Prior authorization updates for radiation therapies
Changes impact Minnesota and Virginia Medicaid members
Effective Feb. 1, 2023, we’ll require prior authorization for the following outpatient radiation therapies for UnitedHealthcare Community Plan members in Minnesota and Virginia:
- Intensity-modulated radiation therapy (IMRT)
- Proton beam therapy (PBT)
- Stereotactic body radiation therapy (SBRT), including stereotactic radiosurgery (SRS)
- Image-guided radiation therapy (IGRT)
- Special and associated services (Special Plan & Services – Special Services – SPS) - (e.g., dosimetry and special physics consults)
- Hypofractionation (aka fractionation) using IMRT, PBT and standard 2D/3D radiation therapy for prostate, breast, lung and bone metastasis cancers
- 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 Feb. 1, 2023, Optum® will manage prior authorization requests for the above-noted outpatient radiation therapies and the existing prior authorization requirement for PBT.
How to submit prior authorization
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.
For PBT, if we’ve already approved for administered treatment prior to Feb. 1, 2023, 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 Dec. 1, 2022, and Jan. 31, 2023, you do not need to submit a prior authorization request. We’ll authorize the radiation therapy service(s) the member was receiving prior to Feb. 1, 2023, 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, we will require prior authorization before the start of services.
The online tool will open on Jan. 25, 2023, for prior authorization requests with a start date of Feb.1, 2023.
Coverage determination guidelines
On Feb. 1, 2023, 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.
