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. Non-network care providers should refer to applicable appeals and grievances laws, regulations and state Medicaid contract requirements.

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

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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. Non-network care providers should refer to applicable appeals and grievances laws, regulations and state Medicaid contract requirements.

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

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
P.O. Box 8207 Kingston, NY 12402

Online Form for Fax or Email: UHCprovider.com/claims

Care Provider Contact Information: 800-600-9007

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

Care Provider Filing Timeframe: Must receive within 45 days

UnitedHealthcare Community Plan Response Timeframe:  30 business 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
P.O. Box 8207 Kingston, NY 12402

Online Form for Fax or Email: UHCprovider.com/claims

Care Provider Contact Information: 800-600-9007

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

Care Provider Filing Timeframe: Must receive within 90 business days

UnitedHealthcare Community Plan Response Timeframe:  45 business 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 Grievance/Appeal Coordinator
P.O. Box 31364 Salt Lake City, UT 84131

Online Form for Fax or Email: UHCprovider.com/claims

Care Provider Contact Information: 800-600-9007

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

Care Provider Filing Timeframe: 60 business days

UnitedHealthcare Community Plan Response Timeframe:  30 business days
 

Member Appeal

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

Who May Submit?: 

  • Member
  • Member’s authorized representative (such  as friend or family member) with written member consent
  • Care provider on behalf of a member with member’s written consent

Submission Address:

UnitedHealthcare Community Plan Grievances and Appeals
P.O. Box 31364 Salt Lake City, UT 84131

Online Form for Fax or Email: UHCprovider.com/claims

Care Provider Contact Information: 800-895-2017TTY 711

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

Care Provider Filing Timeframe: 

Urgent appeals - must receive within 5 business days.
Standard appeals - 60 business days

UnitedHealthcare Community Plan Response Timeframe: 

Urgent appeals - We will respond within 2 business days.
Standard apeals - 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
  • Member’s authorized representative (such  as friend or family member) with written member consent
  • Care provider on behalf of a member with member’s written consent

Submission Address:

UnitedHealthcare Community Plan Grievances and Appeals
P.O. Box 31364 Salt Lake City, UT 84131

Online Form for Fax or Email: UHCprovider.com/claims

Care Provider Contact Information: 800-895-2017, TTY 711

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

Care Provider Filing Timeframe: N/A

UnitedHealthcare Community Plan Response Timeframe: 30 business 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?

You may need to update information on a claim you’ve already submitted. A corrected claim replaces a previously processed or denied claim submitted in error.

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 8207
Kingston, NY 12402-5240

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 5240
Kingston, NY 12402-5240

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. You have 45 days from the date of the Explanation of Benefits (EOB) or Provider Remittance Advice (PRA) to submit your claim reconsideration.

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.
    • If you have a request involving 20 or more paid or denied claims, aggregate these claims on the Claim Project online form and submit the form for research and review. Go to UHCprovider.com > Claims & Payments > Claim Research Project.
  • Phone: Call Provider Services at 800-600-9007 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 8207 Kingston, NY 12402

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 overpayment happens when we overpay a claim.

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?

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.

We resolve disputes within 45 days of receiving the disputed claim and remittance advice.

How to use:

Submit related documents with your appeal. 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 Claims (on Link) application on Link. You may upload attachments.
  • Mail: Send the appeal to:

UnitedHealthcare Community Plan
Attn: Appeals and Grievances Unit
P.O. Box 31364
Salt Lake City, UT 84131-0364

Call Provider Services for questions about your appeal or if you need a status update. If you filed your appeal online, you should receive a confirmation email.

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.
  • 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.

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

Initial Decisions

The “initial decision” is the first decision UnitedHealthcare Connected makes regarding coverage or payment for care. In some instances, you, acting on behalf of UnitedHealthcare Connected, may make an initial decision about whether a service will be covered.

If a member asks us to pay for medical care the member has already received, this is a request for an initial decision about payment for care.

If you or a member asks for preauthorization for treatment, this is a request for an “initial decision” about whether the treatment is covered by UnitedHealthcare Connected.

If a member asks you for a specific type of medical treatment, this is a request for an initial decision about whether the treatment the member wants is covered by UnitedHealthcare Connected.

UnitedHealthcare Connected will generally make decisions regarding payment for care that members have already received within 30 days.

A decision about whether UnitedHealthcare Connected will cover medical care can be a standard decision that is made within the standard time frame (typically within 14 days) or it can be an expedited decision that is made more quickly (typically within 72 hours).

A decision about whether UnitedHealthcare Connected will cover medical care can be a standard decision made within the standard time frame (typically within 15 days) or it can be an expedited decision that is made more quickly (within 72 hours).

A member can ask for an expedited decision only if the member or any physician believes that waiting for a standard decision could seriously harm the member’s health or ability to function. The member or a physician can request an expedited decision. If a physician requests an expedited decision, or supports a member in asking for one, and the physician indicates that waiting for a standard decision could seriously harm the member’s health or ability to function, UnitedHealthcare Connected will automatically provide an expedited decision.

At each encounter with a UnitedHealthcare Connected member, you must notify the member of their right to receive, upon request, a detailed written notice from UnitedHealthcare Connected regarding the member’s services. Your notification must provide the member with the information necessary to contact UnitedHealthcare Connected and must comply with any other CMS requirements. If a member requests UnitedHealthcare Connected to provide a detailed notice of your decision to deny a service in whole or part, UnitedHealthcare Connected must give the member a written notice of the determination.

If UnitedHealthcare Connected does not make a decision within the time frame and does not notify the member about why the time frame must be extended, the member can treat the failure to respond as a denial and may appeal.

Member Benefit Appeals

What is it?

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

You or a member may appeal when the plan:

  • 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 supporting documentation as appropriate.

Where to send:

You or the member may call, mail or fax the information within 60 calendar days from the date of the adverse benefit determination.

We resolve urgent appeals within 48 hours if the member’s condition requires.

UnitedHealthcare Community Plan
Attn: Appeals and Grievances Unit
P.O. Box 31364
Salt Lake City, UT 8413-0364

Toll-free: 800-895-2017 (TTY 711)

If you appeal by phone, you must follow up in writing, ask the member to sign the written appeal, and mail it to UnitedHealthcare Community Plan.

How to use:

Whenever we 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 provide certification of the appeal and evidence and allegations in person or in writing. Provider certification is a written confirmation from you that the expedited request is urgent.
  • 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. As the provider, you cannot ask for a continuation. Only the member may do so.
  • We resolve a standard appeal 30 calendar days from the day we receive it.
  • We resolve an expedited appeal 72 hours from when we receive it.

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.

If submitting the appeal by mail or fax, you must complete the Authorization of Review (AOR) form-Claim Appeal.

A copy of the form is online at UHCprovider.com.

Member Grievance

What is it?

Grievances are complaints related to UnitedHealthcare Community Plan policies and/or procedures. It includes a member’s right to dispute the time UnitedHealthcare takes to make an authorization decision or dissatisfaction about anything other than a benefit determination (see Member Appeals).

When to use:

You may act on the member’s behalf with their written consent.

Where to send:

You or the member may call or mail the information anytime to:

Mailing address:

UnitedHealthcare Community Plan
Attn: Appeals and Grievances Unit
P.O. Box 31364
Salt Lake City, UT 84131-0364

Toll-free: 800-895-2017 (TTY 711)

We will send an answer no longer than 90 calendar days from when you filed the complaint/grievance or as quickly as the member’s health condition requires; we offer a 14 calendar day extension if the member or UnitedHealthcare Community Plan requests additional time.

Further Appeal Rights

If UnitedHealthcare Connected denies the member’s appeal in whole or part, it will forward the appeal to an Independent Review Entity (IRE) that has a contract with the federal government and is not part of UnitedHealthcare Connected. This organization will review the appeal and, if the appeal involves authorization for health care service, make a decision within 30 days. If the appeal involves payment for care, the IRE will make the decision within 60 days.

If the IRE issues an adverse decision and the amount at issue meets a specified dollar threshold, the member may appeal to an Administrative Law Judge (ALJ). If the member is not satisfied with the ALJ’s decision, the member may request review by the Department Appeal Board (DAB). If the Department Appeal Board (DAB) refuses to hear the case or issues an adverse decision, the member may be able to appeal to a District Court of the United States.

What is it?

A state hearing lets members share why they think Ohio Medicaid services should not have been denied, reduced or terminated.

When to use:

Members have 120 days from the date on UnitedHealthcare Community Plan’s adverse appeal determination letter.

How to use:

For details, visit jfs.ohio.gov. The UnitedHealthcare Community Plan member may ask for a state hearing by writing a letter to:

ODJFS Bureau of State Hearings
P.O. Box 182825
Columbus, OH 43218-2825

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. Written consent is required.

If the state fair hearing outcome is to not deny, limit, or delay services while the member is waiting on an appeal, then we provide the services:

  1.  As quickly as the member’s health condition requires or
  2.  No later than 72 hours from the date UnitedHealthcare Community Plan receives the determination reversal.

If the State Fair Hearing decides UnitedHealthcare Community Plan must approve appealed services, we pay for the services as specified in the policy and/or regulation.

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 877-401-9430.

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.

State Laws

States where UnitedHealthcare Community Plan does business have laws that contain civil or criminal penalties for false claims and statements that are in addition to the penalties provided in the Act. Certain states also have whistle-blower protections similar to the Act. In Ohio the applicable laws are ORC Sections 5164.35, 5162.15, 2913.40, 124.341, 4113.52, and 3901.44. For more information on a specific state law, please contact the UnitedHealthcare Community Plan compliance officer or legal department.

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.

Sanctions Under Federal Health Programs And State Law

You must help ensure that no management staff or other persons who have been convicted of criminal offenses related to their involvement in Medicaid, Medicare or other federal health care programs are employed or subcontracted by the participating care provider.

You must disclose to UnitedHealthcare Connected whether you or any staff member or subcontractor has any prior violation, fine, suspension, termination or other administrative action taken under Medicare or Medicaid laws; the rules or regulations of Ohio, the federal government, or any public insurer.

Notify UnitedHealthcare Connected immediately if any such sanction is imposed on you, a staff member or subcontractor.