CurrentUnitedHealthcarePolicy N/A

UnitedHealthcare Medicare Advantage hospital services review process

Defines UnitedHealthcare Medicare Advantage approach to inpatient admission medical necessity reviews, application of the two-midnight benchmark, case-by-case exceptions, use of medical necessity criteria (including InterQual), and adherence to CMS inpatient-only list for Medicare Advantage members.

Policy Summary

PayerUnitedHealthcare

PolicyUnitedHealthcare Medicare Advantage hospital services review process

Policy CodePolicy N/A

Change TypeClarified

Effective DateJan 1, 2024

Next Review Date

Key ActionDocument the admitting physician's reasonable expectation that the patient will require hospital care crossing two midnights and, if the stay did not, record the reason why (e.g., unexpected death, transfer, rapid improvement).

SourceLink

POLICY UPDATE CHANGES

Affirms UnitedHealthcare follows the two-midnight benchmark but does not adopt the two-midnight presumption for Medicare Advantage plans.

2Key time thresholds (two-midnight; <24 hours)

1Use of InterQual as evidence source

1Adherence to CMS inpatient-only list

Coverage Summary

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Overview: UnitedHealthcare Medicare Advantage applies Original Medicare laws for coverage unless superseded by laws specific to Medicare Advantage, and uses internal coverage criteria when Original Medicare statutes, NCDs, and LCDs are not fully specific.

Scope summary: This policy defines UnitedHealthcare Medicare Advantage's approach to inpatient admission medical necessity reviews, including application of the two-midnight benchmark, case-by-case exceptions, use of medical necessity criteria (including InterQual as a source of evidence), and adherence to CMS's inpatient-only list for Medicare Advantage members.

Effective date: Jan. 1, 2024. Status: CURRENT.

Medical-Necessity Criteria

General inpatient admission medical necessity

Covered as inpatient when ALL of the following are met:

ALL of the following

Hospital services are reasonable and necessary for diagnosis or treatment of illness or injury (not custodial or for convenience).
Complex medical factors documented in the medical record support the admitting physician's reasonable expectation that the patient requires hospital care that crosses two midnights.
Reviewers will apply criteria in: Hospital, Emergency and Ambulance Services Medicare Advantage Coverage Summary; UnitedHealthcare Commercial Hospital Services: Observation and Inpatient medical policy; and InterQual as a source of medical evidence.

Two-midnight benchmark and presumption

Rules regarding the two-midnight benchmark and presumption:

ALL of the following

UnitedHealthcare follows the two-midnight benchmark per 42 CFR 412.3(d)(1).
UnitedHealthcare does NOT follow the two-midnight presumption (the CMS presumption does not apply to Medicare Advantage plans).
Time alone (two midnights) is not sufficient; clinical documentation of complex medical factors is required to support inpatient admission.
Extensive delays in provision of medically necessary services are excluded from time counted toward the two-midnight benchmark.

Stays under 24 hours

When stays under 24 hours may be appropriate:

ALL of the following

Generally, stays under 24 hours rarely qualify for inpatient payment.
Exceptions (ANY of the following may support inpatient payment despite <24 hours):
- Unexpected death.
- Unexpected discharge against medical advice.
- Unexpected transfer.
- Unexpected hospice.

Case-by-case exception

Case-by-case exception review requires:

ALL of the following

Clinical judgment of a UnitedHealthcare medical director evaluating the physician's decision when the patient was not expected to require care crossing two midnights.
Review of documented complex medical factors including history and comorbidities, severity of signs and symptoms, current medical needs, and risk of an adverse event.

Inpatient-only procedures

Policy on inpatient-only list:

ALL of the following

UnitedHealthcare follows CMS's Inpatient Only (IPO) list.
If a medically necessary inpatient-only procedure is performed, the admission meets criteria for inpatient admission regardless of expected or actual length of stay.

Actions for Providers / Documentation

Documentation Required

Document physician expectation for two-midnight stay

Document the admitting physician's reasonable expectation that the patient will require hospital care crossing two midnights and, if the stay did not cross two midnights, document the reason why (e.g., unexpected death, transfer, rapid improvement).

If stay <24 hours, include physician expectation that stay would cross two midnights and why it did not (e.g., unexpected death, transfer, discharge against medical advice, hospice, rapid improvement).
Record timing and clinical rationale for admission and any services provided during observation/outpatient time.

Prior Authorization

Case-by-case medical director review

Be aware that admissions not expected to cross two midnights may require clinical review and determination by a UnitedHealthcare medical director under the case-by-case exception.

Documentation Required

Exclude non-medical delays from two-midnight calculation

Do not count extensive delays in provision of medically necessary services toward the two-midnight benchmark; document timing and reasons for any delays.

Specify whether delays were administrative, patient-driven, or clinical, and provide timestamps and explanations.
Document when clinically necessary services were ordered versus when they were actually provided.

Background & Evidence

UnitedHealthcare Medicare Advantage aligns with Original Medicare laws for coverage and complies with payment criteria such as the two-midnight benchmark at 42 CFR 412.3(d)(1) unless superseded by laws applicable to Medicare Advantage plans.

When Original Medicare statutes, NCDs, and LCDs are not fully specific, UnitedHealthcare may adopt internal coverage criteria based on current evidence. InterQual criteria are expressly allowed by CMS as a source of medical evidence and may be used to develop UnitedHealthcare's internal coverage criteria and Medicare Advantage coverage summaries.

Regulatory support

Regulatory supportCMS Final Rule and 42 C.F.R. 422.101(b)(6)(i)(A)-(C) expressly allow Medicare Advantage plans to adopt internal coverage criteria when Original Medicare criteria are not fully established; CMS permits use of InterQual and plans may create internal criteria based on current evidence

Two-midnight presumption: A CMS medical review instruction for fee-for-service contractors that presumes inpatient stays crossing two midnights are appropriate for payment; not applicable to Medicare Advantage plans.

Two-midnight benchmark: The standard per 42 CFR 412.3(d)(1) used to evaluate expected inpatient stays crossing two midnights as part of inpatient payment criteria.

Case-by-case exception: A process where a UnitedHealthcare medical director evaluates clinical judgment and documented complex medical factors to determine inpatient payment eligibility when a stay was not expected to cross two midnights.

Q: Does UnitedHealthcare follow the two-midnight benchmark? A: Yes. UnitedHealthcare complies with general coverage and benefit conditions in Original Medicare laws, including the two-midnight benchmark at 42 CFR 412.3(d)(1).

Q: Does UnitedHealthcare follow the two-midnight presumption? A: No. The two-midnight presumption is a medical review instruction for Medicare FFS contractors and does not apply to Medicare Advantage plans.

Q: Are stays under 24 hours generally considered inpatient? A: No. Stays under 24 hours rarely qualify for inpatient payment except in specific unexpected circumstances (unexpected death, discharge against medical advice, transfer, hospice, or rapid improvement) when documentation supports the physician's reasonable expectation that the stay would cross two midnights and explains why it did not.

Q: What is the case-by-case exception? A: The case-by-case exception requires review by a UnitedHealthcare medical director who evaluates the physician's decision using documented complex medical factors such as history and comorbidities, severity of signs and symptoms, current medical needs, and risk of an adverse event.

Name	Number	Type	Effective Date
Hospital and Skilled Nursing Facility Admission Diagnostic Procedures	70.5	NCD

Policy Summary

PayerUnitedHealthcare

PolicyUnitedHealthcare Medicare Advantage hospital services review process

Policy CodePolicy N/A

Change TypeClarified

Effective DateJan 1, 2024

Next Review Date

SourceLink

On This Page

88 Fed. Reg. 22120; 22191-22195	CMS Medicare Advantage program final rule citations referenced
Medicare Benefit Policy Manual, Ch.1, §10	Inpatient Hospital Services Covered Under Part A
Medicare Program Integrity Manual, Ch.6, §6.5	Medical review guidance

OpenPayer

UnitedHealthcare Medicare Advantage hospital services review process

Coverage Summary

Medical-Necessity Criteria

Actions for Providers / Documentation

Regulatory Citations & References

Background & Evidence

Medicare Determinations

Revision History