Contracted facilities must provide timely notification to both the delegate and UnitedHealthcare within 24 hours of admission for all inpatient and observation status cases. This includes changes in level of care that affect billing category.
For maternity cases, provide notification before the end of the mandated period (48 hours for normal vaginal delivery or 96 hours for C-section delivery). We require notification if the newborn stays longer than the mother does. In all cases, we require separate notification immediately when a newborn is admitted to the NICU.
The delegate must have a clearly defined process with the facility whereby it provides the medical group/IPA and UnitedHealthcare with the facility information on all admissions, updates in member status, and discharge dates daily.
UnitedHealthcare and the medical group/IPA require timely notification of admission so we can verify eligibility, authorize care, including level of care (LOC), and initiate concurrent review and discharge planning.
For emergency admissions, provide notification once the member’s condition is stabilized in the emergency department. For timely and accurate payment of facility claims, we require proper notification on the day of admission.
Submit authorization logs for all inpatient acute, observation status, Skilled Nursing Facility (SNF) cases and Denial Logs at least twice a week to the Authorization Log Unit at firstname.lastname@example.org, by fax at 866-383- 1740 or EDI transmission.
We also require specific markets to submit Outpatient Prior Authorization Logs. For new submitters, please arrange a log delivery schedule with the Authorization Log Unit prior to the first submission.
The Authorization Log Unit must agree in writing and in advance with changes to your submission schedule.
Any medical group/IPA undergoing a system change or upgrade that may affect delivery of authorization logs must notify the Authorization Log Unit prior to change date and work with us to help ensure a seamless transition.
Logs must be compliant with state and federal regulations and include all concurrent IP and SNF admissions between the previous and current log submission:
- Cases generated upon admission.
- Length of stay changes/extensions.
- Discharged cases.
- Submit completed outpatient authorization cases on a separate log.
- If there are no applicable cases to report, the medical group/IPA must submit a weekly authorization log indicating either “no activity” or “no admissions” for each of the designated admission service type for the applicable reporting time.
- Logs must include:
- Member name
- Member date of birth
- Authorization/reference number
- Requesting care provider (name, address, TIN or NPI)
- Attending/servicing care provider (name, address, TIN or NPI)
- Facility care provider (name, address, TIN or NPI)
- Admitting diagnosis (ICD-10-CM or its successor code)
- Actual admission date
- Actual discharge date
- Status (approved/denied)
- Service start date
- Service end date
- Clearly defined level of care description (i.e. Acute IP, Mental Health, Acute Rehabilitation, LTAC, Skilled Nursing, Observation, outpatient procedures at acute facilities, codes must be submitted with descriptions of LOC.)
- Approved length of stay (number of days)
- Denied length of stay (number of days)
- Procedure/surgery (CPT Code)
- Discharge disposition
- Planned admission date
- Planned discharge date
- Service type
- Insurance (Commercial/Medicare)
The medical group/IPA must have a clearly defined process for determining medical necessity and authorizing outpatient services. These services are paid as either shared risk or plan risk per the medical group/IPA contract.
The medical group/IPA must be capable of submitting, pursuant to our request, authorization or denials for all shared risk or plan risk services for which the group has authorized or denied care on behalf of UnitedHealthcare.
A member is stabilized or stabilization has occurred when, in the opinion of the treating care provider, the member’s medical condition is such that, within reasonable medical probability, no material deterioration of the member’s condition is likely to result from, or occur during, a transfer of the member.
UnitedHealthcare and any of its delegates must:
- Have a process to respond to requests for post- stabilization care.
- Respond to requests for authorization of post- stabilization services within 30 minutes for commercial and within one hour for Medicare Advantage members.
- If UnitedHealthcare or our delegate does not respond within the required timeframe, care is viewed as authorized until:
- Member is discharged,
- A network care provider arrives and assumes responsibility for the member’s care, or
- Treating care provider and the organization, defined as the plan or its delegate, agree to another arrangement
Based on the contract, the delegated entity may be financially responsible for:
- ER and post-stabilization services in area.
- OOA services.
Post-Stabilization Care (MA)
CMS defines post-stabilization care as services:
- Related to an emergency medical condition,
- Provided after a member is stabilized, and
- Provided to maintain the stabilized condition, or under certain circumstances to improve or resolve the member’s condition.
UnitedHealthcare or its delegates must:
- Have a process to respond to requests for post- stabilization care, and
- Respond to requests for authorization of post- stabilization services within one hour.
Typically, observation status rules out a diagnosis or medical condition that responds quickly to care. Facility observation status is generally designed to assess a member’s medical condition to determine the need for inpatient admission, or to stabilize a member’s condition. UnitedHealthcare or our delegate will authorize facility observation status when medically indicated and the case meets nationally recognized evidenced based guidelines. A member’s outpatient observation status may later be changed to an inpatient admission if medically necessary and if appropriate criteria have been met.
We expect our medical management delegates to support compliance with the review of criteria. The delegated medical group/IPA must issue a facility denial when the inpatient stay does not meet nationally recognized evidence-based guideline. This happens when:
- It receives notification of the admission.
- It receives a post-service request for admission authorization prior to claims submission. It determines the admission does not meet medical necessity criteria, including relevant Medicare inpatient admission requirements and is not on the CMS list of HCPCS codes that would be paid only as inpatient procedures.
- There is no inpatient order matching the date of the inpatient admission for Medicare members.
When we delegate services for authorization and concurrent review, we expect the delegate to issue a facility denial letter to the contracted facility when the facility’s medical record or claim fails to support the LOC or services rendered. This may be determined through concurrent or retrospective review.
There are three types of facility denial letters:
- Delay in inpatient services.
- Delay in change of LOC within the same facility.
- Delay in facility discharge.
The delegated medical group/IPA must comply with our protocols, policies and procedures for denials. This includes turnaround times for issuing, delivering and submitting facility denial letters to UnitedHealthcare.
When UnitedHealthcare is responsible for paying facility services, the delegated medical group/IPA must comply with UnitedHealthcare’s protocols, policies and procedures for submitting facility denial letters to UnitedHealthcare.
Whether a denial is issued by UnitedHealthcare or its delegate, the UnitedHealthcare Provider Dispute Resolution process manages any facility disputes.
If the delegated medical group/IPA is responsible for paying inpatient facility services, then the delegate need not submit copies of facility denials to UnitedHealthcare. Facility denials are not sent to the member and must specifically exclude the member from liability for the denied LOC and/or services. Under these circumstances, the delegated medical group/IPA’s care provider dispute resolution process manages any care provider facility disputes.
Delegate must provide a copy of the facility denial letter to the member, if requested.
(For Services Carved Out of Capitation)
This policy applies if UnitedHealthcare has financial responsibility for the following outpatient MA services. Prior authorization is required for:
- Intensity Modulated Radiation Therapy (IMRT).
- Radiosurgery (SRS).
- Body Radiation Therapy (SBRT).
We use National Coverage Decision (NCD), Local Coverage Decision (LCD) and UnitedHealthcare medical policies and guidelines to determine eligibility of coverage. We require authorization before the start of therapy and each time a member starts a new IMRT, STS or SBRT treatment regimen.
Prior Authorization Required to Process Payment
Initiate a prior authorization request for outpatient therapeutic radiation services (IMRT, STS, and SBRT) carved out of capitation on UHCprovider.com/paan. We do not process the request or make a determination until we have received all necessary information. Then we make a decision within the applicable timeframe.
For Medicare Advantage plans, the timeframe to review and render a decision begins upon receipt of the initial request.
We authorize therapeutic radiation services based on the member’s benefit design provided the member does not exceed their benefit restrictions.
UnitedHealthcare may, at its sole discretion, use a nationally contracted vendor for utilization management to administer the prior authorization program for all Therapeutic Radiation Services. The nationally contracted vendor uses the NCDs, LCDs and the UnitedHealthcare MA Coverage Summaries for managing the program.
We fax the case resolution to the medical group/IPA for each case serviced. Denials require a letter sent to both member and care provider stating why we denied the requested service. The letter outlines the process for filing standard and expedited appeals.
Delegates that receive requests for services must make decisions and provide notification within applicable regulatory and accreditation timeframes. We hold the delegate to the most stringent requirements for approvals, extensions of decision turnaround times, denials, delays, partial approvals and modification of requested services.
Find additional information in Chapter 6: Medical Management, Medical Management Denials/ Adverse Determinations.
Qualifications of Who Can Deny or Make Adverse Determinations
Only physicians or appropriately licensed clinical personnel can deny or make adverse determinations based on medical necessity. This physician reviewer may be a physician, doctoral level clinical psychologist or pharmacist as appropriate to the requested service.
The physician reviewer must have a current unrestricted license. Delegates must provide evidence of verification according to credentialing requirements.
For MA, the delegate must verify the physician reviewer has experience showing knowledge of Medicare coverage criteria. Evidence of verification may include content of curriculum vitae, training as part of onboarding process, training after onboarding, or interaction between our medical director and the delegate’s physician reviewers. Evidence may also include review of denial records or files indicating appropriate use of criteria applicable to the request for services and member’s condition.
Oral or Verbal Notification
We have various requirements for oral or verbal notification of approvals or denials. This may vary from state to state or by request type (such as pre-service, expedited or concurrent). The delegate must document efforts to provide oral notification and meet written notification requirements as well.
Written Denial Notice
The written denial is an important part of the member’s chart and the delegate’s records. Regardless of the form used, the denial letter documents member and care provider notification of:
- The denial, delay, partial approval or modification of requested services.
- The reason for the decision, including medical necessity, benefits limitation or benefit exclusion.
- Member-specific information about how the member did not meet criteria.
- Appeal rights.
- An alternative treatment plan, if applicable.
- Benefit exhaustion or planned discharge date, if applicable.
Most states require approved standardized templates for member notices, such as denial of services.
UnitedHealthcare provides appropriate and approved templates to the delegates.
Minimum Content of Written or Electronic Notification
A notice to deny, delay or modify a health care services authorization request must include:
- The requested services.
- A reference to the benefit plan provisions to support the decision.
- The reason for denial, delay, modification, or partial approval, including:
- Clear, understandable explanation of the decision.
- Name and description of the criteria or guidelines used.
- How those criteria were applied to the member’s condition.
- A statement the member can get a free copy with the benefit provision, guideline, protocol or other criterion used to make the denial decision.
- Contractual rationale for benefit denials.
- Alternative treatments offered, if applicable.
- A description of additional information needed to complete that request and why it is necessary (for delay of decision).
- Appeal and grievance processes, including:
- When, how and where to submit a standard or expedited appeal.
- The member’s right to appoint a representative to file the appeal.
- The right to submit written comments, documents or other additional relevant information.
- The right to file a grievance or appeal with the applicable state agency, including information regarding the independent medical review process (IMR), as applicable.
- The name and phone number of the health care professional responsible for the decision included in the care provider’s notice. This is not required in the member’s notification.
- Any state-mandated language (commercial)
- ERISA information as applicable (commercial)
- Ombudsman information (commercial)
We may delegate the functions of complex case management (CCM) or disease management. Requirements are based on NCQA accreditation standards.
If these functions are delegated to a medical group/IPA or other organization, we conduct pre-contractual and post-contractual assessments. If assessments identify deficiencies, we require delegates to undergo improvement action. The oversight process mirrors the delegation oversight process for medical management.
The U.S. Department of Health and Human Services published final non-discrimination rules from Section 1557 of the Affordable Care Act. The final rule clarifies and codifies existing nondiscrimination requirements and sets standards for including non-discrimination notices on significant communications sent to health plan members. This includes member-facing letters (e.g., IDN, NOMNC, service denials), documents, notices, newsletters, and brochures sent to the member.
We provide our delegates with our required taglines: a short form and a long form. The delegate must attach the short form to communications one to two pages in length and the long form to communications three or more pages in length. The tagline does not have to be added into the body of the communication. It may be included as a separate sheet in the mailing envelope. Only a single tagline sheet must be included in every mailing, even if the envelope contains multiple communications.