UnitedHealthcare (UHC) is the largest commercial health insurer in the United States, covering over 50 million members. UHC prior authorization requirements are among the most complex in the industry, with extensive clinical documentation needed for advanced imaging, surgical procedures, and specialty medications.
The UnitedHealthcare provider portal allows providers to submit prior authorization requests, check claim status, and verify member eligibility. Many providers also use Availity or Optum as intermediary portals for UHC prior auth submissions.
UnitedHealthcare requires prior authorization for most advanced imaging (MRI, CT, PET), many surgical procedures, specialty drugs, and durable medical equipment. Their PA process often involves clinical review through eviCore or Optum, which applies evidence-based guidelines to evaluate medical necessity.
UnitedHealthcare uses eviCore (now part of Evernorth) for advanced imaging prior authorizations. Providers must demonstrate medical necessity using specific clinical criteria. Common imaging studies requiring PA include MRI, CT with contrast, PET scans, and nuclear cardiology studies. Routine X-rays and screening mammograms are generally exempt.
Submit clinical documentation upfront. Incomplete submissions are the #1 cause of delays and denials with UHC.
Use the correct CPT and ICD-10 codes on the initial submission to avoid rework.
For imaging, reference the eviCore clinical guidelines to ensure your documentation meets their criteria before submitting.
Track PA expiration dates. UHC authorizations typically expire after 60-90 days.
For urgent cases, request expedited review and clearly document the clinical urgency.
Verify whether the member's plan routes through Optum or eviCore, as the submission process differs.
Greenlight Medical submits prior authorizations directly to UnitedHealthcare, assembles all required documentation, and tracks status in real time. No portal logins, no phone holds, no fax machines.
See Greenlight in ActionYou can submit PA requests through the UnitedHealthcare provider portal, Availity, or by phone. For advanced imaging, requests are routed through eviCore. Greenlight Medical automates this entire process, detecting orders, assembling clinical documentation, and submitting directly to the correct UHC portal.
Standard PA requests are typically reviewed within 5-7 business days. Urgent requests may be processed within 24-72 hours. However, incomplete submissions can extend timelines significantly. Greenlight ensures complete submissions on the first attempt to minimize delays.
UHC provides a denial reason and instructions for appeal. You can submit a peer-to-peer review request or a formal appeal with additional documentation. Greenlight automatically prepares appeal-ready documentation when a denial occurs.
Yes, UnitedHealthcare generally requires prior authorization for MRI studies. Requests are processed through eviCore, which evaluates medical necessity based on clinical guidelines. The specific requirements vary by plan and body region being imaged.
CT scans with contrast and advanced CT studies typically require prior authorization through UnitedHealthcare. Routine CT scans without contrast may not require PA depending on the member's plan. Always verify requirements for the specific CPT code and plan.