Medical Management - Chapter 6, 2020 UnitedHealthcare Administrative Guide
Medical Management
The purpose of the UnitedHealthcare Medical Management Program is to determine if medical services are:
- Covered under the member’s benefit plan;
- Clinically necessary and appropriate; and
- Performed at the most appropriate setting for the member.
Topics in this Section
- Benefit Plans Not Subject to this Protocol
- Advance Notification / Prior Authorization Requirements
- Advance Notification / Prior Authorization List
- Facilities: Standard Notification Requirements
- How to Submit Advance or Admission Notifications / Prior Authorizations
- Updating Advance Notification or Prior Authorization Requests
- Coverage and Utilization Management Decisions
- Pre-Service Appeals
- Clinical Trials, Experimental or Investigational Services
- Medical Management Denials / Adverse Determinations
- Medicare Advantage (MA) Part C Reopenings
- Outpatient Cardiology Notification / Prior Authorization
- Outpatient Radiology Notification / Prior Authorization
- Medication-Assisted Treatment (MAT)
- Trauma Services