Benefit Plans Not Subject to this Protocol
Please refer to the Additional Guide, Manual or Supplement in the Benefit Plans Subject to this Guide section for additional details. Some benefit plans may have separate advance notification and prior authorization requirements.
Excluded Plans (Benefit Plans Not Subject to this Protocol)
- UnitedHealthcare Options PPO: Care providers are not required to follow this protocol for Options PPO benefit plans because members enrolled in these benefit plans are responsible for providing notification/requesting prior authorization.
- UnitedHealthcare Indemnity
- UnitedHealthOne - Golden Rule Insurance Company (“GRIC” group number 705214) only
- M.D.IPA, Optimum Choice or OneNet
- Neighborhood Health Partnership (NHP)
- Oxford Commercial, except for UnitedHealthcare Oxford Navigate Individual benefit plans (group number 908410)
- Benefit plans subject to the River Valley Entities Supplement.
- UnitedHealthcare West
- Plans subject to an additional guide or supplement (see Chapter 1) (As explained in the in the Benefit Plans Subject to this Guide section, some UnitedHealthcare Community Plan Medicare Advantage benefit plans are not subject to an additional guide, manual or supplement and, therefore, are subject to this guide and this notification protocol.)
- Other benefit plans such as Medicaid, CHIP and Uninsured that are neither commercial nor MA.
The advance notification requirements outlined in this Protocol do not apply to services subject to the following Protocols, each of which are addressed in separate sections later in this guide:
- Outpatient Cardiology Notification/Prior Authorization Protocol.
- Outpatient Radiology Notification/Prior Authorization Protocol.
- Laboratory Services Protocol.
- Laboratory Benefit Management Program Administered by BeaconLBS™.
Advance Notification vs. Prior Authorization
Advance notification is the first step in determining coverage. We also use it for case and condition management program referrals. The information we receive about planned medical services helps support the preservice clinical coverage review and care coordination. Advance notification helps assist members from preservice planning to discharge planning.
Advance notification is required for services listed on the Advance Notification/Prior Authorization List.
We require prior authorization for all MA benefit plans and some commercial benefit plans. Prior authorization requests allow us to verify if the services are medically necessary and covered. After you notify us of a planned service listed on the Advance Notification/Prior Authorization List, we tell you if a clinical coverage review is required, as part of our prior authorization process, and what additional information we need to proceed. We notify you of our coverage decision within the time required by law. Just because we require notification for a service, does not mean it is covered. We determine coverage by the member’s benefit plan.
If there is a conflict or inconsistency between applicable regulations and the notification requirements in this guide, the applicable regulations govern.