UnitedHealthcare
Largest single health insurer in the United States, offering commercial, Medicare Advantage, Medicaid managed care, and specialty plans.
Important: Payer policies change frequently. Always verify current requirements using official payer manuals, provider portals, and direct contact with the payer. DenialPro provides educational guidance and references but does not replace official payer policy. The information on this page is for educational purposes only and may not reflect the most current payer requirements.
Overview
UnitedHealthcare (UHC) is the largest single health insurer in the United States, serving employers, individuals, Medicare and Medicaid beneficiaries, and the military. UHC offers commercial plans, Medicare Advantage plans, Medicaid managed care plans (UnitedHealthcare Community Plan), and military/veteran plans (TRICARE West). UHC is part of UnitedHealth Group, which also includes Optum (health services) and OptumRx (pharmacy). UMR is a third-party administrator (TPA) subsidiary.
Official Resources
Timely Filing Limits
Most UHC plans allow 90 days from the date of service. Medicare Advantage plans may allow up to 90 days. Check the specific plan's provider agreement for the exact deadline. Some plans offer 365 days for certain claim types.
Appeal Time Limits
UHC typically allows 90 days to submit a provider appeal from the date of the original denial. Check the denial letter or EOB for the exact deadline. UHC also offers a reconsideration process before formal appeal.
Corrected Claim Process
Submit corrected claims using Frequency Code 7 on the CMS-1500 or 837 transaction through the UHC provider portal or clearinghouse. Include the original claim number and a brief explanation of the correction.
Prior Authorization
UHC requires prior authorization for many services including: advanced imaging (MRI/CT/PET/CTA), specialty drugs, DME, behavioral health (certain services), surgical procedures, and genetic testing. Use the UHC Provider Portal to check requirements and submit authorization requests. UHC uses Optum for certain authorization reviews.
Referral Requirements
HMO and EPO plans require PCP referrals; PPO plans generally do not. Check the member's plan type. UHC HMO/EPO plans require referrals before specialist visits.
Eligibility Verification
Verify eligibility through the UHC Provider Portal (Link), the 270/271 transaction, or the UHC IVR system. Check for plan type, deductible, copay, coinsurance, and any carve-out services (e.g., behavioral health to Optum).
Claim Status Resources
Check claim status through the UHC Provider Portal or the 277 transaction. The portal provides detailed claim status including payment and denial information.
Coordination of Benefits
UHC follows the birthday rule for dependents and the active employee rule for adults. Report other coverage on the claim. UHC may use the UHC COB questionnaire to determine primary/secondary status.
Modifier Policies
UHC follows NCCI modifier policies. UHC has specific policies for modifier 25, 59, and therapy modifiers (GN, GO, GP). Check the UHC provider manual for specific modifier requirements and documentation.
Telehealth Policies
UHC expanded telehealth coverage and maintains a list of covered telehealth services. Use modifier 95 for synchronous telehealth. Check the UHC provider portal for current telehealth policies and covered services.
Medical Necessity Resources
UHC uses InterQual or MCG criteria for medical necessity determinations. Check the UHC Medical Policy database for covered services and criteria. UHC may require clinical documentation to support medical necessity.
NDC Billing Requirements
UHC requires NDCs for physician-administered drugs. Report NDCs in the 5-4-2 format on the CMS-1500 claim form. See the UHC provider manual for formatting requirements.
Common Denial Reasons
- CO-16 (missing/incomplete information)
- CO-50 (not medically necessary)
- CO-97 (bundling)
- CO-45 (charges exceed fee schedule)
- CO-197 (authorization/notification absent)
- CO-151 (frequency/number of services not supported)
- PR-1 (deductible)
- PR-2 (coinsurance).
Common Rejection Reasons
- Missing referral (HMO/EPO plans)
- missing prior authorization
- invalid member ID
- eligibility not active on date of service
- missing NPI
- invalid taxonomy
- missing NDC for drugs.
Documentation Requirements
Documentation must support the level of service billed, medical necessity, and treatment provided. UHC may request records through the provider portal or via letter. Check the UHC provider manual for specific documentation requirements.
Electronic Claim Submission
Submit claims electronically via the 837 transaction to UHC. The UHC payer ID is typically 87726 for commercial plans (check your clearinghouse for the correct ID). Use the UHC Provider Portal for direct submission and status check.
Provider Portal
The UHC Provider Portal (Link) provides eligibility, claim status, authorization requests, remittance, and appeals. The portal also includes policy documents, fee schedules, and provider education resources.
Provider Manual
The UHC provider manual is available on the UHC Provider Portal. UHC publishes medical policies, reimbursement policies, and administrative policies separately. Check for plan-specific policies (Medicare Advantage, Community Plan).
Contact Information
Contact UHC Provider Services: 1-877-842-3210 (commercial), 1-877-560-3505 (Medicare Advantage), or check the member's ID card for the correct number. UHC Optum Behavioral Health: 1-877-614-0484. Contact information is also available on the UHC Provider Portal.
Educational Notes
UHC has distinct policies for commercial, Medicare Advantage, and Medicaid (Community Plan) lines of business — always identify the correct plan type. Behavioral health is often carved out to Optum. UMR and Oxford Health are UHC subsidiaries with their own policies. Check the member's ID card for the correct payer ID and contact information.
Always Verify
Payer policies change frequently. This profile is for educational purposes only. Always verify current requirements using the official payer portal, provider manual, and direct communication with the payer.
Explore Other Payers
Medicare
Federal health insurance program for people 65+, certain younger people with disabilities, and people with End-Stage Renal Disease (ESRD). Administered by CMS through Medicare Administrative Contractors (MACs).
Medicaid
Joint federal and state program providing health coverage to eligible low-income individuals. Each state administers its own Medicaid program with federal oversight. State-specific pages coming soon.
BCBS
Federation of 34 independent, locally operated Blue Cross Blue Shield companies providing coverage in every U.S. state and territory. State-specific pages coming soon.
Aetna
Major commercial health insurer offering employer-sponsored, individual, Medicare Advantage, and Medicaid managed care plans. A CVS Health company.
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