May 01, 2022

New Jersey Medicaid: Radiation therapy prior authorization updates effective July 1

Effective July 1, 2022, prior authorization will be required for the following outpatient radiation therapies for UnitedHealthcare New Jersey Community Plan Medicaid members:

  • Intensity modulated radiation therapy (IMRT)
  • Stereotactic body radiation therapy (SBRT)
  • Fractionation intensity-modulated radiation therapy (IMRT), proton beam therapy (PBT) and standard 2D/3D radiation therapy for breast cancer, prostate cancer, lung cancer and bone metastasis
  • Image -guided radiation therapy (IGRT)
  • Special and associated radiation therapy services
  • Selective internal radiation therapy (SIRT), Yttrium 90 (Y90) and implantable beta-emitting microspheres for treatment of malignant tumors

Prior authorization management change
As part of the new prior authorization requirement, we are also changing the way we manage requests.

Starting July 1, 2022, prior authorization requests for the above-noted outpatient radiation therapies and the existing prior authorization requirement for PBT will be managed by Optum®.

How to submit prior authorization
For PBT, if prior authorization for these services is already approved for administered treatment prior to July 1, 2022, you do not need to submit a new prior authorization request for that approved treatment plan.

For IMRT, standard radiation therapy 2D/3D, IGRT, special services, Y90/SIRT or SBRT, including SRS services started between May 1, 2022 and June 30, 2022, you do not need to submit a prior authorization request. We’ll authorize the radiation therapy service(s) the member was receiving prior to July 1, 2022 and the authorization will be effective for 90 days from the treatment start date. For any further radiation therapy services that extend after 90 days from the treatment start date, prior authorization would be required before the start of services.

Please complete prior authorization requests on the UnitedHealthcare Provider Portal using your One Healthcare ID and the Prior Authorization and Notification tool. Once you’re in the tool, select  Radiology, Cardiology, Oncology and Radiation Oncology Transactions > Service Type of Radiation Oncology > Product Type of Medicaid > member state.

The online tool will open on June 24, 2022, for prior authorization requests with a start date of July 1, 2022.

Coverage determination guidelines
On July 1, 2022, medical policies for all radiation therapy services will be available at UnitedHealthcare Community Plan Medical & Drug Policies and Coverage Determination Guidelines.

Training
A Radiation Therapy Prior Authorization – Self Paced Provider Training resource is available to help your staff streamline the prior authorization request submissions process.

Questions?
For answers to specific questions, email unitedoncology@uhc.com.

PCA-22-01100-VCNews