Prior authorizations and referrals, Preferred Care Partners - 2021 UnitedHealthcare Administrative Guide

We do not require prior authorization for certain services. Use the Enterprise Prior Authorization List (EPAL) to see what services do require authorization on UHCprovider.com/priorauth > Advance Notification and Plan Resources > under Plan requirement resources – Medica HealthCare and Preferred Care Partners Prior Authorization Requirements.

WellMed and utilization management

Prior authorization requests for Preferred Care Partners members assigned to a Primary Care Physician belonging to Preferred Care Partners Medical Group (PCPMG) may be done online at eprg.wellmed.net.

Simple referral process

Palm Beach Members: The Simple Referral Process helps PCPs coordinate member care. Referrals are necessary for most participating specialists.* Requests for non-participating care providers need additional authorization.

• You may request a referral for one or multiple visits.
• The referral is good for the number of visits approved, valid for 6 months from the date issued.
• No supporting documentation is needed for referrals to specialists.
• Requests for referrals must be submitted electronically on UHCprovider.com
• Upon submitting a referral request, the system automatically generates the referral number.
• For member convenience, you may also provide members with a copy of the referral confirmation.
• The specialist has the ability to view a referral using the UnitedHealthcare portal.
• For additional questions call us at 1-877-670-8432 or email us at NetworkManagementServices@uhcsouthflorida.com.

WellMed members

WellMed requires a referral from the assigned PCP before rendering services for selected specialty care providers. The referral must be entered by the PCP in the WellMed provider portal at eprg.wellmed.net.

The WellMed Florida Specialty Protocol List gives more information about which specialties/services may be exempt from the referral process. Providers may view the WellMed Specialty Protocol List in the WellMed Provider portal at eprg.wellmed.net in the Provider Resource Tab.

Authorization requirements

• Obtain prior authorization for all services requiring authorization before the services are scheduled or rendered.
• Submit prior authorization for outpatient services or planned Acute Hospital Admissions and admissions to Skilled Nursing Facilities (SNF), Acute Rehabilitation Hospital and Long-Term Acute Care (LTAC) as far in advance of the planned service as possible to allow for coverage review. We require prior authorizations to be submitted at least 7 calendar days before the date of service.
• Submit prior authorizations for home health and home infusion services, durable medical equipment (DME), and medical supply items to MedCare Home Health at 1-305-883-2940 and Infusion/DME at 1-800-819-0751.
• Note: Request an expedited (72 hours) review if waiting for a standard (14 calendar days) review could place the member’s life, health, or ability to regain maximum function in serious jeopardy.
• We require prior authorizations to out-of-network specialty or ancillary care providers when the member requires a necessary service that cannot be provided within the available Preferred Care network. The referring physician must submit a completed Prior Authorization Form for approval.
• You and the member should be fully aware of coverage decisions before services are rendered.
• If you provide the service before the coverage decision is rendered, and we determine the service was not a covered benefit, we may deny the claim. You must not bill the member. Without a coverage determination, a member does not have the information needed to make an informed decision about receiving and paying for services.

Notification requirements

• For any inpatient or ambulatory outpatient service requiring prior authorization, the facility must confirm, before rendering the service, that the coverage approval is on file. The purpose of this protocol is to enable the facility and the member to have an informed pre-service conversation. If the service will not be covered, the member may decide whether to receive and pay for the service.
• Facilities are responsible for admission notification for inpatient services, even if the coverage approval is on file.
• If a member is admitted through the emergency room, you must notify us no later than 24 hours from the time the member is admitted for purposes of concurrent review and follow-up care.
• If a member receives urgent care services, you must notify us within 24 hours of the services being rendered.

Admission notification requirements

Facilities are responsible for admission notification for:

• Planned elective admissions for acute care
• Unplanned admissions for acute care
• Admissions following observation
• Admissions following outpatient surgery
• Skilled Nursing Facility (SNF) admissions
• Long Term Acute Care Hospital (LTACH)
• Acute Inpatient Rehab (AIR)
• Unless otherwise indicated, admission notification must be received within 24 hours after actual weekday admission (or by 5 p.m. ET on the next business day if 24-hour notification would require notification on a weekend or federal holiday).
• Admission notification by the facility is required even if notification was supplied by the physician and a coverage approval is on file.
• Receipt of an admission notification does not guarantee or authorize payment. Payment of covered services is contingent upon coverage within an individual member’s benefit plan, the facility being eligible for payment, any claim processing requirements, and the facility’s Agreement with us.
• Admission notifications must contain the following:
  • Member name and member health plan ID number
  • Facility name
  • Admitting or attending physician name
  • Description for admitting diagnosis or ICD-10-CM (or its successor) diagnosis code
  • Actual admission date
  • Admission orders written by a physician
• For emergency admissions when a member is unstable and not capable of providing coverage information, the facility should notify us as soon as the information is known and communicate the extenuating circumstances. We will not apply any notification-related reimbursement deductions.

If the requirements are not followed, the services may be denied. You may not bill the member.

A notification or prior authorization approval does not ensure or authorize payment, subject to state rules and MA policies. Payment is dependent upon the member’s coverage, the care provider’s eligibility, and Agreement and claim requirements.