Exchange Plans: Prior authorization and site of service updates

Starting Oct. 1, 2021, for UnitedHealthcare Individual Exchange plans, we’re updating the prior authorization requirements and site of service medical necessity reviews for certain surgical, office and magnetic resonance imaging (MRI)/computed tomography (CT) imaging procedures. Here’s what’s changing:

•  We’ll now require prior authorization and site of service medical necessity reviews for certain MRI/CT procedures/CPT® codes if the service is planned to be performed in an outpatient hospital setting
• We’re expanding our prior authorization requirements and site of service medical necessity reviews to include 85 additional surgical procedures/CPT codes if the service is planned to be performed in an outpatient hospital setting
• We’re expanding our prior authorization requirements and site of service medical necessity reviews to include 9 additional office-based procedures/CPT codes, if the service is planned to be performed in an ambulatory surgical center or outpatient hospital setting
• We’ll use the following utilization review guidelines to facilitate these site of service reviews:
  • Outpatient Surgical Procedures – Site of Service – Value & Balance Exchange Utilization Review Guideline
    

More information is available in our Frequently Asked Questions:

• Prior Authorization and Site of Service Reviews for MRI/CT Imaging Procedures - Frequently Asked Questions - UnitedHealthcare Exchange Plans
  

Questions?

Call Provider Services at 800-666-1353.

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