Care Provider Responsibilities, Capitation and/or Delegation - 2020 UnitedHealthcare Administrative Guide

To help ensure we have your most current provider directory information, submit any changes to:

For Delegated providers: email changes to or

For Non-delegated providers: Visit for the Provider Demographic Change Submission Form and further instructions.

For delegated care providers of Medicare Advantage plans, if you are expecting any significant changes to your network, we strongly recommend you notify your provider advocate prior to the third quarter of the calendar year. This helps our members select the correct care provider during the annual enrollment period from October to December, and reduces provider directory errors.

EDI is our preferred choice for conducting business transactions with physicians and health care industry partners. We accept EDI claims submission for all of our product lines. You can find information and help with EDI by going to, and in this guide under Electronic Data Interchange (EDI) section of Chapter 2: Provider Responsibilities. Responsibilities, including information about ASC X12 Technical Report Type 3 publications, companion guides, and a list of standardized HIPAA-compliant EDI transactions.

The ASC X12 Technical Report Type 3 (TR 3 also known as HIPAA Implementation Guides) publications are the authoritative source for EDI Transactions. The ASC X12 Technical Report Type 3 publications are available for purchase from Washington Publishing via

We developed guides to provide transaction specific information required by us for successful EDI submissions. UnitedHealthcare Companion Guides are available for viewing and download from

The following table includes standardized HIPAA-compliant EDI transactions available at UnitedHealthcare:

ANSI ASC X12N Transactions

HIPAA EDI Transactions Acceptable UnitedHealthcare Versions: 005010X279A1
Available at UnitedHealthcare Transaction Descriptions: Eligibility Benefits Inquiry and Response (Real Time and Batch)

HIPAA EDI Transactions Acceptable UnitedHealthcare Versions: 005010X212
Available at UnitedHealthcare Transaction Descriptions: Claim Status Inquiry and Response (Real Time and Batch)

HIPAA EDI Transactions Acceptable UnitedHealthcare Versions: 005010X218
Available at UnitedHealthcare Transaction Descriptions: Premium Payment

HIPAA EDI Transactions Acceptable UnitedHealthcare Versions: 005010X220A1
Available at UnitedHealthcare Transaction Descriptions: Benefit Enrollment and Maintenance

HIPAA EDI Transactions Acceptable UnitedHealthcare Versions: 005010X221A1
Available at UnitedHealthcare Transaction Descriptions: Claims Payment and Remittance Advice

HIPAA EDI Transactions Acceptable UnitedHealthcare Versions: 005010X222A1
Available at UnitedHealthcare Transaction Descriptions: Healthcare Claim/Encounter Professional

HIPAA EDI Transactions Acceptable UnitedHealthcare Versions: 005010X223A2
Available at UnitedHealthcare Transaction Descriptions: Healthcare Claim/Encounter Institutional

The medical group/IPA shall provide us with at least 90 calendar days written notice prior to any changes to the medical group/IPA or network care providers. Include in the notice:

  • Inability of medical group/IPA to properly serve more members due to lack of PCPs.
  • Closing or opening the PCP’s practice to more members.
  • Closure of any office or facility the medical group/IPA, PCPs or other network care provider and health care professional uses.

The medical group/IPA, its care providers and other licensed independent health care professionals shall continue to accept members during the 90-day notice. For purposes of this section, a new member may be a member who has switched health plans and/or coverage plans. This includes a member who switches from a Fee-For-Service (FFS) plan to a Commercial HMO/MCO plan.

California Requirements for Capacity Reporting

We require capitated providers to give us updates within five business days if capacity changes affect your ability to accept new members. If we receive notification your information is inaccurate, you will be subject to corrective action.

You must make reasonable efforts to limit Protected Health Information (PHI) as defined under the Health Insurance Portability and Accountability Act (HIPAA) Privacy Rule to the minimum necessary when using or disclosing PHI. The minimum necessary standard should not affect treatment, payment or health care operations (TPO). The Privacy Rule requires written member authorization for uses and disclosure that fall outside of the TPO.

You must not discriminate against any patient with regard to quality of service or accessibility of services, because they are our member. You must not discriminate against any patient on the basis of:

  • Race
  • Ethnicity
  • National origin
  • Religion
  • Sex
  • Age
  • Mental or physical disability or medical condition
  • Sexual orientation
  • Claims experience
  • Medical history
  • Evidence of insurability
  • Disability
  • Genetic information
  • Source of payment
  • Medicaid status for Medicare members

You must maintain policies and procedures to demonstrate you do not discriminate in the delivery of service and accept for treatment any members in need of the service you provide.

The delegated care provider group must include the California Department of Managed Health Care’s (DMHC) approved Notice of Availability of Language Assistance with each vital document containing member-specific information issued to UnitedHealthcare’s Language Assistance Program (LAP) members. The Notice must be included in UnitedHealthcare’s threshold languages (English, Spanish and Chinese). Vital documents include UM modification, delay, or denial letters issued to our members by the delegated care provider group. We review compliance with this requirement during the annual assessment of delegated medical management.

UnitedHealthcare worked with Industry Collaborative Effort (ICE) to standardize the inclusion of the required notice.

ICE Instructions include two options available at

  • Option 1: UnitedHealthcare of California Notice of Availability of Translative Services as a separate document
  • Option 2: UnitedHealthcare California-Specific Templates, Commercial Service Denial Notice (CSDN), and Commercial Delay-Extension containing LAP Notice of Translation Documents

Interpretive/Auxiliary Aide Services

Delegated care providers must have mechanisms to help ensure the provision of auxiliary aides. This includes sign language interpreters to sensory-impaired members as required to provide members with an equal opportunity to access and participate in all health care services.

If the member requests interpretive/auxillary aide services, you must arrange these services promptly to avoid a delay in care at no cost to the member.

Members have the right to a certified medical interpreter or sign language interpreter to translate health information accurately. The interpreter must respect the member’s privacy and keep all information confidential. Friends and family of limited English proficiency or hearing impaired members may arrange interpretive services only after our standard methods have been explained and offered by the care provider, and the member refuses. Document the refusal of professional interpretation services in the member’s medical record.

In a professional capitation Agreement, the medical group/ IPA receives capitation for medical services. We pay selected facility services out of the HIP. The HIP provides an incentive for the medical group/IPA to utilize facility services such as inpatient activity, in-area emergency services and other selected outpatient services provided to our members efficiently. The HIP calculates surpluses and deficits based on an annual comparison of accumulated actual expenses in accordance with the terms of the UnitedHealthcare medical group/IPA agreement.

This section provides general information for a professional capitation arrangement on the following:

  • How are HIP results calculated?
  • What services are included in the HIP?
  • What information is available to assess HIP performance?

The Integrated Healthcare Association (IHA) P4P Value Based Incentive Program for commercial members is not a component of the capitation Agreement. It is under a separate letter of Agreement.

The budget for the Medicare Advantage Hospital Incentive Program (MAHIP) for Medicare members is based on a percent of premium, less the reinsurance premium. Aside from the budget, all other aspects of the HIP apply to the MAHIP.

Reinsurance is required to protect the HIP budget and medical group/IPA against catastrophic cases.

The Division of Financial Responsibility (DOFR) section of the Agreement defines the actual HIP costs. It typically includes the following:

  • Inpatient costs for facility services rendered to our members by network care providers valued at the actual costs we incur.
  • Other facility services given to our members by network care providers other than inpatient services, valued at actual costs we incur.
  • The actual amount paid for facility services, which are rendered by non-network care providers.
  • A percentage of all facility services incurred during the period but not yet processed (for the interim calculation), minus:
    • Reinsurance recoveries; and
    • Third-party recoveries received during calculation.

We monitor the medical group/IPA performance through:

  • Records of authorized services.
  • Claims paid/denied reports.
  • HIP financial report for the settlement period. The report details:
    • Total number of member months.
    • Total budget allocation for the member months.
    • Total expenses paid during the period.
    • A description of each amount of expense allocated to the risk arrangement by member ID number, date of service, description of service by claim codes, net payment, and date of payment.

We perform interim settlements, the final settlement and reconciliation of the HIP.

We provide a quarterly incentive program report to the medical group/IPA within 45 calendar days of the close of each calendar quarter. The incentive program report contains the monitored information.

In a split capitation Agreement, the medical group/IPA receives capitation for the provision of medical services. The facility receives capitation for facility services and selected outpatient services. The medical group/IPA and facility may create and administer their own facility incentive program under a split capitation Agreement.

A “rider contract” is a contract the medical group/IPA obtains for services covered under capitation or paid for out of the facility incentive program. The medical group/ IPA must submit copies of rider contracts to us.

The most common examples of services for which rider contracts are established include specialist services, ancillary services and outpatient facility services.

Contract Criteria

The rider contract must be signed by both parties. The medical group/IPA must submit the following required information, along with an original, signed letter saying the care provider may access rates as described in the Agreement to pay claims for our members assigned to the medical group/IPA, even if the Agreement includes assignability language:

  • Address.
  • TIN, IRS number.
  • NPI.
  • Phone number.
  • Name and title of contact person at care provider’s office.
  • Care provider specialty.

This contractual documentation needs submission:

  • Cover page of the contract.
  • Definition section.
  • Rate pages, including any withholds, exclusions or special arrangements.
  • Effective date of rates.
  • Signature page (signed by both parties).
  • Payment terms (e.g., due in 45 or 60 calendar days).
  • Rate renewal terms (e.g., automatically or renegotiated).
  • Late penalty terms.
  • Claims timely filing language.
Contract Entry

We review the rider contract. Based on the contract criteria and other considerations, we determine if the rider contract qualifies for data entry into our claims payment system.

If the rider contract qualifies, we enter it into the claims payment system with an effective date beginning the first of the month following a 60-day load and review period. We will not retroactively adjust claims paid prior to receipt, data entry of the contract or the effective date used in our claims payment system.

Let us know if you terminate a rider contract or change the terms of the rider contract relative to reimbursement or claims payment turnaround time. In addition, confirm annually the rates and provisions previously submitted have not changed.

We either post online, or distribute to each medical group/ IPA, a monthly-shared risk claims report that lists the actual costs incurred and denied during the previous month for services included in the HIP. The medical group/IPA should review this report each month to make sure the claims were processed and/or paid correctly.

The following tools will help the medical group/IPA in analyze the Shared Risk Claims Report:

  • Claims Code Sheet.
  • Place of Service Mapping — this document cross-references the CMS place of service codes to UnitedHealthcare’s internal place of service codes.

Use the Discrepancy Report to request research of the payment or denial of a claim we processed. After reviewing the Monthly Shared Risk Claims Report, complete all fields in the Discrepancy report and submit it electronically to our Network Care Provider Management department. If all required fields are not completed, we will return the files to the medical group/IPA. The required fields include:

  • Member ID number (seven-digit number)
  • Member ID number suffix (two-digits) (e.g., 01, 02)
  • Claim number
  • Expected care provider reimbursement
  • Care provider comments — why the medical group/IPA is disputing the payment.

Discrepancy Report Timely Filing

The medical group/IPA must submit Discrepancy Reports monthly. We do not pursue recoveries of overpayments you submit late based on your Agreement with us or by state law.

We reserve the right to deny/reject any request for review submitted beyond the timely filing limit.

Individual Stop Loss (ISL)/Reinsurance (REI) limits the medical group’s/IPA’s/facility’s financial risk for medical and facility services beyond a specified dollar amount per member, per calendar year. This program applies to services for which we capitated the medical group/IPA/ facility.

The ISL program is updated annually. Each medical group/ IPA/facility may take part each year.

The medical group/IPA may purchase ISL/reinsurance from us or an outside carrier.

We determine our premium for ISL based on our experience. We convert the calculated premium for stop loss to either a percentage of premium or flat per member per month (PMPM) rate based on the medical group’s/ IPA’s Agreement. Every month, we subtract the result from the total capitation.

We reimburse a medical group/IPA that purchases ISL through us for services that exceed the ISL deductible at the ISL program rates specified in the Agreement or the ISL election letter for the applicable contract year, minus the medical group’s ISL coinsurance amount.

We reimburse a facility that purchases reinsurance through us for services that exceed the reinsurance deductible at the reinsurance program rates specified in the Agreement or the reinsurance election letter for the applicable contract year, less the facility’s reinsurance coinsurance. The facility must identify all reinsurance claims before submission. The facility reinsurance program is updated annually.

The medical group/IPA or facility may elect to opt out of the UnitedHealthcare ISL/reinsurance program by purchasing ISL/reinsurance coverage through a third- party insurance carrier. Such coverage must be through an entity we approve of and in the amounts required by UnitedHealthcare and state and federal law. Refer to your Agreement for details.

Notification of ISL/Reinsurance Claims

The medical group/IPA or facility provides written notification to us when services for a member equal 50% of the ISL/reinsurance deductible. The written notification submission needs to be to us no later than the 15th day of the month following the month in which the claim amounts reach the 50% threshold.

ISL/Reinsurance Claims Submission Procedure

Submit all ISL/reinsurance claims having met the ISL/ reinsurance deductible to us annually but no later than 90 calendar days after the end of the calendar year.

To receive reimbursement under the ISL/reinsurance program, follow these steps:

  • Submit the ISL/reinsurance claims by spreadsheet to email address Please scan and email all hard-copy images
  • Include these on the submission spreadsheet:
    • Service care provider name
    • Date of service
    • Service description
    • Correct RBRVS or CPT codes and description of services if required
    • Billed charges
    • Place of service
    • Medical group/IPA paid amount
    • Other insurance information
    • Discount adjustments
    • ICD-10-CM diagnosis codes
    • Proof of payment (copies of cancelled checks)
  • Each spreadsheet submission sheet must be for one member only. Combined submissions for an entire family or for more than one member are not acceptable.
  • For capitated services rendered outside the medical group/IPA/facility, copies of cancelled checks showing actual amounts paid will be required. Upon request, you may be required to submit copies of all referral bills and/ or copies of consultation and operative reports.
  • We may ask you to submit a brief member history (copy of a consultant report and/or history dictation). We do not require lab results, X-ray results or records.
  • These are excluded from the calculation of ISL/ reinsurance claims:
    • Member copayment amounts
    • Non-covered services
    • Services paid by Workers’ Compensation
    • Services paid by other health plans
    • Services paid through third party reimbursement

Our Claims Production Unit reviews the claim for completeness and tells medical group/IPA/facility if it needs any other information. It may need supporting records for ISL/reinsurance claim verification. After review, if the claim is accepted, we make a payment within 60 calendar days.  Please submit ISL/Reinsurance claims to