Prior Authorizations - Mid-Atlantic Regional Supplement, 2018 UnitedHealthcare Administrative Guide

How to Submit

There are multiple ways to submit prior authorizations requests to UnitedHealthcare, including electronic options. To avoid duplication, once a prior authorization is submitted and confirmation is received, please do not resubmit.

  • Online: UHCprovider.com/priorauth and via Link: use the Prior Authorization and Notification application.
  • Phone: 877-842-3210. Clinical Services staff are available during the business hours of 8 a.m. to 8 p.m. ET.
  • Fax: Fax your request using the Universal Prior Authorization Request Form found on UHCprovider.com/priorauth > Fax Forms > Mid-Atlantic Health Plans Universal Request for Prior Authorization.
    Fax numbers:
    • General Outpatient:  866-255-0959
    • Infertility:  866-369-4119
    • Durable Medical Equipment:  866-362-6101
    • Homecare:  877-269-1045
    • Radiology:  866-589-4848
    • Transplant:  866-537-9371
    • Medical Injectables:  866-537-9371
    • Inpatient & Acute Rehabilitation:  866-892-4582 

Radiology Prior Authorization Requests and Prior Authorization List

Although prior authorization requests for radiology can be submitted electronically using our online prior authorizations. M.D. IPA and Optimum Choice are not part of the United Healthcare Radiology Prior Authorization Program.

Refer to the UHCprovider.com/priorauth > Advance Notification and Plan Requirement Resources, UnitedHealthcare Mid-Atlantic Health Plan Notification/Prior Authorization Requirements section.

Outpatient Rehabilitation (Physical, Occupational, and Speech Therapy) Prior Authorization Request

Prior authorization requests for physical, occupational, speech, and other therapy-related service can’t be submitted electronically.

Fax these prior authorization requests to the Clinical Care Coordination Department at 888-831-5080 using the Rehab Extension Form found at UHCprovider.com/plans > select your state.

Chiropractic Services Prior Authorization Request

Prior authorization requests for chiropractic services can’t be submitted electronically. Fax these prior authorization requests to the Clinical Care Coordination Department at 888-831-5080 using the Chiropractic Services Extension Form, found on UHCprovider.com/plans, along with a copy of the current Consultant Treatment Plan (PCP Referral).

Please allow two business days for extension request decisions. Missing information may result in a delayed response. Decisions are based on the member’s plan benefits, progress with the current treatment program, and submitted documentation.

Exception Requests

All exceptions to our policies and procedures must be preauthorized by faxing a request to Outpatient Services at 866-255-0959. The most common exception requests are:

  • Immunizations (outside the scope of health benefit plan guidelines)
  • Referral of an HMO member out-of-network to a nonparticipating physician, health care practitioner or facility

Prior authorization is required for the listed elective outpatient services. It is the physician’s responsibility to obtain any relevant prior authorization. But, the facility should verify that prior authorization has been obtained before providing the service. If the facility does not get the required prior authorization, we may deny payment. Final coverage and payment decisions are based on member eligibility, benefits and applicable state law.

If you have a question about a pre-service appeal, please see the section on Pre-Service Appeals under Chapter 6: Medical Management.

Inpatient Admission Notification

It is the facility’s responsibility to notify UnitedHealthcare within 24 hours after weekday admission (or by 5 p.m. local time on the next business day if 24 hour notification would require notification on a weekend or federal holiday). For weekend and federal holiday admissions, notification must be received by 5 p.m. local time on the next business day.

For emergency admissions when a member is unstable and not capable of providing coverage information, the facility should notify us as soon as they know the information and explain the extenuating circumstances.

Prior authorization is required for all elective inpatient admissions for all M.D. IPA and Optimum Choice members. It is the admitting physician’s responsibility to obtain the relevant prior authorization. But, the facility should verify that prior authorization has been obtained before the admission. Payment may be denied to the facility and attending physician for services provided in the absence of prior authorization.

Please remember prior authorization doesn’t guarantee coverage or payment. All final coverage and payment decisions are based on member eligibility, benefits and applicable state law.

Skilled Nursing Facility (SNF) placements do not require prior authorization. You must verify available benefit and notify us within one business day of SNF admission.

Maryland Facility Variations from the Standard Notification Requirements for Facilities

For information specific to members in Maryland, please refer to UHCprovider.com/priorauth > Prior Authorization and Notification Program Summary > and scroll down.

Admission Notification Requirements
Phone: 800-962-2174 or Fax: 800-352-0049

Once we receive your notification we begin a case review. If notification isn’t provided in a timely manner, we may still review the case and request other medical information. We may retroactively deny one or more days based upon the case review.

If a member receiving outpatient services needs an inpatient admission, you must notify us as noted above. Emergency room services resulting in a covered admission are payable as part of the inpatient stay as long as you have notified us of the admission as described above.

Delay in Service

Facilities that provide inpatient services must maintain appropriate staff resources and equipment to help ensure covered services are provided to members in a timely manner. A delay in service is defined as any delay in medical decision-making, test, procedure, transfer, or discharge that is not caused by the member’s clinical condition. Services should be scheduled the same day as the physician’s order.

However, procedures in the operating room, or another department requiring coordination with another physician, such as anesthesia, may be performed the next day unless emergent treatment was required. A service delay may result in sanctions of the facility and nonreimbursement for the delay day(s), if permissible under state law.

A clinical delay in service is assessed for any of the following reasons:

  • Failure to execute a physician order in a timely manner, resulting in a longer length of stay.
  • Equipment needed to fulfill a physician’s order is not available.
  • Staff needed to fulfill a physician’s order is not available.
  • A facility resource needed to fulfill a physician’s order is not available.
  • Facility doesn’t discharge the member on the day the physician’s discharge order is written.

Concurrent Review

Review is conducted onsite at the facility or by phone for each day of the stay using nationally-accepted criteria. Your cooperation is required when we request information, documents or discussions such as clinical information on member status and discharge planning.

If criteria aren’t met, the case is referred to a medical director for assessment. We deny payment for facility days that don’t have a documented need for acute care services.

We require physicians’ progress notes be charted for each day of the stay. Failure to document will result in denial of payment to the facility and the physician.

Facility Post-Discharge Review

A post-discharge review is conducted when a member has been discharged before notification to UnitedHealthcare occurs or before information is available for certification of all the days. A UnitedHealthcare representative will request the member’s records from the Medical Records Department or assess a review by phone, and review each non-certified day.

Inpatient days that don’t meet acuity criteria are referred to a medical director for determination and may be retrospectively denied. Delays in service or days that don’t meet criteria for level of care may be denied for payment. 

Facility to Facility Transfers

The facility must notify us of a facility-to-facility transfer request. In general, transfers are approved when:

  • there is a service available at the receiving facility that isn’t available at the sending facility,
  • the member would receive a medically appropriate level of care change at the receiving facility, or
  • the receiving facility is a network facility and has appropriate services for the member.

If any of the above conditions aren’t met, transfer coverage is denied. Services at the receiving facility will be approved if:

  • Medical necessity criteria for admission were met at the receiving facility, and
  • There were no delays in providing services at the receiving facility.

Injectable Medications

Drugs requiring both prior authorization and use of a specific vendor: this protocol applies when you obtain specialty medications, including prescription ordering and purchase. You must use a participating specialty pharmacy in our specialty pharmacy network, except as otherwise authorized by UnitedHealthcare. The specialty pharmacy bills us for the medication. You only need to bill us for administration of the medication and not for the medication itself.

The specialty pharmacy will advise the member of any medication cost share responsibility and arrange for the collection of payment (if applicable) before dispensing the medication to the physician’s office. For more information please refer to the following resources:

  • The Preauthorization Code List located in the Mid- Atlantic Healthplan Protocols.
  • A listing of specialty drug codes that require procurement through a designated specialty pharmacy.
  • UHCprovider.com/priorauth > Prior Authorization and Notification Resources > Clinical Pharmacy and Specialty Drugs. Note: you may be required to include the member’s specific diagnosis for payment.
  • Information on our medical evidence-based policies is available on: UHCprovider.com/policies > Commercial Policies > Medical & Drug Policies and Coverage Determination Guidelines.

Prior authorization requests can be faxed to 866-537-9371. Please include clinical notes and the name of the specialty pharmacy vendor. We will call you within three business days if conditions aren’t met for prior authorization of the drug. If authorized, Pharmacy Services provides a written authorization number and coverage dates.

This authorization must be submitted to the specialty pharmacy vendor along with the medication order.

Specialty pharmaceutical vendor information is available on: UHCprovider.com/specialtyrx.

Clinical Appeals

To appeal an adverse decision (a decision by us to not prior authorize a service or procedure, or a payment denial because the service wasn’t medically necessary or appropriate), you must submit a formal letter that includes your intent to appeal, justification for the appeal and supporting documentation. The denial letter will provide you with the filing deadlines and the address to submit the appeal.

Urgent Appeal Submissions:

Medical Fax: 801-994-1083
Pharmacy Fax: 801-994-1058

Direct Access Services

Female members may receive obstetrical and gynecological (OB/GYN) physician services directly from a participating OB/GYN, family practice physician, or surgeon identified by the medical group/IPA or UnitedHealthcare as providing OB/GYN physician services.

This means the member may receive these services without prior authorization or a referral from her PCP. In all cases, the physician must be affiliated with the member’s assigned medical group/IPA and participating with UnitedHealthcare.