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

For additional details on prior authorization requirements and processes unique to the Bind plan, see the Bind supplement to this guide.

Benefit plans not subject to this protocol

Some benefit plans may have separate notification or prior authorization requirements. Refer to the Benefit plans subject to this guide table in Chapter 1: Introduction and to the supplements of this guide for additional information for the plans listed.

  • UnitedHealthcare Options PPO health care providers are not required to follow this protocol for Options PPO benefit plans because members enrolled in these benefit plans are responsible for providing notification/requesting prior authorization.
  • UnitedHealthcare Indemnity
  • UnitedHealthOne - Golden Rule Insurance Company (“GRIC” group number 705214) only
  • M.D.IPA, Optimum Choice or OneNet PPO
  • Benefit plans subject to the Neighborhood Health Partnership (NHP) Supplement
  • Benefit plans subject to the Oxford Commercial Supplement, except for UnitedHealthcare Oxford Navigate Individual benefit plans (group number 908410)
  • Benefit plans subject to the River Valley Entities Supplement
  • Benefit plans subject to the UnitedHealthcare West Supplement
  • Medicare Advantage (MA) plans that have delegated arrangements with medical groups/IPAs - in these arrangements, the delegate’s protocols must be followed. Submit prior authorizations as directed on the member’s ID card.
  • Benefit plans subject to an additional guide or supplement (refer to the Benefit plans subject to this guide table).
  • Other benefit plans such as Medicaid, CHIP and Uninsured that are neither Commercial nor MA. 

The advance notification requirements outlined in this protocol do not apply to services subject to the following protocols, each is addressed in separate sections later in this guide:

Advance notification vs. prior authorization protocol

Advance notification is the first step in determining coverage. We also use it for case and condition management program referrals. The information we receive about planned medical services helps support the pre-service clinical coverage review and care coordination. Advance notification helps assist members from pre-service planning to discharge planning.

Advance notification is required for services listed on the Advance Notification/Prior Authorization List located at uhcprovider. com/priorauth > Advance Notification and Clinical Submission Requirements.

We require prior authorization for all MA benefit plans and some commercial benefit plans. Prior authorization requests allow us to verify if services are medically necessary and covered. After you notify us of a planned service listed on the Advance Notification/Prior Authorization List, we tell you if a clinical coverage review is required, as part of our prior authorization process, and what additional information we need to proceed. We notify you of our coverage decision within the time required by law. Just because we require notification for a service, does not mean it is covered. We determine coverage by the member’s benefit plan.

If there is a conflict or inconsistency between applicable regulations and the notification requirements in this guide, the applicable regulations govern.