We know you want to be paid promptly for your services. To help prompt payment:
Note: Use the payer ID number on the member’s health care ID card. The electronic claims submission number does vary. The claim will reject if the correct payer ID is not used.
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.
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:
› 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.
The process does apply for the following situations:
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.