UnitedHealthcare Prior Authorization Process
UnitedHealthcare Prior Authorization: Overview
UnitedHealthcare requires prior authorization for 890+ procedure codes, medications, and services. Authorization confirms that a service is medically necessary and covered under the member's plan before delivery. Submission through uhcprovider.com or Link platform typically returns decisions within 24–72 hours for urgent cases and 5–7 business days for routine requests.
Key Requirements
- Patient insurance identification with active policy effective date.
- Procedure or service code (CPT, HCPCS, or diagnosis code depending on service type).
- Clinical documentation supporting medical necessity (clinical notes, test results, imaging).
- Provider credentials and NPI for the requesting provider.
- Diagnosis codes (ICD-10) linking condition to requested service.
- For medications: pharmacy name and requested drug name/strength/quantity.
Timeline & Process
- Submit authorization request: Log into uhcprovider.com, select "Prior Authorization," enter patient and procedure details, attach clinical documentation. Typical submission time: 10–15 minutes.
- Initial review: UnitedHealthcare reviews within 24–72 hours for urgent (72-hour turnaround required for urgent reviews).
- Receive decision: Check provider portal for approval status, denial code, or conditional approval.
- Proceed or appeal: If approved, submit claim within UnitedHealthcare timelines. If denied, request reconsideration or file appeal.
Common Denials
| CARC Code | Reason | Action |
|---|---|---|
| PR-1 | Prior authorization not obtained | Resubmit with completed authorization from UnitedHealthcare. |
| CO-16 | Claim lacks required documentation | Attach clinical notes, imaging, or lab results supporting medical necessity. |
| CO-50 | Service not covered (out-of-network or excluded) | Verify benefit eligibility and service inclusion in plan. |
| CO-197 | Non-covered service (carve-out or behavioral/dental) | Check plan summary for service inclusion; contact member about out-of-pocket costs. |
Appeal Process
File reconsideration within 12 months of the EOB date with new or additional clinical information. Reconsideration typically resolves within 5 business days. If reconsideration is denied or insufficient, escalate to formal appeal. Formal appeal must be submitted within 12 months of EOB. Include clinical rationale, peer-reviewed literature, and any new test results. UnitedHealthcare responds within 30 days for routine appeals and 72 hours for urgent appeals.
Common Questions
Can prior authorization be submitted via the Link platform?
Yes. UnitedHealthcare accepts prior authorization through both uhcprovider.com and the Link platform. Both channels return decisions in the same timeframe.
What happens if prior authorization is denied?
You can request reconsideration with new clinical information or file a formal appeal within 12 months of the denial. If the service is still deemed non-covered, the patient becomes financially responsible.
Is prior authorization required for all procedures?
No. Only certain procedures, medications, and services require prior authorization. Check the member's plan documents or log into the provider portal to verify requirements for specific codes.
Altair checks UnitedHealthcare requirements before submission . flagging missing authorizations and coding mismatches in real time. See how Altair works.
This reference is for informational purposes. Payer policies change frequently. Always verify against UnitedHealthcare's current provider documentation. Last updated: 2026-03-16.