The Outpatient Radiology Notification & Prior Authorization 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.
The Outpatient Radiology Notification & Prior Authorization protocol requirements apply to all providers subject to the UnitedHealthcare Physician, Health Care Professional, Facility and Ancillary Provider Administrative Guide who render the following advanced outpatient imaging procedures: CT scans, MRIs, MRAs, PET scans and Nuclear Medicine studies, including Nuclear Cardiology. 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. 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. 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.
Effective Feb. 1, 2015, participating physicians, facilities and other health care professionals that practice in Rhode Island must obtain prior authorization for certain advanced outpatient imaging procedures before they are rendered to UnitedHealthcare Commercial members.
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.