New Jersey: Prior authorization and site of service expansion
UnitedHealthcare Community Plan outpatient surgical procedures and sleep studies updates
Effective Nov. 1, 2022, we’re expanding our prior authorization requirements and site of service medical necessity reviews for certain outpatient surgical procedures and sleep studies. This will affect UnitedHealthcare Community Plan of New Jersey members.
Outpatient surgical procedures
We’re adding 150 CPT® codes for surgical procedures that take place in an outpatient hospital setting.
Utilization review guidelines
We’ll use our Outpatient Surgical Procedures – Site of Service (for New Jersey Only) – Community Plan Utilization Review Guideline to facilitate these reviews.
More information
- To see a list of the new codes, please see the New Jersey Community Plan: Prior authorization and site of service expansion appendix
- For more information, please see our Community Plan of New Jersey: Prior authorization and site of service expansion for outpatient procedures frequently asked questions
Outpatient sleep studies
The following 5 new CPT® codes will require prior authorization/notification and medical necessity reviews:
- 95805
- 95807
- 95808
- 95810
- 95811
Coverage determination guidelines
We’re using our Attended Polysomnography for Evaluation of Sleep Disorders (for New Jersey Only) – Community Plan Medical Policy to facilitate our medical necessity determinations.
Resources
- For more information about the changes, please see our UnitedHealthcare Community Plan of New Jersey: Prior authorization and site of service expansion for sleep studies frequently asked questions
Questions?
If you have questions, please see our Community Plan of New Jersey page.
