Before providing a service on the Advance Notification/ Prior Authorization List, the facility must confirm coverage approval is on file. This promotes an informed pre-service discussion between the facility and member. If the service is not covered, the member can decide whether to receive and pay for the service.
If the facility does not confirm a coverage approval is on file and performs the service and we decide the service is not a covered benefit, we may deny the facility claim.
The facility may not bill the member or accept payment from the member due to the facility’s non-compliance with our notification protocols.
*These benefit plans may have separate notification or prior authorization requirements. Refer to the applicable additional guide in the Benefit Plans Table in Chapter 1: Introduction, for additional details. Please see the supplements of this guide for the plans listed.
Facilities are responsible for Admission Notification for the following inpatient admissions. We need admission notification, even if advance notification was provided by the physician, and pre-service coverage approval is on file:
Weekday admissions, you must notify us within 24 hours, unless otherwise indicated. Weekend and holiday admissions, you must notify us by 5 p.m. local time on the next business day.
Emergency admissions (when a member is unstable and not capable of providing coverage information), you must:
Payment is not reduced due to notification delay in an emergency.
Receipt of an admission notification does not ensure payment. Payment for covered services depends on the member’s benefits, facility’s contract, claim processing requirements, and eligibility for payment.
You must include these details in your admission notification:
All Skilled Nursing Facility admissions for UnitedHealthcare Nursing Home and Assisted Living Plan members must be authorized by an Optum nurse practitioner or physician’s assistant. Claims may be denied if authorizations are not coordinated through Optum.
Our Medical Director (or designee) decides if services were emergent. This determination is subject to appeal. You can find a definition of “emergency” in the Glossary.
Facilities must provide timely admission notification (even if advance notification was provided by the physician and pre-service coverage approval is on file) as follows or claims payments are denied in full or in part:
1 The average daily contract rate is calculated by dividing the contract rate for the entire stay by the number of days for the entire length of stay.
2 Reimbursement reductions are not applied to “case rate facilities” if admission notification is received after it was due, but not more than 72 hours after admission As used here, “case rate facilities” means those facilities in which reimbursement is determined entirely by a MS-DRG or other case rate reimbursement methodology for every inpatient service for all benefit plans subject to these Admission Notification requirements.
Note: We do not apply reductions for maternity admissions. We apply reductions for post-acute inpatient admissions on our Commercial plans. We do not apply them for our MA plans.
If advance notification or prior authorization is required for an elective inpatient procedure, the physician must get the approval. The facility must notify us within 24 hours (or the following business day if the admission occurs
on a weekend or holiday) of the elective admission. If the physician gets the approval, but the facility does not get theirs within a timely manner, we reduce payment to only room and board charges.
If the physician received coverage approval, we pay the initial day of the inpatient admission unless any of the following are true:
We require you to comply with our requests:
We issue a denial letter if the level of care or any inpatient bed days are not medically necessary. We decide this through concurrent or retrospective review. We use nationally recognized criteria and guidelines to determine if the service/care was medically necessary under the member’s benefit plan. We can provide the criteria to you upon request.
A facility denial letter is available to the member upon request.
* For state specific variations, refer to UHCprovider.com/priorauth > Advance Notification and Plan Requirement Resources.