For delegated MA care providers, if you expect any significant changes to your network, notify your provider advocate prior to the third quarter of the calendar year. This helps our members select the correct care provider during the annual enrollment period from October to December. It also reduces provider directory errors.
EDI is our preferred choice for conducting business transactions with care providers and health care industry partners. We accept EDI claims submission for all our product lines. Find information and help with EDI on UHCprovider.com/edi. Also see the EDIsection of Chapter 2: Provider Responsibilities, which includes information about ASC X12 Technical Report Type 3 publications, companion guides, and a list of standardized HIPAA-compliant EDI transactions.
The ASC X12 Technical Report Type 3 (TR 3 also known as HIPAA Implementation Guides) publications are the authoritative source for EDI Transactions. You may purchase the ASC X12 Technical Report Type 3 publications from Washington Publishing at wpc-edi.com.
We developed guides to provide transaction specific information we require for successful EDI submissions. These companion guides are available at UHCprovider.com/edi.
The following table includes standardized HIPAA-compliant EDI transactions available at UnitedHealthcare:
ANSI ASC X12N* Transactions
HIPAA EDI Transactions Acceptable UnitedHealthcare Versions: 005010X279A1
Available at UnitedHealthcare Transaction Descriptions: Eligibility Benefits Inquiry and Response (Real-Time and Batch)
HIPAA EDI Transactions Acceptable UnitedHealthcare Versions: 005010X212
Available at UnitedHealthcare Transaction Descriptions: Claim Status Inquiry and Response (Real-Time and Batch)
HIPAA EDI Transactions Acceptable UnitedHealthcare Versions: 005010X218
Available at UnitedHealthcare Transaction Descriptions: Premium Payment
HIPAA EDI Transactions Acceptable UnitedHealthcare Versions: 005010X220A1
Available at UnitedHealthcare Transaction Descriptions: Benefit Enrollment and Maintenance
HIPAA EDI Transactions Acceptable UnitedHealthcare Versions: 005010X221A1
Available at UnitedHealthcare Transaction Descriptions: Claims Payment and Remittance Advice
HIPAA EDI Transactions Acceptable UnitedHealthcare Versions: 005010X222A1
Available at UnitedHealthcare Transaction Descriptions: Healthcare Claim/Encounter Professional
HIPAA EDI Transactions Acceptable UnitedHealthcare Versions: 005010X223A2
Available at UnitedHealthcare Transaction Descriptions: Healthcare Claim/Encounter Institutional
The medical group/IPA must provide us with at least 90 calendar days written notice prior to any changes to the medical group/ IPA or network care providers. Include in the notice:
Inability of medical group/IPA to properly serve more members due to lack of PCPs.
Closing or opening the PCP’s practice to more members.
Closure of any office or facility the medical group/IPA, PCPs or other network care provider and health care professional uses.
The medical group/IPA, its care providers and other licensed independent health care professionals must continue to accept members during the 90-day notice. For purposes of this section, a new member may be a member who has switched health plans and/or coverage plans. This includes a member who switches from a Fee-For-Service (FFS) plan to a Commercial HMO/ MCO plan.
California requirements for capacity reporting
We require capitated providers to give us updates within 5 business days if capacity changes affect your ability to accept new members. If we receive notification your information is inaccurate, you will be subject to corrective action.
You must make reasonable efforts to limit Protected Health Information (PHI) as defined under the Health Insurance Portability and Accountability Act (HIPAA) Privacy Rule to the minimum necessary when using or disclosing PHI. The minimum necessary standard should not affect treatment, payment or health care operations (TPO). The Privacy Rule requires written member authorization for uses and disclosure that fall outside of the TPO.
The delegated care provider group must include the California Department of Managed Health Care’s (DMHC) approved Notice of Availability of Language Assistance with each vital document containing member-specific information issued to UnitedHealthcare’s Language Assistance Program (LAP) members. The notice must be included in UnitedHealthcare’s
threshold languages (English, Spanish and Chinese). Vital documents include UM modification, delay, or denial letters issued to our members by the delegated care provider group. We review compliance with this requirement during the annual assessment of delegated medical management.
UnitedHealthcare worked with Industry Collaborative Effort (ICE) to standardize the inclusion of the required notice.
In a professional capitation Agreement, the medical group/IPA receives capitation for medical services. We pay selected facility services out of the HIP. The HIP provides an incentive for the medical group/IPA to use facility services such as inpatient activity, in-area emergency services and other selected outpatient services provided to our members efficiently. The HIP calculates overages and deficits based on an annual comparison of accumulated actual costs based on the terms of the UnitedHealthcare medical group/IPA Agreement.
This section provides general information for a professional capitation arrangement on the following:
How are HIP results calculated?
What services are included in the HIP?
What information is available to assess HIP performance?
The Integrated Healthcare Association (IHA) P4P Value-Based Incentive Program for commercial members is not a component of the capitation Agreement. It is under a separate letter of Agreement.
The budget for the Medicare Advantage Hospital Incentive Program (MAHIP) for Medicare members is based on a percent of premium, less the reinsurance premium. Aside from the budget, all other aspects of the HIP apply to the MAHIP.
In a split capitation Agreement, the medical group/IPA receives capitation for the provision of medical services. The facility receives capitation for facility services and selected outpatient services. The medical group/IPA and facility may create and administer their own facility incentive program under a split capitation Agreement.
We either post online or distribute to each medical group/IPA, a monthly-shared risk claims report. It lists the actual costs incurred and denied during the previous month for services included in the HIP. Review this report each month to make sure the claims were processed and/or paid correctly.
The following tools will help the medical group/IPA analyze the Shared Risk Claims Report:
Claims Code Sheet.
Place of Service Mapping
This document cross- references the CMS place of service codes to UnitedHealthcare’s internal place of service codes.
Use the Discrepancy Report to request research of the payment or denial of a claim we processed. After reviewing the Monthly Shared Risk Claims Report, complete all fields in the Discrepancy report. Submit it electronically to our Network Care Provider Management department. If all required fields are not completed, we return the files to the medical group/IPA. The required fields include:
Member ID number (7-digit number).
Member ID number suffix (2 digits).
Expected care provider reimbursement.
Care provider comments — why the medical group/IPA is disputing the payment.
Discrepancy report timely filing
The medical group/IPA must submit discrepancy reports monthly. We do not pursue recoveries of overpayments you submit late based on your Agreement with us or by state law.
We reserve the right to deny/reject any request for review submitted beyond the timely filing limit.
Individual Stop Loss (ISL)/Reinsurance (REI) limits the medical group’s/IPA’s/facility’s financial risk for medical and facility services beyond a specified dollar amount per member, per calendar year. This program applies to services for which we capitated the medical group/IPA/facility.
The ISL program is updated annually. Each medical group/IPA/facility may take part each year. The medical group/IPA may purchase ISL/reinsurance from us or an outside carrier.
We determine our premium for ISL based on our experience. We convert the calculated premium for stop loss to either a percentage of premium or flat per member per month (PMPM) rate based on the medical group’s/IPA’s Agreement. Every month, we subtract the result from the total capitation.
We reimburse a medical group/IPA that purchases ISL through us for services that exceed the ISL deductible at the ISL program rates specified in the Agreement or the ISL election letter for the applicable contract year, minus the medical group’s ISL coinsurance amount.
We reimburse a facility that purchases reinsurance through us for services that exceed the reinsurance deductible at the reinsurance program rates specified in the Agreement or the reinsurance election letter for the applicable contract year, less the facility’s reinsurance coinsurance. The facility must identify all reinsurance claims before submission. The facility reinsurance program is updated annually.
The medical group/IPA or facility may elect to opt out of the UnitedHealthcare ISL/reinsurance program by purchasing ISL/ reinsurance coverage through a third-party insurance carrier. Such coverage must be through an entity we approve of and in the amounts required by UnitedHealthcare and state and federal law. Refer to your Agreement for details.
Notification of ISL/reinsurance claims
The medical group/IPA or facility provides written notification to us when services for a member equal 50% of the ISL/ reinsurance deductible. The written notification submission needs to be to us no later than the 15th day of the month following the month in which the claim amounts reach the 50% threshold.
ISL/reinsurance claims submission procedure
Submit all ISL/reinsurance claims having met the ISL/reinsurance deductible to us annually but no later than 90 calendar days after the end of the calendar year.
To receive reimbursement under the ISL/reinsurance program, follow these steps:
Submit the ISL/reinsurance claims by spreadsheet to Individual_stoploss@uhc.com. Scan and email all hard-copy images. Include these on the submission spreadsheet:
Service care provider name
Date of service
Correct RBRVS or CPT codes and description of services if required
Place of service
Medical group/IPA paid amount
Other insurance information
ICD-10-CM diagnosis codes
Proof of payment (copies of cancelled checks)
Each spreadsheet submission sheet must be for one member only. We do not accept combined submissions for a family or for more than one member.
For capitated services rendered outside the medical group/IPA/facility, we require copies of canceled checks showing actual amounts paid. Upon request, submit copies of all referral bills and/or copies of consultation and operative reports.
We may ask you to submit a brief member history (copy of a consultant report and/or history dictation). We do not require lab results, X-ray results or records.
These are excluded from the calculation of ISL/reinsurance claims:
Member copayment amounts
Services paid by Workers’ Compensation
Services paid by other health plans
Services paid through third-party reimbursement
Our Claims Production Unit reviews the claim for completeness and tells medical group/IPA/facility if it needs any other information. It may need supporting records for ISL/reinsurance claim verification. After review, if the claim is accepted, we make a payment within 60 calendar days. Submit ISL/Reinsurance claims toIndividual_stoploss@uhc.com.