The Outpatient Radiology Notification/Prior Authorization Protocol for Commercial members was developed to support a more consistent application of evidence-based and professional society guidance to diagnostic imaging procedures. The Radiology Notification/Prior Authorization Program helps reduce risks to patients and improve the quality, safety and appropriate utilization of imaging procedures.
UnitedHealthcare and our affiliates are standardizing the prior authorization requirements for services provided to our members for greater consistency for our 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 review to determine whether the service is medically necessary in order to be covered and inform you of the decision. If the member's benefit plan does not require clinical 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 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 it is required.
UnitedHealthcare West Plans:
Effective October 1, 2015, participating physicians, facilities and other health care professionals that are subject to the UnitedHealthcare West Non-Capitated Supplement in UnitedHealthcare's Administrative Guide and practice in California, Oklahoma, Oregon, Texas and Washington will have updated prior authorization requirements for certain advanced outpatient imaging procedures before they are rendered to UnitedHealthcare West Commercial non-delegated members.
UnitedHealthOne Individual Plans (Group Numbers 755870 and 902667):
Effective October 15, 2015, participating physicians, facilities and other health care professionals that are subject to the UnitedHealthOne Individual Plans Supplement in UnitedHealthcare's Administrative Guide must obtain prior authorization requirements for certain advanced outpatient imaging procedures before they are rendered to UnitedHealthcare Life Insurance Company (Group Number 755870) and Golden Rule Insurance Company (Group Number 902667) members.
To review the complete protocol in the Physician, Health Care Professional, Facility and Ancillary Provider Administrative Guide, please visit the Outpatient Radiology Notification/Prior Authorization Protocol for Commercial Customer
Click here to provide notification, confirm the notification process has been completed, and confirm that a decision has been made if a clinical review has been conducted.