UnitedHealthcare medical records policy update — Prior Auth

Key Coding and Timeframe Requirements

inv-04: Face-to-face encounter timeframe — within six months

RequirementFace-to-face encounter documented within six months prior to the prescription (written order) from the treating practitioner, including the date.

Applies toDurable Medical Equipment, Orthotics, Medical Supplies, Repairs/Replacements (including mobility devices).

Documentation detailsInclude date of encounter and that it was performed by the treating practitioner when applicable.

Consequence of omissionFailure to include a face-to-face encounter within six months may trigger denial or incomplete review of DME requests.

inv-05: Real-life experience requirement for genital gender-affirming surgery — at least 12 months

RequirementAt least 12 months of documented real-life experience is required for genital gender-affirming surgery requests.

Supporting assessmentA written clinical assessment from a Qualified Healthcare Professional experienced in treating Gender Dysphoria is required, including persistent, well-documented gender dysphoria and capacity to consent.

Additional documentationResults of psychosocial-behavioral evaluation and management of coexisting mental health conditions should be included.

Treatment planProvide a treatment plan that includes ongoing and follow-up care by a Qualified Healthcare Professional and note whether the request is part of a staged procedure.

inv-06: Recent therapy/physician note timeframe for naviHealth admissions — therapy notes within 24-48 hours; physician notes within 24 hours

Therapy notes timeframeMost recent therapy notes: within the past 24-48 hours for initial admission (and within past 24-48 hours for continuation stay evaluations).

Physician notes timeframeMost recent physician note: within the past 24 hours for initial admission and continuation stays.

Initial admission packetInclude hospital face sheet, history & physical, therapy evaluations, physician orders/medication list, post-procedure notes, and nursing admission assessment when applicable.

Continuation of stayTherapy evaluations within the past 48 hours, recent therapy notes within 24-48 hours, most recent physician notes within 24 hours, and recent nursing notes when requested.

Provider Submission Requirements and Action Items

Prior Authorization

Prior Authorization and Portal Submission

Several requests require prior authorization and submission via UnitedHealthcare's external portal. When diagnostic images or color photographs are requested, they must be labeled with the date taken and the applicable case number obtained at time of notification or the member's name and ID number. Submission of diagnostic imaging and required photographs must be via the external portal at www.uhcprovider.com/paan; faxes will not be accepted. Failure to submit required information via the portal or to include complete documentation may delay review or affect coverage decisions.

Prior authorization / Pre-Determination may be required for certain services (e.g., breast reconstruction when Pre-Determination is requested); mastectomy for breast cancer does not require prior authorization but pre-determination documentation requirements apply when requested.
Diagnostic images and color photographs: label with date taken and applicable case number or member name/ID; submit via portal (www.uhcprovider.com/paan); faxes are not accepted.
Portal submission requirement: Required diagnostic images, photographs and many supporting documents must be uploaded to the external portal; do not fax.

Prior Authorization

Prior Authorization Required for DME and Mobility Devices

Durable medical equipment and mobility device requests often require prior authorization and specific documentation. Provide a current prescription/written order and detailed device information. Include evidence of prior interventions and functional impact when applicable.

Include documentation of a face-to-face encounter within six months prior to the prescription when applicable.
Current prescription (written order) specifying initial or replacement, rental or purchase, HCPCS code(s) for item and each accessory requested.
Equipment make, model, configuration, serial number (if replacement), and a detailed equipment quote with billing codes and cost.
If replacement: date of initial acquisition, status of warranty, reason for replacement, history of repairs, and original payer information when available.
For wheelchairs/power mobility devices: ambulation and transfer status, functional limitations for ADLs and MRADLs, measurements (strength, distance moved), estimated duration of use, prior devices tried/failed (with dates and reasons), and home/safety evaluation when applicable.

Prior Authorization

Prior Authorization for Specialty Devices

Specialty devices (for example, electric tumor treatment field therapy, home mechanical ventilators, implantable devices, and certain external or implantable stimulators) require prior authorization and detailed device-specific documentation including HCPCS codes, equipment quotes, and replacement history when applicable.

Provide specific HCPCS code(s) for the item and each accessory requested, equipment make and model, and price quotation.
If replacement, include current device used, date of initial acquisition, warranty status, and reason for replacement.
For home mechanical ventilator requests include current prescription with device/settings/hours of use, indication vs PAP/RAD, and therapies tried/failed (with dates and reasons).
For electric tumor treatment field therapy include physician order, diagnosis, and device/vendor quote documentation.

Prior Authorization

Site of Service Justification

Requests for non-office sites of service (e.g., outpatient hospital) often require justification showing medical necessity for that site. Provide clinical details, patient comorbidities, and elements supporting the need for the requested site.

When requesting an outpatient hospital site, include history, pertinent physical exam (including patient weight and comorbidities), and the surgical/procedural plan.
Provide ASA score when applicable and any specific criteria from coverage rationale that qualify the individual for the requested site of service.
Include physician privileging information related to need for hospital outpatient department when appropriate.

Documentation Required

Ambulance Service - Non-Emergency Transport — Documentation

Non-emergency ambulance transport (ground or air) requires specific documentation to support the medical necessity of the transport method and any special equipment or personnel needed.

Include date of service and ordering physician's name and phone number.
Document physician justification for the requested transport method and the reason transport cannot be accomplished by other means.
Provide member diagnosis and chief complaint, current condition, comorbidities, and current functional limitations.
Document any additional equipment or personnel needed for the transport and, if applicable, details of inpatient stay and progress.

Documentation Required

Image Submission Requirements

When images or photographs are requested as part of a prior authorization review, submit high-quality, clearly labeled files via the external portal. Proper labeling and portal submission are required for successful review.

All diagnostic images must be labeled with the date taken and the applicable case number obtained at time of notification or the member's name and ID number.
When high-quality color photographs are required (e.g., certain breast reconstruction, cosmetic/reconstructive, panniculectomy, gynecomastia, and light/laser therapy requests), label each photo with date taken and applicable case number or member name/ID.
Submit diagnostic images and photographs via the external portal at www.uhcprovider.com/paan; faxes will not be accepted.

Documentation Required

Imaging and Photographs

Imaging and photographs must be complete, labeled, and submitted through the portal to support medical necessity reviews. Missing or unlabeled images may delay or prevent coverage determinations.

Include the applicable case number (obtained at time of notification) or member name and ID number on all images and photographs.
When requested, provide the specific diagnostic images that show the abnormality for which surgery or intervention is being requested (MRI, CT, X-ray, CTA, MRA, duplex ultrasound, etc.).
Portal submission is required for images and photographs; faxes are not accepted.

Documentation Required

General Documentation Requirements

Provide comprehensive medical records that document the member's condition, clinical findings, prior therapies, and treatment plan. Incomplete documentation may lead to additional information requests, delays, or adverse coverage determinations.

Submit condition-specific medical notes documenting diagnosis, relevant history, signs and symptoms, and a pertinent physical exam.
Include physician treatment plan, proposed procedure(s), and expected outcomes when applicable.
Provide recent office notes, therapy evaluations, operative reports, and hospital records as applicable to the request.
Ensure documentation reflects dates, durations, and reasons for discontinuation for prior therapies, treatments, or devices tried and failed.

Documentation Required

Prior Treatments Documentation

For many services the review requires documentation of prior treatments tried, failed, contraindicated, or refused. Provide detailed timelines and clinical rationale to demonstrate medical necessity for the requested service.

Document prior treatments including dates, duration, response, and reasons for discontinuation or failure.
Include conservative therapy attempts where applicable (e.g., pharmacologic therapy, physical therapy, exercises, orthotics, repositioning) and objective measures of response.
For continuation or replacement requests, include evidence of prior device use, benefit, tolerance, and objective measures (e.g., download data for ventilators, functional improvements for mobility devices).

Prior Authorization

Prior Treatments Required

Certain procedures and therapies require documentation that prior conservative therapies were tried and failed before approval. Ensure records include specific measures, timeframes, and reasons supporting escalation to the requested intervention.

For venous procedures and other interventions, document prior conservative therapies (e.g., compression, exercise therapy, smoking cessation attempts, topical/systemic therapy) with dates and duration of each trial.
Include validated functional disability scores when applicable (e.g., Venous Clinical Severity Score, Venous Disability Score) to demonstrate impact on ADLs.
When stepwise therapy is required by the coverage criteria, provide documentation that each required step was completed and unsuccessful before proceeding.

Documentation Required

Prior Conservative Therapy for Venous Procedures

Venous procedures typically require documentation of prior conservative therapy attempts and objective testing to justify procedural intervention. Provide measurements, imaging, and functional assessments as evidence.

Document vein diameter and the specific anatomic location where measurements were taken, and duration/position at time of reflux measurement when applicable.
Provide results of relevant imaging (duplex ultrasound, CTA, MRA, digital subtraction angiography) showing anatomic location and severity, with dates.
Include prior therapies tried, failed, or contraindicated (e.g., compression therapy, exercise, medications, smoking cessation), with dates, duration, and reason for discontinuation.
Provide validated functional disability scales (e.g., VCSS or VDS) showing impact on standing or activity tolerance when required.

OpenPayer

Medical Records Documentation Used for Reviews

Coverage Criteria and Submission Notes

Key Coding and Timeframe Requirements

Provider Submission Requirements and Action Items

Background and Scope