CurrentUnitedHealthcarePolicy BIP031.N

Court, Attorney, or Agency Requested Services

Defines UnitedHealthcare West coverage stance for services and testing requested by courts, attorneys, or agencies, including interactions with California CARE Act requirements; affects members and provider billing in UnitedHealthcare West plans (California context emphasized).

Policy Summary

PayerUnitedHealthcare

PolicyCourt, Attorney, or Agency Requested Services

Policy CodePolicy BIP031.N

Change TypeRevised (CARE Act language)

Effective DateJan 1, 2026

Next Review DateN/A

Key ActionDo not require prior authorization for non-pharmacy services provided pursuant to a court-approved CARE agreement or CARE plan; preauthorization applies for other court/attorney/agency requested services only when medically necessary per the member's EOC/SOB.

SourceLink

POLICY UPDATE CHANGES

Revised language pertaining to the California Health and Safety Code Section 1374.723, Community Assistance, Recovery, and Empowerment (CARE) Act.

Revised list of non-covered services; replaced wording for court-ordered evaluation and therapy for accused sex offenders to 'individuals accused of sexual offenses'.

Archived previous policy version BIP031.M.

CA §1374.723Referenced state statute

2026-01-01Effective

BIP031.NPolicy versions

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Coverage Criteria and Exclusions

Covered when conditions below are met; CARE Act services have statutory protections that modify prior authorization, reimbursement, and member cost-sharing requirements.

Services provided pursuant to a CARE agreement or CARE plan approved by a court must be covered regardless of in‑network status.

Based on California Health & Safety Code §1374.723(a).

Prior authorization shall not be required for services (other than prescription drugs) provided pursuant to a CARE agreement or CARE plan approved by a court.

Per California Health & Safety Code §1374.723(b)(1); plans may conduct post‑claim review and may deny payment only for limited reasons (not enrolled, services not performed, or provider not appropriately licensed).

Reimbursement for non‑pharmacy CARE services must be the greater of the health plan's contracted rate or the Medi‑Cal fee‑for‑service/case rate for same or similar services.greater of plan contracted rate or Medi‑Cal fee‑for‑service/case rate

Per California Health & Safety Code §1374.723(c)(1)(A)–(B).

Prescription drugs provided pursuant to a CARE agreement/plan are reimbursed at the health plan’s contracted rate; prior authorization for drugs may still apply as permitted by statute or department guidance.plan contracted rate

Per California Health & Safety Code §1374.723(c)(2) and (b)(3).

Services provided pursuant to a CARE agreement/plan (excluding prescription drugs) are not subject to copayment, coinsurance, deductible, or other cost sharing and the enrollee must not be billed for such services.no member cost‑sharing for non‑pharmacy CARE services

Per California Health & Safety Code §1374.723(d).

Court/attorney/agency requested services and testing that are not provided pursuant to a CARE agreement or CARE plan are covered only when medically necessary and preauthorized by UnitedHealthcare in accordance with the member's Evidence of Coverage/Schedule of Benefits and Medical Necessity policy.medical necessity and preauthorization per EOC/SOB

Refer to Covered Benefits and Medical Necessity policy guidance.

Not covered examples (illustrative)

Attorney‑requested medical consultation in a civil liability case.
Example of services not covered when not medically necessary or outside CARE plan protections.
Court‑ordered evaluation and therapy for individuals accused of sexual offenses.
Listed as an example of not covered services.
Paternity testing.
Listed as an example of not covered services.

If there is a discrepancy between this policy and the member's Evidence of Coverage/Schedule of Benefits, the EOC/SOB governs.

Standard governing document priority; see Covered Benefits section.

Coding and Reimbursement

Coding referencesmixed

No specific CPT/HCPCS/ICD codes referenced in this document.

Reimbursement and Payment Rules for CARE Services

Reimbursement floor (non‑pharmacy CARE services)Reimburse at the greater of the health plan's contracted rate with the provider OR the Medi‑Cal fee‑for‑service or case reimbursement rate for the same or similar services.

Prescription drugs reimbursementPrescription drugs provided pursuant to a CARE agreement/plan are reimbursed at the health plan's contracted rate.

Timely paymentReimbursement for CARE services must comply with statutory requirements for timely payment of claims.

Post‑claim review limitsPlan may conduct post‑claim review and may deny payment only for specific reasons (member not enrolled, services not performed, or provider not appropriately licensed/authorized).

Provider Actions, Prior Authorization, and Exceptions

Note

Prior authorization not required for non‑pharmacy CARE services; drug and post‑claim rules apply

Do not submit or wait for prior authorization for services (other than prescription drugs) that are provided pursuant to a CARE agreement or a court‑approved CARE plan. UnitedHealthcare will not require prior authorization for those non‑pharmacy CARE services; however, the plan may conduct post‑claim review and may deny payment only for the limited reasons specified by statute (member not enrolled at time of service, services not performed, or provider not appropriately licensed/authorized).

Prior authorization is not required for services, other than prescription drugs, provided pursuant to a CARE agreement or CARE plan approved by a court. [[see statutory exceptions for drugs]]
UnitedHealthcare may perform post‑claim review; payment may be denied only if enrollee was not enrolled at time of service, services were never performed, or provider was not licensed/authorized.
Prescription drugs provided pursuant to a CARE agreement/plan remain subject to the plan's drug prior authorization rules and are reimbursed at the plan's contracted rate.

Key Definitions and Member Cost-Sharing

CARE Agreement / CARE Plan — Definition and Scope

Definition (CARE agreement/plan)Court‑approved CARE agreement or CARE plan authorizing behavioral health and related services for eligible adults under California Health & Safety Code §1374.723 and related Welfare & Institutions Code sections.

Scope of servicesCARE plans may provide behavioral health care including stabilization medication, housing, and other enumerated services delivered by network or out‑of‑network county behavioral health agencies.

Eligible populationAdults experiencing severe mental illness with diagnoses in the schizophrenia and other psychotic disorders class who meet specified statutory criteria.

Member Cost‑Sharing for CARE Services

Cost‑sharing prohibition (non‑pharmacy)Services provided pursuant to a CARE agreement or CARE plan, excluding prescription drugs, shall not be subject to copayment, coinsurance, deductible, or any other form of cost sharing; providers or entities may not bill or seek reimbursement from the enrollee for such services.