Commercial: Prior Authorization and Site of Service Changes

Starting Aug. 1, 2021, for UnitedHealthcare commercial benefit plans, including Oxford, Neighborhood Health Partnership and UnitedHealthcare of the River Valley, we’re changing our prior authorization requirements and site of service medical necessity reviews for certain surgical and office-based procedures.

• We’ll now require prior authorization and conduct site of service medical necessity reviews for 32 additional surgical procedure/CPT® codes if the service is planned to be performed in an outpatient hospital setting
• We’ll now require prior authorization and conduct site of service medical necessity reviews for 7 additional office-based procedure/CPT codes if the service is planned to be performed in an outpatient hospital or ambulatory surgical center
• We’ll no longer require prior authorization or conduct site of service medical necessity reviews for 170 surgical procedure/CPT codes

Please note the following:

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

We’ll use the following Utilization Review Guidelines (URGs) and Oxford clinical policies to facilitate these site of service medical necessity reviews:

• Outpatient Surgical Procedures – Site of Service
• Office Based Procedures – Site of Service

You can access these URGs after June 1, 2021 by visiting our  Commercial Medical & Drug Policies and Coverage Determination Guidelines page and UnitedHealthcare Oxford Clinical, Administrative, and Reimbursement Policies.

More information is available in our Frequently Asked Questions:

• Site of Service Surgical Commercial FAQ
• Site of Service Office Commercial FAQ

Questions?

Call Provider Services at 800-666-1353.

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