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Insurer Playbook

UnitedHealthcareDenial patterns and how to appeal

Also known as: UHC, United, UnitedHealth, UnitedHealthcare, Optum

EmployerIndividualMedicare AdvantageMedicaid

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Known denial patterns

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Appeal best practices

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Points to check

Common Denial Patterns

  • Medical necessity denials citing InterQual criteria
  • Prior authorization denials for imaging and specialty referrals
  • Step therapy requirements for specialty medications
  • Out-of-network denials for services with in-network alternatives

Appeal Best Practices

  1. 1Reference the specific UHC clinical policy number in your appeal
  2. 2If ERISA governs the plan, request all documents and records relevant to the claim, including the clinical criteria used
  3. 3Ask for peer-to-peer review between your doctor and UHC reviewer
  4. 4Submit appeal via certified mail with return receipt
  5. 5Include a cover letter summarizing all attached evidence

Points to Check

  • Clinical policies are public — compare denial language to published criteria
  • Medical necessity reviewers may not be same specialty as treating provider — flag this
  • Compare the InterQual criteria the denial cites with current clinical guidelines, and cite broader evidence where they differ

Contact & Response

Best Contact Method

Member portal > Fax > Certified mail

Typical Response Time

30 days (internal), 45 days (external)

Internal Criteria Used

  • InterQual
  • UHC Clinical Policies

State-Specific Notes

CA

CA Department of Insurance has additional consumer protections

NY

NY DFS has independent external review process

TX

TX DOI has expedited complaint process

General Tips

  • UHC publishes clinical policies online — reference the specific policy in your appeal
  • Peer-to-peer reviews are often available — request one through the provider
  • UHC uses InterQual criteria for medical necessity — ask for the specific criteria applied
  • Appeals can be submitted via the member portal, fax, or mail
  • For Medicare Advantage, a written reconsideration request to the plan within 60 days of receiving the notice is enough; no CMS form is required.

Built for UnitedHealthcare

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This is general guidance compiled by Lysco. Check it against your plan documents and the notice you received, which set the rules for your appeal. It does not constitute legal, medical, or financial advice. Individual results vary. Verify all information independently and consult qualified professionals before acting.