These programs support the consistent use of evidence-based, professional guidelines for cardiology procedures. They were designed with the help of physician advisory groups to encourage appropriate and rational use of cardiology services. Using them helps reduce risks to patients and improves the quality, safety and appropriate use of cardiac procedures.
Notification/prior authorization may be required for the following procedures in the service locations indicated.
Electrophysiology Implants, Diagnostic Catheterization, Echocardiogram*, Stress Echocardiogram: Required for outpatient and office visits. Not required for inpatient, emergency room, urgent care center or observation.
*Note: For Medicare Advantage benefit plans, prior authorization is not required for echocardiograms.
These requirements apply to all providers subject to the UnitedHealthcare Administrative Guide. To review the complete protocol, please refer to the Cardiology Notification/Prior Authorization Protocolsection in that guide.
Special Notes for Congenital Heart Disease
For congenital heart disease codes, notification is required for inpatient services only.
For outpatient help, please refer members to Optum at 888-936-7246.
For inpatient cases, please call the phone number on the back of the member's health care ID card.
Specific Cardiology Programs
Open the section below to view more information.
This program is effective in Arizona, Kentucky, Maryland, Minnesota, Mississippi, Missouri, New Jersey, New York, North Carolina, Pennsylvania, Rhode Island, Tennessee, Texas, Virginia and Washington.
The following Commercial resource materials are inclusive of UnitedHealthcare River Valley and NHP membership.
When you notify us of a planned service that is subject to the protocol, we’ll conduct a clinical review to decide if the service is medically necessary and covered, and will let you know our decision.
If the member's benefit plan does not require a clinical review and the service does not meet clinical guidelines, or if additional information is needed, we’ll let you know if you need to have a physician-to-physician discussion.