Advance notification/prior authorization requirements - Chapter 7, 2022 UnitedHealthcare Administrative Guide

Physicians, health care professionals and ancillary health care providers are responsible for:

• Providing advance notification or requesting prior authorization for services on the Advance Notification/Prior Authorization List, including for non-emergent air transport services.
• Directing members to use health care providers within their network. Members may be required to obtain prior authorization for out-of- network services.

Facilities are responsible for:

• Obtaining prior authorization for non-emergent, fixed-wing transportation services and using in-network, fixed-wing air ambulance providers.
• Obtaining prior authorization for inpatient admission to skilled nursing facility, acute inpatient rehabilitation and/or long-term acute care.
• Confirming coverage approval is on file (for services requiring advance notification/prior authorization) prior to the date of service.
• Providing admission and discharge notification for inpatient services, even if coverage approval is on file.

If you perform multiple procedures for a member in 1 day, and at least 1 service requires prior authorization, you must obtain prior authorization for any of the services to be paid.

If you do not follow these requirements, we may deny claims. In that case, you cannot bill the member. Advance notification or prior authorization is valid only for the date of service or date range listed on it. If services have not been rendered and the specified date of service or date range has passed, you must contact us to update the date of service or date range. When you contact us, we will advise if submission of a new request is required.

• Giving us advance notification, or receiving prior authorization from us, is not a guarantee of payment, unless required by law or Medicare guidelines. This includes regulations about health care providers on either a sanctions and excluded list, the Medicare preclusion list and/or health care providers not included in the Medicare Provider Enrollment Chain and Ownership System (PECOS)1 list. Payment of covered services is based on:
  • The member’s benefit plan.
  • If you are eligible for payment.
  • Claim processing requirements.
  • Your Agreement.

See Coverage and utilization management decisions section for additional details.