Pre- and post-service appeals and reconsiderations
Most network health care professionals (primary and ancillary) and facilities that provide services to UnitedHealthcare® Medicare Advantage (including D-SNP), UnitedHealthcare Community Plan (Medicaid) and commercial plan members are required to submit reconsiderations and pre- and post-service appeals digitally. We also recommend that out-of-network health care professionals submit pre- and post-service appeals electronically.
Benefits of digital submissions
- Eliminate mail delays
- Receive decisions an average of 5 days faster
- Provide real-time information
- Decrease data entry and increase automation
Pre-service appeal options
Peer-to-peer review*
What it is: A discussion where a provider can learn more about a pre-service denial of coverage for inpatient/outpatient services and present previously unavailable clinical information to a UnitedHealthcare medical director.
When to do it: Although this varies by plan and/or state, most reviews need to be requested within 24 hours of coverage denial.
Timing: The review request time frame is dependent on case type and any applicable state guidelines. Inpatient cases must be submitted within 3 business days and outpatient cases within 21 calendar days from posted denial. To begin, complete the peer-to-peer scheduling request form; this takes about 5–10 minutes.
Please note: This review can be done prior to submitting an appeal.
Pre-service appeals
What it is: Before a planned health care service is performed, a pre-service appeal is a request to change a denial of coverage. This process is based on what is outlined in the member’s benefit plan.
When to do it: Initiate a pre-service appeal if a peer-to-peer review is not possible or an adverse determination has been received.
Timing: The pre-service appeal should be made prior to a planned health care service.
*Available for UnitedHealthcare-managed prior authorizations, not third-party vendors
Reconsideration and post-service appeal options
What it is: Except where prohibited by applicable law you must follow a 2-step process when you don’t agree with a claim determination. First, you must submit a claim reconsideration request. If you don’t agree with the outcome of the reconsideration, you may submit an appeal.
Timing: You have 12 months to complete the following steps:
Step 1: File a claim reconsideration request.
Step 2: File an appeal if you disagree with the outcome of the claim reconsideration decision.
You can use either the UnitedHealthcare Provider Portal or an API to submit a reconsideration. For information on submitting reconsiderations in the portal, please view our interactive guide.
You can use either the UnitedHealthcare Provider Portal or an API to submit a post-service appeal. For information on submitting post-service appeals in the portal, please view our interactive guide.
- Step 1: Reconsideration
- Step 2: Post-service appeal
You can use either the UnitedHealthcare Provider Portal or an API to submit a reconsideration. For information on submitting reconsiderations in the portal, please view our interactive guide.
You can use either the UnitedHealthcare Provider Portal or an API to submit a post-service appeal. For information on submitting post-service appeals in the portal, please view our interactive guide.
Frequently asked questions
General
Timelines vary. Please refer to your Participation Agreement for timely filing information.
An expedited appeal may be available if the time needed to complete a standard appeal could seriously jeopardize the member’s life, health or ability to regain maximum function. If you have already provided the service, an expedited or urgent appeal is not available. Submit the claim based on the service provided.
You’ll receive immediate confirmation of receipt and a tracking number.
Use TrackIt to check status.
Peer-to-peer review and pre-service appeals
To request an urgent pre-service appeal on behalf of the member, follow the information in the pre-service denial letter and submit electronically. We consider requests urgent when:
- The standard review time frame risks the life or health of the member
- The member’s ability to regain maximum function is jeopardized
- The member’s severe pain is not able to be managed without the care or treatment requested
When the health care professional appeals on behalf of the covered person, you may be required to provide authorization and/or patient consent when completing a pre-service appeal. An assignment of benefits does not constitute designation of an authorized representative.
Reconsiderations and post-service appeals
From the claim details page, scroll down or jump to Act on Claim and select Explore available actions. Options are enabled and may change based on the details and status of the claim.
A benefit of online submission includes the process for determining whether it is eligible for a reconsideration or appeal by systematically applying plan rules.
Corrected claims replace an original claim submission that had incorrect information. For example, you may submit a corrected claim through the UnitedHealthcare Provider Portal or Electronic Data Interchange (EDI) if you need to correct the date of service or add a modifier. All lines from the original claim should be included even if they were correct in the first submission.
After reconsideration or appeal review: If UnitedHealthcare determines that a claim is eligible for additional payment, you will receive an updated explanation of benefits (EOB) or provider remittance advice (PRA), which serves as notification of the review outcome. If the original claim status is upheld, you may see a letter in Document Library outlining the decision details.
If you submitted the reconsideration electronically, you can check status using the PIQ reference number in either the portal Claims section or within TrackIt.
If you intend to pursue your potential issue beyond the reconsideration and appeal process, you must follow the Notice of Dispute process outlined in your Participation Agreement.
You may electronically submit 20 or more reconsiderations for paid or denied claims with the same administrative issue (attachments are not required). Go to UHCprovider.com > Sign In > Claims & Payments > Claims Research Project.
Need help?
Connect with us through chat 24/7 in the UnitedHealthcare Provider Portal.