Clinical Coverage Review
Certain services require prior authorization, which results in:
- A request for clinical information,
- A clinical coverage review based on medical necessity, and
- A coverage determination.
You must cooperate with all requests for information, documents or discussions for purposes of a clinical coverage review including providing pertinent medical records, imaging studies or reports and appropriate assessments for determining degree of pain or functional impairment.
As a network care provider, you must respond to calls from our UM staff or medical director. You must provide complete clinical information as required within the timeframe specified on the outreach form.
- We may use tools developed by third parties, such as the MCG™ guidelines, to assist us in administering health benefits. These tools assist clinicians in making informed decisions in many health care settings. These tools are intended to be used in connection with the independent professional medical judgment of a qualified health care provider. They do not constitute the practice of medicine or medical advice.
- For Medicare Advantage members, we use CMS coverage determinations, the National Coverage and Local Coverage Determinations (LCD), to determine benefit coverage for Medicare members. If other clinical criteria, such as the MCG™ guidelines or any other coverage determination guidelines, contradict CMS guidance, we follow the CMS guidance.
Clinical Coverage Review Criteria
We use scientifically based clinical evidence to identify safe and effective health services for members for inpatient and outpatient services. For Inpatient Care Management (ICM’s), we use evidence-based MCG Care Guidelines.
Clinical coverage decisions are based on the member’s eligibility, state and federal mandates, the member’s certificate of coverage, evidence of coverage or summary plan description, UnitedHealthcare Medical Policies and medical technology assessment information.
For Medicare Advantage members, we use CMS NCDs and LCDs and other evidence-based clinical literature.
Coverage Determination Decisions
Coverage determinations for health care services are based upon the member’s benefit documents and applicable federal requirements. Our UM staff, its delegates, and the physicians making these coverage decisions are not compensated or otherwise rewarded for issuing adverse non-coverage determinations.
Preferred Care and its delegates do not offer incentives to physicians to encourage underutilization of services or to encourage barriers to receiving the care and services needed. Coverage decisions are made based on the definition of “reasonable and necessary within Medicare Advantage coverage regulations and guidelines.”
Hiring, promoting, or terminating physicians or other individuals are not based upon the likelihood or the perceived likelihood that the individual will support or tend to support the denial of benefits.
Prior Authorization Denials
We may deny a prior authorization request for several reasons:
- Member is not eligible;
- Service requested is not a covered benefit;
- Member’s benefit has been exhausted; or
- Service requested is identified as not medically necessary (based upon clinical criteria guidelines).
We must notify you and the member in writing of any adverse decision (partial or complete) within applicable time frames. Our notice states the specific reasons for the decision. It also references the benefit provision and clinical review criteria used in the decision-making process. We provide the clinical criteria used in the review process for making a coverage determination along with the notification of denial.
Peer-to-Peer (P2P) Clinical Review
For Inpatient Care Management Cases, peer-to-peer requests may come in through the peer-to-peer Support team by calling 800-955-7615.
Peer-to-peer discussions can occur at different points during case activity in accordance with time frames, once a medical director has rendered an adverse determination.
The post-decision peer-to-peer consult process must conclude for the Medicare population. This requires establishing a pre-decision medical director outreach for standard (14 day turn-around-time) requests for both inpatient and outpatient adverse determinations. It excludes expedited pre-service requests and administrative denials.
We must treat the following situations as reconsiderations or appeals:
- Clinical information received after notification is complete.
- Peer-to-peer requests received after notification is complete.
Additional UM Information
External Agency Services for Members
Some members may require medical, psychological and social services or other external agencies outside the scope of their plan benefits (for example, from Health and Human Services or Social Services). If you encounter a member in this situation, contact Network Management Services.
You can also have the member contact our Member Services Department at 866-231-7201 for assistance with, and referral to, appropriate external agencies.
Technology Assessment Coverage Determination
The technology assessment process helps evaluate new technologies and new applications of existing technologies. Technology categories include medical procedures, drugs, pharmaceuticals, or devices.
This information allows us to support decisions about treatments that best improve member’s health outcomes, efficiently manage utilization of healthcare resources, and make changes in benefit coverage to keep pace with technology changes. It also helps ensure members have equitable access to safe and effective care.
If you have any questions regarding whether a new technology or a new application of existing technologies are a covered benefit for your patients, please contact Utilization Management at 800-995-0480.
Hospitalist Program for Inpatient Hospital Admissions
The Hospitalist Program is a voluntary program for members. Hospitalists are physicians who specialize in the care of members in an acute inpatient setting (acute care hospitals and SNFs).
A hospitalist oversees the member’s inpatient admission and coordinates all inpatient care. The hospitalist communicates with the member’s selected physician by providing records and information, such as the discharge summary.
Discharge planning is a collaborative effort between the inpatient care manager, the hospital/facility case manager, the member, and the admitting physician. It helps ensure coordination and quality of medical services through the post-discharge phase of care.
Although not required to do so, we may help identify health care resources available in the member’s community following an inpatient stay.
UM nurses conduct telephone reviews to support discharge planning, with a focus on coordinating health care services prior to the discharge.
The facility or physician is required to contact us and provide clinical information to support discharge decisions under the following circumstances:
- An extension of the approval is needed. Contact must be made prior to the expiration of the approved days.
- The member’s discharge plan indicates transfer to an alternative level of care is appropriate.
- The member has a complex plan of treatment that includes home health services, home infusion therapy, total parenteral nutrition, or multiple or specialized durable medical equipment identified prior to discharge.
To initiate patient discharge, call us at 800-995-0480 or reach us by fax at 866-567-0144.