UHC Participating Provider Laboratory and Pathology Protocol Update

May 2019 ~

Effective June 1, more network care providers will be required to obtain consent from UnitedHealthcare (UHC) or UnitedHealthcare Oxford members before referring them to or using out-of-network laboratories and pathologists for their care.

UHC’s Participating Provider Laboratory and Pathology Protocol were originally implemented in September 2016 for UnitedHealthcare commercial and Exchange members with groups located in Delaware, New York, Oklahoma, Pennsylvania, and Texas. Effective June 1, 2019, the insurer will also apply this policy to UnitedHealthcare commercial members in Connecticut and Maryland*.

As of June 1, participating care provider in the identified states will be required to inform UHC commercial plan members when referring them to or including an out-of-network care provider in that member’s care plan. According to the insurer, the enforcement of this protocol is intended to help that disclosure process and save members potential costs from using an out-of-network care provider.

Affected Services

  • Specimens collected in the office and sent to an out-of-network laboratory or pathologist for processing
  • Providing a member with a prescription, requisition or other form to obtain laboratory or pathology services outside your office

UHC Points to Remember

  • For each episode of care, providers will need to submit a separate Laboratory and Pathology Services Consent Form, unless the occurrence is part of an ongoing monitoring procedure.
  • Each form is only valid for 15 days from the date of signature unless the “Ongoing Monitoring” box is selected, in which case the form is valid for one year from the date of signature.
  • If the member indicates on the consent form that they choose to use an out-of-network laboratory or pathologist and:
    • If the member has out-of-network benefits, then the out-of-network laboratory/pathology claim will be processed according to the member’s out-of-network benefits under the member’s plan and any out-of-network cost shares will apply.
    • If the member does not have out-of-network benefits, then the member will be responsible under their plan for the costs of the out-of-network laboratory/pathology services.
  • If a provider does not send us a signed copy of the form showing the member has consented to the use of an out-of-network laboratory or pathologist within 15 days of request), then UHC will reverse the claim for the Evaluation & Management (E&M) service from the office visit that generated the out-of-network laboratory or pathology service, and administratively deny the claim for non-compliance with this protocol. If UHC has made any previous payments for the E&M service, that amount will be subject to recovery (and the provider may not bill the member for such amount).
  • If a provider collects specimens in the office and uses a network laboratory or pathologist for processing, this protocol will not apply.
  • Use of network laboratories and pathologists is always required, with the exceptions of services authorized by us or a payer, or those provided in emergency situations.

*For Maryland Only

The Participating Provider Laboratory and Pathology Protocol does not apply to claims for services arising under plans underwritten by MAMSI Life and Health Insurance Company, MD-Individual Practice Association, Inc. or Optimum Choice, Inc.

For more details about these changes, view UHC’s Participating Provider Laboratory and Pathology Protocol FAQs, here.



Source(s): UnitedHealthcare Network Bulletin;