Important Changes to and Expansion of Radiology and Cardiology Notification and Prior Authorization Protocols — Effective July 1, 2013
United Healthcare Commercial Plan – Beginning July 1, 2013:
United Healthcare’s existing Outpatient Radiology Notification Protocol and Cardiology Notification Protocol will include a prior authorization requirement when a United Healthcare Commercial member’s benefit document requires health services to be medically necessary in order to be covered. For those members, after you notify United Healthcare of a planned service subject to the protocols, we will conduct a clinical coverage review to determine whether the service is medically necessary. You will be informed of the decision. You do not need to determine whether a clinical coverage review is required in a given case or for a given member because once you notify us of a planned service we will let you know whether a clinical coverage review is required.
Radiology prior authorization – Beginning July 1, 2013:
Ordering providers that are subject to United Healthcare’s Physician, Health Care Professional, Facility and Ancillary Provider 2013 Administrative Guide for Commercial and Medicare Advantage Products (Administrative Guide) must notify United Healthcare prior to scheduling certain CT, MRI/MRA, PET scan, nuclear medicine and nuclear cardiology procedures for United Healthcare Commercial members. The advanced imaging procedures requiring advance notification are referred to as Advanced Outpatient Imaging Procedures. For a complete list of CPT codes requiring notification, please refer to 2013 Radiology Prior Notification/Authorization CPT Code List by clicking here.
Once advance notification of a planned Advanced Outpatient Imaging Procedure is received, United Healthcare will conduct a clinical coverage review to determine whether the service is medically necessary if the member’s benefit document requires health services to be medically necessary in order to be covered. If the member’s benefit document does not require clinical coverage review to determine medical necessity, and if the service does not meet evidence-based clinical guidelines, or if additional information is needed, we will let you know whether you must engage in a physician-to-physician discussion.
Rendering providers that are subject to the Administrative Guide must confirm that the prior authorization process has been completed and a coverage decision has been issued before rendering any Advanced Outpatient Imaging Procedure. If the ordering provider does not participate in United Healthcare’s network and is unwilling to complete the prior authorization process, the rendering provider must complete the prior authorization process and verify that a coverage decision has been issued prior to rendering the Advanced Outpatient Imaging Procedure.
Providers are not required to notify United Healthcare of any advanced imaging procedures rendered in an emergency room, urgent care center, observation unit or during an inpatient stay.