2015-09-08 13:49:09 UTC

New UnitedHealthcare Policy Changes Impact GIs

Sept. 8, 2015

Policies require prior authorization for certain endoscopic procedures and infusions.

Effective Oct. 1, UnitedHealthcare (UHC) will implement prior authorization requirements in order to encourage more cost-effective sites of service for certain outpatient surgical procedures when medically appropriate, according to the provider's September 2015 bulletin

No prior authorization will be required if services are performed at a participating network ambulatory surgery center (ASC). While the policy encourages services to be performed in the ASC setting, it does not prohibit performance of procedures in the hospital outpatient setting. Coverage determinations will consider the availability of a participating network facility, specialty requirements, physician privileges and whether a patient has an individual need for access to more intensive services. The requirements do not apply to Tricare, Medicaid or Medicare Advantage. 

Endoscopic Procedures
The following endoscopic procedures will require prior authorization if performed in an outpatient hospital setting. The policy applies to the UHC Commercial and Exchange membership, including Mid-AtlanticMD, Oxford, Neighborhood Health Partnership and Golden Rule, but excludes UHC West plans. 

The effective date for Colorado is Nov. 1, 2015, and for Illinois and Iowa is Dec. 1, 2015. The effective date for all others is Oct. 1, 2015.

  • 43235 EGD
  • 43239 EGD with biopsy
  • 43249 EGD with dilation <30mm
  • 45378 Colonoscopy
  • 45380 Colonoscopy with biopsy
  • 45384 Colonoscopy with hot biopsy 
  • 45385 Colonoscopy with snare polypectomy

UHC will require prior authorization for administration of Entyvio® and Remicade® in hospital outpatient facilities. Prior authorization is not required for home infusion, infusion in a doctor’s office or in ambulatory infusion centers. Failure to complete the new process prior to administering infusion services for inflammatory conditions will result in claims denial. Providers cannot bill members for services that are denied due to lack of prior authorization. The new requirement applies to UHC Commercial plans, Mid-AtlanticMD, Oxford, NHP and UHC of the River Valley members.

For more information, see pages 4 (infusions) and 11 (endoscopy) of the UHC September bulletin.

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