Prior authorization requirements for the UnitedHealthcare plans
When you seek prior authorization as required, UnitedHealthcare will work with you to implement the care management process and to provide you with information about additional services that are available to you, such as disease management programs, health education, and patient advocacy.
UnitedHealthcare requires prior authorization for certain covered health services. Your network primary physician and other in-network providers are responsible for obtaining prior authorization before they provide these network services to you. There are some out-of-network benefits, however, for which you are responsible for obtaining prior authorization as indicated in this SPD.
It is recommended that you confirm with the UnitedHealthcare that all covered health services listed below have been prior authorized as required. Before receiving these services from an in-network provider, you may want to contact UnitedHealthcare to verify that the hospital, physician and other providers are in-network providers and that they have obtained the required prior authorization. Network facilities and in-network providers cannot bill you for services they fail to prior authorize as required. You can contact UnitedHealthcare by calling the number on your ID card.
When you choose to receive certain covered health services from out-of-network providers, you are responsible for obtaining prior authorization before you receive these services. Note that your obligation to obtain prior authorization is also applicable when an out-of-network provider intends to admit you to a network facility or refers you to other in-network providers.
To obtain prior authorization, call the number on your ID card. This call starts the utilization review process. Once you have obtained the authorization, please review it carefully so that you understand what services have been authorized and what providers are authorized to deliver the services that are subject to the authorization.
The utilization review process is a set of formal techniques designed to monitor the use of, or evaluate the clinical necessity, appropriateness, efficacy, or efficiency of, health care services, procedures or settings. Such techniques may include ambulatory review, prospective review, second opinion, certification, concurrent review, case management, discharge planning, retrospective review or similar programs.
In-network providers are responsible for obtaining prior authorization from UnitedHealthcare before they provide these services to you. There are some benefits, however, for which you are responsible for obtaining prior authorization from UnitedHealthcare prior to receiving a service.
Services for which you are required to obtain prior authorization are identified in the benefit descriptions throughout this SPD. Please note that prior authorization timelines apply. Refer to the applicable Benefit description to determine how far in advance you must obtain prior authorization and any applicable penalties.
Services that require prior authorization include:
- Non-emergency air ambulance transportation;
- Clinical trials;
- Congenital heart disease surgeries;
- Diabetes services for the management and treatment of diabetes that costs more than $1,000 (either retail purchase cost or cumulative retail rental cost of a single item);
- Durable medical equipment, including DME or orthotic that costs more than $1,000 (either retail purchase cost or cumulative retail rental cost of a single item);
- Gender dysphoria services, including both surgical treatment and non-surgical treatment;
- Home health care services;
- Hospice care (as described below);
- Hospital inpatient stays (as described below);
- Outpatient lab, X-ray and diagnostic services including genetic testing and sleep studies (with the exception of major diagnostic and imaging services);
- Mental health services, neurobiological disorders - autism spectrum disorder services, substance-related and addictive disorders services (as described under "Mental health, substance-related and addicative disorder and neurobiological disorder services".
- For out-of-network benefits for a scheduled admission for Mental Health Care and Substance-Related and Addictive Disorders Services (including an admission for services at a Residential Treatment facility and Partial Hospitalization/Day Treatment) you must obtain prior authorization five business days before admission or as soon as is reasonably possible for non-scheduled admissions.
- In addition, for out-of-network benefits you must obtain prior authorization before the following services are received:
- Partial Hospitalization/Day Treatment;
- Intensive Outpatient Treatment programs;
- outpatient electro-convulsive treatment;
- psychological testing;
- transcranial magnetic stimulation;
- extended outpatient treatment visits, with or without medication management;
- Intensive Behavioral Therapy, including Applied Behavior Analysis (ABA).
- Obesity surgery;
- Inpatient stay for the mother and/or newborn following delivery that will be more than 48 hours following a normal vaginal delivery, or more than 96 hours following a cesarean section delivery;
- Prosthetic devices that exceed $1,000 per device;
- Reconstructive procedures (as described below);
- Skilled nursing facility/inpatient rehabilitation facility services;
- Outpatient surgery for sleep apnea surgeries;
- Therapeutic treatments (outpatient), such as dialysis, IV infusion, intensity modulated radiation therapy, and MRI-guided focused ultrasound; and
- Transplantation services.
Please remember for out-of-network benefits for:
- A scheduled admission, you must obtain prior authorization five business days before admission.
- A non-scheduled admission you must provide notification as soon as is reasonably possible.
In addition, you must contact UnitedHealthcare 24 hours before admission for a scheduled admission or as soon as reasonably possible for a non-scheduled admission.
If authorization is not obtained as required, or notification is not provided, benefits will be subject to a $400 penalty.
For out-of-network benefits you must obtain prior authorization from UnitedHealthcare five business days before admission for an inpatient stay in a hospice facility or as soon as is reasonably possible. If you fail to obtain prior authorization as required, benefits will be subject to a $400 penalty.
For out-of-network benefits for:
- A scheduled reconstructive procedure, you must obtain prior authorization from UnitedHealthcare five business days before a scheduled reconstructive procedure is performed.
- A non-scheduled reconstructive procedure, you must provide notification within one business day or as soon as is reasonably possible.
In addition, you must contact UnitedHealthcare 24 hours before admission for a scheduled admission or as soon as reasonably possible for a non-scheduled admission.
If authorization is not obtained from UnitedHealthcare as required, or notification is not provided, benefits will be subject to a $400 penalty.
If your doctor feels it is necessary for the confinement or treatment to continue longer than already approved, you, the physician or the hospital may request additional days by calling UHC. This request must be made no later than the last day that has already been approved. You must pay for continued treatment days that the reviewer determines are not covered.
A $400 penalty will apply if you do not obtain authorization as required. Any penalty amounts you pay will not count toward your deductible or out-of-pocket maximum.