We refer to the terms “prior authorization” and “precertification” in the supplement. You will notice both terms used throughout this supplement.
You may submit prior authorization requests using any of the methods outlined in the How to Contact Oxford Commercial section.
We urge you, facilities, ancillaries and other health care professionals to perform a prior authorization status check first to determine if there is already a prior authorization on file.
Submit prior authorization as far in advance of the planned service as possible to allow for review. We require prior authorization at least 14 business days before the planned service date unless otherwise specified within the Services Requiring Prior Authorization policy at uhcprovider.com/policies > For Commercial Plans > UnitedHealthcare® Oxford Clinical, Administrative and Reimbursement Policies.
Verify the status of an authorization request by the following methods:
Medically necessary services are services or supplies provided by a hospital, skilled nursing facility (SNF) or health care provider which are required to identify or treat a member’s illness or injury, as determined by our medical director. These services or supplies must be:
Oxford Policy Requests and Information
4 Research Drive
Shelton, CT 06484
Changes to the policies related to services appearing on this list are announced in the Oxford Policy Update Bulletin available at uhcprovider.com/policies > For Commercial Plans > UnitedHealthcare® Oxford Clinical, Administrative and Reimbursement Policies > Policy Update Bulletin.
eviCore healthcare (eviCore) provides a secure, interactive web-based program where prior authorization requests may be initiated and determined in real time. If the program finds the request is medically necessary, it issues an authorization number immediately. If the program cannot verify medical necessity through the online process, you may submit more information at the session conclusion and print a procedure request summary page. If an online request for authorization doesn’t meet medical necessity criteria, eviCore forwards it for clinical review. They may request more information for medical necessity review with a medical director.
If the criteria have not been met, your office and the member are notified in writing of the denial. Use the Prior Authorizations tool in the UnitedHealthcare Provider Portal, where the automated system guides you through a series of prompts to collect routine demographic and clinical data. This eliminates the need to call eviCore and lets you enter multiple clinical certification requests at your convenience. Learn more at uhcprovider.com/paan.
Based on the member’s benefit plan design, some high-risk or high-cost medications require advance notification to be eligible for coverage. This process is also known as prior authorization and requires you to submit a formal request and receive advanced approval for coverage of certain prescription medications.
Learn more at uhcprovider.com/priorauth > Clinical Pharmacy and Specialty Drugs.
When we are the secondary or tertiary carrier, we modify normal requirements for prior authorization and referrals as follows: