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Utilization Management, Oxford - 2019 UnitedHealthcare Administrative Guide

Utilization Management

Prior Authorization (Pre-Certification)

We refer to the terms “prior authorization” and “pre-certification” in the supplement. You will notice both terms used throughout this supplement.  

You may submit prior authorization requests using any of the methods outlined in the ‘How to Contact Oxford Commercial’ section.

We urge care providers, facilities, ancillaries and other health care professionals to perform a prior authorization status check first to determine if there is already a prior authorization on file.

Submit prior authorization as far in advance of the planned service as possible to allow for review. We require prior authorization at least 14 business days before the planned service date (unless otherwise specified within the Prior Authorization List located on > Providers (or Facilities) > Tools & Resources > Medical Information > Medical and Administrative Policies > Services Requiring Prior Authorization).

  • Submit authorization requests for obstetrical admissions for normal delivery as early as possible in the course of prenatal care, based on the expected date of delivery.
  • Participating care providers and facilities are responsible for contacting us for:
    • Procedures requiring prior authorization. However, an active referral must also be on file for services to be covered as network benefits, depending on the member’s health benefit plan.
    • Any change of treating care provider, location, CPT codes or dates of service for the authorized service.
    • Member emergency admissions upon admission or on the day of admission. If the care provider/facility is unable to determine on the day of admission that the patient is our member, the care provider/facility must notify us as soon as possible after discovering that the patient has coverage with us.
  • We notify participating care providers of all determinations involving New York members by phone and in writing. All participating care providers are responsible for calling the member the same day that the care provider receives notification of our determination.
  • Neither prior authorization nor referral is required for members to access a participating women’s health specialist (i.e., gynecologists and/or certified nurse midwives) for routine and preventive health care services. Routine and preventive health care services include breast exams, mammograms, and Pap tests.
  • Members are responsible for notifying us of emergency facility admissions to a non-participating facility.
  • We may require a member see a care provider, selected by us, for a second opinion. We reserve the right to seek a second opinion for any surgical procedure. There is no formal list of procedures requiring second opinions. Members may also seek a second opinion when appropriate.

Status of a Submitted Authorization Request

Verify the status of an authorization request by the following methods:

  • Voice Portal: Available 24 hours a day, seven days a week
  • Online: Available 24 hours a day, seven days a week
  • Provider Services: Speak to a service representative during business hours

Medically Necessary Services

Medically necessary services are services or supplies provided by a hospital, skilled nursing facility, or care provider which are required to identify or treat a member’s illness or injury, as determined by our medical director.

These services or supplies must be:

  • Consistent with the symptoms or diagnosis and treatment of a member’s condition
  • Appropriate regarding standards of good medical practice
  • Not solely for the member’s convenience or that of any care provider
  • The most appropriate supply or level of service which can safely be provided.
  • For inpatient services, it further means the member’s condition cannot safely be diagnosed or treated on an outpatient basis.

Prior Authorization List

  1. You can log on to > Provider or Facilities > Transactions to use the Precert Required Inquiry tool on the Transactions tab to check prior authorization requirements for up to 12 CPT codes at one time.
  2. The list of services requiring prior authorization is on > Providers or Facilities > Tools & Resources > Medical Information > Medical and Administrative Policies > Medical &Administrative Policy Index > Services Requiring Prior Authorization.
  3. You can request a copy of the most current list by mail:
    Oxford Policy Requests and Information
    4 Research Drive
    Shelton, CT 06484

Changes to the policies appearing on this list are announced at > Providers or Facilities > Tools & Resources > Medical Information > Medical and Administrative Policies > Policy Update Bulletin (published monthly).

  • A member’s benefit plan may not cover certain services, regardless of whether we require advance notification.
  • If there is a conflict or inconsistency between applicable regulations and the supplement notification requirements, we follow applicable regulations.
  • Prior authorization requirements may differ by individual care providers, ancillary providers and facilities. If additional prior authorization requirements apply, we notify the care provider before applying prior authorization rules.

eviCore Healthcare Prior Authorizations Online

eviCore Healthcare provides a secure, interactive web-based program where prior authorization requests can be initiated and determined in real time. If the program finds the request is medically necessary, it issues an authorization number immediately. If the program cannot verify medical necessity through the online process, care providers may submit more information at the session conclusion and print a procedure request summary page. If an online request for authorization doesn’t meet medical necessity criteria, eviCore forwards it for clinical review. They may request more information for medical necessity review with a medical director.

If the criteria have not been met, the care provider’s office and the member are notified in writing of the denial. Log into where the automated system guides you through a series of prompts to collect routine demographic and clinical data. This eliminates the need for a call to eviCore Healthcare and lets you enter multiple clinical certification requests at your convenience.

Prescription Medications Requiring Prior Authorization

Based on the member’s benefit plan design, some high-risk or high-cost medications require advance notification to be eligible for coverage. This process is also known as prior authorization and requires you to submit a formal request
and receive advanced approval for coverage of certain prescription medications.

The list of prescription medications (including generic equivalents, if available) that require prior authorization is available on > Providers or Facilities > Tools & Resources > Medical Information > Prescription Drug Information > Drugs Requiring Precertification

Prior Authorization and Referral Guidelines When Coordinating Benefits

When we are the secondary or tertiary carrier, we modify normal requirements for prior authorization and referrals as follows:

  • We defer to the requirements of the primary carrier and waive our referral and prior authorization guidelines. We do not waive other requirements (e.g., itemized bills, student verification, consent for exchange of mental health or substance use information, etc.).
  • Exception: Referral and prior authorization guidelines apply:
    • If the primary carrier does not cover a service or applies an authorization penalty.
    • When a motor vehicle accident or workers’ compensation is involved.