UnitedHealthcare Shared Services Prior Authorization List

UnitedHealthcare provides a comprehensive list of services that require prior authorization. This process is critical for ensuring that medical services, treatments, or procedures are covered by insurance before they are rendered. Prior authorization helps manage costs and ensures that patients receive appropriate and necessary care based on established guidelines. In this article, we will explore what prior authorization is, why it's important, and the specific services under UnitedHealthcare that require prior authorization. We will also discuss how to navigate the authorization process effectively.

What is Prior Authorization?

Prior authorization is a requirement by health insurers like UnitedHealthcare that certain medical services, treatments, or prescriptions must be approved before they are provided. This process is designed to control costs and ensure that the proposed treatment aligns with clinical guidelines and standards of care.

Why is Prior Authorization Important?

Prior authorization helps:

1. Control Healthcare Costs: By reviewing the necessity and appropriateness of treatments before they are provided, insurers can prevent unnecessary or potentially harmful services.
2. Ensure Quality of Care: It ensures that patients receive treatments that are medically necessary and supported by clinical evidence.
3. Prevent Fraud and Abuse: By requiring approval, insurers can reduce the likelihood of fraudulent claims and misuse of benefits.

UnitedHealthcare Shared Services

UnitedHealthcare’s prior authorization list covers a broad range of services and treatments. Here’s a closer look at some of the categories typically included in their prior authorization requirements:

1. Medical Procedures:

   • Imaging Services: Advanced imaging techniques such as MRIs, CT scans, and PET scans often require prior authorization to ensure they are medically necessary.
   • Surgical Procedures: Many elective and some urgent surgeries must be approved before they can be scheduled.

2. Medications:

   • Specialty Drugs: Medications that are high-cost or have complex administration requirements often need prior approval.
   • New Medications: New or brand-name medications may require prior authorization to confirm their necessity over generic options.

3. Durable Medical Equipment (DME):

   • Orthotics and Prosthetics: Devices like artificial limbs or customized orthotic devices may need prior authorization to ensure they are appropriate and cost-effective.
   • Home Health Equipment: Equipment such as oxygen tanks or CPAP machines often requires approval.

4. Mental Health Services:

   • Inpatient Care: Admissions to psychiatric hospitals or residential treatment facilities usually need prior authorization.
   • Therapeutic Services: Certain types of mental health therapy and counseling sessions might also require prior approval.

Navigating the Prior Authorization Process

Navigating the prior authorization process can be challenging, but understanding the steps involved can simplify it:

1. Check Requirements: Verify the specific services and procedures that require prior authorization under your UnitedHealthcare plan. This information can typically be found on their website or by contacting customer service.

2. Submit Request: Your healthcare provider usually submits the prior authorization request on your behalf. Ensure that all necessary documentation and clinical information are provided to avoid delays.

3. Await Decision: UnitedHealthcare will review the request and make a decision based on the provided information and clinical guidelines. This process can take several days, so plan accordingly.

4. Receive Notification: Once a decision is made, you and your healthcare provider will receive notification. If the request is approved, you can proceed with the service or treatment. If denied, you have the right to appeal the decision.

Tips for a Smooth Process

• Communicate Early: Inform your healthcare provider as soon as you learn that a service will require prior authorization.
• Follow Up: Keep track of the status of your request and follow up with both your provider and UnitedHealthcare if necessary.
• Understand Your Plan: Familiarize yourself with your insurance plan’s benefits and limitations to avoid unexpected issues.

Conclusion

Understanding the prior authorization process and requirements set by UnitedHealthcare can help ensure that you receive timely and appropriate care. By being proactive and informed, you can navigate this aspect of your healthcare plan more effectively and avoid potential delays or issues.