Prior Authorization Requirement for Certain Hospital Outpatient Surgical Procedures

In an effort to minimize out-of-pocket costs for UnitedHealthcare members and to improve cost efficiencies for the overall health care system, UHC is implementing prior authorization guidelines that aim to encourage more cost-effective sites of service for certain outpatient surgical procedures, when medically appropriate.

These procedures will require prior authorization if performed in an outpatient hospital setting. No prior authorization will be required if they are performed at an ambulatory surgery center. Coverage determinations will consider availability of a participating network facility, specialty requirements, physician privileges and whether a patient has an individual need for access to more intensive services.

These guidelines are effective for dates of service on or after October 1, 2015 in most states, except for Colorado, where the effective date is November 1, 2015, and for Illinois and Iowa, where the effective date is December 1, 2015. Effective dates are determined by the member’s state of residence.

The prior authorization requirement applies to fully insured commercial and exchange membership, including the following plans:

• Golden Rule Insurance Company (group 902667)
• Mid-AtlanticMD Healthplan Individual Practice Association, Inc. (“M.D. IPA”) or Optimum Choice, Inc. (“Optimum Choice”) products
• Neighborhood Health Partnership
• UnitedHealthcare of the River Valley  Health Plan
• UnitedHealthcare Oxford Health Plans*
• UnitedHealthcare
• UnitedHealthcare Life Insurance Company (group 755870)
• UnitedHealthcare West 

*UnitedHealthcare Oxford Health Plans currently require prior authorization for these procedures when they are provided in a setting other than a physician’s office. The change for those plans will be that when these services are provided in a setting outside of a physician’s office, prior authorizations will now also consider the site of service requested by the provider.

The guidelines apply to these codes and procedures:

Prior authorization requests can be filed in multiple ways, including online or by phone:

• Go to UnitedHealthcareOnline.com > Notifications/Prior Authorizations > Notification/Prior Authorizations Submission. Using UnitedHealthcareOnline.com is an easy way to initiate prior authorization and is the preferred option.
• Call the Provider Services number on the back of your patient’s member health care ID card.

If you do not obtain prior authorization before performing these procedures in hospital site of service, claims may be denied. Providers cannot bill members for services that are denied due to lack of prior authorization.

For more information on this requirement, please see the frequently asked q​uestions document. 

If you have questions, please ​contact member of your b&p Sales Team - 888.722.3373.