Health care provider responsibilities- Capitation and/or delegation supplement - 2022 Administrative Guide

To help ensure we have your most current directory information, submit any changes to:

For Delegated Health Care Providers: Contact your local network account manager or health care provider advocate.

For Non-Delegated Health Care Providers: Visit uhcprovider.com > Find a Provider for the Provider Demographic Change Submission Form and further instructions.

For delegated MA health care providers, if you expect any significant changes to your network, notify your health care provider advocate prior to the third quarter of the calendar year. This helps our members select the correct health care provider during the annual enrollment period from October to December. It also reduces health care provider directory errors.

EDI is our preferred choice for conducting business transactions with health care providers and health care industry partners. We accept EDI claims submission for all our product lines. Find information and help with EDI on uhcprovider.com/edi. Also see the EDI section of Chapter 2: Provider responsibilities, which includes information about ASC X12 Technical Report Type 3 publications, companion guides, and a list of standardized HIPAA-compliant EDI transactions.

The ASC X12 Technical Report Type 3 (TR 3 also known as HIPAA Implementation Guides) publications are the authoritative source for EDI Transactions. You may purchase the ASC X12 Technical Report Type 3 publications from Washington Publishing at wpc-edi.com.

We developed guides to provide transaction specific information we require for successful EDI submissions. These companion guides are available at uhcprovider.com/edi.

The following includes standardized HIPAA-compliant EDI transactions available at UnitedHealthcare:

ANSI ASC X12N* Transactions

270/271
HIPAA EDI Transactions Acceptable UnitedHealthcare Versions: 005010X279A1
Available at UnitedHealthcare Transaction Descriptions: Eligibility Benefits Inquiry and Response (Real-Time and Batch)

276/277
HIPAA EDI Transactions Acceptable UnitedHealthcare Versions: 005010X212
Available at UnitedHealthcare Transaction Descriptions: Claim Status Inquiry and Response (Real-Time and Batch)

278
HIPAA EDI Transactions Acceptable UnitedHealthcare Versions: 005010X278
Available at UnitedHealthcare Transaction Descriptions: Health Care Services Review - Request for Review and Response (Real Time and Batch)

278
HIPAA EDI Transactions Acceptable UnitedHealthcare Versions: 005010X216
Available at UnitedHealthcare Transaction Descriptions: Notification and Acknowledgement (Real Time and Batch)

278
HIPAA EDI Transactions Acceptable UnitedHealthcare Versions: 005010X215
Available at UnitedHealthcare Transaction Descriptions: Health Care Services Review - Inquiry and Response (Real Time and Batch)

820
HIPAA EDI Transactions Acceptable UnitedHealthcare Versions: 005010X218
Available at UnitedHealthcare Transaction Descriptions: Premium Payment

834
HIPAA EDI Transactions Acceptable UnitedHealthcare Versions: 005010X220A1
Available at UnitedHealthcare Transaction Descriptions: Benefit Enrollment and Maintenance

835
HIPAA EDI Transactions Acceptable UnitedHealthcare Versions: 005010X221A1
Available at UnitedHealthcare Transaction Descriptions: Claims Payment and Remittance Advice

837
HIPAA EDI Transactions Acceptable UnitedHealthcare Versions: 005010X222A1
Available at UnitedHealthcare Transaction Descriptions: Healthcare Claim/Encounter Professional

837
HIPAA EDI Transactions Acceptable UnitedHealthcare Versions: 005010X223A2
Available at UnitedHealthcare Transaction Descriptions: Healthcare Claim/Encounter Institutional

The medical group/IPA must provide us with at least 90 calendar days written notice prior to any changes to the medical group/ IPA or network providers. Include the following in the notice:

• Inability of medical group/IPA to properly serve more members due to lack of PCPs
• Closing or opening the PCP’s practice to more members
• Closure of any office or facility the medical group/IPA, PCPs or other network provider and health care professional uses

The medical group/IPA, its health care providers and other licensed independent health care professionals must continue to accept members during the 90-day notice. For purposes of this section, a new member may be a member who has switched health plans and/or coverage plans. This includes a member who switches from a Fee-For-Service (FFS) plan to a Commercial HMO/ MCO plan.

You must make reasonable efforts to limit Protected Health Information (PHI) as defined under the Health Insurance Portability and Accountability Act (HIPAA) Privacy Rule to the minimum necessary when using or disclosing PHI. The minimum necessary standard should not affect treatment, payment or health care operations (TPO). The Privacy Rule requires written member authorization for uses and disclosure that fall outside of the TPO.

You must not discriminate against any patient with regard to quality of service or accessibility of services because they are our member. You must not discriminate against any patient on the basis of any of the following:

• Race
• Gender identity
• Ethnicity
• National origin
• Religion
• Sex and gender
• Age
• Mental or physical disability or medical condition
• Sexual orientation
• Claims experience
• Medical history
• Evidence of insurability
• Disability
• Genetic information
• Source of payment
• Medicaid status for Medicare members

You must maintain policies and procedures to demonstrate you do not discriminate in the delivery of service and accept for treatment any members in need of your service.

The delegated health care provider group must include the California Department of Managed Health Care’s (DMHC) approved Notice of Availability of Language Assistance with each vital document containing member-specific information issued to UnitedHealthcare’s Language Assistance Program (LAP) members. The notice must be included in UnitedHealthcare’s threshold languages (English, Spanish and Chinese). Vital documents include UM modification, delay, or denial letters issued to our members by the delegated health care provider group. We review compliance with this requirement during the annual assessment of delegated medical management.

UnitedHealthcare worked with Industry Collaborative Effort (ICE) to standardize the inclusion of the required notice.

Contact your UnitedHealthcare clinical delegation oversight consultant for current UnitedHealthcare letter templates.

In a professional capitation Agreement, the medical group/IPA receives capitation for medical services. We pay selected facility services out of the HIP. The HIP provides an incentive for the medical group/IPA to use facility services such as inpatient activity, in-area emergency services and other selected outpatient services provided to our members efficiently. The HIP calculates overages and deficits based on an annual comparison of accumulated actual costs based on the terms of the UnitedHealthcare medical group/IPA Agreement.

This section provides general information for a professional capitation arrangement on the following:

• How are HIP results calculated?
• What services are included in the HIP?
• What information is available to assess HIP performance?

The Integrated Healthcare Association (IHA) P4P Value-Based Incentive Program for commercial members is not a component of the capitation Agreement. It is under a separate letter of Agreement.

The budget for the Medicare Advantage Hospital Incentive Program (MAHIP) for Medicare members is based on a percent of premium, less the reinsurance premium. Aside from the budget, all other aspects of the HIP apply to the MAHIP.

Reinsurance is required to protect the HIP budget and medical group/IPA against catastrophic cases.

The Division of Financial Responsibility (DOFR) section of the Agreement defines the actual HIP costs. It typically includes the following:

• Inpatient costs for facility services rendered to our members by network providers valued at the actual costs we incur
• Other facility services given to our members by network providers other than inpatient services, valued at actual costs we incur
• The actual amount paid for facility services, which are rendered by non-network providers
• A percentage of all facility services incurred during the period but not yet processed (for the interim calculation), minus:
  • Reinsurance recoveries.
  • Third-party recoveries received during calculation.

We monitor the medical group/IPA performance through:

• Records of authorized services.
• Claims paid/denied reports.
• HIP financial report for the settlement period. The report details:
  • Total number of member months.
  • Total budget allocation for the member months.
  • Total expenses paid during the period.
  • A description of each amount of expense allocated to the risk arrangement by member ID number, date of service, description of service by claim codes, net payment, and date of payment.
  • Risk determination accuracy as identified through review of issue resolution data of risk disputes and risk reconsiderations.

We perform interim settlements, the final settlement and reconciliation of the HIP.

We provide a quarterly incentive program report to the medical group/IPA within 45 calendar days of the close of each calendar quarter. The incentive program report contains the monitored information.

In a split capitation Agreement, the medical group/IPA receives capitation for the provision of medical services. The facility receives capitation for facility services and selected outpatient services. The medical group/IPA and facility may create and administer their own facility incentive program under a split capitation Agreement.

We either post online or distribute to each medical group/IPA, a monthly-shared risk claims report. It lists the actual costs incurred and denied during the previous month for services included in the HIP. Review this report each month to make sure the claims were processed and/or paid correctly.

The following tools will help the medical group/IPA analyze the Shared Risk Claims Report:

• Claims Code Sheet
• Place of Service Mapping
  • This document cross-references the CMS place of service codes to UnitedHealthcare’s internal place of service codes.

Use the Discrepancy Report to request research of the payment or denial of a claim we processed. After reviewing the Monthly Shared Risk Claims Report, complete all fields in the Discrepancy report. Submit it electronically to our Network Care Provider Management department. If all required fields are not completed, we return the files to the medical group/IPA. The required fields include:

• Member ID number (7-digit number).
• Member ID number suffix (2 digits).
• Claim number.
• Expected health care provider reimbursement.
• Health care provider comments — why the medical group/IPA is disputing the payment.

Discrepancy report timely filing

The medical group/IPA must submit discrepancy reports monthly. We do not pursue recoveries of overpayments you submit late based on your Agreement with us or by state law.

We reserve the right to deny/reject any request for review submitted beyond the timely filing limit.

Individual Stop Loss (ISL)/Reinsurance (REI) limits the medical group’s/IPA’s/facility’s financial risk for medical and facility services beyond a specified dollar amount per member, per calendar year. This program applies to services for which we capitated the medical group/IPA/facility.

The ISL program is updated annually. Each medical group/IPA/facility may take part each year. 

The medical group/IPA may purchase ISL/reinsurance from us or an outside carrier.

We determine our premium for ISL based on our experience. We convert the calculated premium for stop loss to either a percentage of premium or flat per member per month (PMPM) rate based on the medical group’s/IPA’s Agreement. Every month, we subtract the result from the total capitation.

We reimburse a medical group/IPA that purchases ISL through us for services that exceed the ISL deductible at the ISL program rates specified in the Agreement or the ISL election letter for the applicable contract year, minus the medical group’s ISL coinsurance amount.

We reimburse a facility that purchases reinsurance through us for services that exceed the reinsurance deductible at the reinsurance program rates specified in the Agreement or the reinsurance election letter for the applicable contract year, less the facility’s reinsurance coinsurance. The facility must identify all reinsurance claims before submission. The facility reinsurance program is updated annually.

The medical group/IPA or facility may elect to opt out of the UnitedHealthcare ISL/reinsurance program by purchasing ISL/ reinsurance coverage through a third-party insurance carrier. Such coverage must be through an entity we approve of and in the amounts required by UnitedHealthcare and state and federal law. Refer to your Agreement for details.

Notification of ISL/reinsurance claims

The medical group/IPA or facility provides written notification to us when services for a member equal 50% of the ISL/ reinsurance deductible. The written notification submission needs to be to us no later than the 15th day of the month following the month in which the claim amounts reach the 50% threshold.

ISL/reinsurance claims submission procedure

Submit all ISL/reinsurance claims having met the ISL/reinsurance deductible to us annually but no later than 90 calendar days after the end of the calendar year.

To receive reimbursement under the ISL/reinsurance program, follow these steps:

• Submit the ISL/reinsurance claims by spreadsheet to Individual_stoploss@uhc.com. Scan and email all hard-copy images. Include these on the submission spreadsheet:
  • Service health care provider name
  • Date of service
  • Service description
  • Correct RBRVS or CPT codes and description of services if required
  • Billed charges
  • Place of service
  • Medical group/IPA paid amount
  • Other insurance information
  • Discount adjustments
  • ICD-10-CM diagnosis codes
  • Proof of payment (copies of cancelled checks)
• Each spreadsheet submission sheet must be for 1 member only. We do not accept combined submissions for a family or for more than 1 member.
• For capitated services rendered outside the medical group/IPA/facility, we require copies of canceled checks showing actual amounts paid. Upon request, submit copies of all referral bills and/or copies of consultation and operative reports.
• We may ask you to submit a brief member history (copy of a consultant report and/or history dictation). We do not require lab results, X-ray results or records.
• These are excluded from the calculation of ISL/reinsurance claims:
  • Member copayment amounts
  • Non-covered services
  • Services paid by Workers’ Compensation
  • Services paid by other health plans
  • Services paid through third-party reimbursement

Our Claims Production Unit reviews the claim for completeness and tells medical group/IPA/facility if it needs any other information. It may need supporting records for ISL/reinsurance claim verification. After review, if the claim is accepted, we make a payment within 60 calendar days. Submit ISL/Reinsurance claims to Individual_stoploss@uhc.com.