medical necessity or medical management.

UnitedHealthcare West Provider Rework or Dispute Process Reference Table