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Claim Reconsideration, Appeals Process and Resolving Disputes - Chapter 9, 2020 UnitedHealthcare Administrative Guide

Claim Reconsideration and Appeals Process

Claim reconsideration does not apply to some states based on applicable state law. Refer to Care Provider Dispute Resolution (CA Delegates OR HMO claims, OR and WA Commercial Plans) section for more information. Note: For Non-Network Care Providers Claim Appeals and Dispute Process, refer to UHCprovider.com/plans > Choose your state > Medicare > Select plan name >Tools & Resources > Non-Contracted Care Provider Dispute and Appeal Rights.

A processed claim in which you do not agree with the outcome of the original claim payment, correction, or denial.

Time Frame

You must submit both your reconsideration and appeal to us within 12 months (or as required by law or your Agreement), from the date of the EOB or PRA. The two-step process as outlined in the Claim Reconsideration and Appeal Process allows for a total of 12 months for timely submission and not 12 months for step one and 12 months for step two.

How to Submit your Reconsideration:

If you believe we underpaid you, the first step in addressing your concern is to submit a Claim Reconsideration Request.

  1. Online: The claimsLink tool. More information is available on  UHCprovider.com/claims > Submit a Claim Reconsideration.
  2. Paper: Use the Paper Claim Reconsideration Form on UHCprovider.com/claims. Mail the form to the applicable address listed on the EOB or PRA. The address may differ based on product. Include a copy of the original EOB or PRA. Please see applicable benefit plan supplement for specific contact information.
  3. Phone: To request an adjustment for a claim that does not require written documentation call the number on the member’s health care ID card.

20 or More Claims (Research Request)

If you have a request to reconsider 20 or more paid or denied claims for the same administrative issue (and attachments are not required), you may submit these in bulk online. Use the Claims Research Project tool on Link.

Attachments

If you are submitting medical documentation we requested for a pended claim:

  1. Online: Use claimsLink tool.
  2. Paper:
    • Complete the Claim Reconsideration Request Form and check “Previously denied/closed for Additional Information” as your reason for request.
    • Provide a description of the documentation submitted along with all pertinent documentation. It is extremely important to include the member name and health care ID number as well as your name, address and TIN on the Claim Reconsideration Request Form to prevent processing delays.

Use claimsLink to submit a Claim Reconsideration Request for a claim denied because filing was not timely:

Please provide one of the following documents:

  1. Electronic Data Interchange (EDI) report - include confirmation that it was received and accepted within your filing limit.
  2. A submission report from your accounting software to include a screen print to show the date the claim was submitted.
  3. A billing software statement to show the claim was submitted timely to the clearing house (if rejected proof is not acceptable).
  4. A resubmission form or letter with a statement that you billed the wrong insurance or the member gave you the wrong insurance information. If available, please include any other evidence you may have such as the other insurance carrier’s denial or rejection, EOB, letter indicating coverage terminated or member not eligible.

All proof must include documentation that the claim is for the right patient and the correct date of service. For electronic claims, include confirmation that we received and accepted your claim.

If you do not agree with the outcome of the claim reconsideration decision in step one, you may use the following claim appeal process.

Time Frame

You must submit your appeal to us within 12 months (or as required by law or your Agreement), from the date of the original EOB or PRA. The two-step process described in the Claim Reconsideration and Appeal Process allows for a total of 12 months for timely submission and not 12 months for step one and 12 months for step two.

Medical Records Request Submission Time frame

If medical records are requested to process an appeal, the following time frames are when the information is due:

  • Expedited appeals – within two hours of receipt of the request.
  • Standard appeals – within 24 hours of receipt of the request.

This includes providing a copy of the denial notice. Time frames may change based on applicable law or your Agreement.

What to Submit

Attach all supporting materials, such as member-specific treatment plans or clinical records to the formal appeal request, based on the reason for the request. Include information which supplements your prior adjustment submission that you wish included in the appeal review.

We make our decision based on the materials available at the time of formal appeal review. If you are appealing a claim denied because filing was not timely:

  • Electronic claims - include confirmation we received and accepted your claim.
  • Paper claims - include a copy of a screen print from your accounting software to show the date you submitted the claim.

All proof of timely filing must also include documentation that the claim is for the correct member and the correct date of service.

Where to Send Your Appeal

Online: A claims appeal may be filed using the claimsLink tool on UHCprovider.com/claimsLink. More information is available online. Not available for all care providers inall locations. You may attach medical records and notes as needed.

Paper: Address may differ based on product. Please see applicable benefit plan supplement for specific contact information.

Response details: If the claim then requires an additional payment, the EOB or PRA will serve as notification of the outcome on the review. If the original claim status is upheld, you will be sent a letter outlining the details of the review.

Response details (California only): If a claim requires an additional payment, the EOB or PRA itself does not serve as notification of the outcome of the review. We will send you a letter with the determination. In addition, you must send payment within five calendar days of the date on the determination letter. We will respond to you within the time limits set forth by federal and state law. After the time limit has passed, contact Provider Relations at 877-842-3210 to obtain a status.

If you are disputing a refund request that you received from us, please reference the Post-audit Procedures section in Chapter 10.

If a member has authorized you to appeal a clinical or coverage determination on the member’s behalf, such an appeal will follow the process governing member appeals as outlined in the member’s benefit contract or handbook.

Eligibility under a benefit plan may change retroactively if:

  1. We receive information an individual is no longer a member;
  2. The member’s policy/benefit contract has been terminated;
  3. The member decides not to purchase continuation coverage;
  4. The member fails to pay their full premium within the three month grace period established by the Affordable Care Act (and applicable regulations) for subsidized Individual Exchange members; or
  5. The eligibility information we receive is later determined to be incorrect.

If you have submitted a claim affected by a retroactive eligibility change, a claim reconsideration may be necessary, unless otherwise required by state and/or federal law. We list the reason for the claim reconsideration on the EOB or PRA. If you are enrolled in Electronic Payment System, you will not receive an EOB. However, you will be able to view the transaction online or in the electronic file. If we implement a claim reconsideration and request refund, we notify you at least 30 business days prior to any adjustment, or as required by law or your Agreement.

MA members who are hospital inpatients have the statutory right to request an immediate review by the Quality Improvement Organization (QIO) when UnitedHealthcare and the hospital, with physician concurrence, determine that inpatient care is no longer necessary. The QIO notifies the facility and UnitedHealthcare of an appeal.

  • When UnitedHealthcare completes the Detailed Notice of Discharge (DND), UnitedHealthcare delivers it to the facility and to the QIO. The facility will give the DND, on behalf of UnitedHealthcare, to the MA member, or their representative, as soon as possible, but no later than 12 p.m. local time of the day after the QIO notification of the appeal. The facility will also fax a copy of the DND to the QIO.
  • When the facility completes the DND, the facility will give the DND on behalf of UnitedHealthcare to the MA member, or their representative, as soon as possible but no later than 12 p.m. local time of the day after the QIO notification of the appeal.

The facility will fax a copy of the DND to the QIO and UnitedHealthcare. If the MA member fails to make a timely request to the QIO for immediate review and remains in the hospital, they may ask for an expedited reconsideration (appeal) by UnitedHealthcare.