How is UHC assessing ED facility commercial claims, 07/01/2021

This policy will become effective as of 07/01/2021 and will apply to commercial claims for “most states”.

The claims will be assessed according to existing plan provisions and evaluated on, including:

• The patient’s presenting problem
• The intensity of diagnostic services performed
• Other patient complicating factors and external causes

If the claims are determined to be non-emergent than the claim will not be paid or subject to limited coverage in accordance with the member’s Certificate of Coverage. 

This enhanced capability will apply to commercial fully insured ED facility claims in many states for dates of service on July 1, 2021, or later. Subject to regulatory approval we will continue to expand this capability to additional states and segments.   

Attestation:

If an ED event is determined to be non-emergent, you’ll have the opportunity to complete an attestation if the event met the definition of an emergency consistent with the prudent layperson standard. 

A notice of the opportunity to submit an attestation will be sent electronically to the facility when an ED event is determined to be non-emergent. Instructions about accessing the attestation through UHCprovider.com will be included. We may also follow up with a mailed letter about the attestation.

If the attestation is submitted within the required time frame, the claim will typically be processed according to the plan’s emergency benefits.

UnitedHealthcare reserves the right to order medical records for claims review, even if an attestation has been submitted.

If providers have any questions, please contact Provider Services at 877-842-3210 or your Network Representative.

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