Chapter 11: Billing and Submission

Ohio providers contracted with Medicare and Medicaid lines of business, serving members enrolled with UnitedHealthcare Connected for Medicare and Medicaid benefits, will be able to take advantage of single-claim submission. Claims submitted to UnitedHealthcare Connected for dual-enrolled members will process first against Medicare benefits and then will process against UnitedHealthcare Connected Medicaid benefits. Most care providers will not need to submit separate claims.

For claims, billing and payment questions, go to UHCprovider.com.

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 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.

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 dates 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.

Based on OAC Rule: 5101:3-1-60, payment by UnitedHealthcare Community Plan is considered payment in full. Participating and non-participating care providers may not bill a member unless all of the following are met:

1. You notified the member of the financial liability before the service delivery.
2. You gave the notification in writing, specific to the service being rendered. It clearly states the member is financially responsible for the service.
3. The member dates and signs the notification.
4. The reason we don’t cover the service is specified and is one of the following reasons:
   - The service is a benefit exclusion.
   - The care provider is not in network, so we have denied approval for the service because it is available from a contracted provider.
   - The care provider is not in network and has not requested approval to provide the service.

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

Use the appropriate modifier 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.

We may require additional information for some services, situations or state requirements.

Submit any services completed by NPs or PAs who are part of a collaborative agreement.

Submit paper claims to:

UnitedHealthcare Community Plan
P.O. Box 8207
Kingston, NY 12402

UnitedHealthcare Community Plan complies with 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 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 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. Call 800-842-1109 for more information.

Find more information at UHCprovider.com. Click Menu, then Resource Library to find Electronic Data Interchange menu.

Important EDI Payer Information

• Claim Payer ID: 87726
• ERA Payer ID: UFNEP

Companion documents for 837 transactions are on UHCprovider.com, Click Menu, then Resource Library to find the EDI section

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

Additional Claim Submission Requirements for C&S FACETS Claims

Follow these tips for 837 claim formats:

1. Use the 2010AA Billing Provider loop when the billing and rendering provider are the same.
2. Use the 2310B Rendering Provider loop when the rendering and billing provider are NOT the same.
3. You may use the 2420A Rendering Provider Line Level when there are multiple rendering providers. However, for claims that process on the Facets system, use one rendering provider per claim. Claims with multiple rendering providers will have to be formatted at separate claims.

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

• Include ICD CM diagnosis codes.
• Identify other services by the CPT/HCPCS and modifiers.

Capitated Care Providers

Capitation is a payment arrangement for health care providers. If you have a capitation agreement with us, we pay you a set amount for each member assigned to you per period of time. We pay you whether or not that person seeks care. In most instances, the capitated care provider is either a medical group or an Independent Practice Association (IPA). In a few instances, however, the capitated care provider may be an ancillary provider or hospital.

We use the term ‘medical group/IPA’ interchangeably with the term ‘capitated care providers’. Capitation payment arrangements apply to participating physicians, health care providers, facilities and ancillary care providers who are capitated for certain UnitedHealthcare Community Plan products. This applies to all benefit plans for members:

• Who have been assigned to or who have chosen a care provider who receives a capitation payment from UnitedHealthcare Community Plan for such member, and
• Who are covered under an applicable benefit plan insured by or receiving administrative services from UnitedHealthcare Community Plan.

Additionally, capitated care providers may be subject to any or all delegated activities. Capitated care providers should refer to their Delegation Grids within their participation agreements to determine which delegated activities the capitated providers are performing on behalf of UnitedHealthcare Community Plan.

For capitated services, include all services related to an inpatient stay on the UB-04 when a member is admitted to the hospital and they received ER treatment, observation or other outpatient hospital services.

We deny claims submitted with service dates that don’t match the itemization and medical records. This is a billing error denial.

• 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.

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.

Hospitals should submit claims to the UnitedHealthcare Connected (MyCare Ohio) claims address as soon as possible after service is rendered, using the standard UB-92 Form or electronically.

To expedite claims payment, identify the following items on your claims:

• Member name
• Member’s date of birth and sex
• Member’s UnitedHealthcare Connected ID number
• Indication of:
  • Job-related injury or illness, or
  • Accident-related illness or injury, including pertinent details
• Appropriate diagnosis, procedure and service codes
• Date of services (including admission and discharge date)
• Charge for each service
• Provider’s ID number and locator code, if applicable
• Provider’s Tax ID Number
• Name/address of Participating Provider

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.

Reporting Birth Weight on Newborn Claims

You must report newborn weight to UnitedHealthcare Community Plan.

To report this data, use the appropriate value code:

• UB-04: Report in block 39, 40 or 41 using value code “54” and the newborn’s weight grams.

If billing electronically, please report birth weight in loop 2300, segment HI, with the qualifier BE and the value code “54” in HI01-2 and the newborn’s weight in grams in HI01-5.

We reference the following codes to identify newborn claims. Therefore, include birth weight on all claims containing these codes:

ICD-10 Procedure Codes:

• 72.x Forceps, vacuum, and breech delivery.
• 73.51 Manually assisted delivery; Manual rotation of fetal head.
• 73.59 Manually assisted delivery; Other.
• 74.0 Cesarean section and removal of fetus; Classical cesarean section.
• 74.1 Cesarean section and removal of fetus; Low cervical cesarean section.
• 74.2 Cesarean section and removal of fetus; Extraperitoneal cesarean section.
• 74.4 Cesarean section and removal of fetus; Cesarean section of other specified type.
• 74.99 Cesarean section of unspecified type.

ICD-10 Diagnosis Codes:

• 080 Normal Delivery.
• V27.x Outcome of Delivery.

The following codes must have a 5th digit equal to 1 or 2:

• 640-648 Complications mainly related to pregnancy.
• 651-659 Normal delivery and other indications for care in pregnancy, labor, and delivery.
• 660-669 Complications occurring mainly during the course of labor and delivery.
• 670-676 Complications of the puerperium.

CPT Codes:

• 59409 Vaginal delivery (with or without episiotomy or forceps).
• 59514 Cesarean delivery only.
• 59612 Vaginal delivery only, after previous cesarean delivery (with or with our episiotomy or forceps).
• 59620 Cesarean delivery only, following attempted vaginal delivery after previous cesarean delivery.

Reporting Date of Last Menstrual Period

You must report the date of a member’s last menstrual period to UnitedHealthcare Community Plan. If billing on paper, report the date of the last menstrual period as follows:

• UB-04: Report anywhere in blocks 32-36 using occurrence code “10” in one block with the date of the last menstrual period in the next block.
• CMS-1500: Report in block 14 using the date of the last menstrual period.

If billing electronically, please report the date of the last menstrual period as follows:

• 837I: Report using occurrence code “10” and the date of the last menstrual period in loop 2300, segment HI, qualifier BH.
• 837P: Report the date of the last menstrual period in loop 2300, segment DTP, qualifier 484.

ODM covers medically necessary, non-experimental transplants. UnitedHealthcare Community Plan covers the transplant evaluation and work-ups. Get prior authorization for the transplant evaluation. Gather all required referrals and evaluations to complete the pre-transplant evaluation process once the member is a possible candidate.

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

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 Services 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 helps 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 with online support 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 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:

UnitedHealthcare Community Plan
P.O. Box 5240
Kingston, NY 12402-5240

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 90 days from date of service or close of business from the primary carrier, the claim is considered late billed. It will be denied timely filing.

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

You may not bill MyCare members. Do not balance bill Medicaid members if:

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

You may 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, call Provider Services.

UnitedHealthcare Community Plan is, by law, the payer of last resort for eligible members. Therefore, you must bill and obtain an explanation of benefits (EOB) from any other insurance or health care coverage resource before billing UnitedHealthcare Community Plan, as required by contract. Refer to your Agreement for third-party claim submission deadlines. Once you bill the other carrier and receive an EOB, the claim may then be submitted to UnitedHealthcare Community Plan. Please attach a copy of the EOB to the submitted claim. The EOB must be complete to understand the paid amount or denial reason.