Claims disputes and appeals, Capitation and/or delegation supplement - 2021 UnitedHealthcare Administrative Guide

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Contracted care providers who have a claim dispute with a delegated medical group/IPA must make sure they have followed all guidelines set forth by the medical group/IPA.

A request for reimbursement for any overpayment of a claim completed in compliance with state and/or federal regulations must:

  • Provide a clear, accurate, written explanation.
  • Be issued within 365 calendar days from the last date of payment for the claim.
  • Commercial claims — Give the care provider 30 working days to send written notice contesting the request for reimbursement for overpayment.

Non-contracted care provider disputes — CMS non-contracted care provider payment dispute resolution process (applicable to non-contracted MA paid claims)

A non-contracted care provider can use the CMS non-contracted care provider Payment Dispute Resolution (PDR) process for any decision where they contend the amount paid by the organization (i.e., the delegated entity) for a covered service is less than the amount which would have been paid under Original Medicare. This PDR process also includes disagreements between a non-contracted care provider and the delegate about the delegate’s decision to pay for a different service than that billed (i.e., bundling issues, rate of payment, DRG payment dispute). The care provider must submit a payment dispute within 120 calendar days from the date of the original claim determination. At a minimum, the delegate must have the following requirements and processes in place when handling claim payment disputes with an MA non-contracted care provider:

  • Well-defined internal payment dispute process that includes:
    • A system for receiving PDRs.
    • Proper identification of payment disputes. Care providers must clearly state what they are disputing and why, supply relevant information that will help support their position, including description of the issue, copy of submitted claim, supporting evidence to demonstrate what Original Medicare would have allowed for the same service, etc.
    • A system for tracking disputes.
    • Monitoring their PDR claims inventory.
  • A requirement to communicate the time frame of 120 calendar days from the original claim determination to submit a payment dispute to the non-contracted care provider at time of claim payment.
  • Information on how to submit an internal claim payment dispute to the organization communicated to the non-contracted care provider at time of claim payment, including their mailing address for submitting disputes and other dispute information (e.g., email addresses, phone numbers).
  • Requirements to process and respond (i.e., to finalize the PDR claim) to the non-contracted care provider within 30 calendar days from the date the PDR claim is received (oldest received date of the PDR claim).
  • Help ensure correct calculation of interest payments on overturned PDRs. Interest payment is required on a reprocessed, non-contracted care provider clean claim if the group made an error on the original determination. Interest is only applied on
  • the additional amount paid if the original claim was clean and calculated from the oldest receive date of the original claim until the check mail date of the additional amount paid.
  • Provide a complete and clear rationale to the non-contracted care provider for upheld PDRs.
  • Help ensure the PRA, EOP and uphold PDR determination letter have the right information and meet requirements.
  • Include information on how to contact the organization in notices of upheld or overturned payment disputes if the non- contracted care provider has questions.
  • Include information in the notices of upheld or overturned payment disputes on how to contact the organization if the non- contracted care provider has questions.
  • If the root-cause of overturned PDRs is system-related, have a process in place to update their claims system so future claims will reimburse appropriately.
  • Have a process in place that identifies trends that contract year for any non-contracted care provider who submitted a payment dispute to help ensure they are paid correctly.
  • Have an ongoing training program in place for any piece of the internal claim PDR process that educates all areas of the organization, such as customer service, claims, appeals.
  • Monitor internal compliance to help ensure CMS requirements are met.
  • Follow an end-to-end quality review process. It should start when a dispute is received from the non-contracted care provider until the dispute decision is sent to the non-contracted care provider.

The following are examples of issues excluded from the PDR process:

  • Instances in which a member filed an appeal, and you filed a dispute regarding the same issue. In these cases, the member’s appeal takes precedence. You can submit a care provider dispute after the member appeal decision is made. If you are appealing on behalf of the member, the appeal processes as a member appeal.
  • An Independent Medical Review initiated by a member through the member appeal process.
  • Any dispute filed outside of the timely filing limit applicable to you, and for which you fail to supply good cause for the delay.
  • Any delegated claim issues not reviewed through the delegated payer’s claim resolution mechanism.
  • Any request for a dispute, which involves reviews by the delegated medical group/IPA/payer or capitated facility/care provider and does not involve an issue of medical necessity or medical management.

All states: Use the most updated MA and commercial Monthly Timeliness Report (MTR) you received from the Claims Delegation Oversight Department.

  1. MTR forms, both monthly and quarterly reports, are due by the 15th of each month or the following business day if the due date falls on a weekend or holiday.
  2. MA CMS Universe Reports (Claims, DMRs and Dismissals) are due on the 10th of each month or the following business day if the due date falls on a weekend or holiday.
  3. PDR quarterly reports are due:
    • First Quarter: April 30
    • Second Quarter: July 31
    • Third Quarter: Oct. 31
    • Fourth Quarter: Jan. 31

If the due date for the PDR falls on a weekend or holiday, provide the following business day.

Delegated entities must complete an Action Improvement Plan (IAP) and submit it to the health plan for submitting untimely reports containing inaccurate or incomplete information.

All delegated entities must upload their MA CMS Universe Reports (Claims, DMRs and Dismissals) and MTR forms to the ECG Connect Portal.

Upload monthly MTR forms to the ECG Connect Portal by the 15th of each month. Upload MA CMS Universes to the ECG Connect Portal by the 10th of each month.

CA: Based on state regulatory requirements, UnitedHealthcare shall verify on a quarterly basis that our delegated entities have the administrative and financial capacity to meet contractual obligations through routine reviews of financial indicators and monitoring financial solvency deficiencies. UnitedHealthcare requires delegated entities to provide copies of quarterly financial statements, including a balance sheet, income statement and statement of cash flow. Prepare these based on generally accepted accounting principles within 45 calendar days of the end of each calendar quarter.

Submit copies of assessed annual financial statements together with copies of all auditors’ letters to management in connection with such reviewed annual financial statements submissions within 150 calendar days of the end of each fiscal year. If these financial statement submissions have deficiencies in financial solvency grading criteria defined by state regulations, submit a self-initiated Improvement Action Plan (IAP) proposal in an electronic format (template may be found on the website) to UnitedHealthcare within 45 calendar days of the end of the reporting period for which the deficiency was reported. In addition, submit quarterly progress reports to UnitedHealthcare within 45 calendar days of the end of each subsequent reporting period until compliance with all financial grading criteria achievement.

Email financial statements and IAPs to UnitedHealthcare at

Both UnitedHealthcare and the delegated entity must provide compliance oversight of the delegated entity’s financial reporting IAP.

Other UnitedHealthcare West delegated states (AZ/CO/NV/OK/TX): The delegated entities in these states must submit the Monthly Self-Reported Timeliness Reports within 15 calendar days following the month being reported.

CA Commercial NPI

The California Department of Managed Health Care (DMHC) Timely Access to Non-Emergency Health Care Services Regulation applies to California Commercial HMO membership only. The regulation establishes time-elapsed standards or guidelines to make sure members have timely and appropriate access to needed health care services, including a 24/7 telephonic triage or screening requirement. Health plans must comply with certain provisions of the regulation and provide an annual report detailing the status of the plan’s network care provider and enrollment, which includes the care provider’s NPI. To comply with this regulation, UnitedHealthcare requires all California Commercial HMO care providers to include their NPI with all care provider additions or when submitting a claim.

The CR&R process applies:

  • If you do not agree with the payment decision after the initial processing of the claim; and
  • Regardless of whether the payer was UnitedHealthcare, the delegated Medical Group/IPA or other delegated payer, or the capitated facility/care provider, you are responsible for submitting your claims to the appropriate entity that holds financial responsibility to process each claim.

UnitedHealthcare will research the issue to identify who holds financial risk for the services. We will abide by federal and state legislation on appropriate timelines for resolution. We work directly with the delegated payer when claims have been misdirected and financial responsibility is in question. If appropriate, direct all care provider-driven claim payment disputes to the delegated payer care provider Dispute Resolution process.

For UnitedHealthcare West Claims Disputes

Additional information, requirements, and mailing addresses regarding claims disputes for UnitedHealthcare West members can be found in the UnitedHealthcare West Supplement, UnitedHealthcare West Bulk Claims Rework Reference Table.

A delegated entity that is contractually delegated to process claims or approve referrals for service must have a fair, fast and cost-effective dispute resolution mechanism. This process must help manage contracted and non-contracted care provider disputes based on state and federal regulations.

If the dispute request is for services payable by the delegated entity, we determine if the appropriate payer has reviewed the request for dispute. If the appropriate payer has not reviewed the dispute request, we forward the dispute request

to the appropriate payer. We notify the care provider of service of the forwarding dispute request to the delegated entity for processing.

The delegated entity must submit all required information to us and the appropriate state agency based on state and federal regulations. All delegated claims processing entities are required to report PDR processing compliance results quarterly based on state and federal regulations. Submit quarterly reports no later than the 30th day following the end of the quarter.

We regularly conduct a compliance assessment of the PDR Process of each delegated entity. We review care providers at least annually.

As part of the compliance assessment, we request copies of Delegated Entity Provider Dispute report. The auditor reviews the reports and randomly selects finalized disputes for review. The auditor also requires a copy of the delegated entity’s PDR Policy and Procedures and evidence of the availability of the PDR mechanism. If the capitated medical group/IPA or capitated facility is non-compliant with UnitedHealthcare state or federal requirements, the delegated entities must develop an IAP designed to bring them back into compliance.

We sanction care providers who do not achieve compliance within the established time frames until they reach compliance. PDR processing is a delegated function subject to revocation. Sanctions may consist of additional/enhanced reviewing, onsite claims/PDR management, and/or revocation. There may be costs to the delegated entity depending on the sanction put in place.

If you continue to have a commercial claims dispute with the delegated entity related to medical necessity and utilization management, forward all claim information and correspondence between the delegated entity and you to UnitedHealthcare for review. We do not begin the review until we receive the supporting documentation.

Commercial care provider claims must be processed based on agreed-upon contract rates or member benefit plan and within state and federal requirements.

Note: Date stamps from other health plans or insurance companies are not valid received dates for timely filing determination.

Commercial interest rates and time frames for processing may vary, depending on the applicable state requirements. In some states, an additional penalty for late claims payments may also apply and be paid by the delegated medical group/IPA/facility.


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