You must submit a claim and/or encounter for your services, regardless of whether you have collected the copayment, deductible or coinsurance from the member. If you have questions about submitting claims to us, please call us at the phone number listed on the member’s health care ID card.
It is important to accurately code the claim because a member’s level of coverage under their benefit plan may vary for different services. To help correctly code your claims, use the Claim Estimator on UHCprovider.com/claims. It includes a feature called Professional Claim Bundling Logic. This helps you determine allowable bundling logic and other commercial claims processing edits for a variety of procedure codes. This is not available for all products.
Pricing and payment calculations for professional commercial claims are available under the Pre- Determination of Benefits option. Allow 45 calendar days for us to process your claim, unless your Agreement says otherwise. Check the status on Claims (on Link) before sending second submissions or tracers. If you do need to submit a second submission or a tracer, please submit it electronically no sooner than 45 days after original submission.
Complete claims by including the information listed under the Requirements for Complete Claims and Encounter Data Submission section. We prefer to receive claims electronically, but we do accept claims submitted on paper. Send the completed and appropriate forms to the claims address listed on the back of the member’s health care ID card.
If we receive a claim electronically with missing information or invalid codes, we may reject the claim, not process it or, if applicable, not submit it to CMS for consideration in the risk adjustment calculation.
If we receive a similar claim using the paper form, we may pend it to get the correct information. We may also require additional information for particular types of services, or based on particular circumstances or state requirements.
To order CMS 1500 and CMS-1450 (also known as UB-04) forms, contact the U.S. Government Printing Office at 202-512-0455, or visit the Medicare website at: cms.gov/Medicare/Billing/ElectronicBillingEDITrans/16_1500.html
We may pend or deny your claim if you do not list:
Include a detailed description of the procedure or service for claims submitted with:
Your claim may be pended or not processed if you do not include:
Your claim must be filed within your timely filing limits or it may be denied. If you disagree with a claim that was denied due to timely filing, you will be asked to show proof you filed the claim within your timely filing limits.
Timely filing limits vary based on state requirements and contracts. Refer to your internal contracting contact or Provider Agreement for your specific timely filing requirements.