Outpatient cardiology notification/prior authorization protocol- Chapter 7, 2021 UnitedHealthcare Administrative Guide

This protocol applies to commercial members and 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.

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
• 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. Note: For MA 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 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:

• Online: UnitedHealthcare, UnitedHealthcare West, UnitedHealthcare Oxford Navigate Individual, All Savers, UnitedHealthcare Level Funded, UnitedHealthcare Oxford Level Funded, Neighborhood Health Partnership, 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 tool.
• Phone: 1-866-889-8054

Non-participating care providers provide notification, and complete the prior authorization process if applicable, either through UHCprovider.com (once registered), or by calling 1-866-889-8054. 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 plan 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.

MA 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:

• 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. 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, or Medicare Preclusion 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.
• The care provider’s participation with UnitedHealthcare.

The notification/prior authorization number is valid for 45 calendar days. It is specific to the cardiac procedure requested, to be performed 1 time, for 1 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/prior authorization number if they determine the service is medically urgent. Make urgent requests by calling 1-866-889-8054. The ordering care provider must state that the case is clinically urgent and explain the clinical urgency. We respond to urgent requests within 3 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 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:

• Within 2 business days of the date of service for:
  • Echocardiograms
  • Stress echocardiograms
• Within 15 calendar days of the date of service for:
  • Diagnostic catheterizations
  • Electrophysiology implants

Request the retrospective review by calling 1-866-889-8054, 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 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 online address or phone number 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 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 urge the ordering care provider to complete the notification process and obtain a notification number 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 and:
• 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 may deny or reduce your claim payment. You cannot bill the member for the service in this instance.
• Services 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 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/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.