Prior Authorization and Site of Service Review Update

For dates of service on or after Sept. 1, 2020, for UnitedHealthcare Medicare Advantage plans, we’re expanding our prior authorization and notification requirements to include the certain procedures/CPT® codes listed here.

We’ll only require notification/prior authorization if these procedures/CPT codes will be performed in an outpatient hospital setting.

  • This change will take effect on Nov 1, 2020, for Iowa and Illinois.
  • States excluded from this requirement are Alaska, Kentucky and Massachusetts.

Outpatient Surgical Procedures — Site of Service Utilization Review Guideline

We’ll use the criteria in our Outpatient Surgical Procedures — Site of Service Utilization Review Guideline to facilitate our site of service medical necessity reviews.

Here is the link to the review guidelines from our Hospital Services (Inpatient and Outpatient) Medicare Advantage Coverage Summary.

When These Changes Apply

This change will apply to all UnitedHealthcare Medicare Advantage benefit plans, except Medicare Advantage Private Fee-For-Service Benefit Plans. The site of service medical necessity reviews will also not apply to Medicare and Medicaid Enrollee benefit plans or Medicare Advantage Senior Care Options benefit plans.