UHC Rejection - Patient Reason For Visit Codes

*This article is out of date. Communication from this payer on June 2020 advised that UHC would be implementing this new edit for HIPAA reasons effective 9/1. Then, a notification from UHC's EDI department again on 9/15/20 stating due to confusion and excessive rejections UHC would be disabling the edit until further notice, effective Wednesday 9/16/20.

 

Effective September 1, 2020, UHC has new requirements for UB-04 outpatient claim submission that must include Box 70 for Patient Reason For Visit Codes (PRVC) when the bill type prefix is 13, 85, or 78.

A Patient Reason For Visit Code is an ICD-10 code that codes the patient's stated reason for seeking outpatient care and may differ from the principal or admitting diagnosis code. Up to 3 codes can be submitted on an outpatient claim.

In order to include the Patient Reason For Visit code on the UB-04 claim, a claim form rule will be required. 

Creating the Claim Rule

In Management Center > Claim Rules, select Create Claim Form Rule. 

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Select the practice that the claim rule will be applied to.

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Select the conditions that will require the patient reason for visit code. Generally, we will see that the Current Sequence Behavioral Payer should be set to United Health Care and the Bill Type Prefix is set to 13, 85, or 78.

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Select the behavior to "Diagnosis - Patient Reason for Visit Code".

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When creating new claims, confirm the claim rule is working by clicking the View link next to the claim. Users should see Box 70a for Patient Reason for Visit 1 and the code.

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Users can also look at the PDF by clicking the Preview link next to the claim to see Box 70 include the Patient Reason DX.

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