UnitedHealth Group is a managed healthcare and insurance company based out of Minnesota. If you look at net premiums - or the number of dollars that the company earns in terms of insurance premium payments - UnitedHealth Group is the largest insurance company in the United States. With a market cap of over $400 billion as of 2021, UnitedHealth is truly a behemoth in the health insurance world. 

United HealthCare plans range from Medicare to Medicaid programs to supplemental plans to employer-based plans for the self-employed, small businesses and large organizations. It goes without saying that UnitedHealth serves many, many different kinds of addiction treatment patients. For that reason, UnitedHealth is by far the top insurance company that addiction treatment and behavioral health professionals deal with on a daily basis. 

Medical Necessity vs. Medically Necessary - Here’s What These Terms Mean to UnitedHealth Group’s Addiction Treatment Coverage

Let’s start with the difference between these two medical billing terms. 

Good news: there is no functional difference between “medical necessity” and “medically necessary.” These phrases are synonymous. In other words, there are two ways of referring to the exact same concept. UnitedHealth Group itself frequently refers to these terms together as one unit.

In general terms, addiction treatments and treatment plans that are considered to be a medical necessity - aka medically necessary treatments - are defined as follows. 

Medically necessary addiction treatment: 

• Is based on “generally accepted standards of medical practice” 

• Is clinically appropriate 

• Is not chosen for the sake of convenience, for either the provider or the patient 

• Has no functional equivalent that is less costly  

These guidelines make sense in a general way, but it’s clear that many, if not all, of the features of “medical necessity” when it comes to addiction treatment are debatable. As in all things insurance billing, it is up to you - the addiction treatment center, provider, or professional - to document exactly how and why your proposed treatment is medically necessary. 

So how does that work? 

UnitedHealth Group Inc Uses PA or Prior Authorization to Green Light Medical Necessity for Addiction Treatment Centers

UnitedHealth Group’s plans vary state-to-state. They also vary plan-to-plan. It is impossible to make blanket statements about what UnitedHealth Group Inc. will or will not cover when it comes to addiction treatment, although federal parity laws certainly go a long way to requiring all insurance providers to cover medically necessary addiction treatment in some capacity. 

Because of all of these variances in coverage, it is critical that addiction treatment providers obtain a PA, or prior authorization, from UnitedHealth Group before providing any services to a patient. This is typically done during a VOB or Verification of Benefits process, typically undertaken by an in-house billing department or a third-party billing service. 

If you fail to get a PA from UnitedHealth Group before providing services, it is very possible that the claim will be denied on those grounds alone. UnitedHealth Group recommends that you allow five business days prior to the start of services to complete their PA process. When the process is complete, UnitedHealth Group Inc. will issue a determination letter, which will either green light treatment or deny coverage for the treatment. If coverage is denied, the letter will provide some grounds for that denial. 

UnitedHealth Group Inc’s PA Establishes Both Medical Necessity and Insurance Coverage Details 

When UnitedHealth is determining whether or not to approve a PA, and to what extent, what it’s doing is determining whether the treatment is considered a “covered health service.” 

UnitedHealth Group has four checks it applies to every PA request it reviews. They are: 

• Is the treatment medically necessary? 

• It is listed as “covered” in the Summary Plan Description? 

• Is it specifically excluded in the Summary Plan Description? 

• Is it specifically excluded in the Exclusions and Limitations? 

The answers to those four questions determine how UnitedHealth Group will treat your PA request.

Stumped on UnitedHealth Group’s Medical Necessity Requirements? We Can Help.

You’re not the first addiction treatment professional to have questions about addiction treatment billing. The process changes constantly and requires an extraordinary attention to detail. 

BehaveHealth’s Revenue Cycle Management (RCM) service includes soup-to-nuts, hyper-detailed, hands-on attention to every single component of your addiction treatment billing needs. We have strong working relationships with every major insurance company in the United States. Even better, we’re not health care generalists.  We only work for behavioral health providers like you.  

Let our team of specialists handle it all: 

• Verification of Benefits (this process includes a PA)

• Utilization Review 

• Billing and Collections 

• Patient Responsibility

• Denials and Appeals 

Get your free trial started today and see why more addiction treatment centers prefer Behave Health.