For proper payment and application of deductibles and coinsurance, it is important to accurately code all diagnoses and services (according to national coding guidelines). It is particularly important to accurately code because a
member’s level of coverage under his or her benefit plan may vary for different services. You must submit a claim for your services, regardless of whether you have collected the copayment, deductible or coinsurance from the member at
the time of service.
To assist you in understanding how your claims will be paid, UnitedHealthcare’s Claim Estimator includes a feature called Professional Claim Bundling Logic which helps you determine allowable bundling logic and other claims
processing edits for a variety of CPT (CPT is a registered trademark of the American Medical Association) and HCPCS procedure codes. Note: Only bundling logic and other claims processing edits are available under this option.
Pricing and payment calculations are not included.
Allow enough time for your claims to process before sending second submissions or tracers, then check their status online at UnitedHealthcareOnline.com. If you do need to submit second submissions or tracers, be sure to submit them
electronically no sooner than forty-five (45) days after original submission.
Complete claims include the information listed under the Complete Claims Requirements section of this Guide.
We may require additional information for particular types of services, or based on particular circumstances or state requirements. If you have questions about submitting claims to us, please contact Customer Care at the phone number listed on the member’s health care ID card.
Complete claims requirements
• Member’s name
• Member’s address
• Member’s gender
• Member’s date of birth (dd/mm/yyyy)
• Member’s relationship to subscriber
• Subscriber’s name (enter exactly as it appears on the member’s health care ID card)
• Subscriber’s ID number
• Subscriber’s employer group name
• Subscriber’s employer group number
• Rendering Physician, Health Care Professional, or Facility Name
• Rendering Physician, Health Care Professional, or Facility Representative’s Signature
• Address where service was rendered
• Physician, Health Care Professional, or Facility “remit to” address
• Phone number of Physician, Health Care Professional, or Facility performing the service (provide this information
in a manner consistent with how that information is presented in your agreement with us)
• Physician’s, Health Care Professional’s, or Facility’s National Provider Identifier (NPI) and federal Tax Identification Number (TIN)
• Referring physician’s name and TIN (if applicable)
• Date of service(s)
• Place of service(s) (for more information see: cms.hhs.gov/PlaceofServiceCodes/Downloads/placeofservice.pdf)
• Number of services (day/units) rendered
• Current CPT-4 and HCPCS procedure codes, with modifiers where appropriate
• Current ICD-9-CM (or its successor) diagnostic codes by specific service code to the highest level of specificity (it is essential to communicate the primary diagnosis for the service performed, especially if more than one diagnosis is
related to a line item)
• Charges per service and total charges
• Detailed information about other insurance coverage
• Information regarding job-related, auto or accident information, if available
• Retail purchase cost or a cumulative retail rental cost for DME greater than $1,000
• Current NDC (National Drug Code) 11-digit number for all claims submitted with drug codes. The NDC number must be entered in the 24D field of the CMS-1500 Form or the LIN03 segment of the HIPAA 837 Professional
electronic form.