UnitedHealthcare Expands Prior-Authorization Requirement for Certain Office-Based Procedures Performed in Other Sites of Service

July 2017 ~

Beginning October 1, 2017, UnitedHealthcare (UHC) will require notification/prior authorization for certain procedures when performed in any setting other than a physician’s office.

UHC will require notification/prior authorization for the following procedures when performed in any setting other than a physician’s office and when performed in a physician’s office, place of service code 11, with an accompanying facility charge – effective for dates of service on or after Oct. 1.

• Dermatologic
  • CPT Codes: 10120, 10140, 11400, 11401, 11404, 11420, 11421, 11423, 11424, 11426, 11442, 11606
• Gastroenterology
  • CPT Codes: 45300, 45330, 46922
• General Surgery
  • CPT Code: 19000
• Muscular/Skeletal
  • CPT Code: 64520
• Obstetrics/Gynecology
  • CPT Code: 57460
• Urology
  • CPT Code: 55250
• Vascular
  • CPT Codes: 36473, 36475, 36478

These requirements apply to the following UHC Commercial plans, including Exchange plans, in states where we already conduct site of service medical necessity reviews.

• Golden Rule Insurance Company (group 902667)
• Mid-AtlanticMD Healthplan Individual Practice Association, Inc. (M.D. IPA) or Optimum Choice, Inc. plans
• UnitedHealthcare of the River Valley
• UnitedHealthcare Oxford
• UnitedHealthcare
• UnitedHealthcare Life Insurance Company (group 755870)

According to the insurer, when the prior authorization/notification request is received, UHC will then determine if the member’s benefit plan requires covered services to be medically necessary. If so, UHC will evaluate the medical necessity of the site of service as part of the prior authorization process. Coverage determinations will take into account whether the patient has a need for more intensive services and whether the office has the equipment needed to deliver the service.

UHC notes that while notification/prior authorization is not required for these procedures to be covered in a physician’s office, notification/prior authorization is required if there is an accompanying facility charge. If billing for a site of service other than a physician’s office without following the notification/prior authorization process, claims will be denied. Members can’t be billed for services that are denied due to failure to comply with notification/prior authorization requirements.

For more information on this update, see UHC’s Policies, Protocols and Guides page.

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Source(s): UnitedHealthcare;