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Eligibility/Authorization Guarantee, Capitation and/or Delegation - 2019 UnitedHealthcare Administrative Guide

Medical Group/IPA’s Responsibility to Monitor Eligibility (CA Commercial Only)

We periodically send each medical group/IPA an eligibility list of assigned members. Current eligibility information is available through the Enterprise Voice website, care provider portal, and member service center. You and/or your network of care providers are responsible for checking eligibility within two business days prior to the date of service for individuals for who/whom services are provided or authorized. If the medical group/IPA checked and confirmed eligibility within two business days prior to the date of service, it is eligible for reimbursement under the Eligibility Guarantee and Authorization Guarantee programs. This program applies to services authorized by the medical group/IPA or UnitedHealthcare or provided by the medical group/IPA prior to the receipt of updated eligibility, showing an individual is no longer eligible.

Eligibility/Authorization Guarantee Procedure

Eligibility/Authorization Guarantee provides an opportunity for reimbursement to the medical group/IPA for covered services provided to an individual whom:

1. We identified as eligible one or two business days before the date of service through our eligibility determination and verification processes and

2. Is later determined to be ineligible for benefits on the date of service, but no authorization has been provided (“Eligibility Guarantee”); and

3. We provided an authorization and who we confirmed as eligible one or two business days prior to the date of service but who is later determined to have been ineligible on the date of service (“Authorization guarantee”).

The Eligibility Guarantee and Authorization Guarantee procedures are designed to limit the medical group/IPA’s risk of rendering care or incurring financial risk for services provided to ineligible members where the individual’s lack of eligibility is only determined after the services are provided.