EDI Quick Tips for Claims

COB Electronic Claim Requirements – Commercial

• Primary Payer Paid Amount: Submit the primary paid amount for each service line reported on the 835 payment advice or EOB. The paid amount on institutional claims can be submitted at the claim level.
• Adjustment Group Code: Submit other payer claim adjustment group code as found on the 835 payment advice or identified on the EOB. Deductible, co-insurance, copayment, contractual obligations and/or non-covered services are common reasons why the other payer paid less than billed.
• Adjustment Reason Code: Submit other payer claim adjustment reason code as found on the 835 payment advice or identified on the EOB. Deductible, co-insurance, copayment, contractual obligations and/or non-covered services are common reasons why the other payer paid less than billed.
• Adjustment Amount: Submit other payer adjustment monetary amount.
• Preference: Submit professional claims at the line level and institutional claims at either the line or claim level. The service level and claim level should be balanced. UnitedHealthcare follows 837P/837I guidelines.

COB Electronic Claim Requirements - Medicare Primary

• Adjustment Group Code: Submit other payer claim adjustment group code as found on the 835 payment advice or identified on the EOB. Do not enter at claim level any amounts included at line level. Deductible, co-insurance, copayment, contractual obligations and/or non-covered services are common reasons why the other payer paid less than billed.
• Adjustment Reason Code: Submit other payer claim adjustment reason code as found on the 835 payment advice or identified on the EOB. Do not enter at claim level any amounts included at line level. Deductible, co-insurance, copayment, contractual obligations and/or non-covered services are common reasons why the other payer paid less than billed.
• Adjustment Amount: Submit other payer adjustment monetary amount.
• Medicare Paid Amount: Submit other payer claim level and line level paid amount when UnitedHealthcare is secondary to Medicare.
• Medicare Approved Amount: Submit other payer claim level and line level allowed amount when UnitedHealthcare is secondary to Medicare.
• Patient Responsibility Amount: Submit monetary amount the member is responsible for as found on the 835 payment advice or as identified on the Medicare EOB.
• Medicare Acceptance of Assignment: Submit value to indicate whether the provider accepts Medicare assignment.
• Preference: Submit professional claims at the line level if primary payer provides institutional claims at either line or claim level. The service level and claim level should be balanced. UnitedHealthcare follows 837P/837I guidelines.

COB Electronic Specifications

For secondary professional or institutional claims to be paid electronically, the COB information must be submitted in the applicable loops and segments.

Loops IDs include:

• 2320 - Other Subscriber Information 
• 2330A - Other Subscriber Name
• 2330B - Other Payer Name 
• 2330C - Other Payer Referreding Provider
• 2330D - Other Payer Rendering Provider
• 2330E -Other Payer Service Facility Location
• 2330F - Other Payer Supervising Provider
• 2430 - Line Adjudication Information 

To learn more about submitting secondary/COB claims electronically to UnitedHealthcare, please consult your vendor, 837P/837I Implementation Guide, or our Companion Guides page for eCOB specifications.

Medicare Crossover

• Medicare Crossover is the process by which Medicare, as the primary payer, automatically forwards Medicare Part A (hospital) and Part B (medical) including Durable Medical Equipment (DME) claims to a secondary payer for processing.
• Medicare Crossover is a standard offering for most Medicare-eligible members covered under UnitedHealthcare Commercial plans. Enrollment is automatic for these members
• Allow 15-20 days to receive and review the Explanation of Benefits (EOB) from Medicare before filing the secondary claim to UnitedHealthcare, if required.
• Remark code MA-18 on the EOB indicates the claim was sent by Medicare to the secondary payer. Allow an additional 15-30 days for UnitedHealthcare to receive and process the crossover claim.
• Claims should not be sent to UnitedHealthcare that were crossed over by Medicare, as denoted by code MA-18 on the EOB. Sending another claim when one is already in our system will slow the payment process and create confusion for the member.
• If code MA-18 is not on the EOB, the secondary claim can be filed electronically by the provider or billing entity (see COB Electronic Claim Requirements ‒ Medicare Primary on this page).
• Allow up to 30 days after receiving the EOB before following up on the receipt of the secondary claim by UnitedHealthcare from Medicare.
• To follow up on the receipt or status of a claim, check claim status (276/277) using your practice management system, a clearinghouse or the UnitedHealthcare Provider Portal.

Submitting Electronic Secondary or Tertiary Claims to UnitedHealthcare

Secondary or tertiary professional and institutional claims can be submitted electronically. This process is commonly referred to as eCOB (electronic Coordination of Benefits).

If sending these types of claims correctly in an electronic format, the paper EOB is not needed by UnitedHealthcare.

System Requirements

• Secondary or tertiary claims must be submitted in HIPAA standard format, 837 X12 Version 5010.
• Contact your software vendor or clearinghouse to determine version you are using or to request upgrade for your Practice Management System or Hospital Information System .
• If using the UnitedHealthcare Provider Portal to submit claims, only professional secondary (no institutional or tertiary) claims are permitted.

Types of Secondary or Tertiary Claims that Can be Submitted Electronically

• Commercial insurance claims when another payer is primary and UnitedHealthcare is secondary or tertiary
• UnitedHealthcare claims secondary to Medicare (see the Medicare Crossover section for additional information)

Participating and Non-Participating

Claims from participating and non-participating physicians and facilities are accepted electronically.

Primary, Secondary and Tertiary Claims

Primary, secondary, and tertiary claims can be submitted electronically to UnitedHealthcare.

For secondary/COB claims, this includes UnitedHealthcare as secondary payer for a commercial claim as well as secondary to Medicare. See the Secondary/COB or Tertiary Claims section for additional information.

Professional and Institutional claims

Professional/Physician (CMS-1500) and Institutional/Hospital (UB-04) claims are accepted electronically by UnitedHealthcare.

Claim Payer List for UnitedHealthcare, Affiliates and Strategic Alliances

All payers receiving electronic claims have one or more Payer ID numbers that indicate where claims are routed, similar to an electronic mailing address. A Payer ID must be indicated to file a claim electronically. Read more on Understanding Payer IDs.

View the Payer List for UnitedHealthcare, Affiliates and Strategic Alliances to learn more about which Payer IDs to use for various UnitedHealthcare plans.

Claim Payer List Provided by Software Vendor or Clearinghouse

Some software vendors or clearinghouses create their own list of Payer IDs to use for each payer.

If Payer IDs in your software system do not look similar to Payer IDs published by the payer, you should ask your vendor for their proprietary payer list indicating what Payer ID to use for claim submissions.

Anesthesia Claims

Submit anesthesia claims with minutes, not units.

Billing and Pay To Address

The ASC X12 Version 5010 format for electronic claims includes specific address location requirements that apply to 837 claim transactions. The address field, required usage and transaction location are:

• Pay To Address (2010AB) 
  • The Pay To Address field has the address where payments are to be sent if different from the practice location (place of service) address.
  • P.O. Box or Lock Box addresses, if applicable, must be submitted in the "Pay To Address" field. Do not submit the actual street location of your P.O. Box or Lock Box in the "Billing Address" field.
• Billing Address (2010AA)
  • The Billing Address field has a street address, and must include the practice location if the address is different from the payment address.
  • If the street address is the same for the practice location and payment address, submit the address in the Billing Address field only and leave the Pay To Address field blank.

Billing Provider National Uniform Claim Committee Taxonomy Code

Submit on all institutional claims in order to facilitate claim adjudication.

Member ID Numbers

Required on all claims. Can be a minimum of nine or maximum of 16 alphanumeric or numeric characters.

Tax ID and NPI Number

Include both the Tax ID and NPI number on claim to promote timely and accurate payments.

Adding New Payers

When adding new payers to your system, immediately determine the Payer ID and set up claims for electronic submission. Even if there is low volume for that payer, all claims submitted electronically are received by the payer quicker and will save you time and money.

For more information on identifying what Payer ID to use, refer to the Payer ID section on the Quick Tips home page.

New Member Records

When adding new members in your system, you will be also be including their insurance information. Immediately set the insurance carrier to receive claims electronically. Most member ID cards include the electronic Payer ID.

Payers with Multiple Street Addresses

If payers are in your computer system several times due to multiple street addresses, verify all are routed to an electronic Payer ID. Payers may have multiple street addresses yet use the same Payer ID for electronic claim submissions.

If primarily filing claims electronically, it may only be necessary to keep track of Regional Mailing Offices (RMO) for payers instead of all individual street addresses. Street addresses are only necessary if filing a claim on paper.

Contact payers to determine if they have RMO addresses for claims that cannot be sent electronically and eliminate the number of times one payer may be listed in your system.

Payer Spelling

The spelling of payer names in software systems may vary to distinguish one payer from another or to identify specific plans, addresses or other information related to the same payer.

Please review these periodically to verify they are still necessary. Set all variances of payer names for electronic submission instead of paper.

Payer Tables

Payer tables in your computer system should be set to generate electronic claims instead of paper claims.

Software Vendor or Clearinghouse

Your software vendor or clearinghouse may need to be contacted for instructions or further information on making changes to your Practice Management System or Hospital Information System.

Do not delete information without making sure it doesn't affect another area within your system.

• Most corrected claims can be sent electronically. Use frequency code 7 on the 837 transaction to indicate that it’s a replacement of a previous claim.
• If you aren’t currently submitting corrected claims using EDI, it’s best to start with a small batch of claims for various UnitedHealthcare payers to ensure they’re accepted and processed accurately.
• If you aren’t able to submit corrected claims using EDI, submit a claim reconsideration request using Claims.  For more information about Claims, including training and quick reference guides, go to UHCprovider.com/portal.

Claim Status Search for Claims Submitted Electronically

To search the status on a claim with UnitedHealthcare, the claim must pass all format requirements with no rejections. Once it enters our processing system for adjudication, we will return an acknowledgement that your claim has been accepted. It should then be available for query as a Claim Status search.

Customer Service Unable to Locate a Claim Submitted Electronically

Customer Service can only find claims that have passed all electronic edits and accepted into UnitedHealthcare's claim payment system. Once UnitedHealthcare returns an acknowledgement that your claim has been accepted, it will be accessible to UnitedHealthcare Customer Service and Claim Status search.

Locating a Missing Claim that Was Submitted Electronically

If a claim filed electronically appears to be missing, this usually means that the claim was rejected either from your software vendor, clearinghouse or the payer. Rejected claims are:

• Electronic claims that do not meet certain data requirements specified by system format or by the payer
• Returned with requests for missing information or correction of invalid information
• Not accepted into UnitedHealthcare's claim payment system

To locate a missing or rejected claim, refer to the Rejection Reports section. If a claim has been rejected for any reason, it must be corrected and resubmitted electronically for acceptance into the payer's processing system for adjudication.

Rejection Reports

If you are submitting professional or institutional claims electronically through your vendor or clearinghouse, your vendor or clearinghouse should be returning two levels of rejection reports to track progress of electronic claims submissions:

1. Clearinghouse level: Claims rejected on a clearinghouse level never reach the payer but are returned to you from the clearinghouse for correction and electronic resubmission.
2. Payer level: Claims rejected by UnitedHealthcare do not enter our claim processing systems for adjudication but are returned for correction and electronic resubmission

Finding, correcting and resubmitting rejected claims is important to avoid timely filing delays or denials. If you are not receiving electronic claim reports, contact your vendor or clearinghouse.

Useful Tips

• A rejected claim is not the same as a denied claim. A denied claim has been accepted by UnitedHealthcare and adjudicated, while a rejected claim was not accepted and did not enter UnitedHealthcare's claim payment system.
• EDI Support can assist with EDI issues and finding claims that may have been rejected by UnitedHealthcare, not those rejected by a clearinghouse.
• Methods for contacting EDI Support are listed on the EDI Contacts page.

Defining an Unlisted or Unspecified Code

Some services or procedures performed by providers might not have specific CPT or HCPCS codes. When submitting claims for these services or procedures that are not otherwise specified, unlisted codes are designated. Unlisted codes provide the means of reporting and tracking services and procedures until a more specific code is established.

Submitting Claims with Unlisted Codes

If you’re submitting EDI claims with an unlisted service code, up to 80 characters of notes can be sent at the claim and service line level for the following loops and segments:

• Professional: 2400 NTE or SV101-7
• Institutional: 2300 NTE or SV202-7

Consult your vendor or the 837 implementation guide for fields required in the loop and segment.

Types of Claims that Can be Submitted Electronically with an Unlisted Code

Professional and institutional claims with unlisted codes can be submitted electronically to UnitedHealthcare.

Useful Tips

• Notes at the line level take precedence over information at the claim level.
• To reduce manual intervention, the notes field should only be used when necessary or as instructed by UnitedHealthcare.

Clearinghouse and Payer Level Reports

Reports from your clearinghouse and the payer should be delivered to your software system so you can track which claims were rejected and which were accepted. If you file claims electronically and are not receiving these reports both from the clearinghouse and the payer, please contact your software vendor.

Electronic Claim Reports

Electronic claim reports should be received for all claim batches submitted. These reports identify claim rejections, which must be resolved and resubmitted with requested information before the payer ultimately accepts the claim for adjudication. This process allows the payer to receive a clean claim, resulting in timely processing and payment. Where you locate these reports and how to retrieve them should be specified by your vendor, clearinghouse or company that maintains the system you use to file claims electronically.

Online Reporting

Some clearinghouses enable you to track all electronic claims through a website, rather than by monitoring individual reports that may be delivered to your system mailbox. Check with your clearinghouse to see if they offer this service.

Rejected Claims

Claims that are rejected do not enter the payer's claim processing system. Corrections are usually made in your computer system and the claim resubmitted electronically. To learn more about rejected claims, see the Missing Claims section.

Eligibility inquiries can reduce claim rejections, especially if run before the initial claim submission. See the Eligibility and Benefit Inquiry and Response page for more information.