Enhancements to Improve Provider Remittance Advice

As a result of provider feedback, UnitedHealthcare will implement a system enhancement that will consolidate more commercial claims into one payment and will improve the layout of the Provider Remittance Advice (PRA). This enhancement impacts all claims associated with UnitedHealthcare commercial fully-insured and commercial self-funded business. This affects both 835s and paper versions. Implementation will begin later in 2010. We will notify providers and clearinghouses prior to deployment.

The enhancements will eliminate the existing limit of eight payments and 50 overpayments on a single PRA. PRAs will now be double-sided with better use of white space and shading on alternate rows in the Service Detail and Overpayment Reduction Detail sections. In addition, PRA details will be sorted in alphabetical order using the patient’s last name.

The 835 improvements will include the addition of the Product Name along with the current Product Code included in the reference lines, making it easier for providers to match the payment with the associated fee schedule. In addition, we have improved the way we split the 835 transactions into 2 separate files. The enhancement will identify by claim, which claims will auto-post and which ones require additional attention. Sorting the claims (instead of the payments), will allow an increased number of claims to be auto-posted to providers’ practice management systems and will allow for earlier and easier identification of payments that may require manual intervention. Finally, providers will see a modification in the TRN02 number, which will change from 10 digits to 11 digits.

Providers who receive 835s will see an expanded use of the Claim Account Reason Codes (CARC) and Remittance Advice Remark Codes (RARC) in the Payment Details section. They will also better understand how the claim payment was determined in the 835 transaction. Where benefits are coordinated with another payer, (called Coordination of Benefits, or COB) the identification of patient responsibility on the outbound 835 transaction reports will be expanded to clarify how UnitedHealthcare determined the patient responsibility based on the applicable co-pay, deductible, coinsurance, “not covered” and “over reasonable and customary” amounts. Coordinated claims will more clearly report payments at the line level for professional claims and claim level for institutional claims, and as a result eliminate the adjustments frequently seen at the claim level. CARC, RARC and COB improvements will be implemented in the third quarter of 2010.