UnitedHealthcare® West Benefit Interpretation Policies

Please read the terms and conditions below carefully.

UnitedHealthcare has developed Benefit Interpretation Policies to assist us in administering health benefits. These policies are provided for informational purposes, and do not constitute medical advice. Treating physicians and health care providers are solely responsible for determining what care to provide to their patients. Members should always consult their physician before making any decisions about medical care.

Benefit coverage for health services is determined by the member specific benefit plan document, such as an Evidence of Coverage or Schedule of Benefits, the Employer's Group Subscriber Agreement, and applicable laws that may require coverage for a specific service. The member specific benefit plan document identifies which services are covered, which are excluded, and which are subject to limitations. In the event of a conflict, the member specific benefit plan document supersedes these policies.

Our Benefit Interpretation Policies are based upon: (1) federal and/or state laws and regulations which may be applicable to UnitedHealthcare® West; and (2) research, studies, and evidence from other sources (including, but not limited to, the Food and Drug Administration). Benefit Interpretation Policies assist healthcare providers in making coverage determinations, but do not replace an individualized case-by- case review and medical necessity determination for each UnitedHealthcare® West member. All services rendered must be medically necessary as determined by the member's provider. All services rendered must be referred and authorized by the member's provider (unless specifically stated in the member specific benefit plan documents).

For California members, note that the materials provided to you are guidelines used by this plan to authorize, modify, or deny care for persons with similar illnesses or conditions. Specific care and treatment may vary depending on individual need and the benefits covered under your contract.

Benefit Interpretation Policies are developed as needed, are regularly reviewed and updated, and are subject to change. They represent a portion of the resources used to support UnitedHealthcare coverage decision making. The information presented in these policies is believed to be accurate and current as of the date of publication, and is provided on an "AS IS" basis.

Benefit Interpretation Policies are the property of UnitedHealthcare. Unauthorized copying, use and distribution of this information are strictly prohibited. Health Plan coverage is provided by or through UnitedHealthcare of California, UnitedHealthcare Benefits Plan of California, UnitedHealthcare of Oklahoma, Inc., UnitedHealthcare of Oregon, Inc., UnitedHealthcare Benefits of Texas, Inc., and UnitedHealthcare of Washington, Inc.

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