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.

Prior Authorization and Notification Tool


Enhanced functionality in the Prior Authorization and Notification tool in the UnitedHealthcare Provider Portal that may provide improved response times for all plans.
  • Check requirements by member or procedure
  • Submit requests
  • Upload medical notes
  • Check status
  • Update cases
  • Radiology, cardiology and oncology transactions
  • Specialty pharmacy transactions
  • Admission notification, discharge notification and observation stay notification

Save time- No need to call, fax or mail information so you can spend time on other things.

Reduce costs- Online solutions are the most efficient and cost-effective way to manage these transactions.

Get information- Check if prior authorization or notification is required by member or procedure code.

Intuitive and accurate- Required information is highlighted and fields automatically adjust as data is entered. Error messages alert corrections needed before submitting.

Superior documentation- Obtain a Decision ID for inquiries and a reference number for submissions. Save PDF confirmation files or print records as you wish.

Find and check status- Many search options are available to check the status of your submissions, regardless of the submission method you used.

Resources:

New user & user access

Interactive Guide for Prior Authorization and Notification in the UnitedHealthcare Provider Portal

  • Use this guide for more details on how to verify requirements, create submissions and check status.

Resource Page

  • Go to uhcprovider.com/paan for more resources. You’ll find self-paced modules, live-webinar training registration information and more.

UnitedHealthcare Web Support

providertechsupport@uhc.com

1-866-842-3278, Option 1, Monday - Friday 7 a.m. - 9 p.m CT

Information required for advance notification/prior authorization requests

Your request must have the following information:

  • Member name and member health plan ID number
  • Ordering health care provider name and TIN or NPI
  • Rendering health care provider name and TIN or NPI
  • ICD-10-CM diagnosis code
  • All applicable procedure codes
  • Anticipated date(s) of service
  • Type of service (primary and secondary) procedure code(s) and, if relevant, the volume of service
  • Place of service
  • Facility name and TIN or NPI where service will be performed (when applicable)
  • Original start date of dialysis (End Stage Renal Disease [ESRD] only)

If the member’s benefit plan requires a clinical coverage review, we may request additional information, as described in more detail in the Clinical coverage review section.

1PECOS is the CMS online enrollment system where health care providers and health care entities are required to register so they can manage their Medicare provider file and establish their Medicare specialty as eligible to order and refer services/items.