Prior Authorization and Site of Service Update

For dates of service on or after Jan. 1, 2021, for UnitedHealthcare commercial benefit plans, including Oxford, Neighborhood Health Partnership and UnitedHealthcare of the River Valley, we’re expanding our notification and prior authorization requirements and site of service medical necessity reviews to include two screening colonoscopy procedures/HCPCS codes G0105 and G0121. We will only require notification/prior authorization and conduct site of service medical necessity reviews if these procedures will be performed in an outpatient hospital setting.

As further outlined below, we’re also implementing a new Utilization Review Guideline (URG) to support site of service medical necessity reviews for screening colonoscopy procedures/HCPCS codes G0105 and G0121 and the following screening colonoscopy procedures/CPT® codes 45378, 45380, 45381, 45384 and 45385, that are currently subject to notification/prior authorization requirements and site of service medical necessity reviews.

Please note the following:

  • These updates will take effect on Feb. 1, 2021 for Iowa and Illinois.
  • At this time, the following states are excluded from these updates: Alaska, Kentucky, Massachusetts, Rhode Island, Texas, Utah and Wisconsin.
  • These updates do not apply to UnitedHealthcare West or Sierra at this time.

Outpatient Screening Colonoscopy Procedures — Site of Service Utilization Review Guideline

We’ll use the criteria in our Screening Colonoscopy Procedures – Site of Service Utilization Review Guideline to facilitate our site of service medical necessity reviews for the screening colonoscopy procedures/CPT® codes listed in the URG.

On Jan. 1, 2021, the URG will be available at UHCprovider.com > Policies and Protocols > Commercial Plan Policies > Medical & Drug Policies and Coverage Determination Guidelines for UnitedHealthcare Commercial Plans. Prior to Jan. 1, 2021, the URG can be accessed from the UnitedHealthcare Commercial Medical Policy Update Bulletin: October 2020.

For Oxford, on Jan. 1, 2021, the URG will be available UHCprovider.com/Policies > Commercial Policies > UnitedHealthcare Oxford Clinical, Administrative, and Reimbursement Policies. For Oxford prior to Jan. 1, 2021 the URG can be accessed from the Oxford Policy Update Bulletin: October 2020.