In This Issue
Local and Other News
Be the first to know about new products, services, health care reform, and more. Subscribe to our Connection Newsletter. Visit our Profile and Preference Center to sign-up today.
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.
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.
UnitedHealth Group News
Visit our newsroom for the latest about programs, reports and initiatives designed to help people live healthier lives.
Get Consultant News Alerts
Get news alerts on the go by texting CONSULTANTNEWS to 52789 from your mobile phone.
Relevant, educational and entertaining video programs that can inspire you to live a healthier life. Watch UHC TV