Outpatient cardiology notification/prior authorization protocol - Chapter 7, 2022 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.

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  • UnitedHealthcare Options PPO: Health 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.
  • UnitedHealthOne – Golden Rule Insurance Company (“GRIC”) group number 705214 only
  • M.D.IPA, Optimum Choice, (See the Mid-Atlantic Regional Supplement), or OneNet PPO
  • 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.)
  • UMR and UnitedHealthcare Shared Services (UHSS)
  • UnitedHealthcare Indemnity / Managed Indemnity
  • Benefit plans sponsored or issued by certain self-funded employer groups

In some instances, we have delegated prior authorization services to a provider group. Call the number listed on the member’s ID card. If you are a network provider who is contracted directly with a delegated medical group/IPA, then you must follow the delegate’s protocols. Delegates may use their own systems and forms. They must meet the same regulatory and accreditation requirements as UnitedHealthcare. Delegated plans include:

  • Arizona: The following groups are delegated to OptumCare: AARP Medicare Advantage Choice Plan 1 (PPO) - Groups 92003, 92004; AARP Medicare Advantage Choice Plan 2 (PPO) - Groups 90024, 92007; AARP Medicare Advantage Patriot (PPO) - Groups 92008, 92015; AARP Medicare Advantage Plus (HMO-POS) - Groups 90108, 90109; AARP Medicare Advantage Walgreens Plan 1 (PPO) - Groups 90021, 92001, 92002; AARP Medicare Advantage Walgreens Plan 2 (PPO) - Groups 92005, 92006, 92009; AARP Medicare Advantage Walgreens Plan 3 (PPO) - Group 92010
  • Colorado: The following groups are delegated to OptumCare: AARP Medicare Advantage Choice Plan 1 (PPO) - Groups 90091, 90092, 90093, 90094; AARP Medicare Advantage Choice Plan 2 (PPO) - Groups 90097, 90133, 90134, 90135; AARP Medicare Advantage Choice Plan 3 (PPO) - Groups 90039, 90057; AARP Medicare Advantage Walgreens (PPO) - Groups 90095, 90096
  • Connecticut: The following groups are delegated to OptumCare: UnitedHealthcare Dual Complete (PPO D-SNP) - Group 09116; AARP Medicare Advantage Choice (Regional PPO) - Groups 90150, 90151; UnitedHealthcare Medicare Advantage Plan 1 (HMO) - Group 27062, 27151; UnitedHealthcare Medicare Advantage Plan 2 (HMO) - Group 27064, 27153; UnitedHealthcare Medicare Advantage Patriot (HMO) - Groups 27155, 27156; UnitedHealthcare Medicare Advantage Plan 3 (HMO) - Groups 27100, 27150, AARP Medicare Advantage Walgreens (PPO) - Group 90125
  • Florida: The following groups are delegated to WellMed: AARP Medicare Advantage (HMO) - Groups 82969, 90028; AARP Medicare Advantage (HMO-POS) - Groups 82980, 82958, 82960, 82977, 82978, 90073, 90078, 90079; AARP Medicare Advantage Focus (HMO-POS) - Groups 70341, 82970; AARP Medicare Advantage Plan 2 (HMO) - Group 82962; UnitedHealthcare The Villages Medicare Advantage 1 (HMO) - Group 82940; AARP Medicare Advantage Choice Plan 2 (Regional PPO) - Group 72811; AARP Medicare Advantage Choice Patriot (Regional PPO) Group 72790; AARP Medicare Advantage Choice (PPO) - Groups 70342, 70343, 70344, 70345, 70346, 70347, 70348, 80192, 80193, 80194, 90086, 90089; UnitedHealthcare Medicare Advantage Walgreens (HMO C-SNP) - Groups 95115, 95116, 95117, 95118
  • Florida: The following groups are delegated to WellMed Pf: Preferred Care Networks MedicareMax (HMO) Groups - 98151, 98152; MedicareMax Plus (HMO D-SNP) Groups - 98153, 98155; MedicareMax Plus 1 (HMO D-SNP) - 98154; MedicareMax Plus 2 (HMO D-SNP) Group - 90163; Preferred Choice Broward (HMO) Group - 99791; Preferred Choice Dade (HMO) Groups - 99790; Preferred Choice Palm Beach (HMO) Group - 99797; Preferred Complete Care (HMO) Groups - 98156; Preferred Medicare Assist Palm Beach (HMO D-SNP) Groups - 99798, 99799, 99800; Preferred Medicare Assist Plan 1 (HMO D-SNP) Groups - 99792, 99793, 99796; Preferred Medicare Assist Plan 2 (HMO D-SNP) Groups - 90030, 90061; Preferred Special Care Miami-Dade (HMO C-SNP) Groups - 99795
  • Hawaii: The following groups are delegated to MDX: AARP Medicare Advantage Choice (PPO) - Groups 77026, 77027; AARP Medicare Advantage Choice Plan 1 (PPO) - Groups 77000, 77007; AARP Medicare Advantage Choice Plan 2 (PPO) - Groups 77024, 77025; AARP Medicare Advantage Choice Patriot (PPO) - Groups 77003, 77008
  • Indiana: The following groups are delegated to OptumCare/American Health Network Indiana: AARP Medicare Advantage Choice (PPO) - Groups 90103, 90105, 90106; AARP Medicare Advantage Choice Plan 1 (PPO) - Groups 67026, 67030, 67034, 90101, 90102; AARP Medicare Advantage Choice Plan 2 (PPO) - Groups 90126, 90127, 90128 92018, 92019, 92020, 92021; AARP Medicare Advantage Focus (PPO) - Group 74000; AARP Medicare Advantage (HMO-POS) - Groups 00744, 00745, 00748, 00749, 00750, 00751, 00755, 00756, 00758, 00761, 00762; AARP Medicare Advantage Profile (HMO-POS) - Groups 00746, 00747; AARP Medicare Advantage Patriot (PPO) - Group 90041; UnitedHealthcare Dual Complete (PPO D-SNP) - Group 90006
  • Kentucky: The following groups are delegated to WellMed: AARP Medicare Advantage Choice - Group 90137; AARP Medicare Advantage Plan 1 (HMO) - Group 90076; AARP Medicare Advantage Plan 3 (HMO) - Group 90044; AARP Medicare Advantage Plan 2 (HMO) - Group 90047, 90077; AARP Medicare Advantage Plan 6 (HMO) - Group 90075; AARP Medicare Advantage Patriot (PPO) - Group 90002, 90141; AARP Medicare Advantage Walgreens (PPO) - Group 90139
  • Nevada: The following groups are delegated to OptumCare: AARP Medicare Advantage Choice (PPO) - Groups 90025, 92011, 92012; AARP Medicare Advantage Walgreens Plan 2 (PPO) - Groups 90027, 92013; UnitedHealthcare Dual Complete (HMO D-SNP) - Groups 90008, 90009 and Intermountain Healthcare Group 90011
  • New Jersey: The following groups are delegated to OptumCare: AARP Medicare Advantage Choice (PPO) - Groups 92014, 92016; AARP Medicare Advantage Patriot (HMO) - Group 09101; AARP Medicare Advantage Plan 1 (HMO) - Groups 90066, 90067; AARP Medicare Advantage Plan 2 (HMO) - Groups 09102, 09103; AARP Medicare Advantage Plan 3 (HMO) - Groups 90068, 90069; AARP Medicare Advantage Plan 4 (HMO) - Groups 90071, 90072
  • New Mexico: The following groups are delegated to WellMed or OptumCare: AARP Medicare Advantage (HMO) - Groups 17087, 38011, 38013, 38018; AARP Medicare Advantage Choice (PPO) - Groups 79718, 79735; AARP Medicare Advantage Choice Plan 1 (PPO) - Groups 90035, 90036, 90037, 90038; Advantage Choice Plan 2 (PPO) - Groups 79710, 79711; AARP Medicare Advantage Patriot (PPO) - Group 74062; UnitedHealthcare Medicare Advantage Assure (PPO) - Group 77016; UnitedHealthcare Chronic Complete Assure (PPO C-SNP) - Group 90132
  • New York: The following groups are delegated to OptumCare: AARP Medicare Advantage Value Care (PPO) - Groups 09117, 09118; UnitedHealthcare Medicare Advantage Choice Plan 1 (Regional PPO) - Groups 90142, 90143; UnitedHealthcare Medicare Advantage Choice Plan 3 (Regional PPO) - Groups 90146, 90147; UnitedHealthcare Medicare Advantage Choice Plan 4 (Regional PPO) - Groups 90148, 90149; UnitedHealthcare Medicare Advantage Patriot (Regional PPO) - Groups 90144, 90145
  • Ohio: The following groups are delegated to OptumCare: AARP Medicare Advantage Choice (PPO) - Groups 90049, 90136; AARP Medicare Advantage Plan 4 (PPO) - Group 92017; AARP Medicare Advantage Patriot (PPO) - Group 90001; AARP Medicare Advantage Walgreens (PPO) - Groups 90138, 90140; AARP Medicare Advantage Plan 1 (HMO) - Group 90007; AARP Medicare Advantage Plan 2 (HMO) - Groups 90046, 90048; AARP Medicare Advantage Plan 3 (HMO) - Group 90045; AARP Medicare Advantage Plan 5 (HMO) - Group 90043; AARP Medicare Advantage Plan 6 (HMO) - Group 90074; AARP Medicare Advantage Plan 7 (HMO) - Group 90005; AARP Medicare Advantage Plan 8 (HMO) - Group 90063
  • Oregon: The following groups are delegated to OptumCare: AARP Medicare Advantage Choice (PPO) - Groups 90081, 90082; AARP Medicare Advantage Patriot (PPO) - Group 90085; AARP Medicare Advantage Walgreens (PPO) - Groups 90083, 90084
  • Texas: The following groups are delegated to WellMed: AARP Medicare Advantage (HMO) Groups - 00300, 00304, 00306, 00309; AARP Medicare Advantage Ally (HMO-POS) - Group 90129; AARP Medicare Advantage Choice (PPO) Groups - 17063, 17064, 17065, 17066, 72806, 72807, 72814, 72815, 79717, 79730, 90112, 90113, 90114, 90115; AARP Medicare Advantage Patriot (HMO-POS) Groups - 00308, 96000; AARP Medicare Advantage Plan 1 (HMO) Groups - 90122, 90123; AARP Medicare Advantage Plan 2 (HMO) Groups - 90116, 90117; AARP Medicare Advantage Walgreens (PPO) Groups - 90110, 90111; UnitedHealthcare Chronic Complete (HMO C-SNP) Groups - 90118, 90119, 90120, 90121; UnitedHealthcare Chronic Complete Ally (HMO-POS C-SNP) - 90130; UnitedHealthcare Dual Complete (HMO D-SNP) Group - 00305; UnitedHealthcare Dual Complete Ally (HMO D-SNP) Group - 90131; UnitedHealthcare Dual Complete Focus (HMO D-SNP) Group - 00310; UnitedHealthcare Dual Complete Plan 1 (HMO D-SNP) Groups - 00303, 00307; UnitedHealthcare Dual Complete Plan 2 (HMO D-SNP) Group - 00012; UnitedHealthcare Medicare Gold (Regional PPO C-SNP) Group - 99951; UnitedHealthcare Dual Complete Choice (Regional PPO D-SNP) Group - 99952; UnitedHealthcare Medicare Advantage Choice (Regional PPO) Group - 99955; UnitedHealthcare Medicare Silver (Regional PPO C-SNP) Group - 99950; UnitedHealthcare Gold (Regional PPO C-SNP) Group - 99954; UnitedHealthcare Medicare Advantage Choice (Regional PPO) Group - 99953
  • Utah: The following groups are delegated to OptumCare: AARP Medicare Advantage Choice (PPO) - Group 90034; UnitedHealthcare Dual Complete Choice (PPO D-SNP) - Groups 90064, 90065; AARP Medicare Advantage Plan 1 (HMO) - Group 42000; AARP Medicare Advantage Plan 2 (HMO) - Group 42022; AARP Medicare Advantage Patriot (HMO) - Group 42004; AARP Medicare Advantage Walgreens (HMO) - Group 42030; UnitedHealthcare Medicare Advantage Assist (HMO C-SNP) - Group 90055
  • Washington: The following groups are delegated to OptumCare: AARP Medicare Advantage Choice (PPO) - Groups 90157, 90158, 90161, 90162; AARP Medicare Advantage Choice Plan 1 (PPO) - Groups 90159, 90160; AARP Medicare Advantage Choice Plan 2 (PPO) - Group 90059; AARP Medicare Advantage Patriot (HMO) - Group 90058; AARP Medicare Advantage Plan 1 (HMO-POS) - Groups 90153, 90154; AARP Medicare Advantage Plan 2 (HMO-POS) - Group 90155; AARP Medicare Advantage Patriot (HMO-POS) - Group 90156

For the Preferred Care Network (formerly Medica HealthCare) and Preferred Care Partners of Florida groups, refer to the Preferred Care Network and Preferred Care Partners Prior Authorization Requirements located at uhcprovider.com > Prior Authorization and Notification > Advance Notification and Plan Requirement Resources > Plan Requirements and Procedure Codes.

Erickson Advantage Plans

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

  • Diagnostic catheterizations
  • Electrophysiology implant procedures
  • 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 for outpatient and office-based services only.

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

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 notification/prior authorization CPT codes, 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 health care provider

The health 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 plans subject to this protocol: uhcprovider.com/paan.
  • Phone: 1-866-889-8054

Non-participating health care providers can provide notification, and complete the prior authorization process if applicable, either through the UnitedHealthcare Provider Portal (once registered) at uhcprovider.com 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 health care provider’s name, TIN/NPI, address, phone and fax number, and email address
  • Rendering health 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 health 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 health care provider. To help ensure proper payment, the ordering health care provider must communicate the authorization number to the rendering health 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 health 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 health 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 health 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 health 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 health 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.
  • If you are eligible for payment.
  • Claims processing requirements.
  • Your 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 procedure notification/authorization number, we use the date issued as the starting date for the 45-day period. The procedure must be performed within the 45 days. 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 health 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 health 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 health care provider determines a cardiac procedure is medically required on an urgent basis, and the ordering health 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 based on the following process:

  • 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 cardiac procedure retrospective notification, and if the member’s benefit plan requires medical necessity for services 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 health care provider will receive a denial notice outlining the appeal process.
  • Once we receive cardiac procedure retrospective notification and if the member’s benefit plan does not require medical necessity for services to be covered:
    • We issue a notification number to the ordering health 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 health 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 health care provider will confirm the procedure ordered and we will issue a notification number.

Rendering health care provider

Prior to performing a cardiac procedure, the rendering health care provider must confirm a notification/authorization number is on file. If the member’s benefit plan requires medical necessity to cover health services, the rendering health care provider must validate they completed the prior authorization process and was issued a coverage determination.

If the rendering health care provider finds a coverage determination has not been issued, and the ordering health care provider does not participate in our network and is unwilling to complete the notification/prior authorization process, the rendering health care provider is required to complete the notification/prior authorization process. The rendering health 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 health 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 health care provider participates in our network, we use reasonable efforts to work with you to urge the ordering health 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 health 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 health 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 health care provider participates in our network, we use reasonable efforts to work with you to urge the ordering health 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 health 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 health 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 health 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.