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State-specific addresses and other pertinent information regarding the PDR process may be found in the UnitedHealthcare West Provider Rework or Dispute Process Reference Table at the end of this section.Īccountability for review of a health care provider dispute

Clear rationale/reason for contesting the determination and an explanation why the claim should be paid or approvedĭisputes are not reviewed if the supporting documentation is not submitted with the request.

Member’s name and health plan ID number.

The PDR process is not a substitution for arbitration and is not deemed as an arbitration.Īs the health care provider of service, submit the dispute with the following information: We do not discriminate, retaliate against or charge you for submitting a health care provider dispute. The PDR process is available to provide a fair, fast and cost-effective resolution of health care provider disputes, in accordance with state and federal regulations. This time frame applies to all disputes regarding contractual issues, claims payment issues, overpayment recoveries and medical management disputes. All disputes must be submitted within 365 calendar days following the date of the adverse payment determination on the claim, unless your Agreement or state law dictate otherwise. You must submit a PDR in writing and with additional documentation for review.

If you disagree with our claim determination, you must initiate and complete the PDR process before commencing arbitration on a claim. Health care provider dispute resolution (CA delegates, OR HMO claims, OR and WA commercial plans) After the applicable time limit has passed, call Provider Relations at 1-87 to obtain a status. We respond to you within the applicable time limits set forth by federal and state agencies. In addition, payment must be sent within 5 calendar days of the date on the determination letter. We send you a letter with the determination. If the original claim status is upheld, you are sent a letter outlining the details of the review.Ĭalifornia: If a claim requires an additional payment, the EOP does not serve as notification of the outcome of the review. Response details: If claim requires an additional payment, the EOP serves as notification of the outcome on the review.

Reworks/disputes requiring claim process determination: Individuals not previously involved in the initial processing of the claim review the rework/dispute request.

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:

Claims research and resolution (OK and TX commercial plans)