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Outpatient Radiology 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 benefit plans. The following benefit plans may have separate radiology 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 groups
  • 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 - 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)
  • Senior Dimensions Medicare Advantage Plans (Health Plan of Nevada)
  • UnitedHealthcare Medicare Direct (PFFS)

This applies to all participating care providers that order or render any of the following advanced imaging procedures:

  • Computerized Tomography (CT)
  • Magnetic Resonance Imaging (MRI)
  • Magnetic Resonance Angiography (MRA)
  • Positron-Emission Tomography (PET)
  • Nuclear Medicine
  • Nuclear Cardiology

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

An advanced imaging procedure for which notification/ prior authorization is required is called an ‘Advanced Outpatient Imaging Procedure’.

Notification/prior authorization is required for outpatient and office-based services only.

Advanced imaging 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 stay.

If you do not complete the entire notification/prior authorization process before you do the procedure, we will reduce or deny the claim. Do not bill the member for denied claims 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/Radiology > Specific Radiology Programs. Please note that for MA benefit plans, prior authorization is not required for CT, MRI, or MRA.

Prior Authorization and Notification Process for Advanced Outpatient Imaging Procedures

Ordering Care Provider

The care provider ordering the Advanced Outpatient Imaging 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. Once we receive notification, we will let you know if we require a clinical coverage review.

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/Radiology; 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/link (once registered) or by calling 866-889-8054.

We may request this 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) 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, including 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

MA 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 and:

  • 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 let the ordering care provider know what we need from them. This includes whether we require a physician-to-physician discussion.
  • If we require a physician-to-physician discussion, you must complete that process to help ensure eligibility to receive payment. Upon completion of the discussion, 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 MA 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 Advanced Outpatient Imaging 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 start date for the 45-day period in which you must perform the procedure. 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 an Advanced Outpatient Imaging 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 within two business days after the date of service. Request the retrospective review by calling 866-889-8054, in accordance with this process:

  • Documentation must explain why:
    • The procedure must be done on an urgent basis
    • You could not request a notification/authorization number w during our normal business hours
  • Once we receive retrospective notification of an Advanced Outpatient Imaging Procedure, and if the member’s benefit plan requires services to be medically necessary to be covered, we conduct a clinical coverage review to determine medical necessity. If we determine the service was not medically necessary, we issue a denial and do not issue an authorization number. The member and care provider receive a denial notice outlining the appeal process.
  • Once we receive retrospective notification of an Advanced Outpatient Imaging 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 let the ordering care provider know if they must have a physician-tophysician 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 confirms the procedure ordered and we issue a notification number.

Rendering Care Provider

Prior to performing an Advanced Outpatient Imaging Procedure, the rendering care provider must confirm that 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 that 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 also need to verify that we issued a coverage d 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 we issued a coverage determination.

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

  • If you render an Advanced Outpatient Imaging Procedure and you 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 procedures 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 and:

  • If you determine we did not issue 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 did not issue a coverage determination and the ordering care 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 issued a coverage decision prior to rendering the service.
  • If you provide the service before we issue a coverage decision, we deny or reduce your claim payment. You cannot bill the member for the service in this instance.
  • Services that are not medically necessary the member’s benefit plan does not cover. 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.

Provision of an Additional or Modified Advanced Outpatient Imaging Procedure

If, during the delivery of an Advanced Outpatient Imaging Procedure, the rendering care provider determines that an additional Advanced Outpatient Imaging Procedure should be delivered above and beyond the service(s) for which a notification/prior authorization number has already been obtained, the ordering care provider must request a new notification/prior authorization number prior to rendering the additional service, in accordance with this protocol.

If, during the delivery of an Advanced Outpatient Imaging Procedure for which the care provider completed the notification/prior authorization processes, the physician modifies the Advanced Outpatient Imaging procedure, and if the CPT code combination is not on the CPT Code Crosswalk Table, then follow this process:

  • Contiguous body part – if the procedure is for a contiguous body part, the ordering or rendering care provider must modify the original notification/ authorization number request online or by calling within two business days after rendering the procedure.
  • Non-contiguous body part – if the procedure is not for a contiguous body part, the ordering care provider must submit a new notification/authorization number request and must have a coverage determination prior to rendering the procedure.

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 UnitedHealthcare Radiology Notification/Prior Authorization Crosswalk Table available online at UHCprovider.com/Radiology > Specific Radiology Programs.

For code combinations not listed on the UnitedHealthcare Radiology Notification /Prior Authorization Crosswalk Table, you must follow the Radiology Notification/Prior Authorization Protocol process.