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Chapter 11: Billing and Submission

UnitedHealthcare Community Plan follows the same claims process as UnitedHealthcare.

For a complete description of the process, go to UHCprovider.com/guides > View online version > Chapter 9 Our Claims Process.

HIPAA requires you have a unique National Provider Identifier (NPI). The NPI identifies you in all standard transactions.

If you have not applied for a NPI, contact National Plan and Provider Enumeration System (NPPES). Once you have an identifier, report it to UnitedHealthcare Community Plan. Call Provider Services at 888-980-8728. For Medicare Advantage-Dual Special Needs Program (MA-DSNP) call 866-622-8054.

Your clean claims must include your NPI and Federal Tax Identification Number. Also include the Unique Care Provider Identification Number (UPIN) laboratory claims.

We only consider reimbursing claims if you met billing and coverage requirements. Submitting a referral does not guarantee we will pay you. Payment depends on the member’s coverage on the date(s) of service, medical necessity, plan rules about limitations and exclusions, and UnitedHealthcare Community Plan policies. We don’t reimburse excessive, inappropriate or non-covered charges. To comply with applicable standards, policies and law, we may adjust previous payments for services and audit claims. We may seek reimbursement for overpayments or offset future payments as allowed by law.

Reimbursements also depend on the fee schedule and the procedure performed. Refer to your bulletins for correct coding.

Use the appropriate modifider codes on your claim form. The modifier must be used based on the date of service.

The member ID card has both the UnitedHealthcare Community Plan member ID and the state Document Control Number (DCN). UnitedHealthcare Community Plan prefers you bill with the member ID.

UnitedHealthcare Community Plan only processes claims submitted on 1500 and UB-04 claim forms.

Use the 02/12 1500 form for ancillary services, ambulatory surgery centers, urgent care centers and hospital services.

Use the UB-04 form for hospital inpatient and outpatient services, dialysis services, skilled nursing homes inpatient services, long-term care facilities, hospice services and other care providers.

Complete a CMS 1500 or UB-04 form whether you submit an electronic or a paper claim. Clean claims have:

  • A health service provided by an eligible health care provider to a covered UnitedHealthcare Community Plan member.
  • All the required documentation, including correct diagnosis and procedure codes.
  • The correct amount claimed.

Submit the claim within one year from the date of service or date of discharge. The member and the State are not responsible for late claims. We may require additional information for some services, situations or state requirements.

Submit any services completed by nurse practitioners or physician assistants who are part of a collaborative agreement.

UnitedHealthcare Community Plan complies with Early and Periodic Screening, Diagnostic and Treatment (EPSDT) state standards based on claims data and chart review. Use the UnitedHealthcare ICD-10-CM Code Lookup Tool to find an ICD-9 or ICD-10 code.

You may submit claims by electronic data interchange (EDI). EDI offers less paperwork, reduced postage, less time spent handling claims and faster turnaround.

  • OptumInsight can provide you with clearinghouse connectivity or your software vendor can connect through an entity that uses OptumInsight.
  • All claims are set up as “commercial” through the clearinghouse.
  • Our payer ID is 87726.
  • Clearinghouse Acknowledgment Reports and Payer- Specific Acknowledgment Reports identify claims that don’t successfully transmit.
  •  We follow CMS National Uniform Claim Committee (NUCC) and National Uniform Billing Committee (NUBC) guidelines for HCFA 1500 and UB-04 forms.

If you treat another diagnosis, use that ICD CM code as well.

For more information, contact EDI Claims. You can also see www.enshealth.com or contact Provider Services.

UnitedHealthcare Community Plan’s companion documents are intended to share information within Implementation Guides (IG) adopted by HIPAA. The companion documents identify the data content requested when it is electronically transmitted.

UnitedHealthcare Community Plan uses companion documents to:

  • Clarify data content that meets the needs of the health plan’s business purposes when the IG allows multiple choices.
  • Provide values the health plan will return in outbound transactions.
  • Outline which situational elements the health plan requires.

The companion document provides general information and specific details pertinent to each transaction. These documents should be shared with your software vendor for any programming and field requirements.

The companion documents are located on UHCprovider.com/edi > Go to companion guides.

Software vendor reports only show the claim left your office and was either accepted or rejected. They don’t confirm the claim status. Acknowledgment reports confirm the information you sent has been received.

Review your reports, clearinghouse acknowledgment reports and the status reports to reduce processing delays and timely filing penalties.

To get your reports, make sure your software vendor has connected to our clearinghouse OptumInsight at enshealth.com.

If you are not yet an OptumInsight client, we will tell you how to receive Clearinghouse Acknowledgment Reports.

UnitedHealthcare Community Plan offices are open 7:45 a.m. – 4:30 p.m. HST, Monday through Friday. They can help you with Electronic Remittance Advices (ERAs) and Electronic Funds Transfers (EFTs). To use ERAs, you must enroll through a clearinghouse or entity that uses OptumInsight.

Support is also available for EDI Claims and EDI Log-on Issues.

Find more information at UHCprovider.com/edi.

Important EDI Payer Information

  • Claim Payer ID: 87726
  • ERA Payer ID: 04567

Companion documents for 837 transactions are on UHCprovider.com/edi.

Visit the National Uniform Claim Committee website to learn how to complete the CMS 1500 form.

Bill all hospital inpatient, outpatient and emergency room services using revenue codes and the UB-04 claim form:

  • Include ICD CM diagnosis codes.
  • Identify other services by the CPT/HCPCS and modifiers.
  • Note the Attending Provider Name and identifiers for the member’s medical care and treatment on institutional claims for services other than non- scheduled transportation claims.
  • Send the Referring Provider NPI and name on outpatient claims when this care provider is not the Attending Provider.
  • Include the attending provider’s NPI in the Attending Provider Name and Identifiers Fields (UB-04 FL76 or electronic equivalent) of your claims.
  • Behavioral health care providers can bill using multiple site-specific NPIs.

Our benefits contracts are subject to subrogation and coordination of benefits (COB) rules:

  • Subrogation: We may recover benefits paid for a member’s treatment when a third party causes the injury or illness.
  • COB: We coordinate benefits based on the member’s benefit contract and applicable regulations.

UnitedHealthcare Community Plan is the payer of last resort. Other coverage should be billed as the primary carrier. When billing UnitedHealthcare Community Plan, submit the primary payer’s Explanation of Benefits or remittance advice with the claim. Use this chart to help determine when you bill to us:

Primary:
Medicare Fee-for-Service
Secondary:
QUEST Integration
Process:
An automatic crossover should occur from Medicare to UnitedHealthcare. UnitedHealthcare will use the crossover information received from Medicare to coordinate the member’s benefits.
Required Action:
Do not submit a secondary claim to UnitedHealthcare unless otherwise requested.
 

Primary: 
UnitedHealthcare Medicare (All UnitedHealthcare Medicare Plans)
Secondary:
QUEST Integration
Process:
An automatic crossover should occur within the UnitedHealthcare systems to coordinate both the Medicare/QUEST Integration benefits.
Required Action:
Do not submit a secondary claim to UnitedHealthcare unless otherwise requested.
 

Primary:
AARP/Medicare Complete Choice and Complete Essential (Insured by UnitedHealthcare – Group# 77000-77007 and 77003/77008); External Medicare Advantage Plans; Commercial; No-Fault; and Other Third Party Liability (TPL) plans
Secondary:
QUEST Integration
Process:
No crossover will occur.
Required Action:
Submit a secondary claim with a copy of the primary EOB to UnitedHealthcare to ensure proper coordination of benefits.

Hospital and clinics must bill for professional services bill on a CMS 1500. The servicing provider’s name is placed in box 31, and the servicing provider’s group NPI number is placed in box 33a.

UnitedHealthcare Community Plan performs coding edit procedures based on the Correct Coding Initiative (CCI) and other nationally recognized sources.

Comprehensive and Component Codes

Comprehensive and component code combination edits apply when a code pair(s) appears to be related. These edits can be further broken down to explain the bundling rationale. Some of the most common causes for denials in this category are:

  • Separate procedures: Only report these codes when performed independently.
  • Most extensive procedures: You can perform some procedures with different complexities. Only report the most extensive service.
  • With/without services: Don’t report combinations where one code includes and the other excludes certain services.
  • Medical practice standards: Services part of a larger procedure are bundled.
  • Laboratory panels: Don’t report individual components of panels or multichannel tests separately.

Submit your laboratory claims with the Clinical Laboratory Improvements Amendments (CLIA) number. In box 23 of the CMS 1500 claim form, enter the 10-digit CLIA certification number for laboratory services billed by an entity performing CLIA-covered procedures.

If you bill electronically, report the CLIA number in Loop 2300 or 2400, REF/X4,02. For more information about the CLIA number, contact the CMS CLIA Central Office at 410-786-3531 or go to the cms.gov.

When billing multiple units:

  • If the same procedure is repeated on the same date of service, enter the procedure code once with the appropriate number of units.
  • The total bill charge is the unit charge multiplied by the number of units.

Follow this reporting procedure when submitting obstetrical delivery claims. Otherwise, we will deny the claim:

  •  If billing for both delivery and prenatal care, use the date of delivery.
  • Use one unit with the appropriate charge in the charge column.

Gather all required referrals and evaluations to complete the pre-transplant evaluation process once the member is a possible candidate.

The Department of Health and Human Services covers medically necessary, non-experimental transplants. UnitedHealthcare Community Plan covers the transplant evaluation and work-ups. Get prior authorization for the transplant evaluation.

Ambulance claims must include the point of origin, destination address, city, state, and ZIP.

We follow State of Hawai’i and Medicare guidelines for reimbursement protocols for hospitals and care providers for HAC. Services related to HAC are typically non- reimbursable under Medicare and Medicaid programs.

Claims must include:

  • National Drug Code (NDC) and unit of measurement for the drug billed.
  • HCPCS/CPT code and units of service for the drug billed.
  • Actual metric decimal quantity administered.

Submit the NDC on all claims with procedure codes for care provider-administered drugs in outpatient clinical settings. The claims must show the NDC that appears on the product. Enter the identifier N4, the 11–digit NDC code, unit/basis of measurement qualified, and metric decimal quantity administered. Include HCPCS/CPT codes.

UnitedHealthcare Community Plan only pays for medically necessary services. See Chapter 4 for more information about medical necessity.

Go to CMS.gov for Place of Service codes.

You can ask about claims through UnitedHealthcare Community Plan Provider Service and the UnitedHealthcare Community Plan Provider Portal. To access the portal, go to UHCprovider.com. Follow the instructions to get a user ID. You will receive your user ID and password within 48 hours.

Provider Services

Provider Services help resolve claims issues. Have the following information ready before you call:

  • Member’s ID number
  • Date of service
  • Procedure code
  • Amount billed
  • Your ID number
  • Claim number

Allow Provider Services 45 days to solve your concern. Limit phone calls to five issues per call.

UnitedHealthcare Community Plan Provider Portal

You can view your online transactions with Link by signing in to Link on UHCprovider.com with your Optum ID. This portal offers you online support at any time. If you are not already registered, you may do so on the website.

LINK: Your Gateway to Unitedhealthcare Community Plan Online Provider Tools And Resources

Link lets you move quickly between applications. This helps you:

  • Check member eligibility.
  • Submit claims reconsiderations.
  • Review the coordination of benefits information.
  • Use the integrated applications to complete multiple transactions at once.
  • Reduce phone calls, paperwork and faxes.

You can even customize the screen to put these common tasks just one click away.

Find Link training on UHCprovider.com.

To resolve claim issues, contact Provider Services, use Link or resubmit the claim by mail.

Mail paper claims and adjustment requests to:

Medical Services:
UnitedHealthcare Community Plan
P.O. Box 31365
Salt Lake City, Utah 841-0365

Behavioral Health Services:
P.O. Box 30757
Salt Lake City, Utah 84130-0757

Allow up to 30 days for UnitedHealthcare Community Plan to receive payment for initial claims and adjustment requests.

For Paper Claims

Submit a screen shot from your accounting software that shows when you submitted the claim. The screen shot must show the correct:

  • Member name
  • Date of service
  • Claim date submission (within the timely filing period)

Timely Filing

Timely filing issues may occur if members give the wrong insurance information when you treat them. This results in receiving:

  • A denial/rejection letter from another carrier.
  • Another carrier’s explanation of benefits.
  • A letter from another insurance carrier or employer group saying that the member either has no coverage or had their coverage terminated before the date of service.

All of the above must include documentation the claim is for the correct member and the correct date of service. A submission report alone is not considered proof of timely filing for electronic claims. They must be accompanied by an acceptance report.

The date on the other carrier’s payment correspondence starts the timely filing period for submission to UnitedHealthcare Community Plan.

To be timely, you must receive the claim within the timely filing period from the date on the other carrier’s correspondence. If we receive the claim after the timely filing period, it will not meet the criteria.

If a claim is rejected, and corrections are not received within 365 days from date of service or close of business from the primary carrier, the clam is considered late billed. It will be denied timely filing.

All primary claims must be filed to us within one year from the date of service. All claims involving coordination of benefits must be submitted within one year of the primary/secondard payer’s EOB. Corrected claims must be submitted within one year of the original denial date.

Do not balance bill members if:

  • The charge amount and the UnitedHealthcare Community Plan fee schedules differ.
  • You deny a claim for late submission, unauthorized service or as not medically necessary.
  • UnitedHealthcare Community Plan is reviewing a claim.

Refer to the following chart for additional scenarios. You are able to balance bill the member for non-covered services if the member provides written consent prior to getting the service. If you have questions, please contact your provider advocate.

If you don’t know who your provider advocate is, email Hawaii_PA_Team@uhc.com. A provider advocate will get back to you.

Scenario:
Non-payment due to your failure to follow UHC’s policies and procedures (i.e. obtain a Prior Authorization, etc.)
Can the Provider bill the Member? (Yes/No)
No
, you may not bill the member.

Scenario:
Non-payment due to the member’s failure to follow UHC’s policies and procedures (i.e. self-referral without obtaining a Prior Authorization, etc.).
Can the Provider bill the Member? (Yes/No)
Yes, however, you must first inform the member of our prior authorizationrequirement. You also need written agreement from the member regarding the cost of the procedure and the payment terms prior to rendering services.

Scenario:
Non-payment due to non-covered services
Can the Provider bill the Member? (Yes/No)
Yes
however, you must first inform the member of the non-covered services. You must get a written agreement from the member regarding the cost of the procedure and the payment terms prior to rendering services.