Advance notification/prior authorization requirements - Chapter 7, 2021 UnitedHealthcare Administrative Guide

Physicians, health care professionals and ancillary care providers are responsible for:

  • Providing advance notification or requesting prior authorization for services on the Advance Notification/Prior Authorization List, including for non-emergent air transport services.
  • Directing members to use care providers within their network. Members may be required to obtain prior authorization for out-of-network services.

Facilities are responsible for:

  • Obtaining prior authorization for non-emergent, fixed-wing transportation services and using in-network, fixed-wing air ambulance providers.
  • Obtaining prior authorization for inpatient admission to skilled nursing facility, acute inpatient rehabilitation and/or long-term acute care.
  • Confirming coverage approval is on file prior to the date of service.
  • Providing admission notification for inpatient services, discharge notification and observation stay notification, even if coverage approval is on file.

If you perform multiple procedures for a member in one day, and at least one service requires prior authorization, you must obtain prior authorization for any of the services to be paid.

If you do not follow these requirements, we may deny claims. In that case, you cannot bill the member. Advance notification or prior authorization is valid only for the date of service or date range listed on it. If that specified date of service or date range has passed, you must submit a new request.

  • Giving us advance notification, or receiving prior authorization from us, is not a guarantee of payment, unless required by law or Medicare guidelines. This includes regulations about care providers on either a sanctions and excluded list, the Medicare preclusion list and/or care providers not included in the Medicare Provider Enrollment Chain and Ownership System (PECOS)* list. Payment of covered services is based on:
    • The member’s benefit plan,
    • If you are eligible for payment,
    • Claim processing requirements, and
    • Your Agreement.

See Coverage and utilization management decisions section for additional details.

1 *PECOS is the CMS online enrollment system where care providers and health care entities are required to register so they can manage their Medicare provider file and establish their Medicare specialty as eligible to order and refer services/items.

Prior Authorization and Notification Tool

UHCprovider.com/link

Enhanced functionality in the Prior Authorization and Notification tool on Link that may provide improved response times for all plans.

  • Check requirements by member or procedure
  • Submit requests
  • Upload medical notes
  • Check status
  • Update cases
  • Radiology, cardiology and oncology transactions
  • Specialty pharmacy transactions
  • Admission notification, discharge notification and observation stay notification

Save time

No need to call, fax or mail information so you can spend time on other things. 

Reduce costs

Self-service options are the most efficient and costeffective way to manage these transactions.

Get information

Check if prior authorization or notification is required by member or procedure code. 

Intuitive and accurate

Required information is highlighted and fields automatically adjust as data is entered. Error messages alert corrections needed before submitting.

Superior documentation

Obtain a Decision ID for inquiries and a reference number for submissions. Save PDF confirmation files or print records as you wish.

Find and check status

Many search options are available to check the status of your submissions, regardless of the submission method you used.

Resources:

New User Registration

• UHCprovider.com/ newuser.

New User Registration Guide

Interactive Guide for Prior Authorization and Notification on Link

• Use this guide for more details on how to verify requirements, create submissions and check status.

Resource Page

• Go to UHCprovider.com/paan for more resources. You’ll find self-paced modules, live-webinar training registration information and more.

UnitedHealthcare Web Support

providertechsupport@uhc.com

1-866-842-3278, Option1, Monday - Friday, 7 a.m. – 9 p.m. CT

Information required for advance notification/prior authorization requests

Your request must have the following information:

  • Member name and member health plan ID number
  • Ordering care provider name and TIN or NPI
  • Rendering care provider name and TIN or NPI
  • ICD-10-CM diagnosis code
  • All applicable procedure codes
  • Anticipated date(s) of service
  • Type of service (primary and secondary) procedure code(s) and, if relevant, the volume of service
  • Place of service
  • Facility name and TIN or NPI where service will be performed (when applicable)
  • Original start date of dialysis (End Stage Renal Disease (ESRD) only)

If the member’s benefit plan requires a clinical coverage review, we may request additional information, as described in more detail in the Clinical coverage review section.