United Healthcare’s PA/Appeals Review Process: A Clarification
I was informed that United Healthcare initially examines the Policy Document (Certificate of Coverage) for coverage issues. Only if the prior authorization isn’t denied based on the COC do they then review the clinical documentation under the Medical Policy to assess medical necessity.
Can anyone verify this information? This is what my UHC advisor just shared with me!
This means that if a service is denied due to coverage issues in the COC, the denial notice will reflect that, even if there are also concerns about medical necessity that won’t be addressed. You may only discover these medical necessity concerns if you successfully appeal the COC denial. This process effectively limits you to just one appeal rather than the two that they advertise, as you’ve already spent time appealing based on an incomplete rationale, wasting both your time and your doctor’s.
Your understanding of United Healthcare’s PA/Appeals review process seems quite accurate based on your description. Typically, insurers like UHC prioritize the review of the Contracted Overview Document (COC) first to determine if a particular treatment or service is covered under the policy. If they determine the service is not covered, this denial is often all you receive, which can be frustrating.
The subsequent review for medical necessity is usually contingent upon a service being deemed covered under the COC. If it isn’t, they may not delve deeper into medical necessity, which can leave patients and healthcare providers in a tough spot when it comes to appealing.
This approach can indeed feel limiting because, as you mentioned, it may lead to situations where you’re only able to pursue one appeal effectively, rather than battling both coverage and medical necessity issues in one go. It’s important to be proactive and thorough when reviewing denial letters and recommendations from your provider. Documenting everything can help build a stronger case if you do need to appeal later on. Additionally, if you feel comfortable, you may want to reach back out to your UHC advisor for further clarification on their appeals process and the rationale behind their review practices.
It’s also worth considering reaching out to your provider’s office, as they may have experience handling similar denials and can guide you through the appeal process more effectively.