Payment accuracy

Prevent waste, fraud and abuse to help make health care more affordable for all

Payment accuracy

Prevent waste, fraud and abuse to help make health care more affordable for all

Payment accuracy

Prevent waste, fraud and abuse to help make health care more affordable for all

Payment accuracy

Prevent waste, fraud and abuse to help make health care more affordable for all

Payment accuracy

Prevent waste, fraud and abuse to help make health care more affordable for all

Payment accuracy

Prevent waste, fraud and abuse to help make health care more affordable for all

Payment accuracy

Prevent waste, fraud and abuse to help make health care more affordable for all

Payment accuracy

Prevent waste, fraud and abuse to help make health care more affordable for all

UnitedHealthcare payment integrity programs are designed to give you the information you need to submit accurate claims, prevent claim denials, avoid rework, receive timely payments and reduce the need to refund overpayments. We’re partnering with you to prevent waste, fraud and abuse and to help make health care more affordable for everyone.

Resources at your fingertips

Smart Edits

Catch billing errors quickly. Smart Edits notifies you within 24 hours of claim submission, so you can make corrections before the claim is processed.

Learn more

Coding Corner

Choose from more than 20 self-paced courses on common coding issues. You’ll gain insight to help you decrease coding errors that cause claim denials.

Visit Coding Corner

Reimbursement policies

Research policies, requirements and protocols for our commercial, Individual and Family Plan (Exchange), Medicare Advantage and Community (Medicaid) plans.

Review policies

Timing and types of payment reviews

Payment reviews can occur during 4 stages of claim processing:

  • Pre-adjudication: After submission and before we review it against a member’s plan benefits
  • Adjudication: When we process the claim and determine if it’s eligible for benefits
  • Pre-payment: Once eligibility has been determined but before payment is made
  • Post-payment: After payment has been made to validate accuracy of the paid amount

Vendors we work with

We work with a number of vendors to perform payment reviews. All vendors have a business associate agreement with UnitedHealthcare, compliant with HIPAA privacy regulations. This means that the vendor can request additional information about the claim for the purpose of payment activities, without additional patient or health care professional authorization. 

Any communication you receive from an authorized vendor will note that they are conducting a review on our behalf, and many will have both the vendor logo and UnitedHealthcare logo.

If you’re contacted by any of the vendors we work with, please send the vendor the information they request as quickly as possible. Vendor-requested information sent to UnitedHealthcare cannot be forwarded, which means your claim may be denied or determined to be an overpayment (depending on the type of review being conducted).

Medical records may be requested

These requests usually occur when the data on the claim form alone isn’t sufficient to validate that the billed codes are correct, or when we need to meet Centers for Medicare & Medicaid Services (CMS) rules to confirm that medical records accurately document the service(s) rendered.

All medical record requests from UnitedHealthcare and the vendors we work with will include instructions on how to submit the records, the deadline and who to contact with questions.

Resources