Confirming Coverage Approvals
Before providing a service that is on the Advance Notification/Prior Authorization List, the facility must confirm coverage approval is on file. This promotes an informed preservice 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:
- If we decide the service is not a covered benefit, we may deny the facility’s 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.
- If a coverage review is in process on the date of the service and that review ultimately decides it is a covered benefit, we do not deny the facility’s claim.
Admission Notification Requirements
Benefit Plans Not Subject to this Protocol*
- 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.
- UnitedHealthcare Indemnity
- 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.
- UnitedHealthcare West
- Erickson Advantage
- Benefit plans subject to an additional guide or Supplement (please refer to Benefit Plans Subject to this Guide.)
- 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:
- Planned/elective admissions for acute care
- Unplanned admissions for acute care
- Skilled Nursing Facility (SNF) admissions
- Admissions following outpatient surgery
- Admissions following observation
- Newborns admitted to Neonatal Intensive Care Unit (NICU)
- Newborns who remain hospitalized after the mother is discharged. Notice is required within 24 hours of the
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:
- Notify us by phone or fax with 24 hours, or the next business day if on a weekend/holiday, from the time coverage information is known
- When notifying us, you must communicate the extenuating circumstances
Payment is not reduced due to delay of notification in an emergency.
We need admission notification, even if advance notification was provided by the physician, and pre-service coverage approval is on file. 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:
- Member name, health care ID number, and date of birth
- Facility name and TIN or NPI
- Admitting/attending physician name and TIN or NPI
- Description for admitting diagnosis or ICD-10-CM diagnosis code
- Actual admission date
- Extenuating circumstances, if an emergency admission
All Skilled Nursing Facility 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.
Our Medical Director (or designee) decides if services rendered were emergent. This determination is subject to appeal. You can find a definition of “emergency” in the Glossary.
Reimbursement Reductions for Lack of Timely Admission Notification
Facilities must provide timely admission notification as follows or claims payments are denied in full or in part:
Notification Timeframe and Reimbursement Reduction
- Admission notification received after it was due, but not more than 72 hours after admission: 100% of the average daily contract rate1 for the days preceding notification.2
- Admission notification received after it was due, and more than 72 hours after admission: 100% of the contract rate (entire stay).
- No admission notification received: 100% of the contract rate (entire stay).
Note: We do not apply reductions for maternity admissions.
Maryland State-Specific Notification Requirements for Facilities
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:
- The information submitted to us regarding the service was false or intentionally misrepresentative;
- Critical information requested by us was missing and our determination would have been different had we known the information;
- A planned course of treatment approved by us was not followed; or
- On the date the pre-authorized or approved service was delivered: (i) the individual was not covered by UnitedHealthcare, (ii) a member eligibility verification system was available to the care provider by phone or internet, and (iii) the member eligibility verification system using eligibilityLink shows no coverage.
Inpatient Concurrent Review: Clinical Information
We require you to comply with our requests:
- For information, documents or discussions related to concurrent review and discharge planning. This includes primary and secondary diagnosis, clinical information, treatment plan, admission order, patient status, discharge planning needs, barriers to discharge and discharge date. When available, provide access to Electronic Medical Records (EMR).
- From our interdisciplinary care coordination team and/or Medical Director. This includes our requests that you help us engage our members directly face-to-face or by phone.
- If you receive the request before 1 p.m. local time: Please supply all requested information within four hours
- If you receive our request after 1 p.m. local time: Please provide the information within the same business day, but no later than 12 p.m. local time the next business day
Facility Denial Process
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.