![]() We send a letter to you outlining our determination and the basis for that decision. Reworks/disputes requiring clinical determination: Individuals with clinical training/background who were not previously involved in the initial decision review all clinical rework/dispute requests.We respond to issues as quickly as possible. Contact the CPM team at the address below to initiate a bulk claim inquiry: UnitedHealthcare West Bulk Claims Rework Reference Table ![]() The Claims Project Management (CPM) team handles bulk claim inquiries. To mail your request, refer to the chart titled UnitedHealthcare West Provider Rework or Dispute Process Reference Table at the end of this section. You may submit your request to us in writing by using the Paper Claim Reconsideration Form on /claims. All rework requests must be submitted within 365 calendar days following the date of the last action or inaction, unless your Agreement contains other filing guidelines. Submit your requests in the UnitedHealthcare Provider Portal. These rework requests typically can be resolved with the appropriate documents to support claim payment or adjustments (e.g., sending a copy of the authorization for a claim denied for no authorization or proof of timely filing for a claim denied for untimely filing). You may request a reconsideration of a claim determination. If appropriate, health care provider-driven claim payment disputes will be directed to the delegated payer Provider Dispute Resolution process.Ĭlaim reconsideration requests (does not apply to capitated/delegated claims in California) We work directly with the delegated payer when claims have been misdirected and financial responsibility is in question. UnitedHealthcare West researches the issue to identify who holds financial risk of the services and abides by federal and state legislation on appropriate timelines for resolution. Regardless of whether the payer was UnitedHealthcare West, the delegated medical group/IPA or other delegated payer, or the capitated hospital/provider, you are responsible for submitting your claim(s) to the appropriate entity that holds financial responsibility to process each claim.If you do not agree with the payment decision after the initial processing of the claim.The Claims Research & Resolution (CR&R) process applies: Physicians with questions or concerns, or that may need to request a hardship exemption from this policy, should contact their UHC Provider Service Advocate or UHC at (877) 842-3210 for more information.Claims research and resolution (OK and TX commercial plans) ![]() ![]() A month later in April, UHC stopped mailing prior authorization and clinical decision letters, including letters requesting additional information, approvals and denials to practices. In March 2022, UHC discontinued mailing appeal decision letters for its Medicare Advantage and commercial plans excluding UnitedHealthcare West plans. The change to electronic claim reconsiderations and post-service appeals is part of UHC’s continuing initiative to move providers to all-paperless communication. UHC indicates that contracted providers can submit claim reconsiderations and post-service appeals electronically in several ways including, via the UnitedHealthcare Provider Portal or via API. UnitedHealthcare (UHC) recently announced in its November Network News that beginning February 1, 2023, providers will be required to submit claim reconsiderations and post-service appeals electronically for UHC commercial and Medicare Advantage products. ![]()
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