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Chapter 12: Claim Reconsiderations, Appeals and Grievances

There are a number of ways to work with us to resolve claims issues or disputes. We base these processes on state and federal regulatory requirements and your provider contract.

The following grid lists the types of disputes and processes that apply:

Member Appeal

Definition:  A request to change an adverse benefit determination that we made.

Who May Submit?: 

  • Member 
  • Care provider on behalf of a member with member consent

Submission Address:

UnitedHealthcare Community Plan Attention:

Grievance and Appeals Department

1132 Bishop St.,

Ste 400 Honolulu, HI 96813

Online Form for Fax or Mail: UHCprovider.com

Contact Phone Number/ Fax:

888-380-0809

HI_AG@uhc.com

Website (Care Providers Only) For Online Submissions:

Use the Claims Management or ClaimsLink application on Link. To access Link, go to UHCprovider.com/link.

Care Provider Filing Timeframe: All appeals = 60 calendar days

Response Timeframe: 

Urgent appeals We will respond within 72 hours

Standard appeals = 30 days

 

Member Grievance

Definition: A member’s written or oral expression of dissatisfaction regarding the plan and/or care provider, including quality of care concerns.

Who May Submit?: 

  • Member 
  • Care provider on behalf of a member with member consent

Submission Address:

UnitedHealthcare Community Plan Attention: Appeals Department

1132 Bishop St.,

Ste 400 Honolulu, HI 96813

Online Form for Fax or Mail: UHCprovider.com

Contact Phone Number/ Fax: 888-380-0809

Website (Care Providers Only) For Online Submissions: Use the Claims Management or ClaimsLink application on Link. To access Link, go to  UHCprovider.com/link.

Care Provider Filing Timeframe: N/A

Response Timeframe:  30 calendar days

 

Care Provider Claim Resubmission

Definition: Creating a new claim. If a claim was denied and you resubmit the claim (as if it were a new claim), then you will normally receive a duplicate claim rejection on your resubmission.

Who May Submit?: Care Provider

Submission Address: 

UnitedHealthcare Community Plan QUEST Integration

P.O. Box 31350 Salt Lake City, UT 84131-0350

Online Form for Fax or Mail: UHCprovider.com

Contact Phone Number/ Fax: 888-980-8728

Website (Care Providers Only) For Online Submissions: Use the Claims Management or ClaimsLink application on Link. To access Link, go to UHCprovider.com/link.

Care Provider Filing Timeframe: must receive within 365 calendar days

Response Timeframe: 30 calendar days

 

Care Provider Claim Reconsideration (step 1 of claim dispute)

Definition: Overpayment, underpayment, payment denial, or an original or corrected claim determination you do not agree with.

Who May Submit?: Care Provider

Submission Address: 

UnitedHealthcare Community Plan QUEST Integration

P.O. Box 31350 Salt Lake City, UT 84131-0350

Online Form for Fax or Mail: UHCprovider.com

Contact Phone Number/ Fax: 888-980-8728

Website (Care Providers Only) For Online Submissions: Use the Claims Management or ClaimsLink application on Link. To access Link, go to UHCprovider.com/link.

Care Provider Filing Timeframe: must receive within 365 calendar days

Response Timeframe: 45 calendar days

 

Care Provider Claim Formal Appeal (step 2 of claim dispute)

Definition: A second review in which you did not agree with the outcome of the reconsideration.

Who May Submit?: Care Provider

Submission Address: 

UnitedHealthcare Community Plan, Attention: Appeals Department

1132 Bishop St., Ste. 400

Honolulu, HI 96813

Online Form for Fax or Mail: UHCprovider.com

Contact Phone Number/ Fax:

888-380-0809

HI_AG@uhc.com

Fax: 844-700-7938

Website (Care Providers Only) For Online Submissions: Use the Claims Management or ClaimsLink application on Link. To access Link, go to UHCprovider.com/link.

Care Provider Filing Timeframe: 60 calendar days

Response Timeframe: 60 calendar days

 

Care Provider Grievance

Definition: A complaint expressing dissatisfaction with operations, activities, or behavior of a health plan or member

Who May Submit?: Care Provider

Submission Address: 

UnitedHealthcare Community Plan Attention:

Grievance & Appeals Department

1132 Bishop St., Ste. 400

Honolulu, HI 96813


Online Form for Fax or Mail: 
UHCprovider.com

Contact Phone Number/ Fax:

888-380-0809

HI_AG@uhc.com

Fax: 844-700-7938

 

Website (Care Providers Only) For Online Submissions: Use the Claims Management or ClaimsLink application on Link. To access Link, go to UHCprovider.com/link.

Care Provider Filing Timeframe: N/A

Response Timeframe: 60 calendar days

 

The above definitions and process requirements are subject to modification by state contracts or regulations. States may impose more stringent requirements.

UnitedHealthcare Community Plan and its contracted providers may agree to more stringent requirements within provider contracts than described in the standard process.

Your claim may be denied for administrative or medical necessity reasons.

An Administrative denial is when we didn’t get notification before the service, or the notification came in too late.

Denial for medical necessity means the level of care billed wasn’t approved as medically necessary.

If a claim is denied for these reasons, you may be able to request a claim reconsideration or file an appeal.

 

Other top reasons for denial include:

Duplicate claim – This is one of the most common reasons for denial. It means resubmitting the same claim information. This can reset the clock on the time it takes to pay a claim.

Claim lacks information. Basic information is missing, such as a person’s date of birth; or information incorrect, such as spelling of a name. You can resubmit this type of claim with the correct information.

Eligibility expired. Most practices verify coverage beforehand to avoid issues, but sometimes that doesn’t happen. One of the most common claim denials involving verification is when a patient’s health insurance coverage has expired and the patient and practice were unaware. Also, in a lot of cases, practices may check eligibility when an appointment is made, but between the appointment being made and the actual visit, coverage can be dropped. We recommend an eligibility check again once the patient has arrived.

Claim not covered by UnitedHealthcare Community Plan. Another claim denial you can avoid is when procedures are not covered by us. You can easily avoid this problem by using real-time verification.

Time limit expired. This is when you don’t send the claim in time.

What is it?

A corrected claim replaces a previously denied submitted claim due to an error. A denied claim has been through claim processing and determined it can’t be paid.

When to use:

Submit a corrected claim to fix one that has already processed.

How to use:

Use the claims reconsideration application on Link. To access Link, sign in to UHCprovider.com using your Optum ID. You may also submit the claim by mail with a claim reconsideration request form. Allow up to 30 days to receive payment for initial claims and a response.

Mailing address:

UnitedHealthcare Community Plan

P.O. Box 31365

Salt Lake City, UT 84131-0365

Additional Information:

When correcting or submitting late charges on 837 institution claims, use bill type xx7: Replacement of Prior Claim. Do not submit corrected or additional information charges using bill type xx5: Late Charge Claim.

What is it?

When you resubmit a claim, you create a new claim in place of a rejected one. A rejected claim has not been processed due to problems detected before processing.

When to use it:

Resubmit the claim if it was rejected. A rejected claim is one that has not been processed due to problems detected before claim processing. Since rejected claims have not been processed yet, there is no appeal — the claim needs to be corrected through resubmission.

Common Reasons for Rejected Claims:

Some of the common causes of claim rejections happen due to:

  • Errors in member demographic data — name, age, date of birth, sex or address.
  • Errors in care provider data.
  • Wrong member insurance ID.
  • No referring care provider ID or NPI number.

How to use:

To resubmit the claim, follow the same submission instructions as a new claim. To mail your resubmission, provide all claim information to:

UnitedHealthcare Community Plan

P.O. Box 31365

Salt Lake City, UT 84131-0365

Warning! If your claim was denied and you resubmit it, you will receive a duplicate claim rejection. A denied claim has been through claim processing and we determined it cannot be paid. You may appeal a denied claim by submitting the corrected claim information or appealing the decision. See Claim Correction and Reconsideration sections of this chapter for more information.

What is it?

Claim issues include overpayment, underpayment, denial, or an original or corrected claim determination you do not agree with. A claim reconsideration request is the quickest way to address your concern about whether the claim was paid correctly.

When to use:

Submit a claim reconsideration when you think a claim has not been properly processed.

For administrative denials:

  • In your reconsideration request, please ask for a medical necessity review and include all relevant medical records.

For medical necessity denials:

  • In your request, please include any additional clinical information that may not have been reviewed with your original claim.
  • Show how specific information in the medical record supports the medical necessity of the level of care performed – for example, inpatient instead of observation.

How to use:

If you disagree with a claim determination, submit a claim reconsideration request electronically, by phone, mail or fax:

  • Electronically: Use the Claim Reconsideration application on Link. Include electronic attachments. You may also check your status using Link.
  • Phone: Call Provider Services at 888-980-8728 or use the number on the back of the member’s ID card. The tracking number will begin with SF and be followed by 18 numbers.
  • Mail: Submit the Claim Reconsideration Request Form to:

UnitedHealthcare Community Plan

P.O. Box 31350

Salt Lake City, Utah 84131-0350

This form is available at UHCprovider.com.

What is it?

Proof of timely filing occurs when the member gives incorrect insurance information at the time of service. It includes:

  • A denial or rejection letter from another insurance carrier.
  • Another insurance carrier’s explanation of benefits.
  • Letter from another insurance carrier or employer group indicating:
    • Coverage termination prior to the date of service of the claim
    • No coverage for the member on the date of service of the claim

A submission report is not proof of timely filing for electronic claims. It must be accompanied by an acceptance report. Timely filing denials are often upheld due to incomplete or wrong documentation submitted with a reconsideration request. You may also receive a timely filing denial when you do not submit a claim on time.

How to use:

Submit a reconsideration request electronically, phone, mail or fax with the following information:

  • Electronic claims: Include the EDI acceptance report stating we received your claim.
  • Mail or fax reconsiderations: Submit a screen shot from your accounting software that shows the date you submitted the claim. The screen shot must show:
    • Correct member name.
    • Correct date of service.
    • Claim submission date.

Additional Information:

Timely filing limits can vary based on state requirements and contracts. If you do not know your timely filing limit, refer to your Provider Agreement.

What is it?

An appeal is a second review of a reconsideration claim.

When to use:

If you do not agree with the outcome of the claim reconsideration decision in step one, use the claim appeal process.

How to use:

Submit related documents with your appeal within 60 days of the date of the health plan’s notice of action or decision. These may include a cover letter, medical records and additional information. Send your information electronically, by mail or fax. In your appeal, please include any supporting information not included with your reconsideration request.

  • Electronic claims: Use the Claims Management or ClaimsLink application on Link. You may upload attachments.
  • Mail: Send the appeal to:

UnitedHealthcare Community Plan

Grievances and Appeals 1132 Bishop Street, Ste. 400

Honolulu, Hi 96813

  • Fax: Send the appeal to 844-700-7938.

We have a one-year timely filing limitation to complete all steps in the reconsideration and appeal process. It starts on the date of the first EOB.

Tips for Successful Claims Resolution

To help process claim reconsiderations:

  • Do not let claim issues grow or go unresolved.
  • Call Provider Services if you can’t verify a claim is on file.
  • Do not resubmit validated claims on file unless submitting a corrected claim.
  • File adjustment requests and claims disputes within contractual time requirements.
  • If you must exceed the maximum daily frequency for a procedure, submit the medical records justifying medical necessity. If you have questions, call Provider Services.
  • UnitedHealthcare Community Plan is the payer of last resort. This means you must bill and get an EOB from other insurance or source of health care coverage before billing UnitedHealthcare Community Plan.
  • When submitting adjustment requests, provide the same information required for a clean claim. Explain the dispute, what should have been paid and why.
  • Refer to your contract for submission deadlines concerning third-party claims. Once you have billed the other carrier and received an EOB, submit the claim to UnitedHealthcare Community Plan. Attach a copy of the EOB to the submitted claim. The EOB must be complete to understand the paid amount or the denial reason.

What is it?

An overpayment happens when we overpay a claim you don’t dispute.

How to use:

If you or UnitedHealthcare Community Plan finds an overpaid claim, send us the overpayment within the time specified in your contract. If your payment is not received by that time, we may apply the overpayment against future claim payments in accordance with our Agreement and applicable law.

If you prefer we recoup the funds from your next payment, call Provider Services.

If you prefer to mail a refund, send an Overpayment Return Check or the Overpayment Refund/Notification form.

Also, send a letter with the check. Include the following:

  • Name and contact information for the person authorized to sign checks or approve financial decisions
  • Member identification number
  • Date of service
  • Original claim number (if known)
  • Date of payment
  • Amount paid
  • Amount of overpayment
  • Overpayment reason
  • Check number

Where to send:

Mail refunds with an Overpayment Return Check or the Overpayment Refund/Notification form to:

UnitedHealthcare Community Plan

ATTN: Recovery Services

P.O. Box 740804 Atlanta, GA 30374-0800

Instructions and forms are on UHCprovider.com.

If you do not agree with the overpayment findings, submit a dispute within the required timeframe as listed in your contract.

If you disagree with a claim adjustment or our decision not to make a claim adjustment, you can appeal. See Dispute section in this chapter.

We make claim adjustments without requesting additional information from you. You will see the adjustment on the EOB or Provider Remittance Advice (PRA). When additional information is needed, we will ask you to provide it.

Sample Overpayment Report Sample Overpayment Report

What is it?

Grievances are complaints related to your UnitedHealthcare Community Plan policy, procedures or payments.

When to file:

You may file a grievance about:

  • Benefits and limitations.
  • Eligibility and enrollment of a member or care provider.
  • Member issues or UnitedHealthcare Community Plan issues.
  • Availability of health services from UnitedHealthcare Community Plan to a member.
  • The delivery of health services.
  • The quality of service.

How to file:

File verbally or in writing.

  • Phone: Call 888-980-9728, 7:45 a.m. to 4:30 p.m. HT, Monday through Friday.
  • Fax: 844-700-7938.
  • Mail: Send care provider name, contact information and your grievance to:

UnitedHealthcare Community Plan

Grievances and Appeals 1132 Bishop St., Ste. 400

Honolulu, HI 96813

UnitedHealthcare Community Plan uses the Centers for Medicare and Medicaid Services (CMS) definitions for appeals and grievances.

Notice of Action (NOA)

If we decide to reduce, put on hold, or stop a service the member is receiving, they receive a written NOA at least 10 days before the action takes place. If the member does not agree, they may file an appeal or they may have their care provider file an appeal on their behalf with the member’s written consent.

We give the member and the referring care provider a written notice of any action. This notice includes:

  • The action we have or plan to take
  • The reasons for the action such as changes in regulation, Federal or State law
  • The member’s or care provider’s right to request an appeal
  • Procedures for filing an appeal
  • The member may represent himself or herself, use legal counsel or an authorized representative
  • The circumstances under which an expedited resolution is available and how to request it
  • The member’s right to have benefits continue pending resolution of an appeal, how to request that the benefits be continued, and the circumstances under which a member may be required to pay the costs of these services

We mail the notice within these time frames:

  • For termination, suspension, or reduction of previously authorized Medicaid-covered services, at least ten days prior to the date the adverse action is to start except for the following reasons:
    • We have factual information confirming the death of a member
    • We receive a clear written statement signed by the member that they no longer want services or gives information that requires termination or reduction of services and understands that this must be the result of supplying that information
    • The member has been admitted to an institution that makes them ineligible for further services
    • The member’s address is unknown and the post office returns our mail directed to the member indicating no forwarding address
    • The member has been accepted for Medicaid services by another local jurisdiction
    • The member’s care provider prescribes a change in the level of medical care
    • There has been an adverse determination made with regard to the preadmission screening requirements for nursing facility admissions
    • In the case of adverse actions for nursing facility transfers, the safety or health of individuals in the facility would be endangered, the member’s health improves sufficiently to allow a more immediate transfer or discharge, an immediate transfer or discharge is required by the member’s urgent medical needs, or the member has not resided in the nursing facility for 30 days
    • The period of advanced notice is shortened to five days if there is alleged fraud by the member and the facts have been verified, if possible, through secondary sources.
  • For denial of payment: at the time of any action affecting a claim.
  • For standard service authorization decisions that deny or limit services: as expeditiously as the member’s health condition requires, but not more than 14 days following receipt of request for service, with a possible extension of up to 14 additional days (total time frame allowed with extension is 28 days from the date of the request for services) if: 1) the member or provider requests an extension or, 2) we justify a need for additional information and how the extension is in the member’s interest. If we extend the time frame, we must: 1) give the member written notice of the reason for the decision to extend the time frame and inform the member of the right to file a grievance if he or she disagrees with the decision to extend the time frame and 2) issue and carry out its determination as expeditiously as the member’s health condition requires but no later than the date the extension expires.
  • For expedited authorization decisions: as expeditiously as the member’s health condition requires but no more 72 hours after receipt of the request for service.
  • Service authorization decisions not reached within the time frames specified constitute a denial

 

Appeals

What is it?

An appeal is a formal way to share dissatisfaction with a claim determination.

You or a member may appeal when the plan:

  • Makes a harmful determination or limits a requested service(s). This includes the type or level of service.
  • Lowers, suspends or ends a previously authorized service.
  • Refuses, in whole or part, payment for services.
  • Fails to provide services in a timely manner, as defined by the state or CMS.
  • Doesn’t act within the time frame CMS or the state requires.
When to use:

You may act on the member’s behalf with their written consent. You may provide medical records and certification of the appeal as appropriate.

Where to send:

Call, mail or email the information within 30 calendar days of the NOA:

UnitedHealthcare Community Plan

Attention: Grievance and Appeals Department 1132 Bishop St., Ste 400

Honolulu, HI 96813

Toll-free: 888-980-8728 (TTY 711). An oral appeal may be submitted but must be followed by a written request.

Email: HI_AG@uhc.com

How to use:

Whenever you deny a service, you must provide the member with UnitedHealthcare Community Plan appeal rights. The member has the right to:

  • Receive a copy of the rule used to make the decision.
  • Ask someone (a family member, friend, lawyer, health care provider, etc.) to help. The member may present evidence, and allegations of fact or law, in person and in writing.
  • The member or representative may review the case file before and during the appeal process. The file includes medical records and any other documents.
  • Send written comments or documents considered for the appeal.
  • Ask for an expedited appeal if waiting for this health service could harm the member’s health. You have two business days to represent evidence and allegations of fact or law in person and in writing.
  • Ask for continuation of services during the appeal. However, the member may have to pay for the health service if it is continued or if the member should not have received the service.
  • We must resolve a standard appeal 30 calendar days from the day we receive it.
  • We must resolve an expedited appeal 72 hours from when we receive it. With approval from DHS, we may extend the response up to 14 calendar days if the following conditions apply:
  1. Member requests we take longer.
  2. We request additional information and explain how the delay is in the member’s interest.

 

Member Grievance

What is it?

Grievances are complaints related to UnitedHealthcare Community Plan policy, procedures or payments.

When to use:

You may file a grievance as the member’s representative.

Where to send:

You or the member may file a grievance by calling Member Services or writing UnitedHealthcare Community Plan at:

UnitedHealthcare Community Plan

Attention: Appeals Department 1132 Bishop St., Ste 400

Honolulu, HI 96813

We will send an answer no longer than 30 working days from when you filed the complaint/grievance.

The member may also file a grievance to the state of HI within 30 calendar days of receipt of the first determination letter.

 

Med-QUEST Division (MQD)

Health Care Services Branch

P.O. Box 700190 Kapolei, HI 96709-0190

Or call 808-692-8094.

The MQD will review the grievance and contact the member within 90 days from the date the request for a grievance review is received. The determination made by MQD is final.

What is it?

A State Administrative Hearing lets members share why they think Hawaii Medicaid services should not have been denied, reduced or terminated.

When to use:

Members have 120 days from the letter date to ask for a hearing. At that point, they will be mailed a hearing form. Once they complete the form and send it back, we set a hearing date.

How to use:

The UnitedHealthcare Community Plan member may ask for a state fair hearing by writing a letter to:

State of Hawai‘i Department of Human Services

Administrative Appeals Office

P.O. Box 339

Honolulu, HI 96809-0339

  • The member may ask UnitedHealthcare Community Plan Customer Service for help writing the letter.
  • The member may have someone attend with them. This may be a family member, friend, care provider or lawyer.
  • Hearings are held on the phone. Members may go to the local Family Support Division office for the hearing or can take part from home.

Expedited hearings are heard and determined within three business days after the date the member files the request for an expedited hearing.

If the State Administration Hearing reverses a decision to deny, limit, or delay services not provided while the appeal was pending, we authorize or provide the disputed services as quickly as the member’s health condition requires. If the decision reverses denied authorization of services and the disputed services were received pending appeal, we pay for those services as specified in policy and/or regulation.

 

Continuation of Benefits During an Appeal or State Administrative Hearing

We continue the member’s benefits if:

  • The member requests an extension of benefits
  • The appeal or request for a State Administrative Hearing is filed in a timely manner, meaning on or before the later of the following:
    • Within ten days of us mailing the notice of adverse action; or
    • The appeal or request for State Administrative Hearing involves the termination, suspension, or reduction of a previously authorized course of treatment; and
    • The services were ordered by an authorized care provider.

If we continue or reinstate the member’s benefits while the appeal or the State Administrative Hearing is pending, we continue all benefits until:

  • The member withdraws the appeal;
  • The member does not request a DHS Administrative Hearing within ten days from when we mail a notice of adverse action; or
  • A State Administrative Hearing decision adverse to the member is made.

If the final resolution of the State Administrative Hearing upholds our denial, we may recover the cost of the services furnished to the member while the appeal is pending, to the extent that they were furnished solely because of the requirements of this section.

If we or the DHS reverses a decision to deny, limit, or delay services that were not furnished while the appeal was pending, we authorize or provide these disputed services promptly, and as quickly as the member’s health condition requires.

If we or the State reverses a decision to deny authorization of services, and the member received the disputed services while the appeal was pending, we will pay for those services.

Call the toll-free Fraud, Waste and Abuse Hotline to report questionable incidents involving plan members or care providers.

UnitedHealthcare Community Plan’s Anti-Fraud, Waste and Abuse Program focuses on prevention, detection and investigation of false and abusive acts committed by you and plan members. The program also helps identify, investigate and recover money UnitedHealthcare Community Plan paid for such claims. We also refer suspected fraud, waste and abuse cases to law enforcement, regulatory and administrative agencies according to state and federal law. UnitedHealthcare Community Plan seeks to protect the ethical and financial integrity of the company and its employees, members, care providers, government programs and the public. In addition, it aims to protect member health.

UnitedHealthcare Community Plan includes applicable federal and state regulatory requirements in its Anti- Fraud, Waste and Abuse Program. We recognize state and federal health plans are vulnerable to fraud, waste and abuse. As a result, we tailor our efforts to the unique needs of its members and Medicaid, Medicare and other government partners. This means we cooperate with law enforcement and regulatory agencies in the investigation or prevention of fraud, waste and abuse.

An important aspect of the Compliance Program is reviewing our operation’s high- risk areas. Then we implement reviews and audits to help ensure compliance with law, regulations and contracts. You are contractually obligated to cooperate with the company and government authorities.

Find the UnitedHealth Group policy on Fraud, Waste and Abuse at uhc.com/fraud or call 888-980-8728.

The Deficit Reduction Act (DRA) has provisions reforming Medicare and Medicaid and reducing fraud within the federal health care programs. Every entity that receives at least $5 million in annual Medicaid payments must have written policies for entity employees and contractors.

They must provide detailed information about false claims, false statements and whistleblower protections under applicable federal and state fraud and abuse laws. As a participating care provider with UnitedHealthcare Community Plan, you and your staff are subject to these provisions.

This policy details our commitment to compliance with the federal and state false claims acts. It provides a detailed description of these acts and of organizational mechanisms that detect and prevent fraud, waste and abuse. It also details how whistleblowing employees are protected. UnitedHealthcare Community Plan prohibits retaliation if a report is made in good faith.

Exclusion Checks

First-tier, downstream and related entities (FDRs), must review federal (HHS-OIG and GSA) and state exclusion lists before hiring/contracting employees (including temporary workers and volunteers), the CEO, senior administrators or managers, and sub-delegates. Employees and/or contractors may not be excluded from participating in federal health care programs. FDRs must review the federal and state exclusion lists every month. For more information or access to the publicly accessible, excluded party online databases, please see the following links:

What You Need To Do For Exclusion Checks

Review applicable exclusion lists and maintain a record of exclusion checks for 10 years. UnitedHealthcare Community Plan or CMS may ask for documentation to verify they were completed.