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.
UnitedHealthcare Option PPO care providers are not required to follow this protocol for Options PPO benefit plans because members enrolled in these benefit plans are responsible for providing notification or requesting prior authorization.
M.D.IPA, Optimum Choice, or OneNet PPO Neighborhood Health Partnership (NHP)
Oxford Commercial, except for UnitedHealthcare Oxford Navigate Individual Benefit Plans (group number 908410) Benefit plans subject to the River Valley Entities Supplement
Benefit plans subject to the UnitedHealthcare West Supplement
MA plans that have delegated arrangements with medical groups/IPAs - in these arrangements, the delegate’s protocols must be followed.
Benefit plans subject to an additional guide or supplement (refer to the Benefit plans subject to this guide table.) Other benefit plans, such as Medicaid, CHIP and Uninsured that are neither commercial nor MA.
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:
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 SNF 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.
Hospitals must notify us observation stays within 24 hours after the member is no longer being held for observation (or by 5 p.m. local time on the next business day if the 24-hour limit would require notification on a weekend or holiday). For weekend and holiday stays, we must receive the notification by 5 p.m. local time on the next business day.
Hospitals must notify us of discharge from acute facility stays within 24 hours after weekday discharge (or by 5 p.m. local time on the next business day if the 24-hour limit would require notification on a weekend or holiday). For weekend and holiday discharges, we must receive the notification by 5 p.m. local time on the next business day.
Decisions regarding whether services met the definition of an “emergency” may be made by our Medical Director (or designee) or another process. 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:
Notification time frame: Admission notification received after it was due, but not more than 72 hours after admission. Reimbursement reduction: 100% of the average daily contract rate1 for the days preceding notification.2
Notification time frame: Admission notification received after it was due, and more than 72 hours after admission. Reimbursement reduction: 100% of the contract rate (entire stay).
Notification time frame: No admission notification received. Reimbursement reduction: 100% of the contract rate (entire stay).
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 determine the medical necessity of inpatient admissions during either concurrent or retrospective review. 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.