Direct the member to call 911, or its local equivalent, or to go to the nearest emergency room. Prior authorization or advance notification is not required for emergency services. However, you should tell us about the member’s emergency by calling 1-800-799-5252 between 8 a.m. and 5 p.m. PT, Monday–Friday.
Provide after-hours and weekend emergency services as clinically appropriate; enter the notification online or call 1-800-799-5252 the next business day.
For benefit plan definitions of an emergency, refer to the member’s Combined Evidence of Coverage and Disclosure Form, Evidence of Coverage or Certificate of Coverage, as applicable. Additional definitions are found in our glossary.
Check the member’s benefits with Member Services or at UHCprovider.com, as applicable, for the benefit plan definition of urgent care. For our commercial members, you must contact the member’s PCP or hospitalist on arrival for urgently needed services. Request these services by calling 1-800-799-5252 between 8 a.m. and 5 p.m. PT, Monday–Friday.
We consider all other services as routine. To request preauthorization for urgent or routine services, the PCP must enter all the necessary information into UHCprovider.com/priorauth, contact the delegated medical group for approval, or complete and submit the appropriate Preauthorization Request Form to obtain approval. Routine and urgent requests are responded to within the following time frames, if all required clinical information is received:
Timeframe: 72 hours Part B drugs (including step therapy drugs) are reviewed in 24 hours.
Timeframe: 14 calendar days Part B drugs (including step therapy drugs) are reviewed in 72 hours.
State: OR, WA
Timeframe: 2 business days
State: CA, OK
Timeframe: 72 hours
Timeframe: 3 calendar days
State: OR, WA
Timeframe: 2 business days; exception: - A delay of decision (DOD) letter
Timeframe: 5 business days; exception: - A delay of decision (DOD) letter
Timeframe: 15 calendar days
Timeframe: 3 calendar days
Only a physician (or pharmacist, psychiatrist, doctoral-level clinical psychologist or certified addiction medicine specialist, as applicable and appropriate) may determine whether to delay, modify or deny services to a member for reasons of medical necessity.
A list of services that require prior authorization is available on UHCprovider.com/priorauth.
We will deny payment for services you provide without the required prior authorization. Such services are the care provider’s liability, and you may not bill the member.
Most PCP services do not require prior authorization. However, if prior authorization is required, the following guidelines apply:
We or our delegates conduct reviews throughout a member’s course of treatment. Multiple prior authorizations may be required throughout a course of treatment because prior authorizations are typically limited to specific services or time periods.
The PCP should identify members with serious or complex medical conditions and develop appropriate treatment plans for them, along with case management. Each treatment plan should include a prior authorization for referral to a specialist for an adequate number of visits to support the treatment plan.
We send the status of the prior authorization request (approved as requested, approved as modified, delayed, or denied) to the specialist by fax or online. For those services that do not require prior authorization, the PCP sends a referral request directly to the specialists.
Note: Mammograms may require prior authorization in California.
The California Department of Managed Health Care (AB 2193) requires licensed health care practitioners who provide prenatal or postpartum care for a patient to offer maternal mental health screening during the second and/or third trimester and/or at the postpartum visit. When screening pregnant and postpartum members for mental health issues, we recommend using the Patient Health Questionnaire 9 (PHQ-9). You can request hard copies of the PHQ-9 by emailing email@example.com.
We authorize and provide a second opinion by a qualified health care professional for members who meet specific criteria. A second opinion consists of one office visit for a consultation or evaluation only. Members must return to their assigned PCPs for all follow-up care. For purposes of this section, a qualified health care professional is defined as a PCP or specialist who is acting within the scope of practice and who possesses a clinical background, including training and expertise related to the member’s particular illness, disease or condition.
The PCP may request a second opinion on behalf of the member in any of the following situations:
We process requests for a second opinion in a timely manner to accommodate the clinical urgency of the member’s condition and in accordance with established utilization management procedures and regulatory requirements. When there is an imminent and serious threat to the member’s health, we or our delegate will make the second opinion determination within 72 hours after receipt of the request.
An imminent and serious threat includes the potential loss of life, limb, or other major bodily function. It may also be when a lack of timeliness would be detrimental to the member’s ability to regain maximum function. For more detailed information and benefit exclusions, refer to UHCprovider.com/policies:
We request that you notify the case management department when a member referred for evaluation, authorized for:
The specialist must request an extension of prior authorization online, or by contacting the delegated medical group/IPA if they desire to perform services:
The extension must be authorized before care is rendered to the member. The request for extension of services must include the following information:
The existing authorization is reviewed by the receiving party, who mails or faxes a response to the care provider and/or makes the information available online There is no need to contact the member’s PCP.