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Advance notification/prior authorization list - Chapter 7, 2021 UnitedHealthcare Administrative Guide

The list of services that require advance notification and prior authorization is the same. The process for providing notification and submitting a prior authorization request is the same. Services that require prior authorization require a clinical coverage review based on medical necessity.

Advance notification/prior authorization lists are available online. They are subject to change. We will post inform you of changes on UHCprovider.com/networknews > Network Bulletin. Sign up to receive the Network Bulletin by email at UHCprovider.com/subscribe.

If you need a paper copy of the requirements, contact your UnitedHealthcare Network Management representative or provider advocate.

Current Advance Notification Requirements

View the most current and complete advance notification requirements, including procedure codes and associated services, at UHCprovider.com/ priorauth > Advance Notification and Plan Requirement Resources.

When to submit advance notification or prior authorization requests

We recommend that you submit advance notification with supporting documentation as soon as possible, but at least 2 weeks before the planned service (unless the Advance Notification Requirements states otherwise). Following a facility discharge, advance notification for home health services and durable medical equipment is required within 48 hours after the start of service.

After submitting your request, you get a service reference number. This is not an authorization. When we make a coverage determination, we issue it under this reference number.

It may take up to 15 calendar days (14 calendar days for standard MA requests and 72 hours for expedited requests) for us to make a decision. We may extend this time if we need additional information. Submitting requests through the Prior Authorization and Notification tool on Link assists in timely decisions.

We prioritize case reviews based on:

  • Case specifics
  • Completeness of the information received
  • CMS requirements
  • State or federal requirements

If you require an expedited review, call the number listed on the back of the member’s ID card. You must explain the clinical urgency. You will need to provide required clinical information the same day as your request.

We expedite reviews upon request when the member’s condition:

  • Could, in a short period of time, put their life or health at risk
  • Could impact their ability to regain maximum function
  • Causes severe, disabling pain (as confirmed by a physician)

Durable medical equipment

Durable medical equipment (DME) provides therapeutic benefits to a member because of certain medical conditions and/or illnesses. DME consists of items which are:

  • Primarily used to serve a medical purpose.
  • Not useful to a person in the absence of illness, disability, or injury.
  • Ordered or prescribed by a care provider.
  • Reusable.
  • Repeatedly used.
  • Appropriate for home use.
  • Determined to be medically necessary.

Refer to our Commercial Coverage Determination Guideline for Durable Medical Equipment, Orthotics, Ostomy Supplies, Medical Supplies and Repairs/Replacements at UHCprovider.com/policies > Commercial Policies > Medical & Drug Policies and Coverage Determination Guidelines for UnitedHealthcare Commercial Plans or our Medicare Advantage Coverage Summary for Durable Medical Equipment, Prosthetics, Corrective Appliances/Orthotics and Medical Supplies on UHCprovider.com/policies > Medicare Advantage Policies > Coverage Summaries for Medicare Advantage Plans.