#HEALTH NET TIMELY FILING LIMIT PROFESSIONAL#

Primary payer claim payment/denial date as shown on the Explanation of Payment (EOP).The following date stamps may be used to determine date of receipt: The calendar day we receive a claim is the receipt date, whether in the mail or electronically. Medicaid (applies only to MA): Follow the instructions in the Member Financial Responsibility section of Chapter 11: Compensation. However, if the employer group benefit plan coverage were secondary to Medicare when the member developed ESRD, Medicare is the primary payer, and there is no 30-month period. After the 30 months elapse, Medicare is the primary payer. If a member has or develops ESRD while covered under an employer’s group benefit plan, the member must use the benefits of the plan for the first 30 months after becoming eligible for Medicare due to ESRD. An itemized bill is required to compute specific reinsurance calculations and to properly review reinsurance claims for covered services. If a submitted hospital claim does not identify the claim as having met the contracted reinsurance criteria, we process the claim at the appropriate rate in the Agreement. Make medical records available upon request for all related services identified under the reinsurance provisions (e.g., ER face sheets).Indicate if a claim meets reinsurance criteria.In addition, when submitting hospital claims that have reached the contracted reinsurance provisions and are being billed in accordance with the terms of the Agreement and/or this supplement, you shall: Claims are submitted in accordance with the required time frame, if any, as set forth in the Agreement.The reinsurance is applied to the specific, authorized acute care confinement.The stipulated reinsurance conversion reimbursement rate is applied to all subsequent covered services and submitted claims.

Applicable eligible member copayments, coinsurance, and/or deductible amounts are deducted from the reinsurance threshold computation.Only those inpatient services specifically identified under the terms of the reinsurance provision(s) are used to calculate the stipulated threshold rate.Only covered services are included in the computation of the reinsurance threshold.If covered services fall under the reinsurance provisions set forth in your Agreement with us, follow the terms of the Agreement to make sure: If your claim is the financial responsibility of a UnitedHealthcare West delegated entity (e.g., PMG, MSO, Hospital), then bill that entity directly for reimbursement.Ĭlaims submission requirements for reinsurance claims for hospital providers Refer to the Prompt Claims Processing section of Chapter 10: Our claims process, for more information about electronic claims submission and other EDI transactions. Mail paper CMS 1500 or UB-04s to the address listed on the member’s ID card.

To avoid processing delays, you must validate with your clearinghouse for the appropriate Payer ID number or refer to your clearinghouse published Payer Lists. In some cases, the Payer ID listed on /edi may be different from the numbers issued by your clearinghouse. For a complete list of Payer IDs, refer to the Payer List for Claims. Submit your claims and encounters and primary and secondary claims as EDI transaction 837.įor UnitedHealthcare West encounters, the Payer ID is 95958. OptumInsight Connectivity Solutions, UnitedHealthcare’s managed gateway, is also available to help you begin submitting and receiving electronic transactions. For information on EDI claim submission methods and connections, go to EDI 837: Electronic Claims. Refer to our online Companion Guides for the data elements required for these transactions found on /edi. Resubmit claims in the UnitedHealthcare Provider Portal at > Sign In > Claims & Payments.

#HEALTH NET TIMELY FILING LIMIT PROFESSIONAL#

Submit all professional and institutional claims and/or encounters electronically for UnitedHealthcare West and Medicare Advantage HMO product lines.ĭo not resubmit claims that were either denied or pended for additional information using EDI or paper claims forms. EDI is the preferred method of claim submission for participating physicians and health care providers.

Health net timely filing limit