In an effort to reduce member cost and improve transparency, we’ve created, subject to state regulatory approval, Designated Diagnostic Provider benefit designs. For fully insured commercial plan members, outpatient laboratory services will covered at the highest tier when delivered by freestanding or hospital lab providers who meet certain quality and efficiency requirements.
Designated Diagnostic Providers are designed to support our members in choosing cost-effective and high-value care providers. Beginning on July 1, 2021 in select state markets, and subject to state regulatory approval, outpatient diagnostic lab services will covered at the highest tier for members with UnitedHealthcare Designated Diagnostic Provider benefit designs if delivered by Designated Diagnostic Providers. Services may not be covered and your patients could be responsible for payment if performed by providers who are not designated. UnitedHealthcare will build out access as necessary to help ensure all members and physicians have access to Designated Diagnostic Providers.
Non-Designated Diagnostic Providers will remain in network with UnitedHealthcare, but outpatient diagnostic lab services will deny as non-covered for members with Designated Diagnostic Provider benefit designs and your patients may be liable for charges. The Designated Diagnostic Provider benefit designs will not apply to lab services rendered as part of inpatient admissions, emergency room visits or outpatient surgery pre-operation testing that is billed as part of a global surgical package.
We are continuing our work toward the Triple Aim of better care, better health and lower costs for UnitedHealthcare members. Designated Diagnostic Provider benefit designs are intended to maximize member benefits for lab services and ensure laboratory services are performed by providers that meets both efficiency and quality requirements.
When you help your patients choose health care services that are high quality with less cost, they are more likely to get needed care and be more engaged in improving, maintaining and managing their health. Together, we can make the health system work better for everyone by consistently promoting cost-effective lab locations that deliver safe, high-quality care.
To become a lab Designated Diagnostic Provider and participate in the benefit designs, you need to meet certain quality and efficiency requirements. You can verify your lab Designated Diagnostic Provider status by contacting your dedicated network representative.
In support of these new benefit designs, you will work with your dedicated network representative.
For Designated Diagnostic Provider benefit designs and subject to state regulatory approval, outpatient diagnostic lab services will be covered at the highest available tier for members when delivered by Designated Diagnostic Providers. To participate, you must meet certain quality and efficiency requirements as follows:
We will have an icon in our directories that identifies Designated Diagnostic Providers.
To check member eligibility, you can use our Eligibility and Benefits feature directly within your EMR using Point of Care Assist or on Link. Both give you instant access to the latest eligibility and benefits information in real time without needing to pick up the phone. Within Link, you can also check coverage dates, policy information and detailed benefit information, as well as access digital ID cards.