Medicare and DSNP: Prior Authorization and Site of Service Updates

Starting June 1, 2021, we’re expanding our notification/prior authorization requirements and site of service medical necessity reviews to include certain procedures/CPT® codes for Dual Special Needs Plans (DSNPs) in New Jersey.

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

Previous announcement of this change

This change was previously announced in the December Network Bulletin for:

  • UnitedHealthcare Medicare Advantage Plans in most states (for dates of service on or after Jan. 1, 2021)
  • UnitedHealthcare Medicare Advantage Plans in Arizona, Colorado, Connecticut, Florida, New Jersey, Nevada, New York and Texas (for dates of service on or after June 1, 2021)

Utilization review guidelines

The revised Utilization Review Guidelines (URGs) can be accessed at > Policies and Protocols > Commercial Policies > Medical & Drug Policies and Coverage Determination Guidelines.