Timely forwarding of misdirected claims.Maximum out-of-pocket (MOOP) administration.Claim operational policies and procedures.Non-contracted health care provider payment dispute resolution (overturns and upholds) claims assessment.Health care provider denial assessment.Customer denial accuracy and denial letter review.Financial accuracy (including proper benefit application, appropriate administration of member cost-share accumulation).Claims timeliness assessment for applicable claim element being reviewed.The delegated entity must be ready for the auditor at the time of assessment. The auditor reviews the reports and selects random claims for further review. Audit of the claims cycle, which includes validation/verification of the date received, acknowledged, processed and closed.Īs part of our compliance assessment, we request copies of the delegated entity’s universal claims listing for all health care providers.Conduct walk-through of delegated entity’s claims operations, which includes mailroom.Significant issues concerning financial stability.
Significant increase in claims-related complaints. Significant increase in members or volume of claims. Established management service organization (MSO) acquires new business. New management company or change of processing entity. Information systems changes or conversion. Allegations of fraudulent activities or misrepresentations. Overall performance warrants a review (claims appeal activity, claims denial letters or member and health care provider claims-related complaints). Non-compliance with reporting requirements. Self-reported timeliness reports indicate non-compliance for 2 consecutive months. Assessment results indicate non-compliance. We review delegated entities at least annually. Our auditors perform claims processing compliance assessments. We have policies and procedures designed to monitor the performance of delegated entities’ compliance with contractual state and federal claims processing requirements. Review presenting symptoms, as well as the discharge diagnosis, for emergency services. The delegated medical group/IPA is accountable for conducting the post-service review of emergency department claims and unauthorized claims. Claims with level of service (LOS) or LOC mismatch. Claim check or modifier edits based on our claim payment software. Implants not identified on our implant guidelines used by our claim department. 
We also perform medical claim reviews on claims that do not easily allow for additional focused or ad-hoc reviews, such as:
Claims-related issues as they relate to medical necessity and UnitedHealthcare claims payment criteria and/or guidelines are identified and resolved. Follow-up for utilization, quality and risk issues was needed and initiated. Admission, length of stay and LOC are appropriate. We perform a medical claim review to provide fair and consistent means to review medical claims and confirm delegates meet the following criteria: We define a post-service/retrospective/medical claim review as the review of medical care treatments, medical documentation and billing after the service has been provided. Appeals and grievances - 2022 Administrative GuideĪ delegated medical group/IPA must implement and maintain a post-service/retrospective review process consistent with UnitedHealthcare processes. Delegate performance management program - 2022 Administrative Guide. CMS premiums and adjustments - 2022 Administrative Guide. Capitation reports and payments - 2022 Administrative Guide. Customer service requirements between UnitedHealthcare and the delegated entity (Medicare and Medicaid) - 2022 Administrative Guide. Contractual and financial responsibilities - 2022 Administrative Guide. Claims disputes and appeals - 2022 Administrative Guide. Claim delegation oversight - 2022 Administrative Guide. Medical management - 2022 Administrative Guide. Referrals and referral contracting - 2022 Administrative Guide. 
Virtual Care Services (Commercial HMO plans – CA only) - 2022 Administrative Guide.Delegated credentialing program - 2022 Administrative Guide.Health care provider responsibilities - 2022 Administrative Guide.Authorization guarantee (CA Commercial only) - 2022 Administrative Guide.Medicare Advantage (MA) enrollment, eligibility and transfers, and disenrollment - 2022 Administrative Guide.
Commercial eligibility, enrollment, transfers, and disenrollment - 2022 Administrative Guide. Verifying eligibility and effective dates - 2022 Administrative Guide. #TIMELY FILING LIMITS BY PAYOR HOW TO#
How to contact us - 2022 Administrative Guide. What is delegation? - 2022 Administrative Guide. What is capitation? - 2022 Administrative Guide. Capitation and/or delegation supplement - 2022 Administrative Guide expand_more
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