Plan and benefit coding on UnitedHealthcare's NICE system is an essential component in defining the products and services that UnitedHealthcare offers. These codes are created and maintained primarily to support operations such as billing, employer contracts, member enrollment, benefit claims payment, member fulfillment and capitation processing.
A 3 character alpha numeric code, which represents a specific set of basic medical benefits. A plan code is necessary to enroll a group and a member in NICE.
What is a Benefit Code?
A 3 character alpha numeric code assigned to employer contracts which represent supplemental benefits purchased by the employer group. Pharmacy would be an example of a supplemental benefit.
What is a Plan Type?
Plan types dictate the plan functionality in the NICE system. A plan type will directly impact claim payment processing, reporting, billing and capitation for a given employer or member. CO = Commercial and SH = Medicare & Retirement
What is a Service Code?
A two character alpha numeric code that represents a specific benefit item. These codes with appropriate co-pays and benefit limits, are assigned to in-network HMO plans in the NICE system. An example of a service code would be 01 = Office Visit.
HMO Deductible Terminologies
Deductible Type Indicator
P1 - Plan Level Deductible - Deductible limits separate from copay limits
P2 - Plan Level Deductible - Deductible limits roll up to copay max/out of pocket
S1 - Service level Deductible - Deductible limits separate from copay limits
S2 - Service Level Deductible - Deductible limits rollup to copay max/out of pocket
Service Level Deductible Excp Indicator
Blank or N - No exception. Deductible applies to service category.
Y - Some exceptions apply to service category.
X - All excluded. Deductible does not apply to any services that fall within that service category.
Service Level Deductible RollUp Code
IP - Inpatient Deductible
OP - Outpatient Deductible
For a service level deductible plan, only those lines that are populated with a deductible roll-up code have a deductible due. If the line were not populated with a deductible roll up code, there would be no deductible due and the deductible exception indicator would be blank.
If for some reason the deductible exception indicator is populated and there is no roll up code tied to that line, the system will ignore the deductible exception indicator and the deductible will not apply.