Coverage Determination Guidelines and Utilization Review Guidelines: UHCprovider.com > Policies and Protocols > Exchange Policies > UnitedHealthcare Value & Balance Exchange Medical & Drug Policies and Coverage Determination Guidelines
We’ll conduct site of service medical necessity reviews for any procedures/codes referenced in UnitedHealthcare’s site of service utilization review guidelines. You can find more information about site of service medical necessity reviews in our frequently asked questions document, available on Nov. 1, 2020 on UHCprovider.com. Look for an update in the November Network Bulletin.
Prior authorizations must be submitted electronically and will not be accepted by phone or fax. Prior authorization or notification requests that also require a referral will not be accepted unless a completed referral was submitted online. If referral requirements are not met, the member may have no coverage for a physician or hospital claim for planned inpatient admissions. Additionally, admission notification/authorization is not a guarantee of coverage or payment (unless mandated by law).
Non-emergent out-of-network services are not a covered benefit and will be subject to additional pre-service review and notification requirements. Participating providers will be receiving more detailed information later this month.
Look for updates on the following in future Network Bulletins:
UnitedHealthcare Value & Balance Exchange Medical Policy Update Bulletin: UHCprovider.com > Policies and Protocols > Exchange Policies > UnitedHealthcare Value & Balance Exchange Medical & Drug Policies and Coverage Determination Guidelines