Beginning June 1, 2023, UnitedHealthcare modified our process for gastroenterology (GI) services. You are asked to provide advance notification in lieu of prior authorization for gastroenterology endoscopy services for UnitedHealthcare commercial plan members, in accordance with the terms of their benefit plan. Please note that screening colonoscopy procedures are not subject to this advance notification process.
All states, except Kentucky, New Mexico and Rhode Island
Iowa effective: Aug. 1, 2023
U.S. territories (U.S. Virgin Islands, Guam and Puerto Rico) are excluded
This requirement pertains to patients with UnitedHealthcare commercial plans, including:
UnitedHealthcare Plan of the River Valley
Neighborhood Health Partnership
UnitedHealthcare Level Funded
Oxford Health Plans
The Advance Notification process for non-screening GI procedures supports our efforts to ensure access to safe and affordable care. During 2023, we will use the data received through advance notification to accelerate gold carding for eligible physician groups in early 2024. During this period, we will not issue medical necessity denials for procedures that are not aligned with clinical evidence. Additionally, we will not issue administrative denials for failure to submit advance notification. Rather, we will provide you the opportunity to engage in a comprehensive peer-to-peer discussion with a board-certified gastroenterologist around clinical guidelines. This approach also enables us to identify geographies where underutilization of GI procedures presents an opportunity for us to educate our members about the importance of screening colonoscopies and advanced diagnostic GI procedures.
Screening colonoscopy procedures only require prior authorization for site of service medical necessity review if the service is planned at an outpatient hospital.