June 01, 2022

Important UnitedHealthcare Medicare Advantage post-acute care requirements

Please be reminded that facilities contracted with UnitedHealthcare and providing post-acute inpatient services for UnitedHealthcare® Medicare Advantage members are required to obtain prior authorization before members can be admitted to a post-acute care facility. 

These prior authorization requirements apply to UnitedHealthcare Medicare Advantage members receiving care in a Skilled Nursing Facility (SNF), Inpatient Rehabilitation Facility (IRF), or Long Term Acute Care Facility (LTAC). 

Note: If you do not complete the prior authorization process before the member is admitted, we may deny the claims and the member cannot be billed for the service. 

Our post-acute care requirements help ensure continuity of care for your patients, as well as contribute to improved health outcomes and lower cost for our members.

Members in scope
The prior authorization requirements will apply to members in the following benefit plans:

  • UnitedHealthcare Medicare Advantage (MA)
  • UnitedHealthcare Dual Special Needs Plan (DSNP)
  • Institutional Equivalent Special Needs Plans (IE-SNP) when transferring from a hospital setting

Members excluded
The prior authorization requirements will not apply to:

  • Members in Institutional Special Needs Plans (ISNP)
  • Members assigned to primary care physicians that are part of a delegated arrangement

Avoid denial of payment
To avoid denial of payment for a post-acute care admission:

  • Obtain an approved prior authorization before admission
  • Provide timely admission notification once member is admitted to facility
  • The level of care or any inpatient bed days must be medically necessary which is determined through concurrent or retrospective review (2022 UnitedHealthcare Provider Administrative Guide Chapter 7).
  • Provide requested clinical supporting documentation within the requested 24-hour time frame
  • Deliver a valid Notice of Medicare Non-Coverage (NOMNC) at least 2 days prior to the last covered date of services, per CMS requirements

Follow these guidelines to avoid liability for claims that are denied as a result of failure to follow protocols. Such claims are not billable to the member.

Questions?
If you have questions, refer to post-acute care contract requirements/protocols which can be found in the 2022 UnitedHealthcare Provider Administrative Guide.

PCA-1-22-01409-M&R-News