Claims Process

Time Frame for Claims Submission

To be considered timely, care providers, other health care professionals and facilities are required to submit claims within the specified period from the date of service:

Connecticut - 90 days
New Jersey - 90 or 180 days if submitted by a New Jersey participating care provider for a New Jersey line of business member
New York - 120 days

The claims filing deadline is based on the date of service on the claim. It is not based on the date the claim was sent or received. Claims submitted after the applicable filing deadline will not be reimbursed; the stated reason will be “filing deadline has passed” or “services submitted past the filing date” unless one of the following exceptions applies.

Exceptions:

If an agreement currently exists between you and Oxford or UnitedHealthcare containing specific filing deadlines, the agreement will govern.
If coordination of benefits caused a delay, you have 90 days from the date of the primary carrier explanation of benefits to submit the claim to us.
If the member has a health benefit plan with a specific time frame regarding the submission of claims, the time frame in the member’s certificate of coverage will govern.

If a claim is submitted past the filing deadline due to an unusual occurrence (e.g., care provider illness, care provider’s computer breakdown, fire, flood) and the care provider has a historic pattern of timely submissions of claims, the care provider may request reconsideration of the claim.

Clean and Unclean Claims, Required Information for all Claim Submissions

For complete details and required fields for claims processing, please refer back to Chapter 9: Our Claims Process.

Time Frame for Processing Claims

The state-mandated time frames for processing claims for our fully insured members are as follows. The time frames are applied based upon the site state of the member’s product:

Connecticut - 45 days (paper and electronic)
New Jersey - 40 days (paper), 30 days (electronic)
New York - 45 days (paper), 30 days (electronic)

We strive to process all complete claims within 30 days of receipt. If you have not received an explanation of benefits (EOB)/remittance advice within 45 days, and have not received a notice from us about your claim, please verify we received your claim.

Hospitals and Ancillary Facilities

A member must be enrolled and effective with us on the date the hospital and ancillary service(s) are rendered. Once the facility verifies a member’s eligibility with us, (We maintain a system for verifying member status.) that determination will be final and binding on us, unless the member or group made a material misrepresentation to us or otherwise committed fraud in connection with the eligibility or enrollment.

If an employer or group retroactively disenrolls the member up to 90 days following the date of service, we may deny or reverse the claim. If there is a retroactive disenrollment for these reasons, the facility may bill and collect payment for those services from the member

or another payer. A member must be referred by a participating care provider to a participating facility within their benefit plan’s network. Network services require an electronic referral or prior authorization consistent with the member’s benefits.

Requirements for Claim Submission with Coordination of Benefits (COB)

Under COB, the primary benefit plan pays its normal plan benefits without regard to the existence of any other coverage. The secondary benefit plan pays the difference between the allowable expense and the amount paid by the primary plan, if the difference does not exceed the normal plan benefits which would have been payable had no other coverage existed.

If Oxford is secondary to a commercial payer, bill the primary insurance company first. When you receive the primary carrier’s explanation of benefits (EOB)/remittance advice, submit it to us along with the claim information.

These claims must be submitted using a paper claim form with primary remittance advice attached. Oxford secondary claims may not be sent electronically.

We participate in Medicare Crossover for all our members who have Medicare as their primary benefit plan. This means Medicare will automatically pass the remittance advice to us electronically after the claim has been processed. We may process these claims as secondary without a claim form or remittance advice from your office.

Note: If Medicare is the secondary payer, you must continue to submit the claim to Medicare. We cannot crossover in reverse.

Determining the Primary Payer Among Commercial Plans When a member has more than one commercial health insurance policy, primary coverage is determined based upon model regulations established by the National Association of Insurance Commissioners (NAIC).

COB provision rule: The benefit plan without a COB provision is primary.
Dependent/non-dependent rule: The benefit plan covering the individual as an employee, member or subscriber or retiree is primary over the benefit plan covering the individual as a dependent.
Birthday rule: The “birthday rule” applies to dependent children covered by parents who are not separated or divorced. The coverage of the parent whose birthday falls first in the calendar year is the primary carrier for the dependent(s).
Custody/divorce decree rule: If the parents are divorced or separated, the terms of a court decree determines which benefit plan is primary.
Active or inactive coverage rule: The benefit plan covering an individual as an employee (not laid off or retired), or as that employee’s dependent, is primary over the benefit plan covering that same individual as a laid off or retired employee or as that employee’s dependent.
Longer/shorter length of coverage rule: If the preceding rules do not determine the order of benefits, the benefit plan that has covered the person for the longer period of time is primary.

Coordinating with Medicare Benefit Plans

We coordinate benefits for members who are Medicare beneficiaries according to federal Medicare program guidelines.

We have primary responsibility if any of the following apply to the member:

65 years or older, actively working and their coverage is sponsored by an employer with 20 or more employees
Disabled, actively working and their coverage is sponsored by an employer with 100 or more employees
Eligible for Medicare due to end-stage renal disease (ESRD) and services are within 30 months of the first date of dialysis

Reimbursement Claim Components

Additional Copies of EOBs/remittance advice: Should you misplace a remittance advice, you may obtain a copy by performing a claims status inquiry on OxfordHealth.com > Providers or Facilities > Transactions > Check > Claims.

Ancillary facility reimbursement: We reimburse ancillary health care providers for services provided to members at rates established in the fee schedule or in attachment or schedule of the ancillary contract.

Fee schedules: Although our entire fee schedule is proprietary and may not be distributed, upon request, we provide our current fees for the top codes you bill. Provider Services may provide this information to answer questions regarding claims payment.

Global surgical package (GSP): A global period for surgical procedures GSP may be found in the Global Days policy at OxfordHealth.com > Providers or Facilities > Tools & Resources > Medical Information > Medical and Administrative Policies > Medical & Administrative Policy Index > or UHCprovider.com/policies > Commercial Policies > UnitedHealthcare Oxford Clinical, Administrative and Reimbursement Policies. Refer to the back of the member’s health care ID card for the applicable website.

Hospital reimbursement: We reimburse hospitals for services provided to members at rates established in the attachment of the hospital contract.

Modifiers: Modified procedures are subject to review for appropriateness consistent with the guidelines outlined in our policies. For complete details regarding the reimbursement of recognized modifiers, refer to the Modifier Reference policy at OxfordHealth.com > Providers or Facilities > Tools & Resources > Medical Information > Medical and Administrative Policies > Medical & Administrative Policy Index > Modifier Reference Policy or UHCprovider.com/policies > Commercial Policies > UnitedHealthcare Oxford Clinical, Administrative and Reimbursement Policies. (Refer to the back of the member’s health care ID card for the applicable website.)

PCP/Specialist reimbursement: All PCPs and specialists agree to accept our fee schedule and payment and processing policies associated with administration of these fee schedules.

Release of information: Under the terms of HIPAA, we have the right to release to, or obtain information from, another organization to perform certain transaction sets.

Requests for additional information: There are times when we request additional information to process a claim. Submit the requested information promptly as outlined in the request. If you don’t submit it within 45 days, you must submit an appeal with the information.

Reimbursement address, phone or TIN changes:

An accurate billing address is necessary for all claims logging, payment and mailings. Notify us of any changes. For instructions and forms on how to do so, refer to OxfordHealth.com > Providers or Facilities > Tools & Resources > Forms > Provider Demographic Change Form.

New York Health Care Reform Act of 1996 (HCRA) The enactment of the HCRA, in part, created an indigent care (bad debt and charity care) pool to support uncompensated care for individuals with no insurance or who lack the ability to pay. Therefore, the New York Bad Debt and Charity (NYBDC) surcharge is applied on a claim-by-claim basis. The NYBDC surcharge applies to most services of general facilities and most services of diagnostic and treatment centers in New York. Your obligation is to:

Understand your eligibility as it relates to HCRA.
Know what services are surchargable services, and bill such services accordingly.

For additional information on HCRA, reference the New York Department of Health’s website: health.ny.gov > Laws and Regulations (on the right under Site Contents) > Health Care Reform Act.

Claims Process, Oxford - 2020 UnitedHealthcare Administrative Guide