Sepsis claims may be reviewed on pre-pay basis

Last updated: Aug. 30, 2022

Effective July 1, 2021, Medicare Advantage and commercial claims for sepsis-related treatment may be reviewed on a pre-payment or post payment basis. These reviews promote accurate diagnosis and treatment of sepsis, and help ensure the claim is coded and billed at the appropriate treatment level.

Claims will be reviewed using UnitedHealthcare’s Sepsis Clinical Guidelines and the patient’s medical records to validate that sepsis was present. Subject to state laws and regulations, and as indicated in the guidelines, UnitedHealthcare uses Sepsis-3, the most recent evidence-based definition of sepsis and supports the International Guidelines for Management of Sepsis and Septic Shock 2016.

Here’s what you need to know

• There is no change to the clinical guidelines themselves: The only change is to the review timing. Currently, we only review sepsis-related claims on a post-payment basis.
• If we can’t validate that sepsis is present: Based on the guidelines and review of the member’s medical records, services may be denied or adjusted. In the event payment for sepsis-related services is denied, the hospital may submit a corrected claim.
• If your claims require review: You will receive a letter with more information, instructions and deadlines for providing the requested member medical records. Please be aware that submitting the information as soon as possible will help prevent possible claim delays and/or denials.
• After review, if your claim is denied: You will receive a letter explaining the outcome of the review. You can also visit UHCprovider.com, click Sign In and log in to the UnitedHealthcare Provider Portal to view claim payment or denial information on your Provider Remittance Advice (PRA).

Questions?

Please contact your Provider Advocate or visit our Contact Us page.

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