Avoid claim denials – make your PNM updates before Oct. 20, 2023
Effective Oct. 20, 2023, Next Generation Medicaid managed care organizations (MCOs), the OhioRISE plan and MyCare Ohio plans must use provider data from Ohio Medicaid’s Provider Network Management (PNM) module as the official system of record. Health care professionals must keep their records updated within the PNM module. If your data in the PNM module does not match the data on your submitted claims, your claims will be denied for payment.
Claims and Payments | UnitedHealthcare Community Plan of Ohio
We have online tools and resources to help you manage your practice’s claim submission and payment.
Need to submit a claim, check status or apply for reconsideration? Go to UHCprovider.com/claims to learn about Claims.
Claim Administrative Disputes/Appeals
If you aren’t satisfied with the outcome of a claim reconsideration request, you may submit a formal claim dispute/appeal using the process outlined in your Care Provider Manual.
A formal claim dispute/appeal is a comprehensive review of the disputed claim(s), and may involve a review of additional administrative or medical records by a clinician or other personnel.
UnitedHealthcare Community Plan generally completes the review within 30 calendar days. However, depending on the nature of the review, a decision may take up to 60 days from the receipt of the claim dispute documentation. We’ll contact you if we believe it will take longer than 30 days to render a decision.
Additional state requirements may apply. Please consult your state’s Care Provider Manual for more details.
Please allow 10 business days from the submission date before requesting a status update to enable us to begin processing the review.
Claims Payment Systemic Error Report
The UnitedHealthcare Community Plan of Ohio is making this information available to participating care providers to help you better understand when we make adjustments or corrections to care provider payments.
Using Electronic Data Interchange (EDI) for all eligible UnitedHealthcare transactions can help your organization improve efficiency, reduce costs and increase cash flow. We encourage you to use the following tools and resources to get started with electronic transactions.
Next Generation program launches new Electronic Data Interchange and fiscal intermediary
Please note that the new Electronic Data Interchange (EDI) and fiscal intermediary, effective Feb. 1, 2023, only apply to UnitedHealthcare Community Plan of Ohio (Medicaid) plans. It does not apply to Dual-Eligible Special Needs Plans (D-SNP) or Medicare-Medicaid (MMP) plans.
In addition, when submitting claims to the fiscal intermediary, please submit with the MMIS ID, not the UnitedHealthcare ID.
Provider Remittance Advice (PRA)
A PRA is generated for every processed claim and includes relevant details about how the claim was processed.