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Payer Policies

UnitedHealthcare Prior Authorization Requirements for Certain Cardiac Imaging Services and Procedures

Effective July 1, 2013, UnitedHealthcare (UHC) will make changes to its existing Outpatient Radiology Notification Protocol and Cardiology Notification Protocol. Importantly, these changes require prior authorization as a condition of payment.

Specifically, ordering providers that are subject to UnitedHealthcare's Physician, Health Care Professional, Facility and Ancillary Provider 2013 Administrative Guide for Commercial and Medicare Advantage Products, must notify UnitedHealthcare prior to scheduling certain CT, MRI/MRA, PET scan, nuclear medicine and nuclear cardiology procedures for UnitedHealthcare Commercial members. Rendering providers must confirm that the prior authorization process has been completed and a coverage decision has been issued before rendering any advanced outpatient imaging service. According to UHC, if the ordering provider does not participate in UnitedHealthcare's network and is unwilling to complete the prior authorization process, the rendering provider must complete the prior authorization process and verify that a coverage decision has been issued prior to rendering the service.

Providers are not required to notify UnitedHealthcare of any advanced imaging procedures rendered in an emergency room, urgent care center, observation unit or during an inpatient stay. For a complete list of CPT codes requiring notification, please refer to > Clinician Resources > Radiology > Radiology Notification >Notification Resources: Reference Materials > 2013 Radiology Notification/Authorization CPT Code List.

Also effective July 1, 2013, UnitedHealthcare will require prior authorization for their Commercial Plans for the following cardiovascular services: echocardiography, stress echocardiography, electrophysiologic implant devices, and diagnostic cardiac catheterization. For a complete list of CPT codes for cardiac procedures that require notification, please refer to > Clinician Resources > Cardiology > Cardiology Notification Program > 2013 Cardiology Notification Table and CPT Code Crosswalk.

It is imperative that you review the full UHC notice for detailed information on the new requirements, the prior authorization process in general, and for information about plans included or excluded from the new requirements. Please click on the following link UHC Network Bulletin to ensure that you have a full understanding of these important changes.


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