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.
In some instances, we have delegated prior authorization services to a provider group. In these cases, the “For Providers” section on the member’s ID card will list the delegated group managing the prior authorization process. 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:
This applies to all participating health care providers that order or render any of the following advanced imaging procedures:
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:
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 based on 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
Ordering health care provider
The health 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:
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:
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:
Notification or authorization number receipt 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 PECOS* list) and MA guidelines require it. Payment for covered services depends upon:
The notification/authorization number is valid for 45 calendar days. It is specific to the advanced outpatient imaging 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 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 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 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 health 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:
Rendering health care provider
Before performing an advanced outpatient imaging procedure, the rendering health care provider must confirm a notification/ authorization number is on file. If the member’s benefit plan requires medical necessity for health services to be covered, 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, before 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 covered services be medically necessary and if you:
If the member’s benefit plan does require medical necessity for covered services and:
Provision of an additional or modified advanced outpatient imaging procedure
If, during the delivery of an advanced outpatient imaging procedure, the rendering health 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 health 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 health 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:
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.