Coverage and utilization management decisions - Chapter 7, 2022 UnitedHealthcare Administrative Guide

We base coverage decisions, including medical necessity decisions, on:

  • Member’s benefits.
  • State and federal requirements.
  • The contract between us and the plan sponsor.
  • Medicare guidelines including national coverage determination (NCD) and local coverage determination (LCD) guidelines.
  • Medicare Benefit Policy Manual (MA members).
  • UnitedHealthcare medical policies, medical benefit drug policies, coverage determination guidelines, utilization review guidelines and MA coverage summaries.

Our employees, contractors, and delegates do not receive financial incentives for issuing non-coverage decisions or denials. We and our delegates do not offer incentives for underutilization of care/services or for barriers to care/service. We do not hire, promote or terminate employees or contractors based on whether they deny benefits.

We use tools such as UnitedHealthcare medical policies, and third party resources (such as InterQual® criteria and other guidelines), to assist us in administering health benefits and determining coverage.

These tools and resources are not equivalent to the practice of medicine or medical advice and you should use them in addition to independent, qualified medical judgment.

Clinical coverage summaries and policy guidelines for Medicare Advantage

We follow CMS guidance (including NCD and LCD guidelines) if the tools and resources we use contradict CMS guidance. If we do not perform a pre-service clinical coverage review, we may use Medicare guidelines, including NCD and LCD guidelines to perform a clinical review when we receive the claim.

The complete libraries of our MA policy guidelines and coverage summaries are on > Medicate Advantage Policies.

Coverage decisions

Some plans require prior authorization through a pre-service clinical coverage review. Once you notify us of any planned service, item or drug on our Advance Notification/Prior Authorization List, we will inform you of any required information necessary to complete the clinical coverage review as part of our prior authorization process. We will notify you of the coverage decision within the time frame required by law.

You and our member must be aware of coverage decisions before you render services. If you provide the service before a coverage decision is made, and we determine the service is not covered, we may deny the claim. The member cannot be billed. If you provide services prior to our decision, the member cannot make an informed decision about whether to pay for and receive the non-covered service.

Clinical coverage review

You can review a list of required information by service on > Medical Record Requirements for Pre-Service Reviews. If you submit required information with the advance notification/prior authorization, your review will go faster. You must:

  • Return calls from our care management team and/or Medical Director.
  • Submit the most correct and specific code available for the services.
  • Comply with our request for additional information or documents and discussions, including requests for medical records and imaging studies/reports:
    • If you receive our request before 1 p.m. local time, provide the information within 4 hours.
    • If you receive our request after 1 p.m. local time, provide the information no later than 12 p.m. local time the next business day.

Medical & drug policies and coverage determination guidelines for members

A complete library of our medical policies and guidelines is available on > Commercial Policies > Medical & Drug Policies and Coverage Determination Guidelines.

We develop medical policies, medical benefit drug policies, coverage determination guidelines, and utilization review guidelines to support the administration of medical benefits. You may request a copy of our medical policies and guidelines by calling our care management team at 1-877-842-3210 or 1-888-478-4760 (Individual Exchange Plans). They are only for informational purposes; they are not medical advice. You are responsible for deciding what care to give our members. Members should  talk to their health care providers before making medical decisions. Drug policies for commercial members covered under the pharmacy benefit are on

Benefit coverage is determined by the following:

  • Laws that may require coverage
  • The member’s benefit plan document
    • Summary Plan Description
    • Schedule of Benefits
    • Certificate of Coverage

The member’s benefit plan document identifies which services are covered, which are excluded, and which are subject to limitations. If there is a conflict, the member’s benefit plan document supersedes our policies and guidelines.

We develop our policies and guidelines as needed. We regularly review and update them. They are subject to change. We believe the information in these policies and guidelines is accurate and current as of the publication date. We also use tools developed by third parties, such as InterQual criteria, to help us manage health benefits. If you believe we should consider new or additional clinical evidence pertaining to a specific medical policy, complete this form for UnitedHealthcare medical policy review. Do not submit protected health information using this form. If you have questions or concerns about a specific service for a member, refer to the appropriate benefits, claims or prior authorization/notification process.

Medical policy updates

For more information on medical policy updates, refer to the Network News section of Chapter 18: Provider communications.