Outpatient Cardiology Notification/Prior Authorization Protocol - Chapter 6, 2018 UnitedHealthcare Administrative Guide

This protocol applies to commercial members and Medicare Advantage (MA) members. It does not apply to the following commercial or Medicare Advantage benefit plans, or other benefit plan types including Medicaid, CHIP, or uninsured benefit plans. The following benefit plans may have separate cardiology notification or prior authorization requirements. Refer to Chapter 1: Introduction for additional supplements or health care provider guides that may be applicable.

  • UnitedHealthcare Options PPO: Care providers are not required to follow this protocol for Options PPO benefit plans because Members enrolled in these benefit plans are responsible for providing notification/requesting prior authorization. Exception: Care providers are required to follow this protocol for Options PPO benefit plans for members in Colorado. Colorado members are not responsible for providing notification or requesting prior authorization).
  • UnitedHealthOne – Golden Rule Insurance Company (“GRIC”) group number 705214 only
  • M.D.IPA, Optimum Choice, (See the Mid-Atlantic Regional Supplement), or OneNet
  • Oxford - USA, New Jersey Small Group, certain NJ public Sector groups, CT public Sector, Brooks Brothers (BB1627) and Weil, Gotshal and Manages (WG00101), any member at VAMC facility.
  • UnitedHealthcare Indemnity / Managed Indemnity
  • Benefit plans sponsored or issued by certain self-funded employer group
  • Florida: AARP® MedicareComplete® (HMO) - Group 82958, 82960, 82963, 82969, 82977, 82978; AARP® MedicareComplete® Focus (HMO) - Group 82970, 82980; AARP® MedicareComplete® Plan 2 - Group 82962; UnitedHealthcare® The Villages® Medicare Complete® 1 (HMO) - Group 82940; UnitedHealthcare® The Villages® Medicare Complete® 2 (HMO-POS) - Group 82971; AARP® MedicareComplete® Choice (Regional PPO) - Group 82955, 82956; AARP® MedicareComplete® Choice (PPO) - Group 82957
  • Hawaii: AARP® MedicareComplete Choice Plan 1 - Group 77000 & 77007 and AARP MedicareComplete Choice Essential - Group 77003 & 77008
  • Illinois: AARP® MedicareComplete® - Group 17243, 17244, 17245, 17246; AARP® MedicareComplete® Plan 1 - Group 18027,18028, 18029, 18030; AARP® MedicareComplete® Plan 2 - Group 55860; AARP® MedicareComplete® Access Group 55306, 55307, 55430, 55431
  • New York: AARP® MedicareComplete - Group 66093; AARP® MedicareComplete Plan 1 - Group 66074 &66091; AARP® MedicareComplete Plan 2 - Group 13012 & 66092; AARP® MedicareComplete Plan 3 - Group 66089; AARP® MedicareComplete Essential - Group 66075; AARP® MedicareComplete Mosaic - Group 66076
  • Existing process of obtaining authorization from Montefiore Care Management Organization (CMO) will continue.
  • Utah:AARP® MedicareComplete Plan 1 - Group 42000; AARP® MedicareComplete Plan 2 - Group 42022; AARP® MedicareComplete Essential - Group 42004; UnitedHealthcare Group Medicare Advantage - Group 42020; UnitedHealthcare® MedicareComplete Choice - Group 42023
  • Medica HealthCare: Medica HealthCare Plans MedicareMax (HMO) – Group 77700, 77701; Medica HealthCare Plans MedicareMax Plus (HMO SNP) – Group 77702, 77703, 77704.
  • Preferred Care Partners: Preferred Choice Broward HMO – Group 78601; Preferred Choice Dade (HMO) – Group 78600; Preferred Choice Palm Beach (HMO) – Group 78606; Preferred Medicare Assist (HMO SNP) – Group 78602, 78603, 78609; Preferred Medicare Assist Palm Beach (HMO SNP) – Group 78607, 78608, 78610; Preferred Special Care Miami-Dade (HMO SNP) – Group78605; Preferred Choice Broward HMO – Group 99791; Preferred Choice Dade (HMO) – Group 99790; Preferred Choice Palm Beach (HMO) – Group 99797; Preferred Medicare Assist (HMO SNP) – Group 99792, 99793, 99796; Preferred Medicare Assist Palm Beach (HMO SNP) – Group 99798, 99799, 99800; Preferred Special Care Miami-Dade (HMO SNP) – Group 99795.
  • For the Medica and Preferred Care Partners of Florida groups above, please refer to the Medica Healthcare and Preferred Care Partners for Prior Authorization Requirements located at UHCprovider.com > Prior Authorization and Notification > Advance Notification and Plan Requirement Resources - Plan Requirement Resources.
  • Erickson Advantage Plans
  • UnitedHealthcare Nursing Home and UnitedHealthcare Assisted Living Plans (HMO SNP), (HMO-POS SNP), (PPO SNP)
  • UnitedHealthcare Senior Care Options (HMO SNP)
  • Senior Dimensions Medicare Advantage Plans (Health Plan of Nevada)
  • UnitedHealthcare Medicare Direct (PFFS)

This protocol applies to all participating care providers who order or render any of the following cardiology procedures:

  • Diagnostic catheterizations
  • Electrophysiology implant procedures (including inpatient)
  • Echocardiograms
  • Stress echocardiograms

Notification/prior authorization is required for certain cardiology procedures listed above.

A cardiology procedure for which notification/prior authorization is required is referred to as a ‘Cardiac Procedure’.

Notification/prior authorization is required under this protocol only for these specified cardiology procedures:

  • Diagnostic catheterizations, echocardiograms and stress echocardiograms: notification/prior authorization is required only for outpatient and office-based services.
  • Electrophysiology implants: notification/prior authorization is required for outpatient, office-based and inpatient services.

Cardiology procedures done in and appropriately billed with any of the following places of service do not require notification/prior authorization:

  • Emergency room visits,
  • Observation unit,
  • Urgent care or
  • Inpatient stays (except for electrophysiology implants).

If you do not complete the entire notification/prior authorization process before you do the procedure, we will reduce or deny the claim. You cannot bill the member if claims are denied in this instance.

For the most current listing of CPT codes for which notification/prior authorization is required pursuant to this protocol, refer to UHCProvider.com/Cardiology - Specific Cardiology Programs. Please note for Medicare Advantage benefit plans, prior authorization is not required for echocardiograms.

Prior Authorization and Notification Process for Cardiac Procedures

Ordering Care Provider

The care provider ordering the cardiac procedure must contact us prior to scheduling the procedure. Once we receive notification of the procedure and if the member’s benefit plan requires health services to be medically necessary to be covered, we conduct a clinical coverage review, pursuant to our prior authorization process, to determine if the service is medically necessary. You do not need to determine if a clinical coverage review is required because once we receive notification, we will let you know if a clinical coverage review is required.

You must notify us, or request prior authorization, by contacting us:

  • Online: UnitedHealthcare, UnitedHealthcare West, UnitedHealthOne, All Savers, Neighborhood Health Partnership and UnitedHealthcare of the River Valley Commercial and Medicare Advantage benefit plans subject to this Protocol: UHCprovider.com/Cardiology; select the Go to Prior Authorization and Notification App.
  • Phone: 866-889-8054

Non-participating care providers can provide notification, and complete the prior authorization process if applicable, either through UHCprovider.com (once registered), or by calling 866-889-8054.

We may request the following information at the time you notify us:

  • Member’s name, address, phone number and date of birth
  • Member’s health care ID number and group number
  • The examination(s) or type of service(s) being requested, with the CPT code(s)
  • The working diagnosis with the appropriate ICD code(s)
  • Ordering care provider’s name, TIN/NPI, address, phone and fax number, and email address
  • Rendering care provider’s name, address, phone number and TIN/NPI (if different)
  • The member’s clinical condition, which may include any symptoms, treatments, dosage and duration of drugs, and dates for other therapies.
  • Dates of prior imaging studies performed.
  • Any other information the ordering care provider believes would be useful in evaluating whether the service ordered meets current evidence-based clinical guidelines, such as prior diagnostic tests and consultation reports.

Medicare Advantage benefit plans and certain commercial benefit plans require health services to be medically necessary to be covered.

If the member’s plan requires services to be medically necessary to be covered, and if the service is determined to be medically necessary, we issue an authorization number to the ordering care provider. To help ensure proper payment, the ordering care provider must communicate the authorization number to the rendering care provider.

If it is determined that the service is not medically necessary, we issue a clinical denial. If we issue a clinical denial for lack of medical necessity, the member and care provider receive a denial notice outlining the appeal process.

Certain commercial benefit plans do not require health services to be medically necessary to be covered.

If the member’s benefit plan does not require health services to be medically necessary to be covered:

  • If the service is consistent with evidence-based clinical guidelines, we issue a notification number to the ordering care provider.
  • If the service is not consistent with evidence-based clinical guidelines, or if we need additional information to assess the request, we will let the ordering care provider know what we need from them, including whether a physician-to-physician discussion is required.
  • If a physician-to-physician discussion is required, you must complete that process to help ensure eligibility to receive payment., Once the discussion is complete, the care provider confirms the procedure ordered and we issue a notification number. The purpose of the physician-to- physician discussion is to support the delivery of evidence-based health care by discussing evidence-based clinical guidelines. This discussion is not a prior authorization, pre-certification or medical necessity determination unless applicable state law dictates otherwise.

Receipt of a notification number or authorization number does not guarantee or authorize payment unless state regulations, (including regulations pertaining to a care provider’s inclusion in a sanction and excluded list and non-inclusion in the Medicare Provider Enrollment Chain and Ownership System (PECOS)* list), and Medicare Advantage guidelines require it. Payment for covered services depends upon:

  • Coverage with an individual member’s benefit plan,
  • The care provider being eligible for payment,
  • Claims processing requirements, and
  • The care provider’s participation with UnitedHealthcare.

The notification/authorization number is valid for 45 calendar days. It is specific to the Cardiac Procedure requested, to be performed one time, for one date of service within the 45-day period. When we enter a notification/authorization number for a procedure, we use the date we issued the number as the starting date for the 45-day period in which the procedure must be performed. If you do not do the procedure within 45 calendar days, you must request a new notification/authorization number. 

Urgent Requests during Regular Business Hours

The ordering care provider may make an urgent request for a notification or authorization number if they determine the service is medically urgent. Make urgent requests by calling 866-889-8054. The ordering care provider must state that the case is clinically urgent and explain the clinical urgency. We respond to urgent requests within three hours of our receipt of all required information.

Retrospective Review Process for Urgent Requests Outside of Regular Business Hours

If the ordering care provider determines that a Cardiac Procedure is medically required on an urgent basis, and they cannot request a notification/prior authorization number because it is outside of our normal business hours, they must make a retrospective notification/prior authorization request following the guidelines:

  • Within two business days of the date of service for:
    ›› Echocardiograms and
    ›› Stress echocardiograms.
  • Within 15 calendar days of the date of service for:
    ›› Diagnostic catheterizations and
    ›› Electrophysiology implants.

Request the retrospective review by calling 866-889-8054, in accordance with the process described below:

  • Documentation must explain why the procedure must be done on an urgent basis and why a notification/ authorization number could not have been requested during our normal business hours.
  • Once we receive retrospective notification of a Cardiac Procedure, and if the member’s benefit plan requires services to be medically necessary to be covered, we will conduct a clinical coverage review to determine whether the service is medically necessary. If we determine the service was not medically necessary, we will issue a denial and we will not issue an authorization number. The member and care provider will receive a denial notice outlining the appeal process.
  • Once we receive retrospective notification of a Cardiac Procedure and if the member’s benefit plan does not require services to be medically necessary to be covered:
    ›› We issue a notification number to the ordering care provider if the service is consistent with evidence-based clinical guidelines.
    ›› If the service is not consistent with evidence-based clinical guidelines, or if we need additional information to assess the request, we will let the ordering care provider know if they must have a physician-to-physician discussion to explain the request, to give us more clinical information, and to discuss alternative approaches. After the discussion is completed, the ordering care provider will confirm the procedure ordered and we will issue a notification number.

Rendering Care Provider

Prior to performing a Cardiac Procedure, the rendering care provider must confirm a notification/authorization number is on file. If the member’s benefit plan requires that health services be medically necessary to be covered, the rendering care provider must validate the prior authorization process has been completed and a coverage determination has been issued.

If the rendering care provider finds a coverage determination has not been issued, and the ordering care provider is not a participating care provider, and is unwilling to complete the notification/prior authorization process, the rendering care provider is required to complete the notification/prior authorization process. They must verify that we have issued a coverage decision in accordance with this protocol, prior to performing the service. Contact us at the phone number or online address listed in the Ordering Care Provider section above if you need to notify us, request prior authorization, confirm that a notification number has been issued or confirm whether a coverage determination has been issued.

If the member’s benefit plan does not require that services be medically necessary to be covered:

  • If you render a Cardiac Procedure and submit a claim without a notification number, we will deny or reduce payment. You cannot bill the member for the service in this instance.
  • If you determine there is no notification number on file, and the ordering care provider participates in our network, we use reasonable efforts to work with you to get the notification number from the participating ordering care provider prior to the rendering of services.
  • If you determine there is no notification number on file, and the ordering care provider does not participate in our network, and is not willing to obtain a notification number, you are required to obtain a notification number.
  • If you do not obtain a notification number for the procedure ordered by a non-participating care provider, we will deny or reduce payment for failure to provide notification. You cannot bill the member for the service in this instance.

If the member’s benefit plan does require services to be medically necessary to be covered:

  • If you determine we have not issued a coverage determination, and the ordering care provider participates in our network, we use reasonable efforts to work with you to urge the ordering care provider to complete the prior authorization process and obtain a coverage decision prior to the rendering of services.
  • If you determine we have not issued a coverage determination, and the ordering care provider does not participate in our network, and is not willing to complete the prior authorization process, you are required to complete the prior authorization process and verify that we have issued a coverage decision prior to rendering the service.
  • If you provide the service before a coverage decision is issued, we deny or reduce your claim payment. You cannot bill the member for the service in this instance.
  • Services that are not medically necessary are not covered under the member’s benefit plan. When we deny services for lack of medical necessity, we issue the member and ordering care provider a denial notice with the appeal process outlined. We do not issue an authorization number if we determine that the service is not medically necessary. We issue an authorization number to the ordering care provider if the service is medically necessary.

Crosswalk Table

You are not required to modify the existing notification/prior authorization request, or request a new notification/ prior authorization record for the CPT code combinations in the Cardiology Notification/Prior Authorization CPT Code List and Crosswalk table available online on UHCprovider.com/PriorAuth > Prior Authorization and Notification Resources > Cardiology - Specific Cardiology Programs.

For code combinations not listed on the Cardiology Notification/Prior Authorization CPT Code List and Crosswalk table, you must follow the Cardiology Notification/Prior Authorization Protocol process.