Electronic Reconsideration and Appeal Submissions Now Mandatory
Beginning June 2, 2025, UnitedHealthcare Community Plan (Medicaid) will demand electronic methods for submitting claim reconsiderations alongside medical pre- and post-service appeals. The new policy has been enacted for most health care providers and facilities participating in network services serving Medicaid members across Florida, New York, Ohio, and Rhode Island.
Patients who work with revenue cycle management companies as external providers need to provide their vendors with knowledge about amended digital workflow standards.
Pre-Service Appeal Submission Process
Before starting with pre-service appeals, Healthcare providers need to use the Prior Authorization and Notification function from the UnitedHealthcare Provider Portal.
- The UHCprovider.com website requires providers to access their account with a One Healthcare ID for sign-in purposes.
- Users should access the “Prior Authorizations” section followed by a search for an existing prior authorization submission.
- You need to find the service reference number (SRN), after which you should verify the coverage status.
- Select “File a Pre-Service Appeal or a Grievance” when the status appears as “Not Covered/Not Approved.”
- Comply with the user guidance to file your appeal and add necessary supporting documents.
- The Document Library can be found using the Advanced Filter feature when looking for appeal decision letters.
Claim Reconsiderations and Post-Service Appeals
Providers may choose between two methods to file claim reconsiderations and post-service appeals:
1. UnitedHealthcare Provider Portal
- The first step is to log in and then access the “Claims & Payments” section through the system.
- The “Act on Claim” button can be found by looking up a claim number on the search function.
2. Application Programming Interface (API)
- API integration provides complete electronic submission capabilities to organizations that have technological resources for system integration.
- To implement this, API providers should refer to UnitedHealthcare’s API documentation.
The Provider Portal enables providers to reach 24/7 chat assistance while UnitedHealthcare Web Support can be reached at 866-842-3278 (select option 1) from 7 a.m.– 9 p.m. CT during Monday through Friday.
