Prior Authorization and Site of Service Review Update
In the September edition of the Network Bulletin, we informed you that for dates of service on or after Jan. 1, 2021, for UnitedHealthcare Medicare Advantage Plans we’re expanding our prior authorization requirements and site of service medical necessity reviews to include certain procedures/CPT® codes.
Please note the following changes:
This will be effective for Arizona, Colorado, Connecticut, Florida, New Jersey, Nevada, New York and Texas for dates of service on or after June 1, 2021.
We’ve removed 20 procedure/CPT® codes from the code list. The removed codes, which include 11 colonoscopy and biopsy and 9 repair of the retina codes are as follows: 45378, 45379, 45380, 45381, 45384, 45385, 45386, 45389, 45390, 44388, 44389, 67036, 67040, 67041, 67042, 67108, 67228, 67113, 67145, 67210. The current code list can be found in the Medicare Advantage: Site of Service Medical Necessity Reviews for Certain Procedure Codes.
Dual Special Needs Plans (DSNP) in NJ are excluded from this prior authorization and notification requirement and site of service medical necessity reviews.
As of Jan. 1, 2021, the revised Utilization Review Guideline can be accessed at Medical & Drug Policies and Coverage Determination Guidelines for UnitedHealthcare commercial plans. Until then, you can view the update to the Utilization Review Guideline in the December edition of our UnitedHealthcare Commercial Medical Policy Update Bulletin.