Utilization and medical management - 2022 Administrative Guide (2024)

Direct the member to call 911, or its local equivalent, or to go to the nearest emergency room. Prior authorization or advance notification is not required for emergency services. However, you should tell us about the member’s emergency by calling1-800-799-5252 between 8 a.m. and 5 p.m. PT, Monday–Friday.

Provide after-hours and weekend emergency services as clinically appropriate; enter the notification online or call 1-800-799-5252 the next business day.

Urgently needed services

Check the member’s benefits with Member Services or at uhcprovider.com, as applicable, for the benefit plan definition of urgent care. For our commercial members, you must contact the member’s PCP or hospitalist on arrival for urgently needed services. Request these services by calling 1-800-799-5252 between 8 a.m. and 5 p.m. PT, Monday–Friday.

Routine Authorizations

We consider all other services as routine. To request preauthorization for urgent or routine services, the PCP must enter all the necessary information into uhcprovider.com/priorauth, contact the delegated medical group for approval, or complete and submit the appropriate Preauthorization Request Form to obtain approval. Routine and urgent requests are responded to within the following time frames, if all required clinical information is received:

Authorization status determination

Only a physician (or pharmacist, psychiatrist, doctoral-level clinical psychologist or certified addiction medicine specialist, as applicable and appropriate) may determine whether to delay, modify or deny services to a member for reasons of medical necessity.

Prior authorization process

A list of services that require prior authorization is available on uhcprovider.com/priorauth.

We will deny payment for services you provide without the required prior authorization. Such services are the health care provider’s liability, and you may not bill the member.

Primary care services

Most PCP services do not require prior authorization. However, if prior authorization is required, the following guidelines apply:

1. The PCP/requesting health care provider is responsible for verifying eligibility and benefits prior to rendering services.
2. To request prior authorization, use our online processes, contact the delegated medical group, or complete and submit the appropriate prior authorization request form (unless the services are required urgently or on an emergency basis). The completed form must include the following information:
   • Member’s presenting complaint
   • Physician’s clinical findings on exam
   • All diagnostic and lab results relevant to the request
   • Conservative treatment that has been tried
   • Applicable CPT and ICD codes
3. The fastest way to check the status of a treatment request is by using the Prior Authorization and Notification tool in theUnitedHealthcare Provider Portal.
4. If approved, the treatment request is given a reference number that may be viewed when you check the status, or by contacting the delegated medical group, or faxed back to the physician office depending on how the PCP/servicing health care provider submitted the form.
5. Notate the reference number on the claim when you submit it for payment.
6. All authorizations expire 90 calendar days from the issue date.
7. Participating health care providers should refer members to network providers. Referrals to non-network providers require prior authorization.
8. Once the PCP refers a member to a network specialist, that specialist may see the member as needed for the referring diagnosis. The specialist is not required to direct the member back to the PCP to order tests and/or treatment.
9. If a specialist feels a member needs other services related to the treatment of the referral diagnosis, the specialist may refer the member to another participating health care provider.

We or our delegates conduct reviews throughout a member’s course of treatment. Multiple prior authorizations may be required throughout a course of treatment because prior authorizations are typically limited to specific services or time periods.

Serious or complex medical conditions

The PCP should identify members with serious or complex medical conditions and develop appropriate treatment plans for them, along with case management. Each treatment plan should include a prior authorization for referral to a specialist for an adequate number of visits to support the treatment plan.

Specialty care (including gynecology) in an office-based setting

We send the status of the prior authorization request (approved as requested, approved as modified, delayed, or denied) to the specialist by fax or online. For those services that do not require prior authorization, the PCP sends a referral request directly to the specialists.

1. All specialist authorizations will expire 90 calendar days from the date of issuance.
2. Plain film radiography rendered by a network provider, or in the specialist’s office in support of an authorized visit, does not require prior authorization.
3. Routine lab services performed in the specialist’s office, or provided by a designated participating health care provider in support of an authorized visit, do not require prior authorization.
4. Members may self-refer to a gynecologist who is a participating health care provider for their annual routine gynecological exams. For women’s routine and preventive health care services, female MA members may self-refer to a women’s health specialist who is a participating health care provider.
5. Female MA members older than 40 years may self-refer to a participating radiology health care provider for a screening mammogram.

Note: Mammograms may require prior authorization in California.

Obstetrics

1. A member may self-refer to an obstetrician who is a participating health care provider for routine obstetrical (OB) care. If the member is referred by her PCP to a non-participating health care specialist, the specialist must notify us using online tools. This helps ensure accurate claims payment for ante and postpartum care.
2. Routine OB care includes office visits and 2 ultrasounds.
3. Plain film radiography that is performed by a participating health care provider or in the obstetrician’s office in support of an authorized visit, does require prior authorization.
4. Routine labs performed in the obstetrician’s office, or provided by a participating health care provider in support of an authorized visit, do not require prior authorization. In-office tests must follow CMS in-office testing CLIA requirements. Specimens collected in the physician’s office and sent out to a nonparticipating laboratory for processing must follow the out-of-network member consent requirements.

Maternal mental health screening requirement (California commercial plans)

The California Department of Managed Health Care (AB 2193) requires licensed health care practitioners who provide prenatal or postpartum care for a patient to offer maternal mental health screening during the second and/or third trimester and/or at the postpartum visit. When screening pregnant and postpartum members for mental health issues, we recommend using the Patient Health Questionnaire 9 (PHQ-9). You can request hard copies of the PHQ-9 by emailinguhccscaqualitydepartment_dl@ds.uhc.com or download a copy on uhcprovider.com > Menu > Resource Library > Behavioral Health Resources.

Second opinions (California commercial plans)

We authorize and provide a second opinion by a qualified health care professional for members who meet specific criteria. A second opinion consists of 1 office visit for a consultation or evaluation only. Members must return to their assigned PCPs for all follow-up care. For purposes of this section, a qualified health care professional is defined as a PCP or specialist who is acting within the scope of practice and who possesses a clinical background, including training and expertise related to the member’s particular illness, disease or condition.

The PCP may request a second opinion on behalf of the member in any of the following situations:

• The member questions the reasonableness or necessity of a recommended surgical procedure.
• The member questions a diagnosis or treatment plan for a condition that threatens loss of life, limb, or bodily function or threatens substantial impairment, including, but not limited to, a serious chronic condition.
• The clinical indications are not clear or are complex and confusing.
• A diagnosis is in doubt due to conflicting test results.
• The treating health care provider is unable to diagnose the condition.
• The member’s medical condition is not responding to the prescribed treatment plan within an appropriate period of time, and the member is requesting a second opinion regarding the diagnosis or continuance of the treatment.
• The member has attempted to follow the treatment plan or has consulted with the treating health care provider and has serious concerns about the diagnosis or treatment plan.

Turnaround time for second opinion reviews

We process requests for a second opinion in a timely manner to accommodate the clinical urgency of the member’s condition and in accordance with established utilization management procedures and regulatory requirements. When there is an imminent and serious threat to the member’s health, we or our delegate will make the second opinion determination within 72 hours after receipt of the request.

An imminent and serious threat includes the potential loss of life, limb, or other major bodily function. It may also be when a lack of timeliness would be detrimental to the member’s ability to regain maximum function. For more detailed information and benefit exclusions, refer touhcprovider.com/policies:

• UnitedHealthcare Medicare Advantage Coverage Summary titled Second and Third Opinions
• UnitedHealthcare West Benefit Interpretation Policy titled Member Initiated Second and Third Opinion: CA
• UnitedHealthcare West Benefit Interpretation Policy titled Member Initiated Second and Third Opinion: OK, OR, TX, WA

Ventricular Assist Device (VAD)/Mechanical Circulatory Support Device (MCSD) Services/ Case management

We request that you notify the case management department when a member referred for evaluation, authorized for:

• VAD/MCSD and admitted for VAD/MCSD and/or may meet criteria for service denial.
• VAD/MCSD evaluations and surgery should be performed at a facility in the Optum VAD Network, or facility approved by UnitedHealthcare West medical directors, to align with heart transplant service centers.

Extension of prior authorization services

The specialist must request an extension of prior authorization online, or by contacting the delegated medical group/IPA if they desire to perform services:

• Beyond the approved visits.
• Beyond the allotted time frame of the approval (typically 90 calendar days).
• In addition to the approved procedures, and/or diagnostic or therapeutic testing.

The extension must be authorized before care is rendered to the member. The request for extension of services must include the following information:

• Member’s presenting complaint
• Health care provider’s clinical findings on exam
• All diagnostic and laboratory results relevant to the request
• All treatment that has been tried
• Applicable CPT and ICD codes
• Requested services (e.g., additional visits, procedures)

The existing authorization is reviewed by the receiving party, who mails or faxes a response to the health care provider and/or makes the information available online There is no need to contact the member’s PCP.

Facility-based outpatient surgery (CA, OR, WA and NV)

Facility-Based Outpatient Surgery services are defined using CMS Guidelines, CPT/HCPCS coding conventions, and clinical and/or proprietary standards. The following denotes services considered Facility-Based Outpatient Surgery services under this definition:

• A procedure with an ASC grouping assigned
• A procedure with a global period of 90 days (according to the health care provider fee schedule)
• Core needle biopsies
• Unlisted or new codes may be considered surgery in the following situation:
  • Unlisted or new code is related to other codes in the same APC group that had an ASC assigned is considered Facility- Based Outpatient Surgery.
• A procedure with surgical risk or anesthetic risk as determined by clinical review