Outpatient radiology 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 radiology notification or prior authorization requirements. Refer to Chapter 1: Introduction for additional supplements or health care provider guides that may be applicable.

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
• 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. Note: 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 before scheduling the procedure. Once we receive procedure notification and if the member’s benefit plan requires covered health services to be medically necessary, 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. 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, UnitedHealthcare Oxford Navigate Individual, All Savers, UnitedHealthcare Level Funded, UnitedHealthcare Oxford Level Funded, Neighborhood Health Partnership, UnitedHealthcare of the River Valley, commercial and MA benefit plans subject to this protocol: UHCprovider.com/radiology; select the Go to Prior Authorization and Notification tool.
• Phone: 1-866-889-8054

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 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) 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 covered health services to be medically necessary.

If the member’s plan requires covered services to be medically necessary, and if the service is 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 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, 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.

Notification or authorization number receipt 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 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
• 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 starting date for the 45-day period 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/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 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 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, the ordering care provider must make a retrospective notification/prior authorization request within 2 business days after the date of service. Request the retrospective review by calling 1-866-889-8054, based on the following process:

• Documentation must explain why:
  • The procedure must be done on an urgent basis
  • You could not request a notification/authorization number 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-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 confirms the procedure ordered and we issue a notification number.

Rendering care provider

Before 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 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 that we have issued a coverage decision in accordance with this protocol, before 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 covered services be medically necessary 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.
• Determine there is no notification number on file, and the ordering care provider participates in our network, we use reasonable efforts to urge the ordering care provider to complete the notification process and obtain a notification number before rendering services.
• 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.
• 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 covered services be medically necessary 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 before rendering services.
• If you determine we did not issue 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 issued a coverage decision before rendering service.
• If you provide the service before we issue a coverage decision, 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.

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 an additional advanced outpatient imaging procedure should be delivered above and beyond the approved service(s) assigned a notification/ prior authorization number, then the ordering care provider must request a new notification/prior authorization number before rendering the additional service, based on 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 2 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 before 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.