07/15/2025
HERE ARE THE FACTS FROM UHC: At UnitedHealthcare, we approve and pay 90% of claims shortly after they’re submitted. The remaining 10% go through an additional review process.
Eligibility: The most common reason a claim might fall into this category is because there’s a possibility the patient is not actually a UnitedHealthcare member. This situation most often occurs when someone has recently switched to a new plan but didn’t share their current health plan ID card with their provider. The review process for these claims is typically simple and straightforward. Once we’ve confirmed the patient is enrolled in one of our plans, we approve and process the claim.
Duplicates: Occasionally providers submit multiple claims for the same treatment or service. In these cases, we collaborate with the physician or hospital to resolve these duplicate submissions, ensuring we are only reviewing one claim per treatment or service.
Documentation and program integrity: Claims fall into this category because the provider didn’t submit all the information necessary to review the claim. In these cases, we follow up with the care provider to notify them of the issue and work to resolve it.
Coverage: We review claims in this category to confirm that the plan sponsor – the employer, CMS or a state government – included coverage for that particular service or procedure when designing their health plan.
Clinical: Claims in this category are reviewed to ensure the care provided aligns with evidence-based clinical guidelines. While we can’t control doctors’ treatment decisions, we believe we have an important role in ensuring our members receive safe, appropriate and high-quality care. When the treatment our members receive does not adhere to widely accepted clinical standards, we do not approve payment to the care provider. It should be noted that only about 0.5% of claims fall into this category.
After this additional review process is completed, UnitedHealthcare’s claims approval rate stands at 98% for claims for eligible members, when submitted in a timely manner with complete information, and after duplicate claims are removed. While we are proud of that number, we also know that nothing is more personal than health care and that there is a person on the receiving end of every claim denial letter. That’s why we work hard to treat these situations with care and sensitivity, explaining the member’s and provider’s options for filing an appeal and encouraging them to reach out to us if they have questions or need further assistance.
