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01/2019: UnitedHealthcare Care Provider Administrative Guide for Commercial and Medicare Advantage

Updated UnitedHealthcare Care Provider Administrative Guide Available Jan. 1, 2019*

We post this essential resource for physicians, hospitals, facilities and other health care providers on UHCprovider. com/guides annually on Jan. 1.

You can view the 2019 Guide as a PDF or webpage at Be sure to save the link to your favorites or download the PDF.

Quick Reference to UnitedHealthcare Care Provider Administrative Guides Now Available

The updated Quick Reference to Provider Administrative Guides is available at We developed this resource based on care provider feedback. It contains information that you are likely to need early and often in your relationship with UnitedHealthcare.

New in the 2019 Guide:

  • Medical Prior Authorization Fax Retirement: Ten fax numbers used for medical prior authorization retired on Jan. 1, 2019 and more will be retired throughout the year. We announced these changes in the September and October 2018 Network Bulletin and details can be found at 
  • Skilled Nursing Facilities require prior authorization: For Medicare Advantage members, facilities providing post-acute inpatient services must request prior authorization for these services and receive a determination from UnitedHealthcare before the member is admitted to a facility or a post-acute care bed in a facility. We provided details in the October 2018 Network Bulletin
  • Additional Notification Requirements on patient safety concerns and any external sanctions or corrective actions. Chapter 2: Provider Responsibilities and Standards, page 10. 
  • Optum Dual Special Needs (DSNP) Protocol: Some members enrolled in our DSNP program may be eligible to participate in UnitedHealthcare Dual Special Needs Plans managed by Optum (UnitedHealthcare Optum DSNPs). Optum provides the Optum Dual Special Needs Plan at Home program. For more information, go to our protocol Primary Care Provider (PCP) UnitedHealthcare Optum DSNP Policy on Chapter 4: Medicare Products, page 23. 
  • Updating Advance Notifications or Prior Authorizations: Removed references about changes to previously approved prior authorization during a procedure and after a procedure. For information on when a prior authorization or notification may be updated, go to Chapter 6: Medical Management, page 33. 
  • Medicare Advantage Pharmacy Coverage Gap: Cost shares updated for 2019 per Centers for Medicare & Medicaid Services (CMS) guidelines. Chapter 7: Specialty Pharmacy and Medicare Advantage Pharmacy, page 48. 
  • Charging Members Additional Fees for Covered Services: Care providers may not charge a member additional fees for reductions applied to services/claims resulting from our protocols and/or reimbursement policies. Chapter 10: Compensation, page 69.
  • Member Out of Pocket Maximums: If you prefer to collect payment at the time of service, you must make a good faith effort to help ensure the member has not exceeded their annual out-of-pocket maximum amount. Chapter 10: Compensation, page 70. 
  • All Quality of Care Correspondence is Considered Confidential: Correspondence from the Quality of Care Department is considered privileged and confidential, and should not to be shared with the patient. Chapter 11: Medical Records Standards and Requirements, page 73. 
  • CMS Preclusion List Policy: The CMS preclusion list applies to claims with dates of service on or after Jan. 1, 2019. The list applies to UnitedHealthcare Medicare Advantage plans and Part D plans. We detailed this in the October 2018 Network Bulletin article New Preclusion List Policy. Chapter 16: Fraud, Waste and Abuse, page 84. 
  • Capitated and Delegated Providers: New steps and deadlines if a member exceeds their maximums. Capitated and Delegated Supplement, page 123. 

*Except as otherwise noted, the new guide is effective on April 1, 2019 for currently contracted care providers and Jan. 1, 2019 for care providers newly contracted on or after Jan. 1, 2019. This guide applies to UnitedHealthcare commercial and Medicare Advantage plans only.