Prior Authorization and Notification Program Summary

This is a summary of the Prior Authorization and Notification Program and is not meant to be comprehensive. Please refer to the UnitedHealthcare Administrative Guide for program details and required protocols.

• Physicians, health care professionals and ancillary care providers are responsible for providing advance notification. Notification should be submitted as far in advance as possible but must be submitted at least five business days before the planned service date (unless otherwise specified).
• It may take up to 15 calendar days to receive a decision (14 calendar days for UnitedHealthcare Medicare Advantage plans). We prioritize case review based on the specifics of the case, the completeness of the information received and Centers for Medicare & Medicaid Services (CMS) requirements or other state or federal requirements.
• Acute care hospitals, skilled nursing facilities and acute rehabilitation facilities are responsible for admission notification for inpatient services, even if the coverage approval is on file. Notification of each inpatient admission must be received within 24 hours after actual weekday admissions (or by 5 p.m. local time on the next business day if 24-hour notification would require notification on a weekend or federal holiday). For weekend and federal holiday admissions, the notification must be received by 5 p.m. local time the next business day.
• For information on submitting admission notifications electronically, please see Electronic Admission Notifications (278N).

California and Washington Variations

California and Washington providers, hospitals and other acute inpatient facilities are subject to the admission notification requirements described in the UnitedHealthcare Administrative Guide.

Maryland Facility Variations

If prior authorization or advance notification is needed for the requested elective inpatient procedure, it is the physician's responsibility to obtain the relevant approval.

The facility must notify UnitedHealthcare within 24 hours (or the following business day if the admission occurs on a weekend or holiday) of the elective admission. If the physician has obtained prior authorization or advance notification, the initial day of the inpatient admission will be paid, unless:

1. The information submitted to UnitedHealthcare was fraudulent or intentionally misrepresented
   
2. Critical information requested by UnitedHealthcare was omitted and UnitedHealthcare's determination would have been different had it known the critical information
3. A planned course of treatment that was approved by UnitedHealthcare was not substantially followed by the care provider
4. On the date the preauthorized or approved service was delivered, the member was not covered by UnitedHealthcare, and the care provider could have verified the member's eligibility status by using UnitedHealthcare's automated eligibility verification system (VETTS). Note that the online verification must indicate that the member is not covered by UnitedHealthcare.
   

If advance notification is obtained but is not made by the facility in a timely manner, payment reductions will be limited to hospital room and board charges, when applicable.

Insurance coverage provided by or through UnitedHealthcare Insurance Company or its affiliates. Health plan coverage provided by UnitedHealthcare of Arizona, Inc., UHC of California DBA UnitedHealthcare of California, UnitedHealthcare Benefits Plan of California, UnitedHealthcare of Colorado, Inc., UnitedHealthcare of the Mid-Atlantic, Inc., MAMSI Life and Health Insurance Company, UnitedHealthcare of New York, Inc., UnitedHealthcare Insurance Company of New York, UnitedHealthcare of Oklahoma, Inc., UnitedHealthcare of Oregon, Inc., UnitedHealthcare of Pennsylvania, Inc., UnitedHealthcare of Texas, Inc., UnitedHealthcare Benefits of Texas, Inc., UnitedHealthcare of Utah, Inc., UnitedHealthcare of Washington, Inc., Optimum Choice, Inc., Oxford Health Insurance, Inc., Oxford Health Plans (NJ), Inc., Oxford Health Plans (CT), Inc., All Savers Insurance Company, or other affiliates. Administrative services provided by OptumHealth Care Solutions, LLC, OptumRx, Oxford Health Plans LLC, United HealthCare Services, Inc., or other affiliates. Behavioral health products provided by U.S. Behavioral Health Plan, California (USBHPC), or its affiliates.