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UHC/Optum Claims

TessaLasky 2 years ago in Industry News/Discussion updated by sarah 2 years ago 2

Hello,

Since the new year all of our claims have come back denied for contractual obligation (code 45). Even on clients that we did not have trouble with previously, we are now having issues with claims coming back this way. Mostly seeing this for code H2014 which is not covered, but we are not getting a denial that we can send to secondary.

I am wondering if there was an update or something that we missed and we are sending our claims to the wrong place? Has anyone heard anything?

If it matters, we preform outpatient mental health services in Minnesota.


We have had a nightmare of a time dealing with United Healthcare and the Optum side. Being one is behavioral health and the other is the actual insurance plan, you would think they communicate with each other.

Thanks in advance!

This has been an ongoing issue with UHC in MN, we have been battling them for 2 years over it.  

First, follow the protocol and contact customer service rep.  There should be a note from Kyle Miller in UHC/OPTUM's system on how to process CTSS claims with PR instead of CO's relating to MN services specifically. Ask the rep to have them reprocessed because they were processed incorrectly. (It has to do with the grants covering as secondary and needing the PR denials).

We have emailed and called multiple people at UHC and OPTUM.  If you stay persistent with customer service and their supervisors, you should be able to get them reprocessed with a PR204 denial.  It's a HUGE headache.  And only after threatening to make a formal complaint with the Dept of Commerce did we see any results.  And you have to watch for your ERA's really closely because they haven't always been hitting our ERA's in Procentive, we've had to go and find them.


We are actually waiting on 3 clients still to come back through with payments, but have had success with at least 9 other clients.  Our company has considered not taking UHC clients until they can comply with proper (their own written) billing practices.


Here is the Dept of Commerce info also - I have already discussed this issue with Ramona Berger there at length and she is willing to open a more formal ticket with her team if multiple companies are having this issue, and if it's affecting eligibility of MH service - which it is.


Small Group/Individual MN plans - Ramona will address directly 


Large Group plans (like Walmart, over 50+ employees) - Dept of Labor 

Anyone with MA or PMAP as secondary - PMAP first (like we are doing here with IMC) and also the Ombudsman Program form should be filled out and sent in, Ramona is linking me to that info. 

Last effort to gain compliance - Kennedy Forum, formal complaint. 

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Hi Shauna,

Here are the resources I promised. These are general resources for clients; however, you can contact any organization to report systematic problems.

  • For mental health coverage or issues causing issues/days for clients who need necessary care and the clients have health insurance through an employer, particularly a larger employer:
  • For issues involving mental health insurance coverage or related programs:  https://parityregistry.org/share-your-experience
  • For Minnesota clients accessing mental health care through public managed health care organization programs/Medical Assistance programs, contact the Minnesota Department of Human Services Ombudsman:  651-431-2660
  • If you have systematic issues involving delays in clients accessing necessary care and you believe clients have individual health insurance coverage or group health insurance coverage from a smaller employer, feel free to contact me.

U.S. Department of Labor:  https://www.askebsa.dol.gov/Webintake/Home.aspx  or call  866-444-3272.

Best wishes, Shauna.

Ramona Berger, M.B.A.

Parity Program Manager

P: 651-539-1755

mn.gov/commerce

Minnesota Department of Commerce

85 7th Place East, Suite 280 | Saint Paul, MN 55101 


Good luck!  I personally know what a nightmare this issue is.  

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Thank you for your reference information, Shauna! We finally got thru to PreferredOne and they are changing how they process our claims (PR instead of CO) so that we are able to bill secondary payers for CTSS codes. It is definitely an arduous process. I appreciate having the information regarding Optum (UHC/Medica/UBH). 


My contact at PreferredOne - in case you have any issues with these same codes - is Jason Roys. He is our contract contact, so yours might be someone different. If it is Jason, his contact information is:


Jason Roys

Contract Manager & Provider Relations Representative

PreferredOne®

6105 Golden Hills Drive

Golden Valley, MN 55416

P:763-847-3248

F:763-847-4854

Jason.Roys@PreferredOne.com


They have been implementing a new claims process for us, with all CTSS codes now processing as Patient Responsibility as opposed to Contractual Obligation. 


I also filed a SBAR with the AUC, and DHS got on board with attempting to get a solution there. They have issued a formal request to commercial payers to process the CTSS codes as PR as opposed to CO, in order to allow agencies to bill secondary payers. Since the clients have the coverage through the secondary payer, that is the only way agencies may be reimbursed. They (the AUC and DHS) can not make commercial payers adhere to this recommendation, but they can stress strongly that they change their practice. 


As of now, we are submitting the individually denied service lines to DHS with something in writing from the primary payer, stating they do not cover the services billed. It is a long and painful process, but we are hopeful that it might bring about change in the future.


Good luck with your claim issues!