CMA recently reported in CMA Alert about a system glitch at PacifiCare/United Healthcare (PC/UHC) that caused claims for services provided to patients with “point of service” (POS) plans to be improperly denied. As you know, POS plans allow patients the freedom to pay higher copays and/or deductibles if they want to see specialists outside their medical groups/IPAs. The insurer had been denying such claims, saying that the responsibility for payment lay with the patients’ medical groups/IPAs. Claims submitted to the patients’ medical groups/IPAs were also denied, because the patient went “out of network.”

CMA brought this problem to the attention of PC/UHC’s liaison team, and it was determined that a system glitch was causing the denials. As of March 5, the glitch had been fixed and PC/UHC expects to have all improperly denied claims reprocessed by May 30. These claims will be reprocessed (with interest, when appropriate).

Contact: CMA’s reimbursement help line, 888/401-5911.