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UnitedHealthcare

Prior Authorization Requirements to be expanded for an outpatient hospital setting


For dates of service on or after Nov. 1, 2019, for most states, UnitedHealthcare is expanding notification/prior authorization requirements to include the procedures/CPT codes listed here

UnitedHealthcare will only require notification/prior authorization if these procedures/CPT codes are performed in an outpatient hospital setting. 

That will affect General Surgeons, Urologists, Podiatrists, Pain Management and other healthcare providers who perform surgeries in an outpatient hospital setting.

This change will take effect on or after Dec. 1, 2019, for California, Colorado, Connecticut, New Jersey, and New York. States excluded from this requirement are Alaska, Kentucky, Maryland, Massachusetts, and Texas. 

UnitedHealthcare will conduct a review to determine whether the site of service is medically necessary for the procedures/CPT codes listed in the link above. 

Site of service medical necessity reviews will also apply to procedures/CPT codes listed here, which are already subject to notification/prior authorization requirements. For these codes, you’ll need to submit a prior authorization request regardless of the site at which the procedure is being performed

The expanded notification/prior authorization requirements and site of service medical necessity reviews will apply to UnitedHealthcare commercial plans, except UnitedHealthcare Oxford, UnitedHealthcare West, and Sierra at this time

Source: https://www.uhcprovider.com/content/dam/provider/docs/public/prior-auth/Changes-Certain-Surgical-Procedures-Effective-11012019.pdf

There are also updates to UnitedHealthcare prior authorization requirements for Specialty Medical Injectable Drugs, please see pages 12- 19 at https://www.uhcprovider.com/content/dam/provider/docs/public/resources/news/2019/network-bulletin/October-2019-Network-Bulletin.pdf   

UnitedHealthcare 2019 summary of changes to Prior Authorization requirements can be viewed here 

Insights
October 2019