![]() Time frame for Submitting a Reconsideration or Appeal Refer to the Member Administrative Grievance & Appeal (Non UM) Process & Timeframes policy at /policies > For Commercial Plans > UnitedHealthcare Oxford® Clinical, Administrative and Reimbursement Policies.ģ. You must follow the process for member administrative claims appeals. Any health care provider or practitioner when appealing on behalf of the member, with signed member consent.Participating health care providers appealing a decision on their own behalf, according to the terms of their Agreement with us.Who May Submit a Reconsideration or Appeal If we determine that additional payment is justified, we reprocess the claim and remit the additional payment.Ģ. We make every effort to clarify or explain our actions. Continue below for Oxford-specific requirements.īefore requesting an appeal determination, contact us, verbally or in writing, and request a review of the claim’s payment. See Claim reconsideration and appeals process found in Chapter 10: Our claims process for general reconsideration requirements and submission steps. CMS makes a retroactive change to enrollment or to primary versus secondary coverage of a Medicare benefit plan member. ![]() A health care provider affirmatively requests additional payment on claims or issues older than 1 year.Misrepresentation of health care provider rendering the services or licensure of such health care provider, and similar issues.Frequent waiver of member financial responsibility.Misrepresentation of services or diagnosis.Oxford has a reasonable suspicion of fraud or a sustained or high level of billing errors related to:.Examples include overpayments related to duplicate claims, fee schedule issues, isolated situations of incorrect billing/unbundling and claims paid when Oxford was not the primary insurer.Įxception: Oxford will pursue collection of overpayments beyond 1 year and use statistical methods and extrapolation in situations where: We do not pursue collection of overpayments from individual participating health care providers when overpayments are identified as isolated mistakes or where the health care provider is not at fault if the overpayments were more than 1 year before the date of notice of the overpayment or use extrapolation. Note: Once a health care provider is given notice, we initiate discussions and take action during the following 1 year period. We use random sampling, examination by external experts and reliable statistical methods to determine claim overpayments in situations involving large volumes of potentially overpaid claims. Oxford may pursue such claim overpayments as permitted by law and following the applicable statute of limitations (usually 6 years). Behavioral issues: Upcoding, misrepresentation of service provided, services not rendered at all, frequent waiver of member financial responsibility.Administrative reasons: Duplicate payments, payments relating to fee schedules or billing/bundling issues, payments made where Oxford was not the primary insurer. ![]() Oxford periodically asks health care providers to return overpayments due to either: The following information applies to health care providers but does not apply to facilities or ancillaries.
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