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Medical Necessity Inpatient Care Management Effective Oct. 1

October 1, 2012

UnitedHealthcare is introducing Medical Necessity as an additional tool in our medical management model to improve health care quality and costs.

As part of the continued rollout of this initiative, effective Oct. 1, UnitedHealthcare will begin applying medical necessity in inpatient concurrent and retrospective reviews in facilities that have agreed to implement this feature and where the member’s coverage document supports it. This enhancement is part of our effort to provide enhanced access to quality care and make health care more affordable.

Evidence-based medicine will be used to evaluate whether the level of care provided to a member and the length of stay are clinically appropriate. Bed days and levels of care that are not medically necessary will result in denial of payment to the participating facility.

About Medical Necessity

As a reminder, Medical Necessity is the process for determining benefit coverage and/or provider payment for services, tests or procedures that are medically appropriate and cost-effective for the individual member. The Medical Necessity process is based upon a foundation of evidence-based medicine and:

  • Provides an opportunity to address covered services at the individual level to support enhanced access to quality care for the member.
  • Utilizes generally accepted standards of good medical practice in the medical community.
  • Offers timely communication between health plans, members and providers to allow for prospective, concurrent and retrospective review as well as appeal rights for adverse determinations.

This foundation supports UnitedHealthcare’s overall goals for providing enhanced access to quality care by raising performance standards and reducing variation in medical practice, and health care affordability by implementing a process that promotes efficient delivery of high-quality care in a cost-effective manner.

Support Communication

A Medical Necessity Overview has been developed to inform your clients of this implementation.

Your UnitedHealthcare representative will be discussing this enhancement with your clients. If you have questions about the new processes or the overview, contact your UnitedHealthcare representative.

Website Enhancements


We've made several changes, including some new sections of the website, to make it easier for you to find the information you need.

Health Insurance Terms Made Simple


Your clients can share this UHC TV video with their employees to help explain insurance terms like deductible, out-of-pocket limit, copay and premium.