Who they are
Plan types on the card
Commercial PPO, EPO, HMO, and POS; UnitedHealthcare Choice / Choice Plus / Options PPO network names; Medicare Advantage plans; Medicaid plans under state-specific brands; and a large volume of self-funded ASO business where UnitedHealthcare administers but the employer bears risk. A large share of UnitedHealthcare volume is self-funded. That changes the governing law — ERISA, with state prompt-pay and external review largely preempted. Determine funding status before escalating or citing a state statute. See Payers vs insurance companies.Enrollment and credentialing
Start at uhcprovider.com. Portal access uses a One Healthcare ID. Credentialing generally pulls from CAQH — authorize UnitedHealthcare in the clinician’s profile and keep attestation current.EDI, ERA, and EFT
- EDI — through your clearinghouse; payer IDs are clearinghouse-specific
- ERA and EFT — commonly via Optum Pay
- Confirm ERA is routed to your current clearinghouse
Portal capabilities
Eligibility, claim status, prior authorization, claim reconsideration, and remittance access. Substantial functionality is available without calling, which is worth training staff on.Appeals
Reconsideration followed by formal appeal, with the process differing between commercial, Medicare Advantage, and Medicaid lines. Medicare Advantage appeals follow the federal MA track, not UnitedHealthcare’s commercial process.Quirks worth knowing
- The behavioral carve-out. Contracting with UnitedHealthcare medical does not get you into the behavioral network. Optum Behavioral Health requires separate contracting and credentialing.
- Multiple product lines, multiple contracts. Commercial, MA, and Medicaid participation are separate.
- Prior authorization requirements are extensive and change; check the current list rather than a saved copy.