Advance and Admission Notification Requirements

It is important that you continue to consult and comply with all other protocols provided in the Administrative Guide.

  • Physicians, health care professionals and ancillary providers are responsible for providing Advance Notification should be submitted as far in advance as possible, but is required to be submitted at least 5 business days prior to the planned service date (unless otherwise specified with the Advance Notification List) with supporting clinical documentation, to allow enough time for coverage review. Advance Notification for home health services and durable medical equipment is required within 48 hours after the start of service. Submitting Advance Notification as early as possible is best.
  • It may take up to 15 calendar days to render a decision (14 calendar days for Medicare Advantage). Prioritization of case review is based on the specifics of the case, the completeness of the information received, CMS requirements, or other state or federal requirements. Time may be extended if additional information is needed
  • Acute Care Hospitals, Skilled Nursing Facilities and Acute Rehabilitation Facilities are responsible for Admission Notification for inpatient services even if the coverage approval is on file. Notification of each inpatient admission must be received within 24 hours after actual weekday admissions (or by 5:00 p.m. local time on the next business day if 24 hour notification would require notification on a weekend or federal holiday).   For weekend and federal holiday admissions, notification must be received by 5:00 p.m. local time on the next business day.
  • For information on submitting Admission Notifications electronically, please visit our Electronic Admission Notifications (278N) page

Notes: Failure to comply with the requirements described in greater detail below may result in claims being denied in whole or in part and, as required under your agreement with us, the Customer being held harmless.

For information regarding the following services visit the: Radiology, Cardiology, Oncology pages.

Advance Notification Lists
Empire Notification List for Medicare Prime Members Oct. 1, 2014 
Empire Plan DME Notification List Effective Oct. 1, 2014 
Medica Healthcare and Preferred Care Partners Prior Authorization Requirements 
Neighborhood Health Partnership Advance Notification Guide 
Neighborhood Health Partnership Advance Notification Guide effective Oct. 1 2017 
UnitedHealthcare Commercial Advance Notification/Prior Authorization Requirements 
UnitedHealthcare Medicare Solutions and UnitedHealthcare Community Plan-Medicare Notification/Prior Authorization Requirements 
UnitedHealthcare Mid-Atlantic Health Plan Notification/Prior Authorization Requirements 
UnitedHealthcare of the River Valley Advance Notification Procedure Codes 
UnitedHealthcare of the River Valley Advance Notification Procedure Codes effective Oct. 1 2017 
State Specific Variations from the Standard Notification Requirements for UnitedHealthcare Commercial Plans

Maryland Facility Variations

If prior authorization or Advance Notification is required for the requested elective inpatient procedure; it is the physician's responsibility to obtain the relevant approval. It is the responsibility of the facility to notify UnitedHealthcare within 24 hours (or the following business day if the admission occurs on a weekend or holiday) of the elective admission.  If the physician has obtained prior authorization or Advance Notification, the initial day of the inpatient admission will be paid unless:

  1. The information submitted to UnitedHealthcare regarding the service to be delivered to the patient was fraudulent or intentionally misrepresentative;
  2. Critical information requested by UnitedHealthcare regarding the service to be delivered to the patient was omitted such that UnitedHealthcare's determination would have been different had it known the critical information;
  3. A planned course of treatment for the patient that was approved by UnitedHealthcare was not substantially followed by the provider; or
  4. On the date the preauthorized or approved service issued through Advance Notification was delivered the member was not covered by UnitedHealthcare and the provider could have verified the member's eligibility status by utilizing UnitedHealthcare's automated eligibility verification system (VETTS) or by accessing 24 hours a day, seven days a week. Note that the online verification must indicate that the member is not covered by UnitedHealthcare.

If Advance Notification is obtained and Admission Notification is not made by the facility in a timely manner, payment reductions will be limited to hospital room and board charges when applicable.

Washington Facility Variations

Effective May 1, 2014, Washington hospitals and other acute inpatient facilities are subject to the Admission Notification requirements described in the Guide. For acute inpatient facility admissions prior to May 1, 2014, and any skilled nursing facility admission, admission notification is required 5 days in advance of the planned admission, and by 5 p.m. the next business day for any unplanned admission.