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Procedures, DME, and Other Services



Certain health care services require preauthorization to help determine whether a proposed treatment plan is medically necessary. The most common services for which preauthorization is necessary are listed under the following categories:

Preauthorization Process

  • When a member sees a network provider, the provider will make the request for preauthorization in writing and submit all necessary medical records to UnitedHealthcare. When a member goes to a non-network physician, it is the member's responsibility to obtain preauthorization.
  • UnitedHealthcare's Clinical Coverage Review Department then makes coverage decisions for preauthorization based on the submitted medical record information. Requests may be submitted by fax to: (888) 242-9058 (midwest) or (888) 242-9078 (southeast) or by mail to UnitedHealthcare, 1300 River Drive, Moline, Illinois 61265.
  • Clinical Coverage Criteria for services requiring preauthorization are addressed in the Medical Policies or Coverage Determination Guidelines posted in the Coverage Policy Library.
  • Once a provider or member submits a request, UnitedHealthcare typically makes a decision within three business days. The decision could take up to 15 days if the provider or member does not submit all necessary information for UnitedHealthcare to make a decision initially. For urgent requests, UnitedHealthcare makes a decision within 24 hours
  • An appropriate reviewer, such as a Board Certified Physician or Registered Pharmacist, makes the final determination on all denials.
  • A copy of the decision is faxed or mailed to the provider and mailed to the member.
  • In the event that coverage for a requested procedure, DME, drug, or service is denied, members have the right to appeal as outlined in their plan documents.
  • Questions regarding coverage for procedures, DME, drugs, or other services can be directed to a UnitedHealthcare Customer Service Representative.
  • TennCare has a different list for preauthorization. Please call 1-800-690-1606 for TennCare preauthorization information.

Medical providers are independent contractors, not employees or agents of the health plan. Our members and their medical providers, not the health plan, decide what medical care members receive and how they receive it. UnitedHealthcare only determines what medical care will be paid for under members' benefit plan. UnitedHealthcare does not provide medical treatment or advice. We encourage you to talk to your doctor about any health concerns you may have.

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