Claims processes, Capitation and/or delegation - 2021 UnitedHealthcare Administrative Guide

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We may delegate claims processing to entities that have requested delegation and have shown through a pre-delegation assessment they are capable of processing claims compliant with applicable state and/or federal regulatory requirements, and health plan requirements for claim processing.

Delegated entities must develop and maintain claims operational and processing procedures that allow for accurate and timely claim payments. Procedures must properly apply benefit coverage, eligibility requirements, appropriate reimbursement methodology, etc. and meet all applicable state and/or federal regulatory requirements, and health plan requirements for claim processing.

Submit a clean claim by providing the required data elements, along with any attachments and additional elements. Also include any revisions to data elements, of which you properly notified, and any coordination of benefits or non-duplication of benefits information if applicable. Refer to Requirements for complete claims and encounter data submission in Chapter 10: Our Claims Process, for further details.

A delegated medical group/IPA must implement and maintain a post-service/retrospective review process consistent with UnitedHealthcare processes.

We define a post-service/retrospective/medical claim review as the review of medical care treatments, medical documentation and billing after the service has been provided.

We perform a medical claim review to provide fair and consistent means to review medical claims and confirm delegates meet the following criteria:

  • Medical necessity determinations.
  • Admission, length of stay and LOC are appropriate.
  • Eligibility was verified.
  • Follow-up for utilization, quality and risk issues was needed and initiated.
  • Billing is correct.
  • Claims-related issues as they relate to medical necessity and UnitedHealthcare claims payment criteria and/or guidelines are identified and resolved.

We also perform medical claim reviews on claims that do not easily allow for additional focused or ad-hoc reviews, such as:

  • High-dollar claims.
  • Claims without required authorization.
  • Claims for unlisted procedures.
  • Trauma claims.
  • Implants not identified on our implant guidelines used by our claim department.
  • Claim check or modifier edits based on our claim payment software.
  • Foreign claims.
  • Claims with level of service (LOS) or LOC mismatch.

The delegated medical group/IPA is accountable for conducting the post-service review of emergency department claims and unauthorized claims. Review presenting symptoms, as well as the discharge diagnosis, for emergency services.

Consideration of emergency department claims must include:

  • Coverage of emergency services to screen and stabilize the member without prior approval where a prudent layperson, acting reasonably, would have believed that an emergency medical condition existed.
  • Coverage of emergency services if an authorized representative, acting for the organization, has authorized the provision of emergency service.
  • Appropriate care provider review of presenting symptoms, as well as the discharge diagnosis.

Medical group/IPA monitors appeals and overturn rates for emergency department claims. They develop and execute improvement action plans when they identify deficient performance or processes.

We have policies and procedures designed to monitor the delegated entities’ compliance with contractual state and federal claims processing requirements. Our auditors perform claims processing compliance assessments. We review delegated entities at least annually. Our auditors also review for:

  • Assessment results indicate non-compliance.
  • Self-reported timeliness reports indicate non-compliance for 2 consecutive months.
  • Non-compliance with reporting requirements.
  • Lack of resources or staff turnover.
  • Overall performance warrants a review (claims appeal activity, claims denial letters or member and care provider claims- related complaints).
  • Allegations of fraudulent activities or misrepresentations.
  • Information systems changes or conversion.
  • New management company or change of processing entity.
  • Established management service organization (MSO) acquires new business.
  • Significant increase in members or volume of claims.
  • Significant increase in claims-related complaints.
  • Regulatory agency request.
  • Significant issues concerning financial stability.

As part of our compliance assessment, we request copies of the delegated entity’s universal claims listing for all care providers. The auditor reviews the reports and selects random claims for further review. The delegated entity must be ready for the auditor at the time of assessment. We review:

  • Timeliness assessment.
  • Financial accuracy (including proper benefit application, appropriate administration of member cost-share accumulation).
  • Administrative accuracy.
  • Customer denial accuracy and denial letter review.
  • Care provider denial assessment.
  • Non-contracted care provider payment dispute resolution (overturns and upholds) claims assessment.
  • Fraud, waste and abuse inspection.
  • Claim operational policies and procedures.
  • Maximum out-of-pocket (MOOP) administration.
  • Timely forwarding of misdirected claims.

When we find a delegated entity is not compliant with contractual state and/or federal regulations, and/or UnitedHealthcare standards for claims processing, they must provide a remediation plan describing how the deficiencies will be corrected.

The remediation plan should include a time frame the deficiencies will be corrected. Delegated entities who do not correct deficiencies may be subject to additional oversight, remediation enforcement and potential de-delegation.

If the delegated entity is non-compliant, we require them to develop an Improvement Action Plan (IAP) to correct any deficiency. Problems include, but are not limited to:

  • Processing timeliness issues.
  • Failure to pay interest or penalties.
  • Failure to submit monthly/quarterly self-reported processing timeliness reports.
  • Canceling assessments.
  • Failure to submit requested claims listings.
  • Failure to have all documentation ready for a scheduled assessment.
  • Failure to provide access to canceled checks or bank statements.

When we put a delegated entity on an IAP, we place them on a cure period. A cure period is the time frame we give a delegated entity to demonstrate compliance or remain in the cure period until they achieve compliance. The cure period is based on

the Agreement but typically up to 60 days. A critical deficiency requires cure within 30 days. We conduct frequent reviews during the cure period. We may place delegated entities who do not achieve compliance within the established cure period on remediation enforcement. Remediation enforcement may consist of conducting an on-site operational assessment, stringent weekly and monthly oversight and monitoring, onsite claims management, revocation of delegated status, and/or enrollment freeze. We bill the delegated entity for all remediation enforcement activities.

When a delegated entity receives a claim for a commercial or MA member, they must assess the claim for the following before issuing a denial letter:

  • Member’s eligibility status with UnitedHealthcare on the date of service.
  • Responsible party for processing the claim (forward to proper payer).
  • Contract status of the care provider of service or referring care provider.
  • Presence of sufficient medical information to make a medical necessity determination.
  • Covered benefits.
  • Authorization for routine or in-area urgent services.
  • Maximum benefit limitation for limited benefits.
  • Prior to denial for insufficient information, the medical group/IPA/capitated facility must document their attempts to get information needed to make a determination.

When a member is financially responsible for a denied service, UnitedHealthcare or the delegated entity (whichever typically holds the risk) must provide the member with written notification of the denial decision based on federal and/or state regulatory standards.

For MA members, the delegated entity must issue a member denial notice within the appropriate regulatory time frame.

The delegated entity must use the most current CMS-approved Notice of Denial of Payment letter template. The letter must accurately document the service provider, the service provided, the denial reason, the member’s appeal rights and instructions on how to file an appeal.

For commercial members, if the member is enrolled in a benefit plan subject to ERISA, a member’s claim denial letter must clearly state the reason for the denial and provide proper appeal rights. The denial letter must be issued to the member within 30 calendar days of claim receipt. For non-ERISA members, issue the appropriate denial letter within 45 working days.

The delegated entity remains responsible to issue appropriate denials for member-initiated, non-urgent/emergent medical services outside their defined service area.

When the member is not financially responsible for the denied service, the member does not need to be notified of the denial. The care provider must receive notification of the denial and their financial responsibility (i.e., writing the charges off for the claims payment).

UnitedHealthcare or the delegated entity’s claims department (whichever holds the risk) is responsible for providing the notification.

The denial notice (letter, EOP, or PRA) issued to any non-contracted care provider of service must state:

  1. Their appeal rights.
  2. The member is not to be balance billed.

When the member has no financial responsibility for the denied service, the denial notice issued to any contracted care provider of service must clearly state the member is not billed for the denied or adjusted charges. In addition, the contracted care provider notifies the member of their right to dispute the decision or discuss it with a care provider reviewer.

Submit clean claims per the time frame listed in your Agreement or per applicable laws. We, or our capitated provider, allow at least 90 days for participating care providers and 180 days for non-participating care providers from the date of service to submit claims. For MA plans, we are required to allow 365 days from the “through” date of service for non-contracted care providers to submit claims for processing. If we, or our capitated provider, are not the primary payer, we give you at least 90 days from the day of payment, contest, denial or notice from the primary payer to submit the claim.

If a network care provider fails to submit a clean claim within the outlined time frames, we reserve the right to deny payment for such claim. You cannot bill a member for claims denied for untimely filing. We have established internal claims processing procedures for timely claims payment to our care providers.

The claims “timely filing limit” is the calendar day period between the claims last date of service or payment/denial by the primary payer, and the date by which UnitedHealthcare, or its delegate, receives the claim.

Determination of the date of UnitedHealthcare’s or its delegate’s receipt of a claim, the date of receipt shall be regarded as the calendar day when a claim, by physical or electronic means, is first delivered to UnitedHealthcare’s specified claims payment office, post office box, designated claims processor or to UnitedHealthcare’s capitated care provider for that claim. We use the following date stamps to determine date of receipt:

  • UnitedHealthcare HMO claims department date stamp primary payer claim payment/denial date as shown on the Explanation of Payment (EOP).
  • Delegated care provider date stamp.
  • Third-party administrator date stamp.
  • Confirmation received date stamp that prints at the top/bottom of the page with the name of the sender.
  • Electronic date stamp

MA claims must use the oldest received date on the claim. Refer to the official CMS website for additional rules and instructions on timely filing limitations.

For commercial claims, refer to the applicable official state-specific website for additional rules and instructions on timely filing limitations.

Delegated entities must have a clearly identifiable date stamp for all paper claims they receive. Electronic claims date stamps must follow federal and/or state standards.

Date of receipt and date of service

“Date of receipt” means the working day when a claim, by physical or electronic means, is first delivered to either the plan’s specified claims payment office, post office box, or designated claims processor or to UnitedHealthcare’s capitated provider for that claim.

“Date of Service,” for the purposes of evaluating claims submission and payment requirements, means:

  • For outpatient services and all emergency services and care: The date the provider delivered separately billable health care services to the member.
  • For inpatient services: The date the member was discharged from the inpatient facility. However, UnitedHealthcare or the capitated provider must accept separately billable claims for inpatient services at least bi-weekly.

We identify, batch and forward misdirected claims to the appropriate delegated entity following state and/or federal regulations. We send the care provider of service, or their billing administrator, a notice that we forwarded the member’s claim to the appropriate delegated entity for processing.

We forward misdirected claims to the proper payer following state and federal regulations. If care providers send claims to a delegated entity, and we are responsible for adjudicating the claim, the delegated entity must forward the claim to us within 10 working days of the receipt of the claim. Weekends and federal holidays are not included in working days.

The delegated entity must identify and track all claims received in error. Tracking must include, but is not limited to, the following relevant information:

  1. The name of the entity of where the claim was sent.
  2. The received date of the claim by the delegate, and the date mailed (date of forwarding the misdirected claim).

The delegated entity must then forward the claims to the appropriate payer and follow state and/or federal regulatory time frames.

When the claim is adjudicated, the delegated entity must notify the care provider of service who the correct payer is, if known, using the EOP they give to the care provider.

For UnitedHealthcare West membership ONLY: If you, the delegated entity, received a claim directly from the billing provider, and you believe that claim is the health plan’s responsibility, forward it to your respective UHC Regional Mail Office P.O. Box, which is found on the back of the member’s ID card. NOTE: For MA member claims only, include the timestamp of your original receipt date on the claim submission.

If you, the delegated entity, believe a claim we forwarded to you is the health plan’s financial responsibility, return the claim with the appropriate Misdirected Claims cover sheet and provide a detailed explanation why you believe these claims are the health plan’s responsibility.

You can download the cover sheet at Send all required information, including the claim and Misdirected Claims cover sheet, to:

P.O. Box 30984
Salt Lake City, UT 84130-0984.

In the event you, the delegate, change your address where we send misdirected claims, you must provide 60 days advance written notice to your provider advocate.

If your address change is related to a platform or MSO change, refer to the Notification of Platform Transitions or Migrations section of this supplement, as those notification timelines may differ.

Out-of-area (OOA) urgent or emergent claims

In most contractual arrangements, UnitedHealthcare has financial responsibility for urgent or emergent OOA medical and facility services provided to our members. We follow laws and regulations regarding payment of claims related to access to medical care in urgent or emergent situations. If we determine the claims are not emergent or urgent, we forward the claims to the capitated/delegated care provider for further review. Medical services provided outside the medical group/IPA’s defined service area and authorized by the member’s medical group/IPA are the medical group/IPA’s responsibility and are not considered OOA medical services.

Care provider delegates must ensure appropriate reimbursement methodologies are in place for non-contracted and contracted care provider claims.

For payment of non-contracted network care provider services, the letter, EOP, or PRA issued must notify them of their dispute rights if they disagree with the payment amount. You may not bill members for the difference of the billed amount and the Medicare allowed amount. MA contracted care provider claims must be processed following contract rates and within state and federal regulatory requirements.

Care provider delegates must automatically pay applicable interest on claims based on state and/or federal requirements.

Delegated entities must have a method of tracking individual member out-of-pocket expenses in their claim processing system. In addition, member cost-share may not be applied once a member has met their out-of-pocket maximum. This helps ensure members pay their appropriate cost-sharing amount. For more information, see the Member out-of-pocket/deductible maximum section of this supplement.

For claims falling under the Department of Labor’s ERISA regulations, you must deny within 30 calendar days. You must issue denials within 30 calendar days of receipt of the complete claim. You must issue payments within 45 working days or within state regulation, whichever is more stringent. The legislation does not differentiate between clean or unclean, or between participating and non-participating claims. Interest must be automatically paid on all uncontested claims not paid within 45 working days after receipt of the claim. Interest accrues at the rate established by state regulatory requirements, per annum, beginning with the first calendar day after the 45 working day period. It must be included with the initial payment. If interest is not included, there is an additional penalty paid to the care provider in addition to the interest payment.

Insured services

Insured services are those service types defined in the Agreement to qualify for medical group/IPA reimbursement, assuming the qualifications of certain designated criteria. The medical group/IPA pays the claim and submits it to UnitedHealthcare for reimbursement. Examples of an insured service could include authorization guarantee, or preexisting pregnancy.

Indemnified services

UnitedHealthcare may retain financial risk for services (or service categories) that cannot be submitted through the regular claims process due to operational limitations. These limitations include ambiguous coding and/or system limitations which may cause the claim to become misdirected. Misdirected claims are a risk to both organizations in terms of meeting regulatory compliance and inflating administrative costs.

Claims for insured or indemnified services qualify for payment to the capitated entity as defined in the medical group/IPA or facility Agreement. Should you have additional questions surrounding this process, speak with your provider advocate.

MA contracted care provider claims must be processed based on agreed-upon contract rates and within applicable federal regulatory requirements. Claims are adjudicated within 60 calendar days of oldest receipt date of the claim.

Medicare Advantage non-contracted care provider claims are reimbursed based on the current established locality-specific Medicare Physician Fee Schedule, DRG, APC, and other applicable pricing published in the Federal Register. Non-contracted, clean claims are adjudicated within 30 calendar days of oldest receipt date. Non-clean claims are adjudicated within 60 calendar days of oldest receipt date.

CMS requires an interest payment on clean claims submitted by non-contracted care providers if the claim is not paid within 30 calendar days. Find information on this requirement on

Entities with Dual Special Needs Plan (D-SNP) delegation must develop and implement a Medicaid reclamation claims process to help ensure compliance with state-specific reclamation requests.

Medicaid reclamation occurs when a state/agency contacts UnitedHealthcare to recover funds they believe they paid in error and are now seeking reimbursement in the form of Medicaid reclamation claims.

Medicaid reclamation claims requirements are state-specific and vary by state.


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