Resolving an Incorrect Payment in EOB - Adjustment or void payment

Introduction 

A provider who receives an incorrect payment for a claim or receives payment from a third party after Medicaid has made payment is required to submit an adjustment or a void to correct the payment.

Adjustment An adjustment is needed if the correction to the payment would result in a partial refund or the claim was underpaid. Only paid claims can be adjusted.

Void A void is needed if the correction to the payment would result in a complete refund of the Medicaid payment to the fiscal agent.


All Claims Are Incorrect on the Remittance Voucher


If a provider receives a payment for claims that the provider did not submit, the provider should return the funds issued by the fiscal agent only when every claim payment listed on the remittance voucher was paid to the provider in error. For example, none of the recipients listed on the remittance voucher are the
provider’s patients. In this situation, return the remittance voucher and funds with a short note of explanation to:

ACS State Healthcare
P.O. Box 14597
Tallahassee, Florida 32314-4597


Partially Incorrect Claims on the Remittance Voucher


If the remittance voucher contains some correct payments and some incorrect payments, do not return the Medicaid check to the fiscal agent. Deposit the check and file a void request for each individual claim payment that should be completely refunded to Medicaid. File an adjustment request for each individual
claim payment that was partially incorrect.

Incorrectly Billed or Keyed Claims

An adjustment or void request will be processed as a replacement to the original, incorrectly paid claim. All claim items on the request must be correctly completed. An adjustment or void must be for the entire amount not just for remaining unpaid amounts or units.

For example, if a provider billed for and received payment for 3 units of a procedure and should have billed for 5 units, the provider must submit a claim for the full 5 units as an adjustment.



Adjustments for Keying Errors


If an incorrect payment was the result of a keying error, the provider can either:

·  Call the fiscal agent at 800-289-7799 (in Florida)
or 800-955-7799 (outside Florida) and request the claim be reprocessed; or

·  Photocopy the claim, circle the item that was incorrectly keyed, sign and
date the form, and resubmit it to the fiscal agent.

The provider should check to be sure that a keying error caused the incorrect payment. In some cases, the claim payment must be reduced due to service limitations. If the maximum allowable amount according to the fee schedule was not paid, the remittance voucher in the adjustment reason code column will specify the reason. All adjustment reason codes are translated at the end of the remittance voucher just after the summary section.


Third Party Recovery After Medicaid’s Payment


If a provider receives payment from a third party after Medicaid paid the claim, the provider must submit an adjustment or void request.

·  A void is required if another carrier’s payment was equal to or higher than Medicaid’s maximum allowable amount.
·  An adjustment is required if the other carrier’s payment was less than the Medicaid maximum allowable amount.

UHC appeal claim submission address - Instruction

Claim appeal


If you believe you were underpaid by us, the first step in resolving your concern is to submit a Claim Reconsideration as described above.

If you still do not agree with the outcome of the Claim Reconsideration decision in Step 1, you may submit a formal appeal request to:

UnitedHealthcare Provider Appeals

P.O. Box 30559
Salt Lake City, UT 84130-0575


For Empire Plan

UnitedHealthcare Empire Plan, 
P.O. Box 1600 
Kingston, NY 12402-1600

Level 1. Expedited Medical Review

UnitedHealthcare Central Escalation Unit 
P.O. Box 30573 
Salt Lake City, UT 84130-0573 
Fax: 801-567-5498


Dental Issues Appeals/Grievance Coordinator Grievance & Appeals Department 
P.O. Box 30569 
Salt Lake City, UT 84130-0569 Fax: (714) 364-6266


Level 3: Expedited External, Independent Review 

Physical Health Issues UnitedHealthcare Central Escalation 
Unit 4316 Rice Lake Road 
Duluth, MN 55811 
Fax: 801-938-2100 or 801-938-2109



Your appeal must be submitted to us within twelve (12) months from the date of the adjustment decision shown on the Explanation of Benefits (EOB) or Provider Remittance Advice (PRA). Attach all supporting materials such as member specific treatment plans or clinical records to the formal appeal request, based on the reason for the request. Include information which supplements your prior adjustment submission that you wish to have included in the appeal review.

Our decision will be rendered based on the materials available at the time of formal appeal review.
If you are appealing a claim that was denied because filing was not timely:


1. Electronic claims – include confirmation that UnitedHealthcare or one of its affiliates received and accepted your claim.

2. Paper claims – include a copy of a screen print from your accounting software to show the date you submitted the claim.

Note: All proof of timely filing must also include documentation that the claim is for the correct patient and the correct visit.


If you are disputing a refund request, please send your letter of appeal to the address noted on the refund request letter. Your appeal must be received within thirty (30) calendar days of the date of the refund request letter, or as required by law or your participation agreement, in order to allow sufficient time for processing the appeal, and to avoid possible offset of the overpayment against future claim payments to you. When submitting the appeal, please attach a copy of the refund request letter and a detailed explanation of why you believe we have made the refund request in error.

If you disagree with the outcome of any claim appeal, or for any other dispute other than claim appeals, you may pursue dispute resolution as described in the Resolving disputes section and in your agreement with us. In the event that a member has authorized you to appeal a clinical or coverage determination on the member’s behalf, such an appeal will follow the process governing member appeals as outlined in the member’s benefit contract

Here You could find the UHC claim reconsideration form

https://www.unitedhealthcareonline.com/ccmcontent/ProviderII/UHC/en-US/Assets/ProviderStaticFiles/ProviderStaticFilesPdf/Claims%20&%20Payments/UnitedHealthcare%20Request%20for%20Reconsideration%20Form/ClaimReconsiderationRequestForm.pdf

UnitedHealthcare Claim Reconsideration Request Form

Instructions: This form is to be completed by UnitedHealthcare – contracted physicians, hospitals or other health care professionals to request a claim reconsideration for members enrolled in commercial benefit plans administered by UnitedHealthcare and Medicare plans administered by SecureHorizons® and Evercare®.

Mail address: Send all Claim Reconsideration requests to the address on the back of the members identification card (ID), or the address on the EOB
or PRA. NOTE: If you are receiving the consolidated 835, you may verify the enrollee’s correspondence address using the eligibility search function on
UnitedHealthcareOnline.com.


Instructions for submitting Claim Reconsideration Requests

A Claim Reconsideration Request is typically the quickest way to address any concern you have with how we processed your claim. With a Claim Reconsideration Request, we review whether a claim was paid correctly, including if your provider information and/or contract are set up incorrectly in our system, which could result in the original claim being denied or reduced.

This reference tool provides instruction regarding the submission of a Claim Reconsideration Request and details the supporting information required for claim reconsiderations or to correct claims, and explains those processes.

There are several ways to submit a Claim Reconsideration Request

1. Electronic Claim Reconsideration Request with attachments on Optum Cloud

For information on registering for access to the Optum Cloud Dashboard, see the Administrator Registration and Importing Users Quick Reference Guide.

By using this method, you can:

• Reduce the overall turnaround time for the request.
• Receive immediate confirmation and a unique tracking number to show we received your request.
• Check submission status throughout the process.

2. If you are a registered user on UnitedHealthcareOnline.com, use Electronic Claim Reconsideration for submissions without attachments.

By using this method:
• You will be notified that your request was received.

To learn more about submitting claim reconsiderations without attachments, you may view the step-by-step instructions in the Claim Reconsideration Quick Reference Guide.

3. To mail in paper Claim Reconsideration requests, complete the form below.

Where to send Claim Reconsideration Requests:

• For UnitedHealthcare and UnitedHealthcare West, if your Claim Reconsideration Request is for a Commercial or Medicare member, send the paper Claim Reconsideration Requests to one of the following:

* The address on the Explanation of Benefits (EOB) or the Provider Remittance Advice (PRA)

* The claim address on the back of the member’s ID card

• For UnitedHealthcare Empire Plan, send to:

P.O. Box 1600
Kingston, NY 12402-1600



Instructions for submitting Claim Reconsideration Requests

A Claim Reconsideration Request is typically the quickest way to address any concern you have with how we processed your claim. With a Claim Reconsideration Request, we review whether a claim was paid correctly, including if your provider information and/or contract are set up incorrectly in our system, which could result in the original claim being denied or reduced.

This reference tool provides instruction regarding the submission of a Claim Reconsideration Request and details the supporting information required for claim reconsiderations or to correct claims, and explains those processes.

There are several ways to submit a Claim Reconsideration Request.

1. Electronic Claim Reconsideration Request with attachments on Optum Cloud

For information on registering for access to the Optum Cloud Dashboard, see the Administrator Registration and Importing Users Quick Reference Guide.

By using this method, you can:

• Reduce the overall turnaround time for the request.

• Receive immediate confirmation and a unique tracking number to show we received your request.

• Check submission status throughout the process.


2. If you are a registered user on UnitedHealthcareOnline.com, use Electronic Claim Reconsideration for submissions without attachments.

By using this method:

• You will be notified that your request was received.

To learn more about submitting claim reconsiderations without attachments, you may view the step-by-step instructions in the Claim Reconsideration Quick Reference Guide.

3. To mail in paper Claim Reconsideration requests, complete the form below.

Where to send Claim Reconsideration Requests:

• For UnitedHealthcare and UnitedHealthcare West, if your Claim Reconsideration Request is for a Commercial or Medicare member, send the paper Claim Reconsideration Requests to one of the following:


* The address on the Explanation of Benefits (EOB) or the Provider Remittance Advice (PRA)

* The claim address on the back of the member’s ID card

• For UnitedHealthcare Empire Plan, send to:

P.O. Box 1600

Kingston, NY 12402-1600

• For UnitedHealthcare Community Plan, if your Claim Reconsideration Request is for a Medicaid/Chip member, go to:

Community Plan Claim Reconsideration Mailing Addresses



NOTE:

• This reference guide should not accompany the paper Claim Reconsideration Request form you are submitting.

• No new claims should be submitted with the paper form.

• Do not use the paper form for formal claims appeals or disputes. When applicable, continue to follow your standard appeals process for formal appeals or disputes as found in your provider manual or agreement.




The following are the explanations of reasons for requesting a paper claim reconsideration

1. Previously denied as “Exceeds Timely Filing”

Timely filing is the time limit for filing claims, which is specified in the network contract, a state mandate or a benefit plan. For a non-network provider, the benefit plan would decide the timely filing limits. When timely filing denials are upheld, it is usually due to incomplete or invalid documentation submitted with Claim Reconsideration Requests.
Submission requirements for electronic claims:

* Submit an electronic data interchange (EDI) acceptance report. This must show that UnitedHealthcare or one of our affiliates received, accepted and/or acknowledged the claim submission.

* A submission report alone is not considered proof of timely filing for electronic claims. It must be accompanied by an acceptance report.

• The acceptance report must indicate the claim was either “accepted,” “received” and/or “acknowledged” within the timely filing period.

Submission requirements for paper claims:

* Submit a screen shot from your accounting software that shows the date the claim was submitted. The screen shot must show the:

• Correct member name

• Correct date of service

• Submission date of claim that is within the timely filing period


2. Previously denied for “Additional Information”

Please attach a copy of all information requested and include the following information on the first page of the request:

* Patient name

* Patient's address

* Patient member ID number

* Provider name and address

* Reference number

Add the additional information requested. Examples include:

* Medical notes

* Anesthesia time units

* Current Procedural Technology (CPT) or Healthcare Common Procedure Coding System (HCPCS) codes (missing, illegible, or deleted)

* Date of service

* Description of service

* Diagnosis code where the primary code is missing, illegible or is the wrong number of digits

* Physician name

* Patient name

* Place of service (POS) code

* Provider's Tax Identification Number (TIN)

* Semi-private room rate

* Accident information





3. Previously denied for Coordination of Benefits information

Commercial Coordination of Benefits claim requirements

* Primary Payer Paid Amount – Submit the primary paid amount for each service line on the 835 Electronic Remittance Advice (835) or EOB. Submit the paid amount on institutional claims at the claim level.

* Adjustment Group Code – Submit the other payer claim adjustment group code found on the 835 or the EOB. Common reasons for the other payer paying less than billed include: deductible, co-insurance, copayment, contractual obligations and/or non-covered services.

* Adjustment Reason Code – Submit the other payer claim adjustment reason code on the 835 or the EOB. Common reasons for the other payer paying less than billed include: deductible, co-insurance, copayment, contractual obligations and/or non-covered services.

* Adjustment Amount – Submit the other payer adjustment monetary amount.

* Preference – Submit professional claims at the line level as allowed by the primary payer. Submit institutional claims at the claims or line level. The service level and claim level should be balanced. UnitedHealthcare follows 837p Health Care Claim Encounter – Professional (837p) and 837i Health Care Claim Encounter - Institutional (837i) guidelines.

Medicare Primary Coordination of Benefits claim requirements

* Adjustment Group Code – Submit the other payer claim adjustment group code on the 835 or the EOB. At the claim level, do not enter any amounts included at the line level. Common reasons for the other payer paying less than billed include: deductible, co-insurance, copayment, contractual obligations and/or non-covered services.

* Adjustment Reason Code – Submit the other payer claim adjustment reason code on the 835 or the EOB. At the claim level, do not enter any amounts included at the line level. Common reasons for the other payer paying less than billed include: deductible, co-insurance, copayment, contractual obligations and/or non-covered services.

* Adjustment Amount – Submit the other payer adjustment amount.

* Medicare Paid Amount – Submit the other payer claim level and line level paid amounts when UnitedHealthcare is the secondary payer to Medicare.

* Medicare Approved Amount – Submit the other payer claim level and line level allowed amounts when UnitedHealthcare is the secondary payer to Medicare.

* Patient Responsibility Amount – Submit the monetary amount for which the patient is responsible from the 835 or the Medicare EOB.

* Medicare Acceptance of Assignment – Indicate whether the provider accepts the Medicare assignment.

* Preference – Submit professional claims at the line level if the primary payer provides the information, and submit institutional claims at either the line or claim level. The service level and claim level should be balanced. 



UnitedHealthcare follows 837p and 837i guidelines.

Medicaid Primary Coordination of Benefits Claims Requirements

Medicaid is the final payer in all coordination of benefits scenarios.






4. Resubmission of a corrected claim

Consistent with Health Insurance Portability and Accountability Act (HIPAA) requirements, submit corrected claims in their entirety.

If a claim needs correction, please follow these guidelines:

* Make the necessary changes in your practice management system, so the corrections print on the amended claim.

* Attach the corrected claim (even line items that were previously paid correctly). Any partially-corrected request will be denied. Enter the words, “Corrected Claim” in the comments field on the claim form. Your practice management system help desk or your software vendor can provide specific instructions on where to enter this information in your system. If you do not have this feature, stamp or write “Corrected Claim” on the CMS 1500 form. Changes must be made in your practice management system and then printed on the claim form. You may not write on the claim itself.

* The resubmitted claim is compared to the original claim and all charges for that date of service. The provider and patient must be present on the claim, or we will send a letter advising that all charges for that day are required for reconsideration.

* Complete the Claim Reconsideration Request form as instructed and mark the box on Line 4 for Corrected Claims. Continue to the comments section and list the specific changes made and rationale or other supporting information.

UB04: UB Type of Bill should be used to identify the type of bill1 submitted as follows:

* XX5 Late Charges

* XX7 Corrected Claim

* XX8 Void/Cancel previous claim

5. Previously processed but rate applied incorrectly resulting in over/underpayment

Network Providers - Please check your fee schedules prior to submitting a claim reconsideration request for this reason. Indicate the contract amount expected by code or case rate, compared to the amount received, as well as other factors related to the over- or under-payment. If you disagree with the fee schedule your claim was paid by, contact your Network Management Representative. Go to and select your state to find the appropriate network management contact for your area.

6. Resubmission of Prior Notification/Prior Authorization Information

Submit a prior authorization number and other documents that support your request. If you spoke to a customer service representative and were told that notification was not required, please submit the date, time and reference number of that call and the name of the representative handling the call. Please also advise if the service was performed on an emergency basis and therefore notification was not possible.

7. Resubmission of a claim with bundled services

Review your claim for appropriate code billing, including modifiers. If the claim needs to be corrected, please submit a corrected claim. If a bundled claim is not paid correctly, submit a detailed explanation including any pertinent information on why the bundling is incorrect.

8. Other (Provide any additional information that supports your request)


UnitedHealthcare Single Paper Claim Reconsideration Request Form

This form is to be completed by physicians, hospitals or other health care professionals for paper Claim Reconsideration Requests for our members.

• Please submit a separate claim reconsideration request form for each request.

• No new claims should be submitted with this form.

• Do not use this form for formal appeals or disputes. Continue to use your standard appeals process for formal appeals or disputes.

Please refer to the attached Claim Reconsideration Reference Guide, your provider administrative manual or our provider website for additional details including where to send paper Claim Reconsideration Requests. You may verify the member’s address using the eligibility search function on the website listed on the member’s health care ID card.

Documentation needed for Outpatient Lab and Diagnostic Tests

•    Please be sure documentation submitted is legible.
•    Please submit records for all dates of service on the claim.
•    Please ensure the medical records submitted provide proof the service(s) was ordered and rendered. Also, ensure the medical records provide justification supporting medical necessity for the service by submission of the following documentation:
o    Physician order/intent.
o    Diagnosis/ progress notes supporting medical necessity of test (may include history and physical).
o    Date of onset.
o    Documentation supporting diagnosis billed, i.e., office notes.
o    Test and/or laboratory report (may need notes from referring physician if clinical indications for ordering the test are not listed on the report). Ex: Reference lab results are often located at offsite lab.
o    Physician interpretation/notification of results.
o    Any other documentation supporting medical necessity such as nurses’ notes, physician follow-up, medication administration records (for blood glucose, physician follow-up and notification are required).
o    Pathology reports for pathology services.
o    Specimen “counts” in progress/physician/operative reports to support units billed for pathology services.
o    Signatures/credentials of professionals providing services.
o    Any other documentation a provider deems necessary to support medical necessity of services billed, as well as documentation specifically requested in the Additional Documentation Request (ADR) letter.

UHC insurance claim appeal - claim reconsideration

Step 1: Claim reconsideration


If you believe you were underpaid by us, the first step in addressing your concern is to request a Claim Reconsideration.

• The quickest way to submit a Claim Reconsideration request is directly through UnitedHealthcareOnline.com. Go to UnitedHealthcareOnline.com  Claims & Payments  Claim Reconsideration. Please identify the specific claims in “paid” or “denied” status which you believe should be adjusted and give a description of the requested adjustment.

• If written documentation, such as proof of timely filing is needed, you must use the Claim Reconsideration
Request Form found on UnitedHealthcareOnline.com  Claims & Payments  Claim Reconsideration  Claim Reconsideration Request Form. The form should be mailed to the claim address on the back of the member’s health care ID card.

If you are submitting a Claim Reconsideration Request Form for a claim which was denied because filing was not timely:

1. Electronic claims – include confirmation that UnitedHealthcare or one of its affiliates received and accepted
your claim.

2. Paper claims – include a copy of a screen print from your accounting software to show the date you submitted the claim.

Note: All proof of timely filing must also include documentation that the claim is for the correct patient and the
correct visit.

• Alternatively, you can call the Customer Care number on the back of the health care ID card to request an
adjustment for issues which do not require written documentation.

• If you have issues involving twenty (20) or more paid or denied claims, aggregate these claims on the Claim Project online form and submit the form for research and review. Go to UnitedHealthcareOnline.com  Claims & Payments

 Claim Research Project.

Documentation needed for Inpatient Rehabilitation Facility (IRF) Services

•    Please be sure documentation submitted is legible.
•    Please submit records for all dates of service on the claim.
•    Please ensure that the medical records submitted provide proof that the service(s) was ordered and rendered. Also, ensure the medical records provide justification supporting medical necessity for the service by submission of the following documentation:
o    Physician’s order for IRF admission/placement.
o    IRF Patient Assessment Instrument (PAI)/initial assessment.
o    Preadmission screening records.
o    Inpatient hospital (acute stay records) including discharge summary.
o    History and physical.
o    Consultation reports.
o    All physician’s orders.
o    All physician certifications.
o    All physicians’, nurses’ and therapists’ progress notes and team conference notes.
o    Therapy initial evaluations and any re-evaluations (if applicable).
o    All plans of treatment from all disciplines.
o    All occupational/physical therapy and/or speech-language pathology and social services notes and minutes of service.
o    All/any documentation to support the three-hour rule.
o    Discharge summaries from all disciplines.
o    Any other documentation to support appropriateness of admission.
o    Signatures/credentials of professionals providing services.
o    Any other documentation a provider deems necessary to support medical necessity of services billed, as well as documentation specifically requested in the Additional Documentation Request (ADR) letter.