UnitedHealthcare runs capitation reports by process month for both commercial and MA products. Typically, each month’s capitation report and payment reflects all current activity and retroactivity up to the standard six-month system window. The Agreement may define a non-standard eligibility window for less than the standard six-month system window. This non-standard eligibility window will override the standard six-month system window. For MA plans, the non-standard eligibility retro window will not limit the retroactivity related to premium increases/decreases from CMS.
Capitation reports and first-of-the-month eligibility reports run from the same snapshot of membership data. The actual date of this snapshot varies but typically occurs on or around the 15th calendar day of the prior month for Commercial and during the last week of the prior month for MA.
The reports mentioned throughout this section are available online and provide detailed information regarding each care provider’s capitation payments. The types of reports available include:
Reports are available on UHCprovider.com/reports on the date specified in your Agreement. If the due date falls on a non-business day, the reports are available the next business day.
Supplemental care provider Reports for Claims Withhold are available online. These reports have two capitation reporting options described below: reports and data files.
Medical Drug Benefit reports are available online.
The Claims Withhold and Medical Drug Benefits reports are one month behind the current Capitation Report month. For example, all claims on the Claims Withhold and Medical Drug Benefit reports that paid in April will process in May capitation. To reconcile May capitation, view the April Claims Withhold and April Medical Drug Benefits Reports.
The Shared Risk Claims Report is also dated one month behind the current Capitation Report month. For example, all Shared Risk claims paid in May will process in the June capitation.
We maintain capitation and eligibility reports online for the current month and the previous two months.
We recommended you complete your capitation download in a timely manner to make sure you have complete and accurate capitation information.
CMS payments are based on the HCC Reporting. This payment methodology requires MA health plans to submit accurate diagnosis information at the greatest level of specificity available.
We offer an alternate method of reporting CMS risk adjustment data in addition to the normal claim/encounter submission process. All encounter submissions are required to process the 837 Claim/Encounter in a HIPAA 5010-compliant format. To supplement a previously submitted 837 Claim/Encounter, submit an 837 replacement Claim/Encounter, or send additional diagnosis data related to the previously submitted 837, through the Optum ASM Operations FTP process. If you choose to submit via ASM, you first need to contact the Optum ASM Operations team at email@example.com to start the onboarding process.
Capitation is typically a per member per month (PMPM) payment to a medical group/IPA or facility that covers contracted services for assigned members. This is an alternative to the fee-for-service arrangement. Capitation payments made whether or not the member seeks services from the capitated care provider.
Refer to the Division of Financial Responsibility (DOFR) grid in your Agreement for a detailed listing of capitated services. Services not specifically excluded from capitation are included in the capitation payment made to the medical group/IPA or facility.
The capitation system uses a 15/30 rule to determine whether capitation is paid for the full month or not at all. If the effective date of a change falls between the first and 15th of the month, the change is effective for the current month, and capitation paid for that month. However, if the effective date falls on the 16th or later, the change reflected the first of the following month and capitation paid for the following month.
For capitation payments, we add members on the first day of the month, or terminated on the last day of the month. Newborns are added on their dates of birth. We pay or recoup commercial capitation for full months.
A member added retroactively between the first and the 15th of the month would generate a capitation payment for the entire month. However, a member added on the 16th or later would not generate a capitation payment for that month even though they would be considered eligible for services.
A member retroactively terminated between the first and 15th of the month would generate a capitation recoupment entry for the capitation previously paid for the entire month. However, a member retroactively terminated on the 16th or later would not generate a capitation recoupment entry for the capitation previously paid for the entire month.
We make monthly capitation payments to the medical group/IPAs and capitated facilities for providing and arranging covered services to our members.
We deliver capitation payments through check or electronic funds transfer on the date listed in the Agreement. If the due date falls on a non-banking day, we deliver the capitation payment the next banking day.
To receive capitation payments through EFT, we require a signed EFT Payments form detailing the bank account and bank routing information. It takes three weeks for the EFT initial setup, or a change in banking information, to take effect.
We deposit capitation payments through EFT by the end of the banking/business day on the date specified in the Agreement.
Note: Most financial institutions charge a per transaction fee on EFTs.
Use Link to access and submit Authorization Agreement Payments forms.
Capitation calculation methods are detailed in your Agreement. For commercial products, we use four capitation calculation methods:
Flat Rate Calculation: A flat rate (PMPM) capitation calculated by applying the flat rate for each member to yield the standard services capitation amount. The flat rate is detailed in your Agreement. Both the flat file and the image reports display each member-level transaction.
Fixed Rate Age/Gender Adjusted Calculation: Fixed rate age/gender adjusted capitation uses age/gender factors to modify the flat base rate up or down to align standard services capitation with age-weighted risk. The flat base rate multiplied by the age/gender factor yields the standard services capitation amount.
Age/gender factors work to weight for age/gender risk consideration with respect to the demographic population. UnitedHealthcare actuarially develops age/gender factors. The age/gender factors may vary between medical groups/ IPAs and are included in the Agreement.
We report the age/gender factors and standard services capitation amount at the member level on the flat file. Only the standard services capitation amount is reported on the image reports.
Fixed Rate Age/Gender/Benefit Adjusted Calculation: Fixed rate age/gender/benefit adjusted capitation contains three components: flat base rate, age/gender factor and benefit factor.
Fixed Rate Age/Gender/Copayment Adjusted Calculation: Copayment adjustment works to evaluate the member’s copayment made directly to the care provider. We actuarially derive the copayment adjustment for each copayment level.
The capitation source system can administer a single commercial contract with multiple rates, if the contract requires a different rate for members enrolled in a specific plan or in-network. These contracts are identified by the Primary Care Provider Network Indicator (PCPNI). The four capitation calculation methods described in the Capitation Calculation Methods section apply. This option is available for commercial contracts. It allows you to manage your capitation under one medical group/IPA number.
Capitation transactions reports can be summarized or detailed. All individual transactions are summarized by PNI code and reported on several capitations image reports. There are also detailed care provider PNI transactions reports on both the flat file (CP7810, column U, field 21) and image reports (CP7210, CP7230). Member PNI is reported on the flat file (CP7810, column AP, field 42).
For MA products, we use three capitation calculation methods:
It contains three components:
The risk-adjusted fixed rate capitation amount will vary monthly resulting in changes in the risk adjustment factor and demographic factors for Medicare Advantage plan members for that month. Both the flat file and image reports show each member-level transaction. The risk- adjusted fixed rate capitation has the standard six-month system retro window. Payments made by CMS outside the six-month retroactivity window are not included.