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Prior Authorization Requirement for Certain Hospital Outpatient Surgical Procedures

Jul 17, 2015

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:

*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:

Procedures & Services

Codes for UnitedHealthcare
Commercial Plans

Abdominal Paracentesis

49083

 

 

 

Carpal Tunnel Surgery

64721

 

 

 

Cataract Surgery

66821

66982

66984

 

Hernia Repair

49585

49587

49650

49651

49652

49653

49654

49655

Liver Biopsy

47000

 

 

 

Tonsillectomy & Adenectomy

42821

42826

 

 

Upper & Lower Gastrointestinal Endoscopy

43235

43239

43249

45378

 45380 

45384

45385 

 

Urologic Procedures

50590

52000

52005

52204

52224

52234

52235

52260

52281

52310

52332

52351

  52352  

  52353  

 52356 

57288 

                                       

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

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.

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