Applicable to all states except NC
There are multiple ways to submit prior authorizations requests to UnitedHealthcare, including electronic options. To avoid duplication, once a prior authorization is submitted and confirmation is received, please do not resubmit.
Find the forms referenced below on the UHCprovider.com/priorauth > Advance Notification and Plan Requirement Resources webpage.
Prior authorization requests for radiology may be submitted electronically using our online prior authorization tool. M.D. IPA and Optimum Choice are not part of the UnitedHealthcare Radiology Prior Authorization Program. Refer to the UHCprovider.com/priorauth > Advance Notification and Plan Requirement Resources > UnitedHealthcare Mid-Atlantic Health Plan Notification/ Prior Authorization Requirements.
Outpatient Rehabilitation (Physical, Occupational, and Speech Therapy) Prior Authorization Request Prior authorization requests for physical, occupational, speech, and other therapy-related service may not be submitted electronically. Fax these prior authorization requests to the Clinical Care Coordination Department at 888-831-5080 using the Rehabilitation Services Extension Request Form found at UHCprovider.com/plans > Choose Your State.
Prior authorization requests for chiropractic services may not be submitted electronically. Fax these prior authorization requests to the Clinical Care Coordination Department at 888-831-5080 using the Chiropractic Services Extension Form, found on UHCprovider.com/plans > Commercial Plans > Mid- Atlantic Health Plan, along with a copy of the current Consultant Treatment Plan (PCP Referral). Please allow two business days for extension request decisions. Missing information may result in a delayed response. Decisions are based on the member’s plan benefits, progress with the current treatment program, and submitted documentation.
All exceptions to our policies and procedures must be preauthorized by submitting a request online at UHCprovider.com/paan or by phone at 877-842-3210. The most common exception requests are:
Prior authorization is required for elective outpatient services. It is the physician’s responsibility to obtain any relevant prior authorization. But the facility should verify prior authorization is obtained before providing the service. If the facility does not get the required prior authorization, we may deny payment. Final coverage and payment decisions are based on member eligibility, benefits and applicable state law.
If you have a question about a pre-service appeal, please see the section on Pre-Service Appeals under Chapter 6: Medical Management.
It is the facility’s responsibility to notify UnitedHealthcare within 24 hours after weekday admission (or by 5 p.m. ET the next business day if 24-hour notification would require notification on a weekend or federal holiday). For weekend and federal holiday admissions, notification must be received by 5 p.m. ET the next business day.
For emergency admissions when a member is unstable and not capable of providing coverage information, the facility should notify us as soon as they know the information and explain the extenuating circumstances. Facilities are responsible for providing admission notification for inpatient admissions, even if advance notification was provided by the physician and coverage approval is on file.
Prior authorization is required for all elective inpatient admissions for all M.D. IPA and Optimum Choice members. It is the admitting physician’s responsibility to obtain the relevant prior authorization. But the facility should verify that prior authorization is obtained before the admission. Payment may be denied to the facility and attending physician for services provided in the absence of prior authorization. Prior authorization doesn’t guarantee coverage or payment. All final coverage and payment decisions are based on member eligibility, benefits and applicable state law.
Skilled Nursing Facility (SNF) placements do not require prior authorization. You must verify available benefit and notify us within one business day of SNF admission.
For information specific to members in Maryland, please refer to UHCprovider.com/priorauth > Prior Authorization and Notification Program Summary > and scroll down.
Once we receive your notification, we begin a case review. If notification isn’t provided in a timely manner, we may still review the case and request other medical information. We may retroactively deny one or more days based upon the case review. If a member receiving outpatient services needs an inpatient admission, you must notify us as noted above. Emergency room services resulting in a covered admission are payable as part of the inpatient stay as long as you have notified us of the admission as described.
Facilities that provide inpatient services must maintain appropriate staff resources and equipment to help ensure covered services are provided to members in a timely manner. A delay in service is defined as any delay in medical decision-making, test, procedure, transfer, or discharge not caused by the member’s clinical condition. Services should be scheduled the same day as the physician’s order. However, procedures in the operating room, or another department requiring coordination with another physician, such as anesthesia, may be performed the next day unless emergent treatment was required. A service delay may result in sanctions of the facility and non-reimbursement for the delay days, if permissible under state law.
A clinical delay in service is assessed for any of these reasons:
Review is conducted onsite at the facility or by phone for each day of the stay using criteria. Your cooperation is required when we request information, documents or discussions such as clinical information on member status and discharge planning. If criteria aren’t met, the case is referred to a medical director for assessment. We deny payment for facility days that don’t have a documented need for acute care services. We require physicians’ progress notes be charted for each day of the stay. Failure to document will result in denial of payment to the facility and the physician.
A post-discharge review is conducted when a member has been discharged before notification to UnitedHealthcare occurs or before information is available for certification of all the days. A UnitedHealthcare representative will request the member’s records from the Medical Records Department or assess a review by phone and review each non-certified day.
Inpatient days that don’t meet acuity criteria are referred to a medical director for determination and may be retrospectively denied. Delays in service or days that don’t meet criteria for level of care may be denied for payment.
The facility must notify us of a facility-to-facility transfer request. In general, transfers are approved when:
If any of the above conditions aren’t met, transfer coverage is denied. Services at the receiving facility will be approved if:
Drugs requiring both prior authorization and use of a specific vendor: this protocol applies when you obtain specialty medications, including prescription ordering and purchase. You must use a participating specialty pharmacy in our specialty pharmacy network, except as otherwise authorized by UnitedHealthcare. The specialty pharmacy bills us for the medication. You only need to bill us for administration of the medication and not for the medication itself.
The specialty pharmacy will advise the member of any medication cost-share responsibility and arrange for collection of payment (if applicable) before dispensing the medication to the physician’s office. For more information, please refer these resources:
You can submit prior authorization requests by phone or use the Specialty Pharmacy Transactions tile on your Link dashboard at UHCprovider.com/paan.
Please include clinical notes, if prompted to do so. List the specialty pharmacy vendor as the servicing provider in the case. We will call you within three business days if the conditions aren’t met for prior authorization of the drug. If authorized, we will provide a written confirmation.
Specialty pharmaceutical vendor information is available on UHCprovider.com/specialtyrx.
To appeal an adverse decision (a decision by us to not prior authorize a service or procedure, or a payment denial because the service wasn’t medically necessary or appropriate), you must submit a formal letter that includes your intent to appeal, justification for the appeal and supporting documentation. The denial letter will provide you with the filing deadlines and the address to submit the appeal.
Urgent Appeal Submissions:
Medical fax: 801-994-1083
Pharmacy fax: 801-994-1058