Claims Submission and Prior Authorization Process Overview
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1 Claims Submission and Prior Authorization Process Overview
2 Agenda: Claims and Billing Prior Authorization PCA _
3 Claims and Billing PCA _
4 Member Copayments To verify eligibility and determine the member s copayment, go to UHCCommunityPlan.com > For Health Care Professionals > Iowa > Claims and Member Information > UnitedHealthcare Plan - IA Health Link If a copayment is required: You may bill the member for their portion You may not deny care because of the member s inability to pay the copayment Call Provider Services at if you have questions about a member s financial responsibility.
5 Claims Submission Guidelines Submit claims using the current 1500 claim form or UB-04 with appropriate coding including, but not limited to, ICD-10, CPT and HCPCS coding. Timely filing: 180 days from date of service Claims processing timeline: Clean claims will be adjudicated within 14 days of receipt. Balance billing: You may not balance bill members for services covered under their benefit plan. When you are contracted with us as part of a group, payment is made to the group, not the individual care provider. Claim submissions must include: Member name, Medicaid ID and date of birth Your tax ID number (TIN) or employer identification number (EIN) National provider identifier (NPI) Nationally recognized Centers for Medicare and Medicaid Services Correct Coding Initiative (CCI) standards as outlined at cms.gov.
6 Online Claims Submission UnitedHealthcareOnline.com > Link > Claims Management Sign-in to Link with your Optum ID. If you don t have an Optum ID, select New User to register. OR UnitedHealthcareOnline.com > Claims & Payments > Claims Submission Sign-in with your user ID and password. If you don t have a user ID, select New User at the top right.
7 Electronic and Paper Claims Submission Electronic Claims Submission You may use any clearinghouse vendor to submit claims. Payer ID: Paper Claims Submission Mail to: UnitedHealthcare PO Box 5220 Kingston, NY
8 Sample CMS-1500 Form Box 24J: For groups/agencies Enter supervising care provider s NPI number in the non-shaded portion.
9 Sample CMS-1500 Form (cont d.) Box 24J: For Consumer-Directed Attendant Care (CDAC) and Atypical Providers, such as those who provide taxi and respite services and home and vehicle modifications: Do not bill with atypical NPI (X ). Leave blank. System will pay based on TIN/EIN.
10 Sample CMS-1500 Form (cont d.) Box 31: Enter the name and licensure of the supervising care provider exactly as it appears on the agency roster. Only supervising care providers should appear in Box 31.
11 Sample CMS-1500 Form (cont d.) Groups/Agencies with Registered Care Providers Box 33: Enter the agency name, address and phone number. Box 33a: Enter the agency s NPI.
12 Sample CMS-1500 Form (cont d.) CDAC and Atypical Providers Box 33: Enter the agency s name, address and phone number. Box 33a: Leave blank. Do not bill with Atypical NPI. System will pay based on TIN/EIN.
13 Claims Submission Best Practices Avoid Common Coding Errors Incomplete or missing diagnosis CDAC/Waiver care providers should use Z Invalid or missing HCPC/CPT codes (e.g. codes for services that are not covered services or are missing required data elements) Incorrect or missing care provider information Obtain Prior Authorization Obtain authorization for services that require authorization. Make sure units billed match units authorized. (e.g. if authorization was given for 10 days, only bill for 10 days)
14 Claims Reconsideration Online: UnitedHealthcareOnline.com > Link > Claims Reconsideration OR UnitedHealthcareOnline.com > Claims & Payments > Claims Reconsideration Mail: UnitedHealthcareOnline.com > Tools & Resources > Forms > Paper Claim Reconsideration Form to: UnitedHealthcare PO Box 5220 Kingston, NY
15 Claims Resolution Dispute Process If you are not satisfied with the outcome of a claim reconsideration request, you may submit a claim dispute using the process outlined in your Provider Manual at UHCCommunityPlan.com > For Health Care Professionals > Iowa > Provider Administrative Manual. Mail to: UnitedHealthcare Community Plan Attn: Provider Dispute PO Box Salt Lake City, UT Reviews take days depending on the complexity of the claim.
16 Electronic Payments and Statements Electronic payments and statements (EPS) allows you to: Have your claims payments deposited directly to your bank account Access your care provider remittance advice online To register for EPS, go to myservices.optumhealthpaymentservices.com > How to Enroll.
17 Prior Authorization PCA _
18 Prior Authorization Requirements Prior authorization is required for certain in-network services. All out-of-network services require prior authorization. For a complete list of services that require prior authorization, go to: UHCCommunityPlan.com > For Health Care Professionals > Iowa > Prior Authorization. For radiology and cardiology prior authorization requirements, go to: UnitedHealthcareOnline.com > Link > UnitedHealthcare Community Plan > For Health Care Professionals > Iowa > Radiology or Cardiology.
19 Prior Authorization Requests Request prior authorization any of the following ways: Go to UnitedHealthcareOnline.com > Link > Eligibility & Benefits OR UnitedHealthcareOnline.com > Notifications/Prior Authorizations Complete and fax a prior authorization form to The form is available at located at UHCCommunityPlan.com > For Health Care Professionals > Iowa > Provider Forms > Prior Authorization Fax Request Form Call Prior authorizations will be processed within: 7 calendar days of request 3 calendar days for expedited requests 24 hours for pharmacy requests
20 Prior Authorization Transition APRIL From April 1, 2016 through March 31, 2017, we will honor standing prior authorizations for 90 calendar days for acute outpatient services when a member joins our health plan. MAR
21 Case Management Transition From April 1 through Sept. 30, 2016, new members may continue to work with their current case manager. We will also assign a UnitedHealthcare Community Plan community-based case manager to new members with chronic medical conditions to help: Assess and identify health care needs Develop and maintain care plans Help ensure access to care Personalize care to the members individual requirements and preferences Coordinate services Transition from their current case manager to a UnitedHealthcare Community Plan community-based case manager
22 Quick Reference Guide Prior Authorization Requests Phone: Fax: Medical Benefits UnitedHealthcareOnline.com > Link > Eligibility & Benefits UnitedHealthcareOnline.com > Notification/Prior Authorizations Paper Claims Submission UnitedHealthcare P.O. Box 5220 Kingston, NY Electronic Claims Submission UnitedHealthcareOnline.com > Link > Claims Management UnitedHealthcareOnline.com > Claims & Payment > Claims Submission Payer ID: Claims Status Provider Services: UnitedHealthcareOnline.com > Link > Claims Management UnitedHealthcareOnline.com > Claims & Payments > Claim Status Claims Appeals Provider Advocates UnitedHealthcare Attn: Appeals Department P.O. Box Salt Lake City, UT Find yours at UHCCommunityPlan.com > For Health Care Professionals > Iowa > Provider Information
23 Questions and Thank you! PCA _
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