These programs support the consistent use of evidence-based, professional guidelines for cardiology procedures. They were designed with the help of physician advisory groups to encourage appropriate and rational use of cardiology services. Using them helps reduce risks to patients and improves the quality, safety and appropriate use of cardiac procedures.
Notification/prior authorization may be required for the following procedures in the service locations indicated.
Electrophysiology Implants: Required for outpatient, inpatient and office visits. Not required for emergency room, urgent care center or observation.
Diagnostic Catheterization, Echocardiogram*, Stress Echocardiogram: Required for outpatient and office visits. Not required for inpatient, emergency room, urgent care center or observation.
*Note: For Medicare Advantage benefit plans, prior authorization is not required for echocardiograms.
These requirements apply to all providers subject to the UnitedHealthcare Administrative Guide. To review the complete protocol, please refer to the Cardiology Notification/Prior Authorization Protocol section in that guide.
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This program is effective in Arizona, Kentucky, Maryland, Mississippi. Missouri, New Jersey, New York, Pennsylvania, Rhode Island, Tennessee, Texas, Virginia and Washington.
The following Commercial resource materials are inclusive of UnitedHealthcare River Valley and NHP membership.
When you notify us of a planned service that is subject to the protocol, we’ll conduct a clinical review to decide if the service is medically necessary and covered, and will let you know our decision.
If the member's benefit plan does not require a clinical review and the service does not meet clinical guidelines, or if additional information is needed, we’ll let you know if you need to have a physician-to-physician discussion.
Resources materials are included in the Commercial tab above.
Resources materials are included in the Commercial tab above.