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Core Medical Necessity with Prior Authorization Required for Existing Self-funded 100+ Groups

August 1, 2017

Despite advancements in technology and efforts to improve consistency, variation in the cost and the quality of care continues to be an industry-wide challenge.  Our members who utilize cost data as part of their decision before having a procedure, save, on average, 36 percent.* Addressing this issue has been an organization-wide focus for UnitedHealthcare for over 10 years and has resulted in the creation of a wide range of programs including:  

  • Identifying the doctors in our provider directory who follow evidence-based medicine and deliver cost efficient (17 percent greater average savings*) and quality care for our members in 16 specialties (UnitedHealth Premium® Designation);
  • Providing members with local cost estimates for procedures and for an individual physician’s fees (myuhc.com Find and Price Care)
  • Medical Necessity review for inpatient and outpatient treatments as a standard for all existing and new clients, at no additional cost.  

In 2018, Core Medical Necessity with Prior Authorization will be required for existing 100+ self-funded group clients. It has been required for all new self-funded clients since 2015. 

Core Medical Necessity with Prior Authorization reduced medical spend by 1 percent overall, or $ 3.43 per member per month savings, for all participating self-funded clients in 2016. Prior Authorization and Inpatient Care Management are offered together as part of our Core Medical Necessity program at no cost to our clients and cannot be separated. 

Prior Authorization is a pre-service, evidence-based medical necessity determination for a service or test. Inpatient Care Management takes medical necessity criteria and applies it to bed days when a patient is hospitalized. This process helps to determine if procedures and bed days are medically appropriate, clinically effective and cost-effective.  

Medical necessity compliance for in-network services is managed by the physician.  Members are responsible for out-of-network services they receive.  Both the member and provider are provided the exact medical reason if there is a denial and may refute the denial through our appeal process.  In 2016, there were a total of 909,000 prior authorization requests and inpatient reviews for our self-funded clients. Only 8 percent were denied and upheld after appeal.**

We will be communicating this information to clients in the August Customer Connection. For more information, please contact your UnitedHealthcare representative.  

* For all 16 Premium specialties evaluated in the UnitedHealth Premium program, Premium Care physicians1 had 17% lower per episode or per patient cost than non-Premium Care Physicians.   2016 UnitedHealthcare Network (Par) Commercial Claims analysis for 16 specialties and 163 markets.  Rates are based on historical information and are not a guarantee of future outcomes.

** ASO National and Key Account clients with Medical Necessity demonstrated 2016 savings. All data is post appeals. These figures are based on historical experience and are not intended to be predictive of individual customer results or a guarantee of future performance.

January 1, 2017 PDL Updates


The following updates will take effect for the OptumRx direct Prescription Drug Lists (PDLs) on January 1, 2017. Learn more

New Sales Automation Management Tool


Check out our new Sales Automation Management (SAM). Learn more

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