Wiki OPTUM / UHC Community inappropriate denials

[AbeDream]

(This is my first post- so please go easy on me if I missed this from an earlier post - TY)

UHC Community Plan in NY had requested records from the provider through "their vendor OPTUM" and records were send and reviewed. Part of the claim (an allergy test 95004 @ 60) was denied as "The submitted medical records do not support the units billed." Meanwhile the records CLEARLY state the procedure done, number of antigens tested, signed, dated, and otherwise complete. This is not the first claim they request in this fashion and they all passed in the past. Nonetheless, OPTUM has rejected other tests done as incomplete in the past despite supporting documentation.

Obviously we would like to file an appeal, does anyone have some strongly worded templates I can use? PLease PM me or attach as a reply. Are there any resources beyond the appeal process? I am sure that I am not the only one seeing this sort of problem. Obviously just a tactic used by the insurance to dodge claims....

Thank you in advance.

 

[hopepg]

Yup, not the only one seeing these kind of denials! (ugh!)
Luckily Optum's provider portal is a great tool for submitting reconsiderations. If you don't have a login for Optum, register for one & then select the payers they have available to be on your "LINK" dashboard. UHC Community is one. Also make sure you have the UHC Claims Management & UHC Claims Reconsideration "apps" are added to your dashboard. I use them often.

I don't have a specific template but I would suggest when you word your request specify where the documentation lists what you are billing for & reference the CPT book description of the codes you are billing for.

Assuming they are actually incorrect in their denial & the records/documentation truly do support what you have billed - A reconsideration/appeal verbiage could look something like -

"Charges have been denied for _____________(briefly summarize the denial reason). This is incorrect. Please reconsider the __________ (description of CPT ) as described with CPT code XXXXX for $xx.xx. This ________ (service/procedure/etc...) is specifically noted by Dr. XX XX on page XX of the attached clinic note. According to the __________(list out your CPT manual info like - Current Procedural Terminology Professional Edition for 2016), the description for CPT code XXXXX says this is for _________ (briefly tell desc of CPT) per number of tests. This charge is supported by this documentation & has been billed appropriately according to the CPT Manual. I respectfully request that this denial be reconsidered & release for payment/allowance."

This is just meant as a suggestion in how I would word it if the denial is really incorrect & you have documentation to support the billing. I wouldn't copy & paste word for word. Also, check grammar...I'm sure mine has all sorts of issues

When you have a template written out or created, save it so you can save time later with future denials that need to be "appealed".

 

[glanter]

A great appeal letter does not change the fact that Optum has a training & education

A great appeal letter does not change the fact that Optum has a serious training & education problem. It's awful and they are extremely rude/unprofessional. No accountability for incorrect claims reviews. No process for filing a complaint. I have one today that states "documentation does not indicate the exact size" although 38 cm is CLEARLY documented within the operative text. This is one of many inaccurate reviews. They hang up on providers when they can't answer questions, do not return calls, and there is no way to speak to someone in the actual review area. It's shameful that we have to deal with these kinds of issues as contracted providers. I'm thinking we are probably going to walk away from our contract in the very near future - we would be paid substantially more as an out of network provider for our niche services if we were not in network. Their loss for not fixing their problems.

Gail

 

[christinnagle]

OPTUM/ UHC Community Inappropriate Denials

just my 2 cents- if the denials are for UHC, it seems as though UHC outsources their claims processing to another country, at least that's where the calls are answered initially. When i call, i go thru the whole process with the 1st CSR person, then ask for the call ref# and then ask to be transfered to a claim specialist back in the united states for an expeditated (?) claims appeal; make sure you get that call reference #. I've spent a painful amount of time on the phone and found with this info when it comes to UHC. the first CSR person says they will send it thru for reprocessing, but it usually just denies as a duplicate denial, so i try to skip this step. good luck!