This content applies to Medicare Advantage and UnitedHealthcare Dual Special Needs Plan (DSNP).
The prior authorization information on this page is effective as of January 1, 2017. It applies only to Medicare Advantage members who are receiving intensity modulated radiotherapy (IMRT), stereotactic radiosurgery (SRS) or stereotactic body radiation therapy (SBRT) treatment.
For Commercial members receiving IMRT services, please see the Commercial Intensity Modulated Radiation Therapy Prior Authorization Program.
On January 1, 2017, UnitedHealthcare began a pilot program to eliminate most prior authorization requirements for eligible Medicare Advantage members. To support the care provider's role in managing and determining the appropriateness of a member's treatment, we're studying how limiting or eliminating certain Prior Authorization requirements will improve both member and care provider experiences.
You'll find the full list of prior authorization requirements in Therapeutic Radiation Therapy Prior Authorization Included and Excluded Plans.
As of January 1, 2017, prior authorization for most therapeutic radiation treatments is no longer needed in these states for Medicare Advantage members:
- North Carolina
- Rhode Island
However, prior authorization may still be required for:-
- Intensity modulated radiotherapy (IMRT)
- Stereotactic radiosurgery (SRS)
- Stereotactic body radiation therapy (SBRT)
You can submit your request online or by phone:
• Online: Sign in to UHCprovider.com and then go to the Prior Authorization and Notification Tool on Link.
• Phone / Fax: To start your submission by phone or for instructions on faxing your request, please call the UnitedHealthcare Clinical Request Line at 866-889-8054 from 7 a.m. - 7 p.m. Eastern Time, Monday – Friday
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- If you don't have a required prior authorization before administering IMRT, SRS or SBRT services, your claim may be denied. Please remember that members can't be billed for claims that are denied because you didn't have prior authorization.
- If you have questions about the member's benefits, please contact the care provider service phone number on the back of the member's ID card. For prior authorization questions, please call the UnitedHealthcare Clinical Request Line at 866-889-8054.
- Having a prior authorization or pre-determination on file does not guarantee or authorize payment. Payment for covered services depends on the member's benefit plan and eligibility on the date of service, care provider eligibility for payment, claim processing requirements and the care provider participation agreement. Post-service determinations may still apply based on criteria published in medical policies as well as local and national coverage determination criteria. For these requirements, please see UnitedHealthcare Medicare Advantage Coverage Summaries.
- Commercial Medical & Drug Policies and Coverage Determination Guidelines
- Medicare Advantage Therapeutic Radiation - Coding Guidelines (Codes Requiring Prior Authorization)
- Medicare Advantage Therapeutic Radiation - Included and Excluded Plans
- Medicare Advantage Therapeutic Radiation - Prior Authorization Submission Process