Prior Authorization Requirements for the UnitedHealthcare Plans Care Management 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. Contacting UnitedHealthcare or a health advisor is easy. Simply call the number on your ID card. Services that require prior authorization include:
Prior Authorization Requirement for Hospital inpatient stays Please remember for out-of-network benefits for:
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 (including emergency admissions). If authorization is not obtained as required, or notification is not provided, benefits will be subject to a $400 penalty. Prior Authorization Requirement for Hospice Care 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. Prior Authorization Requirement for Reconstructive Services For out-of-network benefits for:
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 (including emergency admissions). If authorization is not obtained from UnitedHealthcare as required, or notification is not provided, benefits will be subject to a $400 penalty. To Continue Treatment 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. Penalties 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. |