Use electronic data interchange (EDI) to submit claims and conduct other business with us electronically. To enroll, call EDI customer service at 866-509-1593, or email RVITEDISolutions@uhc.com.
Tell your office software vendor that you want to begin transmitting electronic claims to the River Valley payer ID 87726 for medical claims and 95378 for dental.
We receive all claims through our clearinghouse, OptumInsight. The clearinghouse sets up claims as commercial. Your EDI software vendor must establish connectivity to the clearinghouse. They can make sure you meet the requirements to transmit claims.
Your software vendor will give you a report showing an electronic claim left your office. It does not confirm we or the clearinghouse received or accepted the claim.
Clearinghouse acknowledgment reports show the status of your claims. They are given to you after each transmission. This lets you confirm whether a claim reached us, rejected because of an error or needed additional information.
We will also send you status reports providing more data on claims. These include copies of EOBs/remittance advice and denial letters that may request more information.
Carefully review all vendor reports, clearinghouse acknowledgment reports and the River Valley status reports when you receive them.
Submit all medical or hospital services claims using, as applicable, the CMS 1500 or UB-04 claim forms. Or use their successor forms for paper claims and HIPAA-standard professional or institutional claim formats for electronic claims. Use black ink when completing a CMS 1500 claim form. This helps us scan the claim into our processing system.
We require you to submit claims electronically, with few exceptions. For electronic claims submission requirements, refer to Requirements for Complete Claims and Encounter Data Submission section in Chapter 9: Our Claims Process.
Share this document with your software vendor. We update the Companion Guide regularly, so review it to help ensure you have the most current information about our requirements.
For more information about electronic claims, refer to UHCprovider.com/claims.
Exceptions to Electronic Claims Submission Guidelines The following claims require attachments. This means they must be submitted on paper:
Modifier 59 helps identify procedures/services commonly bundled together but may be appropriate to report separately. No special rules apply to electronic claims joined using Modifier 59 or for dental pre-treatment claims.
› Institutional: Payer Prior Payment, Medicare Total Paid Amount, Total Non-Covered Amount, Total Denied Amount.
› Professional: Payer-Paid Amount, Line Level Allowed Amount, Patient Responsibility, Line Level Discount Amount (contractual discount amount of other payer), Patient-Paid Amount (amount that the payer paid to the member, not the care provider).
› Dental: Payer Paid Amount, Patient Responsibility Amount, Discount Amount, Patient Paid Amount.
› Span Dates: We require exact dates of service when the claim spans a period of time. Put the dates in Box 24 of the CMS 1500, Box 45 of the UB-04, or the Remarks field. This will prevent the need for an itemized bill and allow electronic submission.
Refer to Claim Reconsideration and Appeals Process in Chapter 9: Our Claims Process and in the How to Contact River Valley section of this supplement.
If you have a question about a pre-service appeal, please see Pre-Service Appeals in Chapter 6: Medical Management.