DISCLAIMER: This content is for general information only and not medical, clinical, legal, financial, compliance, or regulatory advice. No professional relationship is formed. Consult qualified professionals before acting. We disclaim liability for reliance on this content. Use of this page constitutes acceptance of these terms.

Introduction
UnitedHealthcare (UHC) is one of the nation’s largest health insurers and a major payer for substance abuse and mental health treatment. In fact, UnitedHealth Group (UHC’s parent company) serves more behavioral health patients than any other insurer (How to Determine the Medical Necessity of Addiction Treatment Services for UnitedHealth Group, Inc — Behavehealth.com). For administrative staff, billing specialists, and clinicians at addiction treatment facilities, understanding UHC’s coverage policies is critical to facilitating patient care and securing reimbursement. This comprehensive guide breaks down the essential aspects of UnitedHealthcare addiction treatment coverage – from verifying benefits and meeting medical necessity criteria to obtaining prior authorizations, managing concurrent reviews, contracting in-network, handling utilization review, navigating provider enrollment, overcoming denials, and correctly coding claims. We’ll provide step-by-step guidance, insider tips, and key considerations at each stage of the process. By mastering UHC’s requirements and best practices, your facility can streamline insurance workflows, minimize payment delays or denials, and ensure patients receive the treatment they need under their UnitedHealthcare plans.

Whether you’re verifying a new patient’s benefits, preparing documentation to justify medical necessity under ASAM criteria, or appealing a denied claim, this guide offers the depth and clarity to help you succeed. Let’s dive into each component of UnitedHealthcare’s addiction treatment coverage process.

Verifying UnitedHealthcare Addiction Treatment Benefits

Before admitting a patient or rendering services, the first crucial step is verification of benefits (VOB) for their UnitedHealthcare plan. Verifying benefits confirms exactly what addiction treatment services are covered, under what conditions, and what the patient’s financial responsibility will be. Missing this step or verifying incompletely can lead to unexpected denials or patient billing issues down the line. Below we outline how to verify UHC benefits, key questions to ask, and common pitfalls to avoid.

Steps to Verify UHC Benefits

Gather Patient Insurance Information: Obtain a copy of the patient’s UHC insurance card (front and back). Note the member ID, group number, plan type (e.g. PPO, HMO, UHC Community Plan/Medicaid, Medicare Advantage), and any indicated behavioral health administrator (often Optum for UHC plans ). Also collect the patient’s date of birth and subscriber information if the patient is a dependent.
Contact UHC/Optum for Eligibility and Benefits: Call the provider services or eligibility phone number on the insurance card. For UHC behavioral health benefits (including substance use treatment), you may be directed to Optum (United Behavioral Health), which manages mental health/SUD benefits for UHC . Alternatively, log in to the UnitedHealthcare Provider Portal and use the eligibility/benefits inquiry tool. Have your facility’s Tax ID or NPI ready, as well as the patient info.
Ask for Behavioral Health Coverage Details: Specifically request information on the patient’s substance abuse treatment benefits. Verify coverage for all levels of care you might provide, such as detoxification, inpatient rehabilitation, residential treatment, partial hospitalization (PHP), intensive outpatient (IOP), and outpatient services. Confirm if these services are covered and whether any exclusions or limitations apply.
Determine In-Network vs Out-of-Network Status: Confirm whether your facility is in-network with the patient’s plan. If you are not in-network, ask if the plan has out-of-network (OON) benefits for substance abuse treatment. Many UHC plans offer no OON coverage for behavioral health, meaning the patient would owe most costs if treated out-of-network. If OON benefits exist, verify the deductible and coinsurance the patient would face. If no OON benefits, you may need to pursue a single-case agreement or have the patient switch to an in-network provider.
Verify Cost-Sharing and Deductibles: Ask about the patient’s deductible, co-pay, or co-insurance for the relevant level of care. For example, there may be a separate deductible for inpatient treatment or a copay per outpatient visit. Also inquire about the patient’s out-of-pocket maximum and how close they are to meeting it. This information helps you inform the patient of any expected costs.
Check Prior Authorization Requirements: Critically, ask if prior authorization or precertification is required for each level of care (detox, residential, PHP, IOP, etc.). UHC often requires prior authorization for inpatient, residential, and PHP, and sometimes even for IOP or certain medications . Make sure you know what services need approval before treatment starts. If a referral from a primary physician is needed (common in some HMO plans), note that as well.
Obtain Reference Information: Request a reference number for the call and note the representative’s name and the date/time. This provides documentation in case there’s a dispute later about what was quoted.
Ask About Coverage Limitations: Although parity laws prohibit strict visit/day limits for behavioral health, ask if there are any soft limits or guidelines (for example, some plans may anticipate up to 30 days inpatient per year, though not a hard cap). Also inquire if any specific treatments are excluded (e.g. experimental therapies, wilderness programs, etc. – these are often not covered). Ensure medications related to treatment (like Suboxone for MAT or Vivitrol injections) are covered benefits as well, and whether they fall under medical or pharmacy benefits.

By following these steps, you will have a clear picture of the patient’s UHC coverage and requirements, allowing you to plan treatment accordingly. UnitedHealthcare also offers digital tools to assist with real-time eligibility and benefits checks via their provider portal, which can save time ( Prior Authorization and Notification | UHCprovider.com ).

Key Questions to Ask During UHC Benefit Verification

When speaking with UHC/Optum, be sure to ask pointed questions to uncover any nuances in coverage. Important questions include:

“Does the plan cover detox, inpatient rehab, residential, PHP, IOP, and outpatient counseling?” – Verify each category of service explicitly. For example, confirm that inpatient and outpatient addiction services are covered benefits.
“Is prior authorization or notification required for any of these levels of care?” – As noted, many UHC plans require prior auth for higher levels of care . Get details on how and when to obtain it.
“What are the patient’s cost-sharing obligations (deductible, copays, coinsurance) for these services?” – Understanding the patient’s financial responsibility helps avoid surprise bills and allows you to collect any copays upfront.
“Are there any day or visit limits or maximums for substance abuse treatment?” – Ideally there aren’t strict limits due to parity, but check if, for instance, only a certain number of days will be initially authorized without review.
“Does the plan cover medications for addiction treatment (like Suboxone, methadone, naltrexone)?” – Some plans might require separate authorization for MAT medications or cover them under pharmacy benefits. UHC often covers MAT drugs like Suboxone (often as a Tier 1 generic) and methadone , but confirm any formulary restrictions or needed authorizations.
“Is our facility in-network? If not, can we arrange a single-case agreement?” – If you are out-of-network, UHC may agree to a single-case agreement at in-network rates for that patient. This usually requires negotiation with UHC’s network management.
“What is the process for submitting claims and getting paid as an out-of-network provider?” – If you’ll be OON, ask if UHC will pay you directly or reimburse the patient. UHC has an out-of-network provider registration process to facilitate claim payment (discussed later) ( Out-of-network registration | UHCprovider.com ).

Document the answers to all these questions. Having thorough benefit verification notes will guide your treatment authorization process and help prevent avoidable denials (for example, due to not knowing a prior auth was needed). It also equips you to inform the patient about their coverage and any expected costs.

Common Pitfalls in the VOB Process

Even seasoned billing staff can encounter pitfalls when verifying benefits. Watch out for these common issues:

Incomplete Information from Representatives: Sometimes the insurance rep may give a general statement like “Yes, inpatient rehab is covered” without volunteering specifics on prior auth or network requirements. Always probe deeper with the questions above. Don’t assume coverage details that weren’t explicitly confirmed.
Not Verifying Behavioral Health Separately: Many UHC plans “carve out” behavioral health to Optum or a mental health subcontractor. Ensure you are speaking with the behavioral health benefits department. Verifying only the medical benefits could miss crucial requirements specific to SUD treatment.
Overlooking Out-of-Network Consequences: A major pitfall is verifying that a service is covered, but not clarifying that your facility is out-of-network. For example, UHC might say “Residential treatment is covered” but if you’re not contracted and the plan lacks OON benefits, the claim will still be denied or paid at a much lower rate. Always confirm network status and OON coverage details .
Failing to Note Authorization Requirements: If you don’t explicitly ask about prior authorization, you might proceed with treatment and later find the claims denied for no auth. This is a very common reason for denial. Always confirm if an authorization is needed and the process to obtain it.
Missing Policy Changes or Plan Nuances: Insurance plans can change coverage terms year to year. Verify benefits even for returning patients or seemingly identical plans. For example, a plan might newly require notification within 24 hours of an admission. Stay alert to any such nuances during the call.
Not Documenting the Call: If a dispute arises (e.g., UHC later says a service isn’t covered), your only proof might be your verification notes including the reference number and what you were told. Skipping this documentation could weaken your position in an appeal. Always log the call details.
Assuming Parity = Unlimited Coverage: Mental Health Parity law mandates equal coverage, but it doesn’t mean unlimited days automatically approved. Utilization review still applies. Don’t assume UHC will approve an extended stay just because “no limits” – you still must meet medical necessity (as discussed next).

By diligently verifying benefits upfront and avoiding these pitfalls, you set a solid foundation for the authorization and billing process. In short: never skip the VOB step. Confirm the patient’s UHC coverage details in writing if possible, and make sure both the clinical and billing teams at your facility understand any requirements (like needing a prior authorization or using in-network providers for certain services). This due diligence will pay off in smoother interactions with UHC down the line.

UnitedHealthcare’s Medical Necessity Criteria for Addiction Treatment

Insurance coverage for addiction treatment isn’t automatic – it hinges on the care being deemed medically necessary. UnitedHealthcare evaluates each treatment request against medical necessity criteria to decide if it will be covered. Understanding UHC’s criteria and how to document medical necessity is crucial for providers. This section explains what standards UHC uses (including ASAM guidelines), how to ensure your documentation meets these standards, and tips for demonstrating the need for various levels of care.

UHC’s Medical Necessity Standards (ASAM Criteria and More)

“Medically necessary” addiction treatment generally means the services are clinically appropriate, effective, and in line with accepted standards of care for the patient’s condition (How to Determine the Medical Necessity of Addiction Treatment Services for UnitedHealth Group, Inc — Behavehealth.com). UnitedHealthcare, like most insurers, has specific guidelines to make these determinations:

ASAM Criteria for Substance Use Disorders: UnitedHealthcare relies on the American Society of Addiction Medicine (ASAM) Criteria as the gold standard for SUD level-of-care decisions (Inpatient and Outpatient Mental Health: OK, OR, TX, WA – UnitedHealthcare West Benefit Interpretation Policy). ASAM’s multidimensional assessment framework helps determine whether a patient needs outpatient, IOP, residential, or inpatient treatment based on severity in six dimensions (acute withdrawal risk, biomedical conditions, emotional/behavioral conditions, readiness to change, relapse risk, and living environment). UHC’s policies explicitly reference using The ASAM Criteria: Treatment Criteria for Addictive, Substance-Related, and Co-Occurring Conditions for adults and adolescents (Inpatient and Outpatient Mental Health: OK, OR, TX, WA – UnitedHealthcare West Benefit Interpretation Policy). In practical terms, this means UHC expects that a patient recommended for residential rehab, for example, truly meets ASAM’s definitions for that level (e.g. significant relapse risk and unsafe home environment, etc.).
Generally Accepted Standards of Practice: For mental health conditions, UHC may use other accepted tools (like LOCUS for mental health level of care) . But for addiction treatment, ASAM is key. These criteria are part of UHC’s adherence to the Mental Health Parity and Addiction Equity Act requirements – insurers must use clinical standards that are in line with medical practice guidelines. In fact, after a landmark court case (Wit v. UBH), UHC was required to align its behavioral health criteria with generally accepted standards. Now UHC’s own guidelines are supposed to not be more restrictive than ASAM for SUD treatment.
Plan Coverage vs Medical Necessity: Even if treatment is medically necessary, UHC also checks if that service is covered under the member’s specific plan. During prior authorization UHC asks: (1) Is the treatment medically necessary? (2) Is it a covered benefit in the plan documents? (3) Is it excluded by any policy terms?. Most Affordable Care Act-compliant plans cover SUD treatment broadly (it’s an essential health benefit), so outright exclusions are rare. However, some plans might exclude certain modalities (like long-term residential beyond a certain time, or experimental therapies). By and large, if you meet medical necessity and it’s standard treatment, it should be covered – federal parity law ensures insurers must cover medically necessary addiction treatment similarly to other medical care (How to Determine the Medical Necessity of Addiction Treatment Services for UnitedHealth Group, Inc — Behavehealth.com).

In summary, UHC uses ASAM Criteria to gauge if the intensity and length of treatment are justified. They also ensure the treatment matches what the plan covers. The implication for providers is: you should structure your assessments and clinical justifications in the language of ASAM and accepted guidelines. Make it easy for UHC reviewers to see that the patient meets the Level of Care criteria for the service being requested.

Documentation Tips to Demonstrate Medical Necessity

Providers carry the burden of proof to show why a patient needs a certain level of care. High-quality documentation can make the difference in getting a UHC authorization approved. Here are documentation best practices to meet UHC’s medical necessity expectations:

Perform a Comprehensive Assessment Aligned with ASAM Dimensions: Your intake assessment should thoroughly address each of the six ASAM dimensions. For example, document the patient’s withdrawal symptoms or history (Dimension 1), any medical issues (Dimension 2), psychiatric diagnoses or behaviors (Dimension 3), motivation level (4), substance use history and relapse triggers (5), and home/support environment (6). Specifically note factors that warrant a higher level of care. E.g. “Patient has severe withdrawal risk (CIWA score 18) requiring medical monitoring (ASAM Dim. 1), and no safe support at home (Dim. 6), indicating need for inpatient detox.” This directly ties the patient’s condition to ASAM Criteria for that level (Intensive Outpatient Program - UnitedHealthcare Community Plan of Tennessee Behavioral Health).
Justify Why a Lower Level of Care is Insufficient: UHC will not approve a higher-cost level of care if a less intensive option could reasonably suffice. In documentation, explicitly state why outpatient or a lower level won’t meet the patient’s needs. For example: “Outpatient services have been attempted and failed” or “Patient’s cravings and co-occurring depression are too severe for outpatient management, requiring 24-hour structure.” UHC’s definition of medically necessary care includes that there is no less costly or less intensive alternative that would be effective (How to Determine the Medical Necessity of Addiction Treatment Services for UnitedHealth Group, Inc — Behavehealth.com). Make sure your notes reflect that consideration.
Include Clinical Evidence and Quantify Severity: Use objective scales, test results, and specific examples. Document frequency and amount of substance use, any failed treatment attempts, medical complications (liver enzymes, etc.), psychiatric evaluations, and risk factors (like suicidal ideation, OD history). The more concrete data you provide, the easier it is to substantiate necessity. For instance, noting “Patient drank daily for 10 years, experienced seizures during last detox attempt” is powerful evidence to justify a supervised detox level of care.
Treatment Plan that Matches the Diagnosis: Ensure the treatment plan goals and interventions correspond to the identified problems. UHC reviewers look for a clear link: diagnosis -> symptoms -> proposed treatment -> expected outcomes. If a patient is approved for residential, the treatment plan should show intensive therapies addressing those needs (trauma therapy, relapse prevention, etc.) which justify staying in that setting. Vague or boilerplate treatment plans can weaken the case; customize it to the patient’s situation.
Emphasize Danger of Inadequate Treatment: If appropriate, state the risks if treatment is not provided or is cut short. For example, note if the patient is at high risk of overdose death without residential treatment, or that their pregnancy could be endangered by withdrawal without medical detox. Highlighting medical necessity means showing that without this care, the patient’s health (or life) is in jeopardy.
Continued Stay Criteria: For ongoing reviews (discussed in the next section), document progress but also remaining challenges. UHC will require evidence that continuing the current level is still necessary. Each progress note or review update should address why stepping down now would be premature (if you’re seeking continued authorization). For instance: “After 2 weeks of residential treatment, patient has reduced cravings but continues to experience depression and urges; still not stable enough for outpatient. Another 1–2 weeks residential recommended per ASAM Dimension 5 and 6 status.”
Use UHC’s Language When Possible: Leverage phrasing from UHC’s medical necessity criteria or denial rationales. If UHC criteria (or state guidelines) say a patient must have “serious impairment in social functioning” to qualify for residential, use that phrase in your documentation if it fits. Show that the patient meets each required element. This can preemptively address any checkboxes the reviewer is looking for.
Provider Attestation: Have the attending physician or clinical director include a concise statement supporting the level of care. A letter or statement in the chart that says, for example, “In my professional judgement as an addiction psychiatrist, this patient requires inpatient care due to XYZ” adds weight. While utilization reviewers focus on criteria, a clear physician recommendation can still influence borderline cases.

Remember, if it isn’t documented, it didn’t happen (as far as insurance is concerned). Robust documentation is your best defense if UHC initially doubts medical necessity. It’s also essential for appeals. In any denial letter, UHC will state the reason (e.g. “lack of evidence of withdrawal symptoms” or “patient could be treated at a lower level of care”). By anticipating and addressing those points in the medical record from the start, you improve your chances of approval.

Lastly, keep in mind that under parity laws, UHC cannot apply stricter medical necessity criteria for addiction treatment than they do for analogous medical treatments. If you suspect UHC’s criteria are too stringent, that could be appeal fodder referencing parity. But ideally, by aligning with ASAM and clearly demonstrating the need, you can avoid denials up front.

Obtaining Prior Authorization from UHC for Addiction Treatment

Prior authorization (PA) is a prerequisite for coverage of many addiction treatment services under UnitedHealthcare plans. This means UHC must review and approve the medical necessity of the service before you provide it (except in emergencies) in order to pay the claim. Navigating the prior authorization process is critical: failure to get a required PA will almost certainly result in a denial of payment (How to Determine the Medical Necessity of Addiction Treatment Services for UnitedHealth Group, Inc — Behavehealth.com). In this section, we detail when prior auth is needed, how to request it (step by step), and common challenges with UHC authorizations.

When is Prior Authorization Required?

The requirement for prior authorization can vary by plan, but generally UnitedHealthcare requires pre-authorization for all higher levels of addiction care. This typically includes:

Inpatient Detoxification – Almost always requires pre-certification. Some UHC plans might allow urgent admissions then notify within 24 hours, but you should assume prior auth is needed for non-emergency detox admissions (A Guide to UnitedHealthcare Detox Coverage | Cornerstone).
Inpatient Rehabilitation (hospital-based) – Requires prior authorization in most cases.
Residential Treatment – Yes, UHC/Optum will require an authorization for residential program stays. This is considered a sub-acute inpatient service.
Partial Hospitalization Programs (PHP) – Generally require prior auth. PHP is a intensive day program and UHC manages it as a specialty service needing approval.
Intensive Outpatient Programs (IOP) – Many UHC plans also ask for prior authorization or at least notification for IOP, especially for SUD IOP. Always check – if unsure, treat it as needing authorization to be safe.
Medication-Assisted Treatment (MAT) – Outpatient MAT (like office-based buprenorphine) usually does not require prior auth for the office visits, but certain medications might (for example, Suboxone might require a prior authorization under pharmacy benefits if not on formulary, and extended-release injections like Sublocade or Vivitrol could require auth). For OTP programs (methadone clinics), some UHC plans require authorization for admission to the program or certain services.
Psychiatric Evaluation or Therapy – Typically standard outpatient therapy or psych visits do not need prior auth under UHC plans. They fall under routine behavioral health visits.
Other services – If your facility provides ancillary services (like psychological testing, neurofeedback, etc.), verify if those need separate auth. They often do if covered.

In summary, assume all non-routine, intensive services (detox, residential, PHP, IOP) need prior approval from UHC. When you verified benefits, you should have confirmed this. If unsure, contact UHC’s care authorization department before starting treatment. Not getting a required PA is one of the most common and preventable denial reasons.

Also note: some plans might use the term “notification” instead of authorization – meaning you just have to inform UHC of an admission. Don’t be fooled: even if called “notification,” always provide clinical information and get a documented approval.

Steps to Obtain Prior Authorization from UHC

Once you know an authorization is needed, here’s how to secure it:

Gather Clinical Information: Compile the patient’s intake assessment, diagnosis, recommended level of care, and any relevant medical records. You’ll need to present a case for medical necessity. Include DSM-5 diagnoses, substance use history, current withdrawal risk, past treatment attempts, co-morbid conditions, and ASAM dimensional assessment. Essentially, have your preauthorization packet ready – this might be a form UHC provides or just your clinical notes.
Initiate the Authorization Request: Most providers either call UHC’s designated number for behavioral health authorizations or use the online portal. UHC’s Provider Portal has a Prior Authorization tool where you can submit requests digitally ( Prior Authorization and Notification | UHCprovider.com ). Many find the portal efficient: UHC states that requests submitted electronically often get faster decisions (sometimes within an hour) . If calling by phone, be prepared for a clinical interview where a care manager asks about the case. For non-urgent admissions, you typically initiate this during business hours before admitting the patient (or within 24 hours of an urgent weekend admission). For outpatient services like IOP, initiate auth before the program starts.
Provide Necessary Details: Whether by phone or portal, give all required information: patient demographics and insurance ID, facility/provider information, requested level of care and start date, and clinical justification. Be concise but thorough in explaining why the patient needs that level of care (use the talking points from your ASAM-based assessment). Mention any safety risks and lack of alternatives. Essentially, you are doing a mini utilization review upfront.
Obtain Authorization Decision: UHC will review the request against their criteria. If the information clearly meets medical necessity, approval can sometimes be given immediately over the phone or within the same day via portal response . The care advocate may say, for example, “Approved for 7 days of residential treatment, auth #12345, next review on X date.” Make sure to record the authorization number and approved length of stay or number of visits. If the request is faxed, it can take longer (UHC must assign it to a reviewer). UHC recommends allowing up to 5 business days for the prior auth process, so don’t wait until the last minute (How to Determine the Medical Necessity of Addiction Treatment Services for UnitedHealth Group, Inc — Behavehealth.com).
Handle Additional Information Requests or Peer Review: If the initial reviewer feels the case does not fully meet criteria, they might not outright deny; instead, they may escalate to a peer reviewer or ask for more info. UHC’s process is to have a physician or psychologist peer reviewer consider cases that the first-level reviewer can’t approve (Presentation Title). Turnaround for a peer review decision is quick – typically within 1 business day for inpatient and a few days for non-urgent levels (Presentation Title). You (or your facility physician) might be invited to a “peer-to-peer” phone call to clarify the patient’s needs. It’s wise to accept that opportunity – it’s your chance to advocate directly to the UHC medical director reviewing the case.
Receive the Determination: If approved, you will get an authorization letter or portal message from UHC confirming the approval, what service is authorized, and for what date range or number of sessions. For example, “Residential rehab approved from 3/1/2025 to 3/14/2025.” If denied, UHC will issue a denial letter outlining the reason (lack of medical necessity, or benefit exclusion, etc.) and appeal rights. We’ll cover appeals later, but note that an initial denial at prior auth stage can often be overturned with a quick peer-to-peer discussion or supplying missing information, before resorting to a formal appeal.

Pro Tip: When possible, use UHC’s digital tools for prior auth. Their portal allows real-time submission and you can check status updates easily ( Prior Authorization and Notification | UHCprovider.com ). Some providers report faster responses electronically. UHC even has an initiative (Gold Card program) to streamline auth for providers with a track record of approvals ( Prior Authorization and Notification | UHCprovider.com ). Still, always follow up if you don’t get a timely response. Don’t assume “no news is good news” – verify the auth is in place.

Common Challenges in the UHC Prior Authorization Process

Obtaining prior authorization isn’t always smooth. Be prepared to encounter and manage these challenges:

Incomplete Clinical Information: One frequent issue is not providing enough detail initially, leading UHC to delay or pend the request. For example, simply stating “patient needs rehab for alcohol use” is not sufficient. If UHC has to come back asking for specifics (e.g., withdrawal symptoms, failed outpatient attempts), that slows the process and risks a denial. Always err on the side of too much pertinent information in your request.
Difficulty Reaching Clinical Staff for Peer Review: If UHC schedules a peer-to-peer review, make sure your physician or clinician is available at the appointed time. Missed peer call appointments can result in an auth denial by default. If the suggested time doesn’t work, proactively reschedule. Keep communication open until a decision is made.
Authorization Denied or Partially Approved: Sometimes UHC may approve a lower level of care than requested (a partial denial). For example, you request inpatient, they approve residential, or you request 14 days and they approve 7 days. If this happens, carefully review the rationale provided. You may need to initiate an appeal or provide additional info to get the higher level or longer duration. We’ll address strategies for that in the denial section.
Plan-Specific Nuances: Certain UHC plan types (like UHC Community Plan Medicaid, or UHC Medicare Advantage plans) might have different processes or additional hoops (such as requiring the primary care physician to initiate auth for some Medicaid plans). Always check the plan’s requirements. For instance, UHC Medicaid plans often strictly require authorization for any SUD services and have their own forms.
Authorization Expiration: Note the period the auth covers and don’t let it lapse if the patient is still in treatment. If the patient needs to continue beyond the initially authorized period, you must request a continuation (concurrent) review before the auth expires (discussed below). If you fail to do so, coverage for days beyond the auth could be denied as “no authorization.” Mark the next review date from your initial approval and set reminders.
Administrative Hurdles: Occasionally, providers run into issues like not having the correct fax number, or portal access issues, or confusion if the patient’s plan requires the auth through a different vendor (e.g., Beacon Health for a specific employer plan, though for UHC this is rare since Optum usually handles it). If something feels off, call UHC’s provider line to clarify the correct authorization pathway.

By anticipating these challenges, you can mitigate them. Persistence and clear communication with UHC’s care management staff go a long way. One positive aspect: UHC typically makes prior auth decisions within a fairly short window – often within 72 hours for urgent requests (Coverage determinations and appeals | UnitedHealthcare), and within 15 days for non-urgent (per standard requirements). In practice, behavioral health auths are often decided much quicker (same day or a few days), especially if all info is provided. So invest the effort up front to submit a solid authorization request; it will pay off in faster approvals and fewer back-and-forths with the insurer.

Concurrent Reviews and Continued Stay Authorizations (Utilization Management)

Getting the initial authorization is only half the battle in many cases. For inpatient, residential, and PHP levels of care, UnitedHealthcare conducts concurrent reviews (continued stay reviews) to decide whether a patient can continue at that level or should be stepped down. These reviews are a core part of UHC’s utilization management. Providers must navigate them effectively to avoid premature termination of coverage. Here we explain how UHC’s concurrent review process works, what timelines to expect, and best practices for securing continued stay approvals.

How UHC’s Concurrent Review Process Works

After an initial authorization is granted for a set number of days or visits, UHC assigns your case to a care manager – often called a Facility Based Care Advocate (for inpatient/residential cases). This person is your point of contact for ongoing reviews. Key aspects of the process include:

Last Covered Day and Reviewer Call: UHC will authorize treatment up to a specific “last covered day.” On that day (or the business day before if the last day falls on a weekend), the UHC care advocate will reach out to your facility to perform a concurrent review . For example, if the patient was initially approved through September 10, the reviewer will call on September 10 (the last covered day) to get an update and determine if additional days are medically necessary. If the last covered day is a Sunday or holiday, they usually call the next business day .
Provider Submission of Continued Stay Requests: You don’t have to wait passively for their call. In-network providers can submit clinical updates via fax or the provider portal instead of a phone call . Many facilities prepare a continued stay review form or letter and fax it a day ahead of the last covered day, detailing the patient’s current status and need for continued treatment. Out-of-network providers are typically required to do these reviews via phone call with UHC .
Review of Clinical Progress: During the concurrent review, the UHC care advocate (usually a licensed clinician) will ask for a summary of the patient’s progress, current symptoms/behaviors, response to treatment, and treatment plan going forward. They are essentially checking if medical necessity criteria are still met for the current level of care. They’ll be looking at things like: Is the patient improving? Do they still have acute issues that require this level? Could they safely step down to a lower level of care now? For SUD, they’ll again use ASAM criteria to evaluate continued stay.
Decision and Next Review Date: If the patient continues to meet criteria, the reviewer will approve an extension of the authorization – e.g. “Approved 5 more days, new last covered day is 9/15, next review on 9/15.” They will give you an updated auth number or document it under the original authorization. If the patient does not appear to meet criteria for continued stay, the case will be escalated to a physician advisor for potential denial (similar to the initial auth process). A peer review may be scheduled if the care advocate cannot approve the extension . The turnaround for a decision in that scenario is usually prompt – within 24 hours for inpatient or a few days for lower levels. UHC must notify you of a denial decision within 24 hours of that decision being made .
Frequency of Reviews: The interval of concurrent reviews can vary by level of care and patient status. In many cases: Inpatient detox or acute psych – review may be daily or every 2-3 days; Residential or rehab – review perhaps every 5-7 days; PHP/IOP – maybe weekly or at certain milestones. The UHC care advocate will tell you when the next review is due each time they extend. It is crucial to be prepared on that schedule; you generally cannot get “pre-approved” further in advance than the last covered day. (UHC explicitly notes that providers cannot request an extension early – they will only review on the last covered day or after .) This can be stressful, but it’s their policy to assess at those intervals.

Overall, expect a collaborative but systematic process. UHC’s goal is to ensure members are in the appropriate level of care for the appropriate duration – not longer or shorter than necessary. As providers, you need to present a strong case at each review point for why continued treatment is justified (or proactively step the patient down if it’s appropriate, to avoid a denial). Maintaining good communication with the assigned care advocate can also help; some care advocates will work with you to plan the transition when the time is right.

Best Practices for Continued Stay Documentation

For each concurrent review, you should provide updated documentation that builds the case for either continuing at the current level or transitioning to a lower level with aftercare. Here’s how to put your best foot forward:

Prepare a Summary for Each Review: Don’t rely on the reviewer to dig through the entire chart. Prepare a concise continued stay review summary. This could be a written document or talking points for the call. It should include: current patient presentation, progress made, remaining issues, and treatment plan ahead. Highlight any persistent problems (cravings, mental health symptoms, etc.) and any new developments (e.g., “patient experienced strong urges when confronted with trauma memories in therapy yesterday, indicating need for continued 24h support”).
Highlight Ongoing Medical Necessity Factors: Tie your update back to the criteria. For example, if in the last review the patient still had withdrawal symptoms or unstable vitals, note whether that’s resolved or not. If not resolved, that’s a reason to continue. If resolved, then emphasize other dimensions like relapse potential or co-occurring conditions that still warrant stay. Always answer the implicit question: “Why can’t this patient be safely treated at a lower level yet?” in your update.
Provide Objective Measures of Progress: UHC likes to see progress (or lack thereof) in measurable terms. For instance: report results of drug tests (if positive, that supports continued stay; if negative, then focus on cravings or triggers that remain). Mention if depression scores have improved but still moderate, or if attendance in groups is now consistent but patient is still struggling in individual therapy. Objective data points lend credibility.
Detail the Treatment Plan Forward: Explain what will be done in the next period that justifies staying. E.g., “Over the next week in residential, we will focus on trauma processing in a safe environment – something not feasible at a lower level given her current instability. We plan to initiate naltrexone injection before discharge, which requires coordination and observation.” Showing a clear plan of action can reassure UHC that the continued days are purposeful, not just custodial.
Address Discharge Planning: Ironically, part of justifying continued stay is showing you’re preparing for discharge appropriately. UHC wants to see that you’re regularly evaluating for step-down readiness. Document what discharge criteria you’re looking for and why they’re not met yet. For example: “Discharge/step-down will be appropriate when patient has achieved 5+ days of mood stability and completed initial trauma sessions. As of today, patient still has daily mood swings and has only begun trauma therapy.” Also document efforts to arrange aftercare (outpatient therapist, sober living, etc.), noting any barriers that necessitate staying a bit longer to arrange or stabilize. This demonstrates you’re not trying to keep the patient unnecessarily; rather, you’re ensuring a safe handoff.
Be Responsive and Timely: When it’s time for review, ensure your team is available and responsive. If submitting by portal or fax, send it early enough on the review day. If by phone, be ready for the call and have the chart accessible. Delays or failure to communicate can lead UHC to make decisions with incomplete info. If a care advocate can’t reach you and has no update, they might assume the patient can be discharged. So set internal reminders for these review dates and treat them as high priority.
Escalate if Disagree: If during a concurrent review the care advocate indicates they plan to deny further days (and you strongly believe the patient still needs care), immediately request a peer-to-peer with a UHC medical director before the denial is finalized. You often have a short window (the same or next day) to plead your case to a psychiatrist or addiction specialist on UHC’s side. Come prepared with a focused argument on why criteria are met. This can sometimes avert a denial or gain a short extension to safely discharge.

By providing thorough and clear information, you increase the likelihood that UHC will continue to approve treatment until the patient truly is ready to step down. It transforms the review from a potential adversarial process into a more collaborative care planning discussion.

Timeline and Communication Considerations

A few additional timeline considerations to keep in mind with concurrent reviews:

Don’t Miss the Review Date: As emphasized, UHC will not review extensions before the last covered day, but they also expect the review on that day. If you realize you won’t be available (e.g., physician on vacation), make arrangements for another clinical staff member to handle it, or send in documentation via fax/portal. Missing the review could result in a coverage lapse.
Urgent vs Standard Review: If a continued stay request is urgent (patient would have to be discharged otherwise), UHC processes it as an urgent concurrent review – typically a decision within 24 hours once they have the info . Standard concurrent reviews (for lower levels, or if you send info early) might be within a few days. For example, IOP concurrent reviews might be considered “standard” with up to 5 days to decide . In practice, though, most concurrent decisions are made very quickly especially if the patient is still admitted.
Denial Notification and Next Steps: If UHC decides to deny further coverage (either a partial denial – e.g., “we approve 2 more days but not the full week requested” – or a full denial – “no further days approved, patient should step down now”), they will notify you and the patient in writing within 24 hours . The denial letter will state the reason and how to appeal. Importantly, UHC will work with you on a transition plan for the patient . This may involve helping find an outpatient provider or discussing safe discharge. From a provider standpoint, if you get a denial but keep the patient longer, those additional days will not be covered (unless an appeal overturns the decision). We’ll discuss denial appeals later, but you generally have 60 days to appeal a concurrent denial – UHC even suggests doing so within 48 hours for best chances.
Keep the Patient and Family Informed: These utilization reviews can impact the patient’s financial liability (if continued stay is denied but the patient stays, they could be responsible for costs). It’s good practice to keep the patient/family apprised: “Your insurance has approved your stay through X date; we will be reviewing with them on that date for further coverage.” If a denial occurs and the patient disagrees with discharge, let them know about appeal options. Clear communication can prevent misunderstandings where a patient might think you are discharging them prematurely when in fact insurance denied further days.

By skillfully handling concurrent reviews, you can maximize the authorized treatment days that truly benefit the patient and ensure a smooth transition at the appropriate time. Many providers find that establishing a good rapport with UHC care advocates (returning their calls promptly, providing solid clinical info) can lead to a relatively smooth continued stay management process. It shows UHC that your facility is responsible and focused on patient welfare, which ultimately can make them more comfortable authorizing the care needed.

Becoming an In-Network Provider with UnitedHealthcare (Contracting & Credentialing)

For addiction treatment facilities, becoming an in-network provider with UnitedHealthcare can have significant advantages: easier patient referrals, lower out-of-pocket costs for patients, and a more straightforward billing process (with generally higher payment rates than out-of-network after discounts). However, joining UHC’s network requires a formal contracting and credentialing process. In this section, we outline the steps to become in-network, UHC’s credentialing requirements (especially via Optum Behavioral Health), and tips for negotiating a favorable contract.

Steps to Join the UnitedHealthcare Network

Assess Readiness and Eligibility: UHC typically requires that facilities meet certain standards before contracting. Ensure your program is fully licensed by the state for all levels of care you intend to provide (detox, residential, etc.). Having accreditation from The Joint Commission (JCAHO), CARF, or another accepted body is highly recommended – UHC gives preference to accredited facilities, and if you’re not accredited, they may insist on conducting a site audit as part of credentialing (Join Our Network). Also check that you carry adequate malpractice/liability insurance. UHC/Optum’s requirement is often $1 million per occurrence / $3 million aggregate for general and professional liability (and higher, e.g. $5M, for hospital-based programs) (Join Our Network). Make sure you meet these coverage minimums. If you don’t, raise your policy limits accordingly before applying.
Submit a Network Participation Request: UnitedHealthcare’s behavioral health network is managed through Optum (United Behavioral Health). To start the process, you will typically go through Optum’s Provider Express platform. On Provider Express, there is a “Join Our Network” section specifically for facility providers (Join Our Network). You’ll need to complete a Facility Application (Join Our Network) which collects information about your organization (levels of care, licenses, insurance, ownership, etc.). UHC may also have regional network reps; alternatively, on UHC’s provider site there is a general “Join our network” page, but for behavioral health the process funnels to Optum ([PDF] Your provider can join the UnitedHealthcare network - UMR) ([PDF] UHC - Behavioral Health - IN.gov). Fill out the application thoroughly, selecting all the levels of care you provide (Join Our Network).
Provide Required Documentation: Along with the application form, you must submit a packet of supporting documents. Based on UHC/Optum’s list, prepare copies of: all relevant State Licenses or Certificates for your facility (for each service type and location), Accreditation certificate (JCAHO, CARF, etc., if you have one) (Join Our Network), Medicare/Medicaid enrollment letters (if you plan to join UHC’s Medicare or Medicaid networks) , proof of liability insurance coverage, a completed W-9 form (for your Tax ID) , a Staff Roster with your key clinical staff and their credentials, program descriptions and daily schedules for each level of care , and key policies (such as intake/admission criteria, discharge planning process, and any specialty procedures like handling medical emergencies or restraints). Essentially, UHC wants to verify that your facility is legitimate, safe, and offers the services you claim. Missing documents will delay your application, so double-check that you include everything they list (Join Our Network).
Credentialing Review and Site Visit: Once your application is submitted, Optum’s credentialing team will review all info. They may reach out for clarification or additional data. If you are not accredited, be prepared for a site audit by Optum prior to credentialing (Join Our Network). An auditor may visit your facility to ensure it meets quality standards (checking physical environment, reviewing policies, etc.). If you are accredited, this step is often waived. During this phase, Optum also verifies your licenses with primary sources and may check references or your track record. It’s essentially a due diligence process.
Contract Negotiation: After the credentialing info is reviewed (and found satisfactory), UHC/Optum will determine if there’s a network need for your services in your geographic area. Assuming they wish to proceed, they will send you a participation agreement (contract) with proposed fee schedule (Join Our Network). Review this contract carefully. It will outline terms such as the rates they will pay for various services (often per diem rates for each level of care, or bundled rates), your obligations (like utilization review cooperation, timely filing limits, etc.), and credentialing/recredentialing requirements. At this stage, you can attempt to negotiate on rates or terms. For example, if the proposed per diem for residential is lower than you can accept, you can counter-offer with justification (perhaps your costs or the quality of your program). UHC’s willingness to negotiate may vary – sometimes rates are standard, but if you bring unique value or there is a shortage of providers, you might have leverage. It helps to come prepared with data: show outcomes, unique programs, or costs that justify higher rates. Also clarify which lines of business the contract covers (Commercial employer plans, UHC Medicare, UHC Medicaid, etc.) (Join Our Network) and whether rates differ by line. Ensure you’re comfortable with any utilization management clauses (they will have them – but see if any language can be adjusted if too onerous) and appeal procedures. Negotiating might take a few rounds of discussion with a network manager.
Contract Signing and Provider Onboarding: Once both parties agree, you sign the contract, and UHC/Optum executes it. Congratulations – you’re now in-network! They will load your facility into their provider system and issue you a provider ID if applicable. You’ll receive a welcome packet or orientation on how to submit claims as in-network, how to access their portal for authorizations, etc. Also note that being in-network means you’ll be subject to routine re-credentialing (usually every 3 years) and you must notify UHC of any significant changes (like ownership changes, location changes, etc.). Mark your calendar for recredentialing deadlines to avoid lapses in network status.

The timeline for this entire process can be a few months. It’s wise to follow up if you don’t hear back in a reasonable time at each stage.

Credentialing Requirements and Tips

As seen above, UHC/Optum credentialing for behavioral health facilities is detailed. To improve your chances and speed up the process:

Ensure Accurate and Complete Application: Double-check every field in the application form. An error in your Tax ID or NPI, or a missing checkbox for a service, could cause delays or omissions in your contract. Provide all required attachments in the format requested. Incomplete applications are a common cause of delays or rejection (Join Our Network).
Highlight Quality and Compliance: In any narrative sections, emphasize your facility’s quality of care, any evidence-based practices, staff qualifications, and compliance history. If you have outcomes data (like success rates, average lengths of stay vs. relapse rates), it doesn’t hurt to include a summary. UHC is ultimately concerned with admitting reputable, high-quality providers to their network.
Licensure and Insurance Up to Date: Make sure your licenses (and those of key staff, if asked) and insurance policies are current and not expiring during the process. A lapse in any license will halt credentialing. If your state license is conditional or probationary for any reason, be prepared to explain. Maintain the required liability coverage at all times; UHC might ask for updated insurance certificates if they expire soon after contracting.
Be Responsive to Inquiries: If the credentialing team emails or calls with questions or requests (e.g., clarification of ownership disclosures, or asking for a policy copy), respond as quickly as possible. Any lag on the provider side can cause your application to be put aside. Showing that you are organized and responsive also reflects well on how you’ll be as a network provider.
Site Visit Preparation: If a site audit is happening, prepare your facility and staff. Treat it somewhat like an accreditation survey. Have key documents ready (policy binders, procedure manuals, personnel files showing staff credentials, etc.). Ensure the facility is clean and all safety protocols are in place. The auditor will likely verify that what you attested in your application matches reality. Passing a site audit will green-light the credentialing, whereas failing could require corrective actions.
Follow Up on Network Need: Sometimes providers apply and are told “network is full” or they are placed on hold. If you believe your area has unmet demand (e.g., patients have long wait times or travel far for care), gather data and share that with UHC. Periodically follow up with the network representative expressing your continued interest and any new developments (like you earned accreditation, or expanded services). Persistence can pay off when a spot opens or priorities change.

Negotiation Strategies for Contracting

Negotiating with large insurers like UHC can be challenging, but you do have some ability to advocate for fair terms:

Know Your Costs: Understand the cost of providing each service at your facility. What daily rate covers your expenses for residential treatment? What margin do you need to sustain operations? Having these numbers allows you to evaluate UHC’s rate offer critically. If the offered fee schedule is below cost, you’ll need to negotiate – otherwise you lose money on each patient, which is unsustainable.
Research Market Rates: It’s helpful to know what other payers or nearby competitors are paid, if possible. If you have contracts with other insurers like Aetna, Cigna, etc., compare those rates. If UHC’s offer is significantly lower, you can use that as justification: “Our other major partners pay $X for residential; we would expect UHC to be in a similar range.” You may not get parity with the highest payer, but it provides a benchmark.
Emphasize Quality and Outcomes: If your program has exceptional outcomes (low readmission rates, special certifications, etc.), leverage that. Highlight how your quality can save UHC money long-term (e.g., patients who complete your program have lower relapse and re-treatment rates). This can support higher reimbursement. Insurers are increasingly interested in value-based care, so any data on how your treatment reduces total healthcare costs could strengthen your case.
Negotiate Case Rates or Bundles if Favorable: UHC might propose per diem rates per level of care. If you find those rates limiting (for instance, if you provide a lot of services on one day and the per diem doesn’t reflect that), you might negotiate alternative payment structures. Some providers negotiate a case rate for a whole program (e.g., a 30-day program at $X all-inclusive). Only do this if you’re confident in average lengths of stay and costs. Another point – clarify if certain services are carved out or need separate billing (e.g., physician services, labs). The contract should specify what is covered in the per diem.
Ask about Rate Increases: Try to include clauses for periodic rate increases or renegotiation. A multi-year contract without any increase means inflation will eat into your reimbursement. If possible, negotiate an annual percentage increase or the right to renegotiate rates after a year or two of network participation.
Out-of-Network during Credentialing: If you are negotiating and not yet in-network, you might still be treating UHC patients out-of-network. In some cases, you can negotiate a Single Case Agreement (SCA) for specific patients during the interim. While not directly part of contracting, showing UHC the volume of members you treat (and the outcomes) during this period might strengthen your position that contracting is mutually beneficial. Also, once contracting, you might negotiate that any patients currently in treatment out-of-network can be transitioned to in-network rates to ease their burden.
Be Professional and Patient: Large insurers have bureaucratic processes. You may be dealing with a contracting manager who has to get approvals for any concessions. Present your requests clearly and with justification, and be prepared to wait for internal approvals. Don’t burn bridges with ultimatums unless you truly are willing to walk away. Sometimes demonstrating willingness to collaborate (like offering to participate in UHC quality initiatives or data reporting) can incentivize UHC to finalize the contract on agreeable terms.

In the end, joining UHC’s network is a bit of work, but it can open the door to a larger patient base and smoother operations in the long run. Once in-network, make sure to maintain compliance with the contract terms. Deliver quality care, submit clean claims, and cooperate with UHC’s policies – this will set the stage for a positive ongoing relationship, and possibly easier negotiations when it’s time to renew the contract.

Utilization Review and Compliance under UHC (Including Appeals Process)

UnitedHealthcare’s utilization management (UM) protocols aim to ensure that the care delivered to members is medically necessary and efficient. For providers, this means UHC will be actively monitoring and sometimes questioning the use of services like prolonged residential stays or high-frequency treatments. A solid understanding of UHC’s utilization review policies, as well as having strategies for compliance and appeals, is crucial for providers to avoid conflict and get paid for services rendered. In this section, we discuss UHC’s approach to utilization review, what happens when UHC issues denials or adverse decisions, and how providers can stay in compliance and successfully appeal decisions when needed.

UHC’s Utilization Management Overview

UnitedHealthcare’s UM program operates on several levels:

Prospective Review (Pre-authorization): As covered earlier, UHC reviews proposed treatment before it starts for medical necessity. This is the first gate of utilization management.
Concurrent Review: UHC performs ongoing reviews during treatment to verify continuing necessity (this covers things like extending inpatient stays, etc., as we detailed). They evaluate the appropriateness of the admission, continued stay, and level of care during the treatment (Consumer's right to know about health plans in Massachusetts | Legal).
Retrospective Review: In some cases, UHC might review services after they’ve been provided, especially if prior auth wasn’t obtained (this can happen for emergency admissions or out-of-network cases). They’ll determine after the fact if it was necessary.
Claims Review: When claims are submitted, UHC’s systems and medical reviewers might flag issues like unusually high utilization, billing that doesn’t match auth, etc. This is more of an administrative check but ties into utilization – for example, if more units were billed than authorized, they will likely deny the excess.

UHC’s UM criteria are based on “generally accepted standards of care.” As noted, for SUD they adhere to ASAM Criteria and for mental health to LOCUS/CALOCUS, etc. They also have internal guidelines documented in their policies and Provider Administrative Guides. By regulation, UHC must make these criteria available upon request to providers.

An important regulatory aspect: under the Mental Health Parity Act, the non-quantitative treatment limitations (like UM rules) that UHC applies to behavioral health can be no more stringent than those for analogous medical/surgical care. For example, if UHC doesn’t require prior auth for most medical hospitalizations but does for all psych hospitalizations, that could be a parity issue. UHC has had to adjust policies to comply with parity and various state laws that prohibit excessively frequent reviews ([PDF] UnitedHealthcare POC). Some states (like Rhode Island in [30]) explicitly ban “frequent, short duration concurrent reviews unrelated to the patient’s clinical condition,” meaning UHC can’t harass providers with unnecessary reviews. In practice, UHC tries to balance ensuring necessity with not overstepping boundaries.

Providers, however, may still feel UM is burdensome – requiring lots of paperwork and phone calls. It’s part of the landscape. UHC’s perspective is UM helps manage costs and quality; our perspective is to cooperate while advocating for patient needs.

Appeals Process for Adverse UM Decisions

When UHC’s UM process results in a denial or reduction of service (e.g., denying an authorization request, or ending coverage for treatment because criteria are no longer met), providers and members have the right to appeal those decisions. It’s critical to understand how to navigate appeals:

Internal Appeal (First Level): The first step is usually a “reconsideration” or appeal submitted to UHC itself. For a pre-service denial (denying authorization before service or during service), the provider or member should file an appeal within the timeframe given. UHC’s standard is often 60 days from the denial notice ([PDF] Time frames for claim submissions and appeals - UHCprovider.com) (some plans allow up to 180 days). It’s best not to wait – start the appeal ASAP, especially if the patient is mid-treatment and you’re trying to get coverage reinstated. The appeal should include any additional information or arguments that address the denial reason. If UHC said “not medically necessary,” provide more clinical records, physician letters, and reference the ASAM (or relevant) criteria point by point to show necessity (Time frames for claim submissions and appeals - Quick reference guide for Wisonsin - UnitedHealthcare Community Plan of Wisconsin). If they denied for administrative reasons (no auth), you can still appeal by asking for a retrospective medical review – essentially pleading your case that the treatment was emergent or medically needed and that the lack of prior auth was an oversight (Time frames for claim submissions and appeals - Quick reference guide for Wisonsin - UnitedHealthcare Community Plan of Wisconsin). When submitting an appeal, clearly mark it as an “Appeal” and include the denial reference number. This can often be done via the provider portal, by faxing an appeal form, or mailing a letter – the denial letter will have instructions. UHC aims to decide internal appeals typically within 30 days for non-urgent appeals (Claims reconsiderations and appeals - 2022 Administrative Guide).
Second Level or Peer Review Appeal: If the first appeal is denied, some UHC plans offer a second internal appeal. In other cases, especially for employer plans, after one appeal you move to an external review. Check the plan’s specifics. For Medicaid or Medicare Advantage, there are defined multi-level appeal processes. Providers can often represent the member in these appeals with consent. During appeals, you may request a copy of the criteria used and any clinical notes from UHC’s reviewer to specifically counter them.
External Appeal (Independent Review): Under federal law (ACA) and many state laws, patients can seek an external, independent review after exhausting internal appeals. This brings in an outside medical reviewer (not employed by UHC) to reconsider the denial. External reviews are usually reserved for medical necessity or clinical judgment disputes, not simple coding errors. If you truly believe UHC’s denial violates the standard of care or parity, an external review can overturn it. These must be filed within a certain time (often 4 months from final internal denial) and are decided within a set timeframe (e.g., 45-60 days). The external reviewer’s decision is binding on UHC. As a provider, you might need to help the patient with the paperwork for this, and provide any supporting letters.
Peer-to-Peer Discussions: It’s worth noting that separate from formal appeals, UHC often offers a peer-to-peer consultation around the time of initial denial (especially concurrent denials). This is an informal chance to reverse a denial by talking with a UHC medical director. While not an official “appeal,” it can effectively resolve the issue quickly if successful. We mentioned this earlier – always take advantage of peer discussions within the appeal window. It does not replace the right to appeal later if needed.
Claims Payment Appeals: In addition to utilization review denials, you might face claims denials (like coding errors, timely filing denials, etc.). UHC’s process for those is often called a “claim reconsideration” first, then an appeal. For instance, if a claim was denied for no auth but you believe auth was obtained, you submit a reconsideration with proof. This must usually be done within 60-180 days of the Explanation of Benefits (EOB) (Time frames for claim submissions and appeals - Quick reference guide for Wisonsin - UnitedHealthcare Community Plan of Wisconsin). If still denied, then you escalate to a formal appeal. Many of the same principles apply – provide evidence, reference any conversations or reference numbers, and state clearly the resolution you seek.

When appealing, a few tips increase success:

Address the Denial Reason Head-On: If UHC denied saying “criteria X not met,” your appeal letter should explicitly rebut that: e.g., “Criterion for continued stay requires persistent relapse risk: Patient has severe cravings and lack of sober support, which does constitute persistent relapse risk, satisfying the criterion.” Include quotes from medical records that back this up. Essentially, use UHC’s own criteria language in your appeal.
Include Supporting Letters: A letter from the treating physician or an external specialist can bolster an appeal. For example, a psychiatrist stating “In my professional opinion, stepping this patient down at this time would likely result in relapse and harm, due to XYZ reasons” can carry weight, especially in external review.
Leverage Parity and Guidelines: If you suspect UHC’s decision is inconsistent with parity obligations or standard guidelines, mention it. For instance, “According to ASAM Criteria, the patient’s presentation warrants Level 3.7 care, which we provided. UHC’s denial appears inconsistent with ASAM guidelines . Parity law requires that coverage decisions for SUD follow generally accepted standards, so we request reconsideration in light of ASAM.” While you don’t want to come off as adversarial, citing these standards shows you know the rules.
Timeline Awareness: Mark your calendar for appeal deadlines. If a denial letter says 60 days, ensure your appeal is in well before then. Also track how long UHC takes to respond. If they exceed regulatory timeframes without response, you might escalate or file a complaint. But usually UHC is timely.
Escalate if Needed: If you feel an appeal was not adequately considered, sometimes involving the patient’s employer (if it’s an employer-sponsored plan) or state insurance department can help. Many states have an ombudsman for insurance issues. This is more so if you encounter a pattern of problematic denials. One high-profile example: a class action suit (Wit v. UBH) found UHC’s behavioral denial criteria were too restrictive (Landmark Decision: UnitedHealthcare Used Defective Criteria to ...) (How to Determine the Medical Necessity of Addiction Treatment ...); while that was a broad case, it underscores that appeals and pushing back can lead to change. For an individual case, external review is the formal route.

Provider Compliance Strategies in UR

To minimize friction with UHC’s utilization management (and reduce the need for appeals), consider these compliance strategies:

Develop Internal UM Expertise: If your facility has a utilization review specialist or insurance liaison, ensure they are well-versed in UHC’s processes and criteria. They can preempt issues by doing internal chart reviews with an eye to UHC’s standards and coaching clinical staff on documentation.
Stay Educated on UHC Policies: Review UHC’s provider manuals and policy updates regularly. For example, UHC’s Administrative Guide often outlines authorization requirements, timely filing limits, and appeal procedures. Being aware of any changes (like if UHC introduces a new policy for peer support services authorization, etc.) keeps you in compliance. The UHC provider website and newsletters (Network News) are sources of such updates.
Monitor Your Outcomes and Data: UHC may track providers for things like average length of stay, readmission rates, etc. If your facility consistently keeps patients much longer than others or has many denials overturned on appeal, that data is visible to them. Aim to be in line with best practices – treat each patient to the appropriate length of stay, not a one-size-fits-all. When you do have a longer stay, ensure it’s well-documented why. This can prevent UHC from seeing your facility as over-utilizing care.
Build Relationships with UHC Representatives: If your facility is high-volume with UHC, you may get to know some of the care advocates or local network liaisons. Professional, collaborative relationships can help. For instance, having a UHC network rep you can reach out to in order to troubleshoot recurring issues (like authorization glitches) can expedite resolutions. Occasionally UHC may offer provider trainings or meet-and-greets – participating shows goodwill.
Comply with Administrative Requirements: Many denials are avoidable administrative issues – missing authorizations, late filing, incorrect coding. By having a robust internal protocol (checklist for admissions to get auth, double-checking claims before submission, etc.), you can avoid poking the UHC bear unnecessarily. Compliance isn’t just clinical; it’s also about meeting all those policy requirements (e.g., using correct billing codes, which we’ll cover next, and submitting documentation when asked).
Utilization Review Meetings: Some facilities hold weekly UR meetings with clinical teams to discuss each insurance patient’s status. In these meetings, consider “Would UHC continue to approve this patient’s stay based on current info?” If the answer is doubtful, either improve documentation or consider stepping down if appropriate. By proactively managing each case from a UM perspective, you’re in sync with UHC’s expectations, reducing conflicts.
Know When to Discharge vs. Fight: As patient advocates, we want to secure as much treatment as needed. But sometimes continuing to fight for a few extra days of residential, for example, might not be in the patient’s best interest if UHC is firmly denying and the patient could safely continue in a lower level. Knowing when to concede and arrange a solid discharge plan is part of compliance too. Save your energy (and appeal capital) for the cases that truly need pushing.

By aligning your utilization management approach with UHC’s (while still advocating for patients), you can strike a balance that leads to fewer denials and a smoother authorization process. And when denials do occur, having a strong appeal game ensures you can overturn those that truly should be covered. It’s all about being proactive, organized, and persistent.

Provider Enrollment and Payer Registration with UnitedHealthcare

Whether you are joining UHC’s network or simply seeing UHC patients out-of-network, your facility must handle certain enrollment and registration tasks to work with UHC effectively. This includes things like obtaining provider IDs, accessing UHC’s provider portal, and setting up electronic billing. In-network providers typically go through formal credentialing (as discussed), but out-of-network providers also have steps to ensure claims can be processed. Let’s cover how addiction treatment facilities can enroll or register with UHC, common obstacles in doing so, and solutions to streamline the process.

Enrolling as a UHC Provider (In-Network)

If you have completed contracting and credentialing with UHC/Optum (see the in-network contracting section), you will be enrolled in UHC’s systems as a participating provider. Key things to do upon enrollment:

Provider ID and Welcome Letter: UHC or Optum will issue you a welcome letter. It may contain a UHC provider ID number (or your Tax ID/NPI simply becomes activated in their system without a separate number). Keep this information handy. If multiple service locations or programs were credentialed, ensure each is listed.
Portal Registration: Set up access to the UnitedHealthcare Provider Portal if you haven’t already. Even if you used it for auths while out-of-network, now as in-network you can link your Tax ID to the portal fully. The portal registration requires creating a One Healthcare ID (if you don’t have one) and then requesting access tied to your organization’s TIN (Provider portal registration - UHCprovider.com). UHC’s site has guides on portal registration (Provider portal registration - UHCprovider.com). This portal will be your go-to for checking eligibility, submitting auths, claims, and checking payments.
EDI (Electronic Data Interchange) Setup: If you plan to submit claims electronically (highly recommended), ensure your billing system or clearinghouse is configured for UHC’s payer codes. UHC’s commercial and most plans use Payer ID 87726 for EDI claims (Time frames for claim submissions and appeals - Quick reference guide for Wisonsin - UnitedHealthcare Community Plan of Wisconsin). (Certain UHC plans, like specific Medicaid state plans, might have different Payer IDs – but 87726 is broadly used.) Register with your clearinghouse to send claims to UHC’s payer ID. If you want Electronic Remittance Advice (ERA) and Electronic Funds Transfer (EFT) for payments, you may need to enroll separately for Optum Pay, which handles UHC’s payments ( Out-of-network registration | UHCprovider.com ). Optum Pay enrollment will get you direct deposits of claim payments and electronic EOBs. Often, UHC’s contracting packet includes Optum Pay sign-up forms. If not, visit the Optum Pay site to register.
Update Your CAQH and NPPES: For individual practitioners, keeping CAQH data up-to-date is important (though for facility, CAQH isn’t used; they rely on your direct credentialing info). Ensure your NPI (National Provider Identifier) is correct and associated with the proper taxonomies for the services you offer. UHC will use NPIs on claims to identify the provider. A facility should have an Organization NPI (Type 2) and possibly subpart NPIs for different programs if applicable. Check that the NPI and Tax ID combination you bill under is what UHC has on file.
Enroll in State Medicaid (if applicable): If you are participating in UHC’s Medicaid plans, some states require that you also be an enrolled Medicaid provider in that state. UHC may have needed your Medicaid ID during contracting. Make sure all those enrollments are done; otherwise claims to a UHC Medicaid plan could be denied if you’re not recognized by the state. Similarly, for UHC Medicare Advantage, you usually need your clinicians to be enrolled in Medicare (have an active PTAN/NPI in Medicare) to treat MA patients.

In-network enrollment is mostly handled via the credentialing contract process, so once that’s done, there’s not much separate “enrollment” to do – it’s about getting into their systems (portal, EDI, etc.) and aligning all your identifiers.

Out-of-Network Provider Registration

If you are not in-network with UHC but will be treating their members (either because the plan has OON benefits or you have a one-time agreement), UHC offers a process to register as an out-of-network provider for ease of claims processing. This is crucial; otherwise your claims may be delayed or the checks sent to patients. Key steps for OON provider registration:

TIN Registration: UHC has an online portal for out-of-network providers to register their Tax Identification Number (TIN) and practice details (UnitedHealthcare introduces online portal for out-of-network ...) ( Out-of-network registration | UHCprovider.com ). This is a recent improvement by UHC to streamline OON claims. By registering your TIN, you essentially let UHC know “I am a legitimate provider who will be submitting claims, here is my info on file.” You can access this via UHC’s public provider site under “Out-of-network registration.” The process involves entering your organization info, TIN, NPI, address, and possibly uploading a W-9. UHC will confirm and add your TIN to their system. This helps prevent claims from being held up for provider verification.
Submit an Initial Claim: Interestingly, UHC’s instructions suggest that if you haven’t already, you submit a claim after registering ( Out-of-network registration | UHCprovider.com ). Often, when UHC receives a first claim from an unknown provider, they create a profile for that provider. The registration process combined with a claim submission ensures you’re in their payment system. If possible, submit a test claim or the first patient’s claim soon after registration to get the ball rolling.
Provider Portal Access for OON: Out-of-network providers can also use the UHC Provider Portal by creating a One Healthcare ID. However, access is limited. You likely won’t see patient-specific info or be able to do auths online unless you get linked to the patient’s account via an auth. But you can still use it to submit claims through their web portal if needed and to follow up. The portal registration for OON might require the TIN to be registered first. According to UHC, once you’ve done Step 1 (Register TIN) and submitted a claim, you can register for the portal to manage claims and payments ( Out-of-network registration | UHCprovider.com ). This is useful if you plan to continue seeing UHC patients out-of-network – you can track claim status and even chat with advocates via the portal.
Digital Payment Setup: As an OON provider, you’ll want to get payments efficiently. UHC uses Optum Pay for both in-network and out-of-network payments ( Out-of-network registration | UHCprovider.com ). After registering your TIN, you can enroll in Optum Pay (there’s a free ACH option or a paid option for additional features). This way, you don’t have to wait for paper checks (which might otherwise go to the patient if assignment of benefits isn’t on file). Be sure to have the patient sign an Assignment of Benefits (AOB) so that UHC will pay you, the provider, directly for OON services. If UHC doesn’t have an AOB, they might send reimbursement to the member, leaving you to collect – a headache to avoid. Many UHC plans include an AOB automatically if the provider bills on a UB-04 or CMS-1500 with the appropriate fields filled, but check plan specifics.
Understand OON Policies: Some UHC plans, especially employer self-funded ones, may have penalties or special rules for out-of-network services (like higher deductibles, or paying only usual & customary rates). When you register as OON, UHC will still process claims per the plan rules. Sometimes they might reach out to you with offers to join the network or a one-time negotiation for a lower rate on an OON claim (through a third-party like Viant). It’s up to you how to handle those, but be aware of them. If you get such offers and you’re going to decline, make sure to clearly indicate you expect payment per the member’s benefit (which might be a percentage of your charges or UHC’s allowed amount).
Stay Organized for Multiple Patients: If you treat multiple UHC OON patients, maintain a log of their plan details and any reference numbers (like if UHC assigns a provider reference for you). While UHC’s OON registration is a global setup, each patient’s claims might have nuances. Always verify eligibility and benefits as described earlier – being OON, verify if you need separate auth (almost always yes), and how claims will be handled.

Common obstacles in these enrollment steps include mismatches of information (e.g., the address or NPI on your claim doesn’t exactly match what UHC has in their system, causing claim suspension). To avoid that, ensure consistency: use the same facility name, address, NPI, and TIN across all documents, registrations, and claims.

Overcoming Enrollment and Registration Challenges

Network Closed / Application Denied: If you attempted to join UHC’s network but were denied due to “network need,” you might operate OON for a while and try again later. To bolster a future application, gather evidence of demand (number of UHC members you’ve treated, referrals you had to turn away or patients who had high costs due to no network provider). Engage the local UHC representative periodically to express interest and share this data. Sometimes demonstrating that UHC members are going out-of-network (and costing UHC more) can motivate them to contract with you.
Claims Rejections for Provider Not Found: If you submit a claim and get a rejection like “Provider not recognized” or “Billing provider not eligible,” it likely means you need to register that TIN/NPI with UHC (the OON registration) or there’s an info mismatch. Immediately do the out-of-network registration if you haven’t ( Out-of-network registration | UHCprovider.com ), or call UHC’s provider line to confirm your provider record. Providing a W-9 to UHC’s claims department can also help establish your entity in their system.
Portal Access Issues: It’s possible you create a One Healthcare ID but can’t see or do much because you’re not officially tied to a contracted provider group. UHC has a help desk for portal issues. They may need to manually link your account to your TIN (especially if out-of-network). Don’t hesitate to use their New User help line to get this resolved, as portal access is very useful.
Coordination for Multi-TIN Organizations: If your facility has multiple Tax IDs (for example, a non-profit parent and a for-profit subsidiary or different billing entities for different locations), make sure each is separately registered or enrolled. UHC contracts are usually at the entity level, so ensure all relevant entities are in-network or registered as needed. If you inadvertently bill under a TIN that UHC doesn’t recognize (maybe you have a new LLC), it will cause denials. Keep your enrollment info updated whenever there are changes.
Medicaid/Medicare Specific Hurdles: For UHC Community Plans (Medicaid), you often must list all your rendering providers (doctors, counselors) with their NPIs in their system too. Medicaid managed care is strict about that. Ensure all your clinicians who provide billable services are enrolled or at least their NPIs are provided to UHC, otherwise their services might deny. Similarly for Medicare Advantage, the facility and the rendering practitioner might both need to be enrolled with Medicare. Check UHC’s requirements in their provider guide or with the network rep for these scenarios ([PDF] UHC - Behavioral Health - IN.gov).
Revalidation and Updates: Keep track of re-credentialing requests from UHC. In-network providers will get them typically every 36 months. If you miss recredentialing deadlines, UHC might terminate your contract. Also update UHC if you add new services that you want covered (say you start a new PHP program – you may need to get that level of care added to your contract). Similarly, if key info changes (tax ID change due to reorganization, address move, etc.), notify UHC through their Demographics Update process (UnitedHealthcare Provider Portal resources) to avoid claim issues.

In summary, whether in-network or out-of-network, make sure your facility is properly set up in UHC’s systems. Register your TIN/NPI, get portal access, and set up electronic transactions for smooth operations. Taking the time to do these administrative steps will pay off by reducing technical denials and payment delays.

Overcoming Denials and Appealing UHC Claims

Even with diligent verification, authorization, and utilization management, denial of coverage or payment can still occur. UnitedHealthcare might deny a claim for various reasons – some medical, some administrative. How you respond can determine if you ultimately get paid. In this section, we’ll explore common denial reasons for addiction treatment claims under UHC, and outline best practices to appeal and overturn denials. We’ll also walk through a brief case study example to illustrate a successful appeal.

Common Reasons for UHC Denials in Addiction Treatment

Understanding why denials happen is the first step to preventing and addressing them. Here are some of the most frequent denial reasons:

No Prior Authorization / Notification: This is a top culprit. If a service required prior auth and none was obtained, UHC will deny the claim for lack of authorization. For instance, if a patient was admitted to residential treatment without pre-cert, expect a denial. Sometimes even if you later prove it was medically necessary, the technical no-auth denial stands (though you should appeal, especially for emergency situations).
Not Medically Necessary (Clinical Denial): UHC may deny coverage stating the treatment was not medically necessary at that level or duration. This often occurs in concurrent reviews (e.g., “continued residential stay beyond X date not medically necessary as patient improved”) or retrospective reviews. The denial letter typically cites their criteria: e.g., patient did not have severe withdrawal or high risk to justify inpatient, or had supports that would allow outpatient care, etc. This type of denial requires a strong clinical appeal demonstrating necessity. It’s a common reason for behavioral health claims being denied – UHC or their reviewers felt criteria weren’t met.
Coverage Exclusion or Limit Reached: Although parity outlaws many limits, occasionally a plan might have exclusions such as no coverage for certain levels (some older or non-ACA plans might not cover residential treatment or IOP , though this is rare now). Or a plan may have an annual limit (also not allowed on essential benefits, but could appear in grandfathered plans or some employer exclusions). If a claim is denied because “service not covered by plan” or “max days exceeded,” that falls here. For example, a plan might exclude “long-term residential beyond 45 days” (Chemical Dependency/Substance Abuse Rehabilitation – UnitedHealthcare West Benefit Interpretation Policy), leading to denial after 45 days.
Out-of-Network / No Benefit: If you are out-of-network and the patient’s plan doesn’t have OON benefits (or they didn’t get an approved gap exception), UHC will deny as not covered. They might use codes like “provider not in network” or “coverage available only for in-network providers.” This type of denial means the patient is responsible, unless you negotiate a single-case agreement or can appeal on a parity basis (e.g., no available in-network alternative).
Administrative/Billing Errors: These include things like coding errors, incorrect member ID, missing information, or filing the claim past the deadline. For example, using the wrong CPT/HCPCS code for the service provided can trigger denial (either UHC doesn’t recognize the code or says not payable). Or if your claim lacks a required modifier, it might be denied. Timely filing denials happen if you submit after the limit (often 90 or 180 days from service for UHC). Also, if the patient wasn’t eligible (coverage termed, etc.), claims will deny for no coverage – that’s more an eligibility issue.
Duplicate or Concurrent Service Denials: If two providers bill the same service, UHC might deny one as duplicate or overlapping. In addiction treatment, this could occur if, say, the facility bills residential per diem and an outside physician bills evaluation on the same day without proper modifier – UHC might bundle or deny one. Similarly, if a patient was in two programs in overlapping dates (shouldn’t happen, but sometimes administrative overlap), one claim may be denied.
Lack of Documentation (when requested): In some cases, UHC might pay a claim initially but later audit it, or they might pended it awaiting medical records (especially for out-of-network high-cost cases). If you fail to submit records when asked, they can deny for lack of documentation. This is less common on initial claim (because they use prior auth for that), but can occur on retrospective review or appeals.

The denial letter or EOB from UHC will include a denial code and description. Always read it carefully to classify the denial into one of the above categories. Sometimes multiple reasons are given (e.g., no auth and not medically necessary – you’ll need to address both).

Best Practices for Appealing UHC Denials

Appealing a denial can be labor-intensive, but a well-crafted appeal can turn a “NO” into a paid claim. Here are best practices when pursuing appeals:

Act Quickly and Follow Procedure: As soon as a denial is received, note the appeal deadline (often 60 days) ([PDF] Time frames for claim submissions and appeals - UHCprovider.com) and start gathering materials. Adhere to UHC’s stated process: if they have an appeal form, use it; if a specific address or fax is provided, send to that exact location. Mistakes in submission can waste precious time. For concurrent review denials, you may need to fax an appeal or call a certain department promptly – sometimes within 48 hours for an expedited reconsideration . Don’t miss those windows.
Collect Comprehensive Supporting Documentation: Tailor the documentation to the reason for denial. For medical necessity denials, assemble all progress notes, physician notes, treatment plans, lab results – anything that substantiates the necessity. Highlight or call out relevant parts if possible (to help the reviewer). Include the initial assessment and any updates that show ongoing need. If something was not documented well initially (maybe staff under-documented withdrawal severity), have a clinician write a summary or addendum clarifying the patient’s condition during treatment. For administrative denials, gather proof (e.g., phone records showing you attempted auth, emails from UHC, etc., or correct coding references to show the code you used is valid).
Write a Clear and Concise Appeal Letter: The appeal letter is your narrative to connect the dots. It should reference the patient, dates of service, denial code/reason, and then clearly state why the denial should be overturned. Use a professional and factual tone. For example: “We are writing to appeal the denial for John Doe (ID####) for residential treatment from 5/1–5/10, denied as ‘not medically necessary.’ We believe this decision was made without full clinical information. We are providing documentation showing Mr. Doe’s severe alcohol withdrawal (CIWA scores 18-20 on 5/2 and 5/3) and suicidal ideation, which met UHC’s medical necessity criteria for residential care. Specifically, UHC’s guideline requires evidence of impending severe withdrawal or risk of harm (Intensive Outpatient Program - UnitedHealthcare Community Plan of Tennessee Behavioral Health) ; Mr. Doe exhibited both, as detailed in Dr. Smith’s notes on 5/2. Therefore, the treatment was medically necessary and should be covered.” This kind of letter directly tackles the denial rationale and backs it up with evidence (citing the records, and even UHC’s or ASAM’s criteria). If parity or inconsistency is an issue, you could add: “Denying coverage at this level when generally accepted criteria (ASAM) indicate its necessity may violate mental health parity requirements (How to Determine the Medical Necessity of Addiction Treatment Services for UnitedHealth Group, Inc — Behavehealth.com).” End the letter with a specific request: “We respectfully request that UHC overturn the denial and issue payment of $X for these services.”
Use Citations and References: If you have UHC’s clinical policy (some are on UHCprovider.com or obtained by request) or external authoritative guidelines, reference them. For example, referencing ASAM criteria that were met , or a SAMHSA guideline, can lend weight. If appealing a medication denial, cite FDA approvals or treatment guidelines. This shows the appeal isn’t just opinion; it’s grounded in standards.
Include Patient’s Voice if Relevant: Sometimes a letter from the patient or family, while not clinically determinative, can humanize the case. For instance, a parent could write how their teen had multiple relapses and only the inpatient stay at issue helped stabilize them. UHC is primarily looking at clinical criteria, but in external appeals especially, patient impact statements can help.
Escalate Urgently for Ongoing Treatment: If the patient is still in treatment and a denial happens (like concurrent denial but you and the family decide to continue a few days hoping appeal works), mark the appeal as URGENT. UHC is required to expedite appeals for ongoing services that are urgent. This could mean a decision in 72 hours or less. Clearly state that the patient is still admitted and that a delay in coverage decision could jeopardize their health (if true). This can expedite the review process significantly.
Keep Meticulous Records: Document every call (date, time, name of rep) when following up on an appeal. If UHC said they’d reconsider after peer review, note that. If you fax an appeal, keep confirmation. Should you need to further contest or involve regulators, having a paper trail that you followed all steps timely is important.
Leverage Member Benefits/HR if Employer Plan: If the patient is on an employer plan and your initial appeal doesn’t budge UHC, sometimes raising the issue to the employer’s HR (if the patient is comfortable with that) can help. Large employers can put pressure on UHC if they sense a member isn’t getting needed care. This is delicate and requires patient consent, but in cases where denial seems very unjust, it’s another avenue.
External Review for Stubborn Denials: For denials that you believe are truly wrong and UHC upholds internally, file for External Review (through the state or federal process, as instructed in the final denial letter). Prepare an external review packet similar to an appeal, often with even more supporting info and a cover letter referencing all the points. External review organizations often side with providers if the evidence clearly supports medical necessity, because they are independent. This is often the last resort, but success here will not only get the claim paid but also force UHC to cover similar scenarios going forward for that plan.

Example Case Study of an Appeal

Case: A 28-year-old patient with opioid dependence and depression was admitted to a residential treatment program. UHC initially authorized 14 days. At day 14, the provider requested an extension citing continued depression and cravings. UHC denied additional days, stating patient no longer met residential criteria as vitals were stable and no withdrawal risk.

Denial Reason: “Continued stay not medically necessary – criteria for continued residential care not met (patient can be treated at lower level).”

Provider Appeal Actions:

The treatment team quickly gathered documentation: progress notes from days 10-14 showed the patient had intense cravings when discussing trauma, and had thoughts of using if discharged. A psychiatric consult note on day 12 indicated the patient’s depression was still severe (PHQ-9 score 18) and they had started antidepressant medication, which needed monitoring. The patient’s living environment was also documented as high-risk (roommate currently using drugs).
The provider obtained a letter from the psychiatrist stating, “In my medical opinion, discharging this patient at day 14 would likely result in relapse given her ongoing cravings and lack of stable housing. An additional one to two weeks of residential care is medically necessary to stabilize her mood with the new medication and arrange a safe living situation.”
The facility’s Utilization Reviewer wrote an appeal letter citing ASAM Criteria: According to ASAM, continued stay is justified when there’s imminent danger if treatment is stopped or patient has not yet achieved goals and has the potential to improve with continued care (Inpatient and Outpatient Mental Health: OK, OR, TX, WA – UnitedHealthcare West Benefit Interpretation Policy). The letter pointed out that the patient still had active Dimension 3 and 5 issues (mental health and relapse potential) and that her ASAM Dimension 6 (environment) was not supportive, all supporting continued 24-hour care. It noted that while acute withdrawal (Dimension 1) was resolved, the other dimensions had not stabilized sufficiently.
The appeal letter also referenced parity: “Ending coverage at this stage could violate parity, as her treating clinicians have deemed this care necessary just as an extended hospitalization for a medical condition would be if the patient were still unstable.”
The appeal was marked urgent since the patient remained in residential treatment for a few days at the facility’s expense pending the appeal. The provider submitted it via the portal and also faxed to ensure receipt, within 24 hours of denial.

Outcome: Within two days, UHC reversed its decision and approved an additional 7 days of residential treatment for the patient. The reversal letter cited “additional clinical information reviewed demonstrates continued risk of relapse and need for structured setting – approval granted.” The facility’s detailed documentation and tying the appeal to UHC’s own criteria were likely key in this success. The patient was able to continue treatment, transition safely to a sober living environment after those 7 days, and the provider received payment for the entire stay.

Lessons: The case illustrates that even if UHC denies further treatment, a strong appeal aligning with medical necessity criteria and providing new information can change the outcome. It’s important the appeal introduced details perhaps not emphasized in the concurrent review (e.g., the high-risk home environment and new antidepressant therapy). Providing that context gave UHC justification to overturn the denial.

Preventive Measures Post-Appeal

After resolving a denial, it’s wise for the provider team to debrief: What could we improve in our initial authorization or concurrent review process to avoid similar denials? In the case study, perhaps highlighting the patient’s environment and mental health needs during the concurrent review might have prevented the denial in the first place. Use each appeal as a learning opportunity to tighten documentation or communication with UHC.

In summary, denials are not the end of the road. By understanding why UHC denied a claim and responding with a focused, evidence-backed appeal, providers can often overturn many denials – especially those related to medical necessity. It requires persistence and attention to detail, but recovering payment for services rightly provided to the patient is worth the effort. And by addressing root causes, you can reduce the frequency of denials over time, making the whole UHC reimbursement process more seamless for your facility.

Coding and Billing Claims to UnitedHealthcare for Addiction Treatment Services

Accurate coding and billing are the final pieces of the puzzle to ensure your facility gets paid by UHC for the services rendered. Using the correct CPT, HCPCS, and revenue codes for addiction treatment services is critical – it not only affects whether you get paid, but also whether you’re complying with coding rules. In this section, we’ll review the proper codes for common levels of care (IOP, PHP, residential, inpatient, detox, MAT, peer support) and provide billing tips and compliance insights specific to UHC.

Key Codes for Common Addiction Treatment Services (IOP, PHP, Residential, etc.)

Addiction treatment often uses HCPCS Level II H-codes and sometimes S-codes, in addition to CPT codes, to describe services. UHC generally accepts these standard codes. Here’s a breakdown by service type:

Detoxification (Inpatient or Residential Detox):

H0010 – Alcohol and/or drug services; sub-acute detoxification (residential inpatient program) per diem (HCPCS Code for Alcohol and/or drug services; sub-acute ... - AAPC). Use this for a medically monitored detox in a residential setting (non-hospital) or certain inpatient detox programs, when sub-acute.
H0011 – Alcohol and/or drug services; acute detoxification (residential inpatient program) per diem (acute detoxification (residential addiction program inpatient) H0011 ...). Use this for higher-intensity, medically managed detox (often hospital-based or requiring 24-hour medical staff).
These codes are per diem (per day). Choose H0010 vs H0011 based on the level of medical acuity. If the patient was in a hospital’s detox unit with medical supervision, H0011 is appropriate. Always pair with the correct revenue code (if billing on UB-04) such as Rev Code 0116 or 0126 (chemical dependency detox).

Inpatient Rehabilitation (Hospital inpatient substance abuse treatment):
If a patient is in a general hospital for rehab (not just detox), you might still use H0011/H0010 if the program is considered detox/rehab. However, many hospital inpatient stays for SUD are billed under mental health DRGs or per diems negotiated. If using CPT/HCPCS:

H0012 – (Less commonly used, but some use H0012 for “substance abuse residential, short-term, with detox” per diem, but in general H0010/H0011 cover detox.)
Alternatively, hospital inpatient can be billed with revenue codes (010x) and no specific HCPCS for the daily charges, relying on diagnosis and DRG grouping. Check UHC contract/payment methodology for inpatient psych vs detox.

Residential Treatment (Non-Hospital Rehab):

H0018 – Behavioral health; short-term residential (non-hospital) treatment program, without room and board, per diem. Use H0018 for residential treatment programs typically 30 days or less (28-day programs, etc.). This code covers the clinical services. Note “without room and board” – UHC usually doesn’t separately pay for room/board as it’s part of the per diem or considered not covered (since room/board is not a medical expense in many plans).
H0019 – Behavioral health; long-term residential (non-hospital) treatment program, without room and board, per diem . Use H0019 for longer-term residential (programs longer than 30 days, or extended stays such as 60-90 days) (Understanding HCPCS and CPT Billing Codes for Residential Addiction Treatment: H0017, H0018, H0019 — Behavehealth.com). Not all payers differentiate H0018 vs H0019, but Optum/UBH does recognize them. If a patient stays beyond 30 days, you might switch to H0019. Some plans just use H0018 for any residential and H0019 for certain state programs – but following the official definitions is best.
H0017 – Behavioral health; residential (hospital or non-hospital) without room/board, per diem. H0017 is sometimes used for hospital-based residential or simply as another residential code. Optum’s guidelines mention H0017 as well (Understanding HCPCS and CPT Billing Codes for Residential Addiction Treatment: H0017, H0018, H0019 — Behavehealth.com). It may depend on contract which one they prefer. Many providers use H0018 and H0019 predominantly as above.
Ensure you also include the appropriate place of service code on professional claims or revenue code on facility claims:

Place of Service 55 for Residential Substance Abuse Treatment Facility (Place of Service Code Set | CMS) on CMS-1500 claims, or revenue code 1002 for UB-04 as needed.

Partial Hospitalization Program (PHP):

H0035 – Mental health partial hospitalization, treatment, less than 24 hours, per diem (HCPCS Code for Mental health partial hospitalization, treatment ...). Use H0035 for SUD partial hospitalization days (usually 4-8 hours/day of intensive programming). Magellan (another BH payer) and others align PHP SUD with H0035 and revenue code 0912/0913 ([PDF] Magellan Standard Services Simplified Billing Codes).
S0201 – Partial hospitalization services, less than 24 hours, per diem (Partial hospitalization services, less than 24 hours, per diem S0201). S0201 is a HCPCS S-code that also denotes PHP (often used in general medical context). UHC might accept either S0201 or H0035 for PHP; check UHC’s preference. Optum’s guidelines often list S0201 for PHP.
S9480 – Intensive outpatient psychiatric services, per diem (S9480: Mastering Intensive Outpatient Psychiatric Services Billing). Note: S9480 technically is for IOP (intensive outpatient) mental health, but some payers use it for PHP psych as well. For SUD, stick to H0035/S0201 for PHP.
On UB-04, PHP is indicated with revenue codes 0912 (PHP individual) or 0913 (PHP group) along with the HCPCS code. On CMS-1500, use POS 52 (Psych Facility-Partial Hospitalization) or POS 57 (Non-residential SUD treatment facility – though POS 57 might be more apt for IOP; POS 52 is specific partial hospital) (Place of Service Code Set | CMS) (Place of Service Code Set | CMS).

Intensive Outpatient Program (IOP):

H0015 – Alcohol and/or drug services; intensive outpatient program, per diem (usually defined as 3+ hours per day, 3 days/week) (Comprehensive Guide to Intensive Outpatient Program Billing Codes). This is the primary code for SUD IOP. For example, UHC would expect H0015 to bill each day the patient attends IOP. Blue Cross NC explicitly directs H0015 for IOP SUD (Changes to Billing for Partial Hospitalization Programs and Intensive ...), and Optum typically does the same.
S9480 – Intensive outpatient services, psychiatric, per diem (Comprehensive Guide to Intensive Outpatient Program Billing Codes). Use S9480 for mental health IOP programs (if you have a co-occurring IOP or a mental health track). For purely SUD IOP, H0015 is preferred.
If billing professional, use POS 57 (Non-residential Substance Abuse Treatment Facility) for IOP (Place of Service Code Set | CMS). For facility billing, rev code 0906 (IOP services) is often used with H0015.

Outpatient Counseling and Aftercare:
After IOP or higher levels, patients often go to regular outpatient therapy or medication management. These services use standard CPT codes:

90834, 90837 for individual therapy (45 min, 60 min)
90853 for group therapy
90847 for family therapy with patient
99213, 99214 etc. for medication management (psychiatric E/M codes)
H0004 – Behavioral health counseling and therapy, per 15 min (sometimes used for SUD counseling in certain payer systems, but UHC typically prefers standard CPT therapy codes for outpatient).
These typically do not require auth under many plans (except perhaps certain Medicaid plans). Ensure to include modifiers if required (for instance, some payers require modifier HQ for group therapy on 90853, etc., but UHC/Optum generally doesn’t for their claims).

Medication-Assisted Treatment (MAT) Services:
MAT can encompass various components:

Methadone treatment (Opioid Treatment Program): Use H0020 – Alcohol and/or drug services; methadone administration and/or service, per week (HCPCS Code for Alcohol and/or drug services; methadone ... - AAPC). Yes, H0020 is typically a weekly bundled code for methadone dosing and services in an OTP (some payers allow per day, but officially many use one unit = one week of methadone maintenance). UHC Community Plans in some states might allow multiple units but note that Medicare (and some payers following suit) have specific G-codes for OTP bundles. As of now, UHC often still recognizes H0020 for OTP billing. Check your contract or UHC’s reimbursement policies ([PDF] Reimbursement Policy - UnitedHealthcare Community Plan) – one UHC policy snippet suggests it allows H0020 in place of service 53 without certain edits ([PDF] Reimbursement Policy - UnitedHealthcare Community Plan).
Buprenorphine (Suboxone) office visits: If your doctors prescribe buprenorphine in an office setting, typically you bill the appropriate E/M code for the visit (e.g., 99214 for a med management visit), possibly with a modifier or suboxone-related code for induction. There are HCPCS codes like H0047 (alcohol/drug abuse tx, not otherwise specified) that some use for “medication visits,” but most insurers prefer standard E/M. The medication (Suboxone films) is usually covered under the pharmacy benefit with a prior authorization. If you dispense buprenorphine on site, you’d bill the medication by NDC under medical (rare; most often pharmacy covers it).
Extended-release Naltrexone (Vivitrol): The medication J Code is J2315 (Injection, naltrexone, 1 mg). You’d bill the number of units (380 mg = 380 units, but often they require a single unit since 380mg is one vial – check billing guidelines). Also bill an administration code (96372 for therapeutic injection). UHC often requires prior auth for Vivitrol under medical. Ensure documentation of medical necessity (e.g., opioid/alcohol dependence) and that the injection was given.
Buprenorphine Extended-release (Sublocade): Use Q9991 (100 mg) or Q9992 (300 mg) for Sublocade doses. Prior auth likely required.
Naloxone kits: If dispensing a take-home naloxone, use J3490 (unlisted drug) or specific codes if directed; often covered under pharmacy benefit when patient picks up from pharmacy.
For MAT, also consider billing counseling components if done (use therapy codes for counseling sessions, or H0004 for SUD counseling 15 min units if payer prefers). OTPs often have bundled payment, but outside OTP, you’ll bill each service separately (E/M, therapy, drug test, etc.).

Drug Testing (Labs): UHC often covers drug testing but has policies to prevent over-utilization. Common codes:

80305 (presumptive drug screen, CLIA waived), 80306, 80307 for presumptive tests depending on complexity.
G0480 – G0483 for definitive (quantitative) drug testing (G0480 up to 7 drug classes, G0481 8-14 classes, etc.).
Check UHC’s reimbursement policy on drug testing; they follow CMS guidelines usually. Don’t overbill unnecessary panels. Ensure medical necessity (document why testing was needed). Excessive frequency can be denied as not medically necessary or as experimental if beyond guidelines.

Peer Support Services:

H0038 – Self-help/peer services, per 15 minutes (HCPCS Code for Self-help/peer services, per 15 minutes H0038). Use H0038 for services provided by certified peer support specialists. Note that peer support coverage depends on the plan – many Medicaid plans cover it, some commercial might not. If covered, UHC may require a modifier to distinguish it (for example, some plans use modifier HW or HO to indicate substance abuse vs mental health peer support, or a credential modifier). New Jersey, for instance, uses H0038 with HF for substance abuse peer support (Self-Help/Peer Support Billing Guidelines - Horizon NJ Health). Check your state/plan specifics or the UHC Community Plan manual if it’s Medicaid.
H0025 – Behavioral health prevention education service (also used for peer support in some locales) ([PDF] San Diego Certified Peer Support Specialists – BILLING CODES). Optum San Diego document mentions H0025 and H0038 for peer specialists ([PDF] San Diego Certified Peer Support Specialists – BILLING CODES). H0025 might be used for group peer sessions or community support. Again, usage is plan-specific. For UHC commercial, peer support might not be a standard benefit unless mandated by state law or offered as part of a program. For Medicaid, likely covered if state plan does.
Ensure documentation of the peer service (goals, interventions by the peer supporter) as UHC could audit these new service types for appropriate use.

Coding Tip: Always use the most specific code available and recognized by UHC. Avoid generic codes if a specific exists (e.g., use H0015 for IOP rather than a generic 990XX code). Also, pair codes with proper modifiers if required: e.g., modifier HG is sometimes used to denote substance abuse service, or HF for substance abuse program (especially for Medicaid billing of H-codes). Optum may require HF on certain H-codes to designate substance abuse vs mental health (HF = substance abuse program). For example, a state Medicaid might want H0015 HF. Check if your contract or provider manual specifies any modifier. Some UHC plans use modifier TJ for child/adolescent services. If unsure, contact UHC provider support or reference their billing guidelines.

Billing Tips and Compliance Insights for UHC Claims

Use Correct Place of Service (POS) Codes: The POS on a CMS-1500 claim should reflect where the service was provided, as it can affect payment. Key POS codes for our context include: 11 (office, for outpatient visits), 57 (non-residential SUD treatment facility, e.g., IOP/PHP not at hospital) (Place of Service Code Set | CMS), 55 (residential SUD facility) (Place of Service Code Set | CMS), 52 (partial hospitalization program) (Place of Service Code Set | CMS), 03 (school, if services provided at school), etc. UHC looks at POS for payment logic (for instance, some codes are only payable in certain settings). Ensure the POS aligns with the code (billing H0018 with POS 55, for example).
Revenue Codes on UB-04: If billing as a facility on UB-04 (which many residential or inpatient centers do), include appropriate revenue codes for each line of service. Common ones:

0100-0170 series for room/board (though room/board might not be reimbursed, still used for billing structure in residential packages).
1001 or 1002 for general residential treatment daily charges.
0912, 0913 for PHP (as noted).
0906 for IOP.
0905 for Day Treatment (some use for partial as well).
0450 or 0510 for therapy services if unbundled. UHC’s payment might be per diem so you might only put one revenue code line with the appropriate code per day. If you’re contracted, follow the billing structure agreed (some contracts want a bundled per diem code only, others allow detail). If out-of-network, using standard revenue codes and HCPCS gives them the info to calculate allowed amounts.

Timely Filing: Know UHC’s timely filing limits – often 90 days for commercial plans (from date of service or discharge) unless contract states otherwise; for UHC Medicare, it follows Medicare rules (within 1 year); for UHC Medicaid, it follows state Medicaid (could be 90 or 180 days). If you miss the window, UHC will deny for timely filing and these are hard to reverse unless you have proof of a submission error. Pro tip: If you submit electronically, always get an acknowledgment. If a claim was stuck or rejected, fix and resubmit before time runs out. Keep documentation of initial submission if appealing a timely denial (e.g., clearinghouse reports).
Match Auth to Claim: Ensure the billing matches what was authorized. If UHC authorized 14 days of H0018 and you keep patient 16 days, those extra 2 days will likely deny (or you need to have an auth for them). Also, if UHC authorized a certain code, use that code. For example, sometimes UHC might authorize “Res Tx H0018 7 days.” If you mistakenly bill H0019 or break it into therapy codes, you might get denied for no auth. Consistency is key.
One Claim vs Multiple: Generally, bill the entire episode after discharge if inpatient/residential (UB-04) unless contract says otherwise. For IOP/PHP on CMS-1500, you might accumulate and bill weekly or monthly, or per diem. Just ensure you don’t span beyond your auth period in one claim without proper auth extension.
Diagnosis Coding: Use appropriate ICD-10 diagnosis codes for substance use disorders and any co-occurring conditions. The primary diagnosis should usually be the SUD (e.g., F11.20 for opioid dependence, etc.) for SUD-focused treatment. If treating mental health primarily with secondary SUD, code accordingly. UHC uses these for parity tracking and such, but mainly ensure accuracy. Include codes for withdrawal if in detox, etc.
Coding for Group vs Individual Therapy: If billing individual therapy sessions in outpatient, use individual CPT; for group, use group CPT (90853). Do not bill individual therapy code for a group session – that’s a compliance no-no and could be seen as upcoding. Likewise, in IOP/PHP context, if you’re billing per diems (H0015, H0035), don’t also bill individual therapy codes separately for services that day – the per diem is all-inclusive for that program day. UHC expects no duplicate billing. They might deny the lesser code or even flag for audit if they see it.
Use Modifiers for Multiple Same-Day Services: If by chance two different services occur same day that might be considered overlapping, use appropriate modifiers. E.g., therapy on same day as a psychiatric E/M – add modifier 25 to the E/M to indicate separate service. Or, if two group sessions same day, some payers want a modifier like 76 (repeat procedure). Clarify with UHC if needed; generally, IOP per diem covers all in one, so you wouldn’t bill multiples.
Coordination of Benefits: If the patient has other insurance primary (e.g., UHC is secondary to another insurance or Medicare), submit to primary first then to UHC with the EOB. UHC will deny until primary pays or denies, as per COB rules. Ensure to include the primary payer’s info on the claim (proper COB fields or attachment of primary EOB).
Audit Preparedness: UHC, like others, may audit charts for high-cost cases or out-of-network claims. Always ensure documentation supports the codes billed. For example, if you bill 4 units of H0038 (an hour of peer support), your notes should reflect peer support services for that duration on that date. If you bill G0483 (drug test 15+ substances), ensure lab results show that many substances tested and that it was necessary. Being compliant in documentation will protect you in case of audits or recoupment attempts.

Finally, stay current on coding changes. Codes and billing rules do change over time. For example, new Category I CPT codes might emerge for digital therapeutics or new MAT treatments; or CMS might update lab testing codes which UHC will follow. Subscribe to UHC’s provider bulletins and coding updates. For 2025, make sure you’re using 2025 CPT and HCPCS codes as of Jan 1, and ICD-10 2025 updates as of Oct 1 of prior year.

Compliance Insights

Follow the Contract and Policies: If you’re in-network, your contract’s reimbursement exhibit will detail what codes are covered and how (e.g., “Residential day rate covers all services except physician fees”). Don’t unbundle services that are meant to be bundled. UHC might not pay separately for a doctor’s round in residential if they consider it included, unless contract says otherwise. For out-of-network, payment is often based on usual/customary which stems from coded charges, so ensure your charges are aligned with realistic usual fees for each service to maximize reimbursement (but also note patient may be balance billed, depending on state surprise billing laws and if it’s an emergency or not).
Stay within Scope: Only bill for services your facility is licensed/credentialed for. For instance, don’t bill a psychiatric inpatient code if you’re not a licensed inpatient psych hospital, even if a patient stayed overnight. Use the code matching your setting (residential). UHC looks at the billing provider type; mismatches can cause denials (like a freestanding rehab billing a CMS inpatient hospital code set – likely denied).
Avoid Upcoding: Billing a higher-intensity code than appropriate (e.g., billing H0011 acute detox when you really provided a lower level residential service) may temporarily get paid but could lead to takebacks when audited. Always code truthfully to the care given. Similarly, if patient was PHP but you bill inpatient days – that’s improper.
Use Updated Code Sets: Use the latest CPT/HCPCS codes – UHC disallows obsolete codes. For example, older H-codes like H0001 (assessment) might be accepted but if there’s a more standard code (90791 for psych diagnostic evaluation), better to use standard. Also, ensure correct units – for timed codes like H0038 per 15 min, calculate units accurately. Overstating units = overbilling.
Check Edits (NCCI): The National Correct Coding Initiative (NCCI) edits apply to Medicare and many private payers adopt similar logic. This means some codes can’t be billed together on same day or need modifiers. For example, you generally wouldn’t bill 90837 (therapy 60 min) and H0015 (IOP per day) same day (that’s duplicate). If you bill E/M and therapy same day, use modifier 25 on E/M or they might deny one as inclusive. UHC likely has automated edits for common issues. Use billing software or a coding consultant to ensure your claim doesn’t violate such edits.
Follow State and Federal Billing Laws: E.g., the No Surprises Act (if applicable) – mainly for emergency services or if patient can’t consent to OON charges. Usually doesn’t apply to scheduled addiction treatment unless emergency admission out-of-network. But be mindful in states with specific laws about OON billing or parity documentation. Always provide Advance Notice to patients if required when OON. For Medicaid, follow any specific code requirements unique to the state (like some require UA drug testing codes use state-specific codes).

By coding correctly and billing meticulously, you not only reduce denials but also expedite payment. UHC’s systems process clean, correct claims faster – sometimes within 10-15 days for electronic claims. Dirty claims (errors) can bounce around for weeks or months.

Key Takeaway: Align your billing with the treatment provided and UHC’s guidelines. Use the right codes (H0015 for IOP, H0035 for PHP, H0018/H0019 for residential, H0010/H0011 for detox, etc.), include necessary modifiers and info, and double-check everything before submission. This attention to detail in coding and billing, combined with all the prior steps (benefit verification, auth, documentation, etc.), will result in smooth reimbursement and fewer back-and-forths with UnitedHealthcare.

Conclusion:
Managing UnitedHealthcare coverage for addiction treatment is undoubtedly complex, but with the comprehensive approach outlined in this guide – from verifying benefits and obtaining prior authorizations, to meeting medical necessity criteria, navigating concurrent reviews, securing network contracts, and coding claims accurately – your facility can significantly improve its success with UHC. By staying proactive, organized, and informed about UHC’s processes and expectations, you can reduce administrative headaches, get reimbursed in a timely manner, and most importantly, ensure your patients receive the treatment they need with minimal disruption from insurance issues.

UnitedHealthcare insures millions, and their decisions can greatly impact your program’s operations and your patients’ recovery journeys. But armed with the insights and strategies provided here, administrative staff, billing specialists, and clinicians can confidently collaborate with UHC. This not only helps your bottom line but also fosters a smoother experience for patients, who can then focus on healing rather than insurance logistics.

Keep this guide as a reference and update your knowledge as policies evolve. With unparalleled depth in understanding UHC’s addiction treatment coverage, your facility will be well-positioned to thrive and continue delivering life-saving services to those in need.

References: UnitedHealthcare and Optum Provider Guidelines (Intensive Outpatient Program - UnitedHealthcare Community Plan of Tennessee Behavioral Health) (Inpatient and Outpatient Mental Health: OK, OR, TX, WA – UnitedHealthcare West Benefit Interpretation Policy) (How to Determine the Medical Necessity of Addiction Treatment Services for UnitedHealth Group, Inc — Behavehealth.com) (Join Our Network) ( Out-of-network registration | UHCprovider.com ) (HCPCS Code for Alcohol and/or drug services; sub-acute ... - AAPC) ([PDF] Magellan Standard Services Simplified Billing Codes) (Changes to Billing for Partial Hospitalization Programs and Intensive ...) (HCPCS Code for Self-help/peer services, per 15 minutes H0038) (HCPCS Code for Alcohol and/or drug services; methadone ... - AAPC) (Understanding HCPCS and CPT Billing Codes for Residential Addiction Treatment: H0017, H0018, H0019 — Behavehealth.com) (See inline citations throughout article for specific sourcing).