Prior Authorization and Notification

Helpful Resources

Medical Records Requirement for Pre-Service: Prepare suggested materials in advance to decrease the need for repeated requests, improve turnaround time for medical records reviews and help improve the claims process.

M&R Part B Specialty Medical Injectable Drugs QRG: This Quick Reference Guide (QRG) informs providers about changes to the Prior Authorization process for Part B drugs, that became effective January 3, 2022. 

A peer to peer review is an optional, but recommended, service intended to improve both the UnitedHealthcare-physician experience and the physician-patient experience. During a peer to peer review, a UnitedHealthcare clinical director will discuss the following with the physician and/or facility:

• Medical policies used to make a prior authorization decision
• New clinical information the physician/facility may have that was unavailable at the time of original prior authorization submission

What to know before making your request

• Peer to peer requests can only be made prior to submitting an appeal. Don’t fill out this form if you have already initiated an appeal.
• If you are submitting on behalf of a physician, please ensure they’re willing to speak with the UnitedHealthcare clinical director that reviewed the prior authorization request
  • You will need to provide an actively monitored phone number that will be picked up by a member of your team leading up to and on the designated day and time
  • Please ensure the physician is aware of and available for the peer to peer review during the confirmed day and time

What’s needed to request a review

Before beginning a peer to peer request, please have the following information ready:

• Member name and date of birth (DOB)
• Physician phone and email
• Physician availability (dates and times)

Please see the Administrative Guide for Commercial, Medicare Advantage and DSNP for complete information on health care professional and facility peer to peer requests.

Questions?

For general questions about peer to peer reviews, please call UnitedHealthcare Provider Services, toll-free, at 877-842-3210, 7 a.m.–5 p.m. CT, Monday–Friday. To schedule or reschedule a peer to peer review, contact the peer to peer support team by email at UHC_PeerToPeer_Scheduling@uhc.com or, toll-free, at 800-955-7615, 7 a.m.–7 p.m. CT, Monday–Friday.

For information on specific prior authorization and notification clinical programs by specialty, choose from below:

• Cardiology
• Clinical Pharmacy and Specialty Drugs
• Oncology
• Radiology

Check current prescription coverage and price, including out-of-pocket prescription costs for UnitedHealthcare members at their selected pharmacy with the PreCheck MyScript Tool in the UnitedHealthcare Provider Portal.

• Get information on lower-cost prescription alternatives, if available, to help save members money.
• See which prescriptions currently require prior authorization, or are non-covered or non-preferred.
• Request prior authorization and receive status and results.

Learn more about PreCheck MyScript Solution.

If you do not yet have access to the PreCheck MyScript tool, you may request it from the portal Marketplace.

Note: This application is available to physicians and facilities, not to pharmacies.

Starting Nov. 1, 2017, notification is required for certain genetic and molecular lab tests for certain UnitedHealthcare Commercial benefit plans.

Ordering care providers will complete the notification/prior authorization process online or over the phone.

Labs must register their tests to participate as part of the Genetic and Molecular Lab Testing Notification/Prior Authorization process.

Learn more about the Genetic & Molecular Lab Testing Notification / Prior Authorization Process.

We’re continuously looking for ways to provide greater administrative simplicity for care providers and reduce the costs of doing business with us. 

As part of this effort, we retired certain fax numbers for medical prior authorization requests in 2019, and asked you to use the Prior Authorization and Notification tool in the UnitedHealthcare Provider Portal — the same website you use to check eligibility and benefits, manage claims and update your demographic information. 

Learn more about retired medical prior authorization fax numbers.

In line with UnitedHealthcare’s multi-year efforts to go digital, Admission Notification fax numbers used by facilities to notify us that a member has been hospitalized will be retired in phases this year. Instead of faxing your notification, we ask you to use the HIPAA Electronic Data Interchange (EDI) 278N transaction or the Prior Authorization and Notification tool in the UnitedHealthcare Provider Portal.

Learn more about retiring Admission Notification fax numbers.

To submit a pre-service appeal and or grievance after entering your One Healthcare ID above, access the Community Plan (Medicaid) Pre-Service Appeals & Grievances.