This protocol applies to commercial members and Medicare Advantage (MA) members. It does not apply to the following commercial or MA 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.
The following plans are aligned with delegated medical groups/IPAs and must follow the delegate’s protocols.
This protocol applies to all participating care providers who order or render any of the following cardiology procedures:
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:
Cardiology procedures done in and appropriately billed with any of the following places of service do not require notification/prior authorization:
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.
Ordering Care Provider
The care provider ordering the cardiac procedure must contact us prior to scheduling the procedure. Once we receive procedure notification and if the member’s benefit plan requires medical necessity to cover services, we conduct a clinical coverage review, based on 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:
Non-participating care providers 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:
Medicare Advantage benefit plans and certain commercial benefit plans require covered services be medically necessary.
If the member’s plan requires covered services to be medically necessary, 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 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 covered health services to be medically necessary.
If the member’s benefit plan does not require covered health services to be medically necessary and:
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, or Medicare Preclusion List), and Medicare Advantage guidelines require it.
Payment for covered services depends upon:
The ordering care provider may make an urgent request for a notification/prior 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.
If the ordering care provider determines that a cardiac procedure is medically required on an urgent basis, and the ordering care provider cannot request a notification/prior authorization number because it is
outside of our normal business hours, they must make a retrospective notification/authorization request using the following guidelines:
Request the retrospective review by calling 866-889-8054, in accordance with the process described below:
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 covered health services be medically necessary, 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 does not participate in our network, and is unwilling to complete the notification/prior authorization process, the rendering care provider is required to complete the notification/prior authorization process.
The rendering care provider must verify we have issued a coverage decision based on 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 and:
If the member’s benefit plan does require services to be medically necessary to be covered and:
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/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.