sadie twite 2 years ago in Payments/ERA Modules updated by dsalazar 2 years ago 7

Has anyone been successful in getting paid from UHC-PMAP for residential treatment and SUD outpatient services? We are getting conflicting information on how they want us to bill residential treatment so I would love to hear what form and what codes you are billing especially if you are a 1115 waiver provider. Thank you in advance!

We don't bill for residential tx but after not being paid for a while, I finally called UHC PMAP to find out they actually were paying claims.  Funds were being deposited electronically but we were not receiving the ERAs in Procentive.  I had to log into OptumPay to get the remit for the payments.  I did contact Procentive to find out what was the problem and we just received our first ERA last week.  The payer is UHC of Illinois.  

I'm curious if this ever got resolved. We haven't been paid for anything except for housing stabilization services since they became PMAP. We're getting authorizations for residential services but no payments for res or outpatient.

We needed to get a separate contract.  Our UHC contract didn't cover the UHC PMAP claims. 

Bumping this topic because I'm struggling with getting UHC PMAP claims paid.  My contacts at Optum are insisting that I need to bill OUTPATIENT claims like a residential claim:

For the 944/945/953 with H2035 I am seeing a lot of F25 Denial - Invalid Discharge Status-Submit Valid Discharge Date and/or Discharge Status for this claim. Please see the education below on how to submit these claims correctly to allow them to reimburse per the contract.

Code H2035: these claims have denied F25. Please see below for further details.

  • The Type of Bill (Box4) must end in a frequency digit that supports the status (Box 17)

If bill type ends in a “1” then status must be “01”- Bill type ending in “1” means the patient has received all services and are done. The patient has been discharged (as in the member will no longer be receiving this service or all services have been rendered)

*Any interim/continuing services submitted after a member has been “discharged” would require a different Type of Bill Code *

  • If Status is “30” then bill type must end in:

“2” for the first claim of the series.

“3” for all interim claims being submitted for the same ongoing services.

“4” will be used for the final billing of the services as they are done and the patient has been discharged.

I've NEVER billed outpatient claims in this manner.  Does anyone have any insight?  I'm fighting this with them.

Hey Heather,

I have defaulted claims under the payer information to a "3" this seems to have streamlines our claims. ( we dont' bll medica often so not sure if it will solve for them) 

You can also look at the data after you check your claims in the billout ---- it allows you to select a status accordingly manually.

We residential were set to "default" setting and process great according to 1/2/3 etc without us being manual but for some reason OP has not. 

I'll can add further input on this topic too - I did the same by defaulting all of the Oupatient claims to "3" and it seems to have worked, at least for outpatient. Our Residential claims still aren't getting paid, but that's a separate issue for us. It had something to do with our PMAP contract not being set up with the revenue codes for residential and we're still working on getting that fixed with UHC. But the OP claims seem to be getting paid now with sending them as continuing claims "3".