Certain services require prior authorization, which results in:
You must cooperate with all requests for information, documents or discussions for purposes of a clinical coverage review including providing pertinent medical records, imaging studies or reports and appropriate assessments for determining degree of pain or functional impairment.
As a network care provider, you must respond to calls from our UM staff or medical director. You must provide complete clinical information as required within the time frame specified on the outreach form.
We use scientifically based clinical evidence to identify safe and effective health services for members for inpatient and outpatient services. For Inpatient Care Management (ICM’s), we use evidence-based MCG Care Guidelines.
Clinical coverage decisions are based on the member’s eligibility, state and federal mandates, the member’s certificate of coverage, evidence of coverage or summary plan description, UnitedHealthcare medical policies and medical technology assessment information. For Medicare Advantage members, we use CMS NCDs and LCDs and other evidence-based clinical literature.
Coverage determinations for health care services are based upon the member’s benefit documents and applicable federal requirements. Our UM staff, its delegates, and the physicians making these coverage decisions are not compensated or otherwise rewarded for issuing adverse non-coverage determinations. Preferred Care and its delegates do not offer incentives to physicians to encourage underutilization of services or to encourage barriers to receiving the care and services needed.
Coverage decisions are made based on the definition of “reasonable and necessary within MA coverage regulations and guidelines.” Hiring, promoting, or terminating physicians or other individuals are not based upon the likelihood or the perceived likelihood that the individual will support or tend to support the denial of benefits.
We may deny a prior authorization request for several reasons:
We must notify you and the member in writing of any adverse decision (partial or complete) within applicable time frames. Our notice states the specific reasons for the decision. It also references the benefit provision and clinical review criteria used in the decision-making process. We provide the clinical criteria used in the review process for making a coverage determination along with the notification of denial.
For Inpatient Care Management Cases, P2P requests may come in through the P2P Support team by calling 800-955- 7615.
P2P discussions may occur at different points during case activity in accordance with time frames, once a medical director has rendered an adverse determination.
The post-decision peer-to-peer consult process must conclude for the Medicare population. This requires establishing a pre-decision medical director outreach for standard (14 day turn-around-time) requests for both inpatient and outpatient adverse determinations. It excludes expedited pre-service requests and administrative denials.
We must treat the following situations as reconsiderations or appeals:
Some members may require medical, psychological and social services or other external agencies outside the scope of their plan benefits (for example, from Health and Human Services or Social Services). If you encounter a member in this situation, contact Network Management Services. You may also have the member contact our Member Services Department at 866-231-7201 for assistance with, and referral to, appropriate external agencies.
The technology assessment process helps evaluate new technologies and new applications of existing technologies. Technology categories include medical procedures, drugs, pharmaceuticals, or devices. This information allows us to support decisions about treatments that best improve member’s health outcomes, efficiently manage utilization of health care resources, and make changes in benefit coverage to keep pace with technology changes. It also helps ensure members have equitable access to safe and effective care. If you have any questions regarding whether a new technology or a new application of existing technologies are a covered benefit for our members, please contact Utilization Management at 800-995-0480.
The Hospitalist Program is a voluntary program for members. Hospitalists are physicians who specialize in the care of members in an acute inpatient setting (acute care hospitals and SNFs). A hospitalist oversees the member’s inpatient admission and coordinates all inpatient care.
The hospitalist communicates with the member’s selected physician by providing records and information, such as the discharge summary.
Discharge planning is a collaborative effort between the inpatient care manager, the hospital/facility case manager, the member, and the admitting physician. It helps ensure coordination and quality of medical services through the post-discharge phase of care.
Although not required to do so, we may help identify health care resources available in the member’s community following an inpatient stay.
UM nurses conduct telephone reviews to support discharge planning, with a focus on coordinating health care services prior to the discharge.
The facility or physician is required to contact us and provide clinical information to support discharge decisions under the following circumstances:
To initiate patient discharge, update the case directly online at UHCprovider.com/paan or call us at 800-995-0480.