CurrentUnitedHealthcarePolicy N/A

Uniform electronic prior authorization form for prescription drugs

Governs use of a standardized electronic prior authorization form for prescription drug benefits for prescribing providers submitting requests to commercial health insurers regulated by the Illinois Department of Insurance; describes submission, timelines, and required information for UnitedHealthcare plan submissions.

Policy Summary

PayerUnitedHealthcare

PolicyUniform electronic prior authorization form for prescription drugs

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionPrescribing providers must complete and submit the uniform electronic prior authorization form to the patient's health plan (file electronically via www.UHCProvider.com/paan for UnitedHealthcare).

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

24 hoursinsurer response time (urgent)

72 hoursinsurer response time (regular)

www.UHCProvider.com/paansubmission URL

Mon-Fri 8am-5pmcoverage team hours

Form Submission Requirements and Review Criteria

Policy Summary

PayerUnitedHealthcare

PolicyUniform electronic prior authorization form for prescription drugs

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

SourceLink

On This Page

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Form submission criteria and required fields

Information required on the prior authorization form and considerations for review:

ALL of the following

Provider indicates review type: Expedited Review Request or Standard Review Request; if expedited, certifies that standard review may seriously jeopardize patient life/health or ability to regain maximum function and provides direct contact phone and initials.
Request type and reason: Initial Authorization Request or Renewal Request; note that the form does not apply to certain medical exception requests under the Managed Care Reform and Patient Rights Act and providers should contact the health plan for those forms.
Patient demographics: name, date of birth, street address, city, state, ZIP code, phone number, sex, patient health plan ID, and group number (if applicable); indicate whether patient is hospitalized (Yes/No).
Prescribing provider information: provider name, NPI, specialty, DEA (required for controlled substance requests only), contact name, contact phone, contact street address, suite/room, city, state, ZIP code, contact email (optional), contact fax, and health plan provider ID (if accessible).
Pharmacy information: pharmacy name and pharmacy phone.
Requested prescription drug information: drug name, strength, dosing schedule, duration, specific diagnosis, diagnosis ICD# (diagnosis coding field requested), place of infusion/injection (if applicable), facility/provider ID or NPI, whether patient has already started the medication and date if applicable, and ingredients within the drug.
Clinical rationale and supporting information: Rationale for prior authorization (history of present illness, past medical history, current medications — attach chart notes if helpful), failed or contraindicated therapies (drug name, strength, dosing schedule, duration, adverse event/specific failure), and other pertinent information (diagnostic labs, measures, response to treatment, etc.).
Submission instructions and review considerations: Prescribing providers must submit this form to the patient's health plan (do not send to the Department of Insurance). Sending the form with insufficient clinical information may result in extended review or adverse determination; insurers may request additional information depending on the drug type which could require follow-up.

Submission Process, Timelines, and Required Actions

Prior Authorization

Deemed Grant When Insurer Noncompliant

Prescribing providers must use the uniform electronic prior authorization form and follow the timelines and submission instructions below. If UnitedHealthcare fails to accept the uniform electronic prior authorization form or fails to respond within statutory timelines (24 hours for urgent/expedited requests, 72 hours for standard requests), the prior authorization request will be deemed granted under 215 ILCS 5/364.3(f). Providers should only include a direct contact number and initials when requesting an Expedited Review Request.

Deemed grant if insurer fails to accept the uniform electronic prior authorization form or fails to respond within 24 hours for urgent requests
Deemed grant if insurer fails to accept the uniform electronic prior authorization form or fails to respond within 72 hours for standard requests
Provide direct contact number and initials only when requesting Expedited Review

Note

UnitedHealthcare Submission Contact

Submit the completed electronic prior authorization form to UnitedHealthcare using the electronic submission link below. For further assistance or questions about coverage review, call the toll-free number on the member's health plan ID card. UnitedHealthcare's coverage review team is available Monday through Friday, 8:00 a.m. to 5:00 p.m. CST.

Electronic submission URL: www.UHCProvider.com/paan
Phone: Toll-free number on the patient's health plan ID card (Mon–Fri 8am–5pm CST)

Documentation Required

Documentation and Follow-up

Prior authorization alone does not guarantee payment. Insurers may request additional clinical information; submitting insufficient information may result in extended review periods or adverse determinations. Insurers may require extra information for certain prescription types and may follow up with the provider. Do not send forms to the Department of Insurance; submit them to the patient's health plan.

Insurer may request additional information based on the drug requested
Insufficient clinical information may delay review or result in adverse determination
Do not send forms to the Department of Insurance — submit to the patient's health plan

Key Definitions

inv-07: Prior authorization request — definition of the term

Definition'Prior authorization request' means a request for pre-approval from an insurer for a specified prescription or quantity of a prescription before the prescription is dispensed.

Statutory source215 ILCS 5/364.3 (Illinois Insurance Code)

PurposeUsed by prescribing providers to initiate a prior authorization with a commercial health insurance issuer regulated by the Illinois Department of Insurance.

inv-08: Prescribing provider — statutory definition reference

Definition reference'Prescribing provider' has the meaning ascribed in Section 364.3 of the Illinois Insurance Code [215 ILCS 5].

ContextTerm used throughout the uniform electronic prior authorization form to identify the clinician authorized to submit the request.

Related obligationPrescribing providers must complete and submit the uniform electronic prior authorization form to the patient's health plan.

inv-09: Prescription — statutory definition reference

Definition reference'Prescription' has the meaning ascribed in Section 3(e) of the Pharmacy Practice Act [225 ILCS 85].

Use on formAppears as the regulated term describing the medication subject to prior authorization under the statute.

Related statutePharmacy Practice Act [225 ILCS 85], Section 3(e).

OpenPayer

Uniform electronic prior authorization form for prescription drugs

Form Submission Requirements and Review Criteria

Diagnosis / Coding References

Submission Process, Timelines, and Required Actions

Key Definitions