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.
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.
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