Why UHC Denies Home Health Services
Patient is not homebound
Skilled need not documented
Services exceed reasonable frequency
Know UnitedHealthcare's Criteria
UHC uses InterQual criteria and their own Clinical UM Guidelines (CG series). Medical directors are typically accessible for P2P within 5 business days.
Key policies to know:
- Requires eviCore for MSK and advanced imaging prior auth
- Clinical UM Guidelines (CG series) are publicly available online
- Prior auth through Optum/UHG portal
- Known for strict step therapy requirements on biologics
Building Your Medical Necessity Argument
Document homebound status with specific functional limitations
Define the skilled need (wound care, medication management, PT/OT)
Note why outpatient services are not feasible
Reference recent hospitalization or change in condition
P2P Call Tips for UHC
Reference UHC's own Clinical UM Guideline number (e.g., CG-SURG-71)
UHC medical directors respond well to InterQual criteria language
Be specific about which InterQual subset applies
Have the CG policy number ready -- shows you've done your homework
Guidelines to Reference
- CMS Home Health Coverage Requirements
- Medicare Benefit Policy Manual Ch. 7
Relevant CPT Codes
Specialty: Internal Medicine / Family Medicine
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