Payment accuracy
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.
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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.
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