Tag: #facilityclaims

Posted in #unitedhealthcare, Updates

UHC: Inpatient Readmission Review Policy, Facility-new 09/1/2021

Posted on by KR2Medical Billing

This policy will be applied to UHC commercial Facility claims, starting for DOS 09/01/2021 and thereafter.

The following guidelines will apply:

1.The same day readmissions with same or related condition are required to be combined and reported on the same institutional claim (UB04-claim form or electronic equivalent) to be eligible for reimbursement

2. Same day readmissions with unrelated condition are required to be reported with condition code B4 on the institutional claim in order to be eligible for reimbursement

3. Planned readmissions or leave of absences, are required to be combined and reported on the same institutional claim with occurrence code 74 to report the dates the leave began and ended.

Exceptions to this policy:

  • Admissions for chemotherapy or immunotherapy treatment
  • Admissions for substance abuse unit or facility
  • Admonitions to an inpatient rehab unit
  • Readmissions after a patient is discharged from hospital against medical advice

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Posted in #unitedhealthcare, Updates

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

Posted on by KR2Medical Billing

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.

Would like to learn more about recent changes medical coding and billing guidelines? Please visit the Recent Posts:

#emergencyclaims, #UHCcommercial, #attestation, #facilityclaims