CurrentUnitedHealthcarePolicy N/A

Opioid Attestation for Chronic or High‑Dose Opioid Therapy

This document governs required provider attestation and documentation for members receiving chronic opioid therapy or opioid doses exceeding specified MME thresholds; it affects prescribers and pharmacies submitting authorization requests to UnitedHealthcare Community Plan in NC. The completed form and supporting documentation must be faxed to the plan to avoid denial.

Policy Summary

PayerUnitedHealthcare

PolicyOpioid Attestation for Chronic or High‑Dose Opioid Therapy

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionFax the completed, printed, signed attestation form with supporting documentation (medical records required for >200 MME/day) to 1-866-940-7328.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

42 dayschronic use threshold (within 90 days)

120 MME/dayMME requiring attestation/consult

200 MME/dayMME requiring medical records

12 monthsstandard authorization interval

1-866-940-7328fax to submit attestation

Coverage Criteria for Opioid Attestation

Chronic Opioid Attestation Criteria

Covered when ALL of the following are met for chronic non-cancer pain:

Chronic Opioid Attestation - required elements: i. On-going clinical need for chronic opioid use at the prescribed dose (more than 42 days per 90 day calendar period) documented in the medical record; AND ii. Patient is using appropriate non-opioid medications and/or non-pharmacologic therapies; OR iii. Patient has tried and failed non-opioid medications and non-pharmacologic therapies for the treatment of this pain condition; AND iv. For long-acting opioids, patient has tried a short-acting opioid for at least 42 days or there is clinical justification why short-acting opioids were inappropriate or ineffective; AND v. Baseline objective pain and function scores recorded with periodic assessments to demonstrate clinically meaningful improvements; AND vi. Patient screened for mental health disorders, substance use disorder, and naloxone use; AND vii. Periodic urine drug screens are conducted; AND viii. PDMP checked to determine other opioid therapy and concurrent therapy with benzodiazepines and other sedatives; AND ix. Discussion documented with patient of realistic goals of pain management, including discontinuation as an option; AND x. Patient understands and has signed a pain contract or informed consent document.

Prescriber must attest that all criteria are met or document why one or more are not applicable.

High-dose Opioid (>120 MME/day) Attestation Criteria

Covered when ONE of the following overarching clinical reasons AND the provider meets qualification/consultation requirements:

Policy Summary

PayerUnitedHealthcare

PolicyOpioid Attestation for Chronic or High‑Dose Opioid Therapy

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionFax the completed, printed, signed attestation form with supporting documentation (medical records required for >200 MME/day) to 1-866-940-7328.

SourceLink

On This Page

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Acceptable clinical reasons: i. Active cancer pain, palliative care, end-of-life care, or hospice requiring an opioid dosage that exceeds 120 MME per day; OR ii. Temporary medically necessary need requiring an opioid dosage that exceeds 120 MME per day for no more than 42 days (includes discharge, surgery, or other trauma) — coordination with other prescriber required if patient is on chronic therapy from another prescriber; OR iii. Patient is following a tapering schedule with a starting dose > 120 MME per day; OR iv. Medically necessary need to exceed 120 MME per day documented in the medical record.

Temporary high-dose attestation expires in 42 days; other attestation periods default to 12 months unless an earlier end date is specified.

Provider qualification or consultation: Provider meets one of the following: 1) Is a pain management specialist as defined in WAC 246-919-945; OR 2) Completed ≥12 category I CE hours on chronic pain management within the previous 4 years (≥2 hours on substance use disorders); OR 3) Works in a multidisciplinary chronic pain treatment center or multidisciplinary academic research facility; OR 4) Has ≥3 years clinical experience in chronic pain management with ≥30% of current practice in direct pain care; OR 5) Has consulted with a pain management specialist regarding high-dose opioid use (office visit, telephone/electronic consultation, or remote audiovisual evaluation with the patient present) and the consultation is documented in the medical record.

Consultation documentation is acceptable as an alternative to specialist credentials; supporting documentation required for requests exceeding 200 MME/day.

Definitions and Dose Thresholds

inv-04: Chronic use definition

DefinitionMore than 42 days of opioid use within a 90‑day period is considered chronic use.

ContextApplies to any opioid use either as a single prescription or multiple prescriptions that cumulatively exceed 42 days in a 90‑day window.

Attestation triggerBeginning chronic opioid use (>42 days in a 90‑day period) requires completion of the Opioid Attestation form.

inv-05: High-dose MME thresholds

Primary thresholdDaily opioid dosing exceeding 120 morphine milligram equivalents (MME) per day triggers the high‑dose attestation and mandatory pain‑management consultation or prescriber qualification.

Elevated thresholdDaily opioid dosing > 200 MME per day requires submission of supporting medical records with the attestation.

Authorization intervalHigh‑dose (>120 MME/day) and chronic use may be authorized in 12‑month intervals when the prescriber signs the attestation.

Required Provider Actions and Documentation

Documentation Required

Submission and supporting documentation

This Opioid Attestation form must be completed, printed, signed, dated, and faxed to UnitedHealthcare Community Plan. Fax responses to: 1-866-940-7328. Failure to provide the completed attestation form and required supporting documentation may result in denial of the request.

Complete and sign the Opioid Attestation form
Fax completed form and supporting documentation to 1-866-940-7328
Medical records required for requests >200 MME/day

Prior Authorization

Attestation required for chronic use or >120 MME/day

This attestation form is required when patients begin chronic opioid use (>42 days in a 90-day period), when daily opioid doses exceed 120 MME, or when both occur. Chronic opioid use and doses above 120 MME may be authorized in 12-month intervals when the prescriber signs this attestation. If authorization is needed for less than 12 months, specify an earlier end date on the form.

Chronic use defined as >42 days within a 90-day period
Attestation required for daily doses >120 MME
Authorization typically up to 12 months unless prescriber specifies earlier end date

Documentation Required

Non-opioid therapy requirement

For chronic non-cancer pain, the prescriber must attest that the patient is using appropriate non-opioid medications and/or non-pharmacologic therapies OR that the patient has tried and failed such therapies. The prescriber must also document ongoing clinical need, baseline and periodic pain/function assessments, screening for mental health and substance use disorder, PDMP review, periodic urine drug screening, discussion of realistic goals including discontinuation, and a signed pain contract or informed consent.

Attest patient is using appropriate non-opioid meds and/or non-pharmacologic therapies OR has tried and failed them
Document ongoing clinical need (>42 days/90 days) in medical record
Record baseline and periodic objective pain and function scores
Screen for mental health disorders, substance use disorder, naloxone use
Conduct periodic urine drug screening and check PDMP
Obtain signed pain contract or informed consent

Denial Risk

Missing documentation may trigger denial

Failure to provide the completed attestation form and all required supporting documentation (including medical records when >200 MME/day and documentation of pain specialist consultation when applicable) may result in denial of the request.

Provide medical records for requests >200 MME/day
Include documentation of consultation with pain management specialist when required
Incomplete submissions may be denied

Authorization Intervals and Temporary Dose Limits

inv-14: temporary opioid doses >120 MME/day

Temporary high‑dose limitTemporary opioid doses that exceed 120 MME per day are authorized only for up to 42 days with a temporary attestation.

Coordination requirementWhen prescribing a temporary high‑dose to a patient on chronic therapy from another prescriber, the prescriber must review the PMP and coordinate care with the other opioid prescriber.

Situations listedTemporary high‑dose justification examples include discharge from hospital, surgery, or other trauma.

inv-15: chronic opioid use or high-dose attestation

Standard authorization intervalAttestations for chronic opioid use or high‑dose opioids default to a 12‑month authorization interval unless the prescriber specifies an earlier end date.

Option to shortenPrescribers may request an attestation authorization for less than 12 months by specifying a specific end date on the form.

Temporary exceptionsTemporary high‑dose attestation (for >120 MME/day) expires in 42 days instead of the 12‑month default.

OpenPayer

Opioid Attestation for Chronic or High‑Dose Opioid Therapy

Coverage Criteria for Opioid Attestation

Definitions and Dose Thresholds

Required Provider Actions and Documentation

Background and Purpose

Key Definitions

Non-Opioid and Conservative Therapy Requirements

Authorization Intervals and Temporary Dose Limits