Exchange Plans: Prior Authorization and Site of Service Changes

Starting Aug. 1, 2021, for UnitedHealthcare Individual Exchange plans, we’re making changes to the prior authorization requirements and site of service medical necessity reviews for certain surgical and screening colonoscopy procedures. Here’s what’s changing:

Site of service medical review and prior authorization expansion

  • We’re expanding our prior authorization requirements and site of medical necessity reviews to include two screening colonoscopy procedures (HCPCS codes G0105 and G0121) if these procedures will be performed in an outpatient hospital setting
  • We’re implementing a new URG, Screening Colonoscopy Procedures- Site of Service Utilization Review Guideline, to support site of service medical necessity reviews for G0105 and G0121, as well as screening colonoscopy procedure/CPT® codes 45378, 45380, 45381, 45384 and 45385
    • These codes will continue to require prior authorization and will continue to be subject to site of service medical necessity reviews

Additional prior authorization changes starting Aug. 1, 2021

In addition to the changes listed above, certain CPT® or HCPCS codes will no longer require prior authorization starting Aug. 1, 2021. These changes also apply to UnitedHealthcare Individual Exchange plans.

More information is available in our Frequently Asked Questions:

Questions?

Call Provider Services at 800-666-1353.

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