MMC Benefits Handbook
Utilization Review
Which utilization review services are offered?
The Plan offers prior authorization and case management review.
You may obtain more information about these review services by calling the Claims Administrator.
What is Prior Authorization
Prior Authorization is a utilization review service performed by licensed healthcare professionals. The intent is to determine medical necessity and appropriateness of proposed treatment, including level of care, benefit coverage and eligibility.
To obtain prior authorization for Covered Services from non-Network providers, call the toll-free number on the back of your ID card.
In many cases, your Non-Network Benefits will be reduced if the Claims Administrator has not provided prior authorization.
What services require prior authorization?
The following types of medical expenses require prior authorization or benefit determination, according to your Claims Administrator's medical policies:
  • Ambulance - non-emergent
  • Clinical trials;
  • Durable Medical Equipment for items that will cost more than $1,000 to purchase or rent, including diabetes equipment for the management and treatment of diabetes;
  • Gender Reassignment Surgery
  • Genetic testing – BRCA;
  • Home health care for nutritional foods and skilled nursing;
  • Home Infusion Therapy (billed by home infusion specialist)
  • Hospice care - inpatient;
  • Hospital Inpatient Stay - all scheduled admissions;
  • Infertility services;
  • Lab, x-ray and diagnostics – Outpatient – sleep studies;
  • Maternity care that exceeds the delivery timeframes;
  • Mental Health Services - inpatient services (including services at a Residential Treatment Facility), electro-shock therapy (ECT), partial hospitalization; intensive outpatient (IOP), Intensive Behavioral Therapies including Applied Behavorial Analysis (ABA), extended outpatient sessions of 50 minutes or more, psychological and neuropsychological testing of more than 5 hours and transcranial magnetic stimulation (TMS);
  • Obesity surgery;
  • Private Duty Nursing Care
  • Reconstructive Procedures, including breast reconstruction surgery following mastectomy and breast reduction surgery;
  • Skilled Nursing Facility/Inpatient Rehabilitation Facility Services;
  • Substance Use Disorder Services - inpatient services (including services at a Residential Treatment Facility); partial hospitalization, day treatment medicationassisted treatment (MAT) and methadone maintenance;
  • Therapeutics - outpatient dialysis treatments, intensity modulated radiation therapy and MR-guided focused ultrasound as described under Therapeutic Treatments – Outpatient; and
  • Transplants.
If you have an emergency hospital admission, surgery or specified procedure, you, a family member, your physician or the hospital must notify your Claims Administrator within 48 hours of service.
If the procedure or treatment is performed for any condition other than an emergency condition, the call must be made at least 14 days before the date the procedure is to be performed or the treatment is to start. If it is not possible to make the call during the specified time, it must be made as soon as reasonably possible before the date the procedure or treatment is to be performed.
If you are receiving an infused medication, certain medications may require use of the lowest cost site of care.
Do I need to have my maternity coverage prior authorized?
No. Prior Authorization within 48 hours is not required for the initial hospital admission.
You must notify the prior authorization service if the mother or her newborn stay in the hospital longer than 48 hours after a vaginal delivery or 96 hours after a Cesarean birth. This notification must occur within 24 hours of the determination to extend the stay.
When do I obtain prior authorization?
You, your family member or health care professional must obtain prior authorization as soon as you know you need a service requiring prior authorization, but not less than 14 days prior to the procedure or treatment.
Note: You are responsible for ensuring your service has been prior authorized.
How do I obtain prior authorization?
Initiate the prior authorization process by calling the Claims Administrator at the toll-free number on the back of your ID card.
What happens if I fail to obtain prior authorization?
If you fail to obtain prior authorization, your out-of-network benefits will be reduced by 50%. (Prior Authorization penalties do not apply towards your deductible or out-of-pocket maximum.)
You are responsible for preauthorizing out-of-network services only. Your in-network provider will preauthorize all other services to the extent required by your Claims Administrator.
What approvals do I need if I am going into the hospital?
You must obtain prior authorization as soon as possible but at least 14 days before you are admitted for a non-emergency hospital admission or stay.
If you have an emergency hospital admission, surgery or specified procedure, you, a family member, your physician or the hospital must preauthorize within 48 hours of the service.
Case Management Review (Personal Health Support)
UnitedHealthcare provides a program called Personal Health Support (PHS) which is designed to encourage personalized, efficient care for you and your covered Dependents. Personal Health Support Nurses center their efforts on prevention, education, and closing any gaps in your care. The goal of the program is to ensure you receive the most appropriate and cost-effective services available. A Personal Health Support Nurse is notified when you or your provider calls the toll-free number on your ID card regarding an upcoming treatment or service.
If you are living with a chronic condition or dealing with complex health care needs, UnitedHealthcare may assign to you a primary nurse, referred to as a Personal Health Support Nurse, to guide you through your treatment. This assigned nurse will answer questions, explain options, identify your needs, and may refer you to specialized care programs. The Personal Health Support Nurse will provide you with their telephone number so you can call them with questions about your conditions, or your overall health and wellbeing.
Personal Health Support Nurses will provide a variety of different services to help you and your covered family members receive appropriate medical care. Program components are subject to change without notice.
When you call to obtain prior authorization, a Personal Health Support Nurse can identify a major medical condition, that condition will be subject to case management review. Case management review aims at identifying major medical conditions early in the treatment plan and makes recommendations regarding the medical necessity of requested health care services.
Personal Health Support Nurses with experience in intensive medical treatment and rehabilitation provide case management services. The case manager works with the patient's physician to identify available resources and develop the best treatment plan and may even recommend services and equipment Situations that may benefit from case management include severe illnesses and injuries such as:
  • Head trauma
  • Organ transplants
  • Burn cases
  • Neo-natal high risk infants
  • Multiple fractures
  • HIV-related conditions
  • Brain injuries
  • Cancer
  • Prolonged illnesses
  • Degenerative neurological disorders (e.g. multiple sclerosis).
To best help the patient, the Personal Health Support Nurses should be involved from the earliest stages of a major condition. This service gives you access to a knowledgeable professional who will use his or her expertise to assist you and your physician in considering your treatment options.
If the Personal Health Support Nurses questions the necessity of the proposed hospital admission or procedure, a physician advisor may contact your physician to discuss your case and suggest other treatment options that are generally utilized for your condition. You, your physician, and the case manager will be informed of the outcome of the review, and the Claims Administrator will determine the level of benefit coverage you will receive. You and your physician will be notified of the utilization reviewer's recommendation by telephone and in writing. You will also be informed of the appeal process if the procedures your physician ultimately recommends are not covered under the Plan (as determined by the Claims Administrator).