Claims Process, UnitedHealthOne- 2020 UnitedHealthcare Administrative Guide

Claims Process

We know you want to be paid promptly for your services. To help prompt payment:

1. Notify us, based on the notification requirements in this supplement.
   • For Navigate referrals, refer to Chapter 5: Referrals.
2. Prepare a complete and accurate claim form. For facility (UB-04/8371) claims see number four below.
3. Submit electronic claims using the electronic payer ID on the health care ID card, or submit paper claims to the address listed on the member’s health care ID card. GRIC payer ID is 37602.
4. Requirements for claims (paper or electronic) reporting revenue codes:

• All claims reporting revenue codes require the exact dates of service if they are span dates.
• If you report revenue code 274, you are required to provide a description of the services or a valid CPT or HCPCS codes.
• All claims reporting the revenue codes on the following list require that you report the appropriate CPT and HCPCS codes.

Claim Adjustments

If you believe your claim was processed wrong, call the number on the back of the member’s health care ID card and request an adjustment as soon as possible, in accordance with applicable statutes and regulations. If you identify a claim overpayment, or we notify you of an overpayment, send us the overpayment within 30 calendar days from the date of identification or notification.

Claim Reconsideration, Appeals and Disputes

If you disagree with a claim payment determination or adjustment, you may appeal. Send a letter requesting a review to the following address:

Grievance Administrator

P.O. Box 31371

Salt Lake City, UT 84131-0371

Standard Fax: 801-478-5463

Phone: 800-657-8205

If you feel your situation is urgent, request an expedited (urgent) appeal by phone, fax or in writing to:

Grievance Administrator 3100 AMS Blvd.

Green Bay, WI 54313

Expedited Fax: 866-654-6323

Phone: 800-657-8205

Your appeal must be submitted within 12 months from the date of payment shown on the EOB, unless your Agreement with us or applicable law provide otherwise.

Please refer to Claim Reconsideration and Appeals Process section in Chapter 9: Our Claims Process.

If you disagree with the outcome of the claim appeal, you may file an arbitration proceeding as described in your Agreement.

Claim reconsideration does not apply to some states based on applicable state law (e.g. Arizona, California, Colorado, New Jersey, Texas). For states with applicable law, dispute requests will follow the state specific process.

New Jersey Care Provider Dispute Process Disputes involving New Jersey (NJ) commercial members are subject to the NJ state-regulated care provider dispute process.

The state-regulated care provider dispute process does not apply in the following situations:

• Our determination involves a utilization management (UM) denial. UM denials are refusals to pay a claim or to authorize a service or supply because we have determined the service or supply is:

› Not medically necessary;

› Experimental or investigational;

› Cosmetic;

› Dental rather than medical; or

› Treatment of a pre-existing condition.

UM denials include prescription quantity limit denials and requests for in-plan exception denials. You may appeal a UM denial by going through the Internal UM Appeals Process described under the Member Complaints and Grievances section. You must submit a completed Consent to Representation in Appeals of Utilization Management Determinations and Authorization for Release of Medical Records in UM Appeals and Independent Arbitration of Claims form to begin the UM appeal process.

• Our determination indicates we denied the service or supply as not covered under the terms of the plan or because the person is not our member.
• The dispute is due to coordination of benefits.
• We have provided you notice that we are investigating this claim (and related ones, as appropriate) for possible fraud.

The process does apply for the following situations:

• The claim was not paid for any reason other than previously listed;
• The claim was paid at a rate you did not expect based on your network contract or the terms of the plan;
• The claim was paid at a rate you did not expect because of differences in our treatment of the codes in the claim from what you believe is appropriate;
• We required additional substantiating documentation to support the claim, and you believe the required information is inconsistent with our stated claims handling policies and procedures or is not relevant to the claim;
• You believe we failed to adjudicate the claim, or an uncontested portion of a claim, in a timely manner consistent with law and the terms of your network contract, if any;
• Our denial was due to lack of appropriate authorization, but you believe you obtained appropriate authorization from us or another carrier for the services;
• You believe we failed to appropriately pay interest on the claim;
• You believe our statement that we overpaid on one or more claims; a claim is erroneous or the amount we calculated as overpaid is erroneous;
• You believe we have attempted to offset an inappropriate amount against a claim because of an effort to recoup for an overpayment on prior claims.

If the dispute is eligible, the following process will apply: Submit a written request for appeal using the Health Care Provider Application to Appeal a Claims Determination Form created by the New Jersey Department of Banking and Insurance. Submit the request within 90 days following receipt of our initial determination notice to:

UnitedHealthcare Oxford Navigate Individual Grievance Administrator

P.O. Box 31371

Salt Lake City, UT 84131-0371

Standard Fax: 801-478-5463

We will review the request and tell you our decision in writing within 30 calendar days of receipt of the form.

If you are not satisfied with the decision, you may initiate the New Jersey Program for Independent Claims Payment Arbitration (PICPA) process. Submit your requests to Maximus, Inc. within 90 calendar days from receipt of the internal dispute decision. A dispute is eligible if the payment amount in dispute is $1,000 or more. The arbitration decision is binding.