Radiology Notification - Prior Authorization Requirement added Effective July 1, 2013
The Outpatient Radiology Notification Protocol for commercial members was developed to support a more consistent application of current scientific clinical evidence and professional society guidance to diagnostic imaging procedures.
UnitedHealthcare and our affiliates are standardizing the prior authorization requirements for services provided to our members for greater transparency and consistency with network providers and greater consistency with prevailing industry standards.
Effective for dates of service on and after July 1, 2013, UnitedHealthcare's Outpatient Radiology Notification Protocol will include a prior authorization requirement when a UnitedHealthcare Commercial member's benefit document requires health services to be medically necessary in order to be covered. For those members, once UnitedHealthcare is notified of a planned service that is subject to the protocol, we will conduct a clinical coverage review to determine whether the service is medically necessary in order to be covered. The requesting provider will be informed of the decision. The provider does not need to determine whether a clinical coverage review is required in a given case or for a given member because once the provider notifies UnitedHealthcare of a planned service, we will confirm whether a clinical coverage review is required. If the member's benefit document does not require clinical coverage review to determine medical necessity, and if the service does not meet evidence-based clinical guidelines, or if additional information is needed, UnitedHealthcare will confirm whether the provider must engage in a physician-to-physician discussion.
Notification is required for certain of the following advanced outpatient imaging procedures: CT scans, MRIs, MRAs, PET scans, and nuclear medicine studies, including nuclear cardiology. To see a complete listing of CPT codes for which notification is required, please click on the link below.
Notification is not required for procedures rendered in an emergency room, observation unit, urgent care center or during an inpatient stay.
Please note that providers subject to the UnitedHealthcare Physician, Health Care Professional, Facility and Ancillary Provider Administrative Guide For Commercial and Medicare Advantage Products who practice in certain states were not required to notify UnitedHealthcare of planned services in accordance with the Outpatient Radiology Notification Protocol for dates of service prior to July 1, 2013. However, effective for dates of service on and after July 1, 2013 these providers are now required to notify UnitedHealthcare of planned services that are subject to the protocol and must complete the prior authorization process.
Click here to provide notification, confirm the notification process has been completed, and confirm that a coverage decision has been made if a clinical review has been conducted.
Click here for information on the Medicare Advantage Prior Authorization program