New UnitedHealthcare policy brings reviews of certain outpatient imaging procedures

Beginning with services performed on Jan. 1, 2019, UnitedHealthcare will be reviewing the site of care for certain CT and MR imaging procedures to be performed in an outpatient hospital setting. Anthem implemented a similar policy in 2017.

According to the insurance giant, this change to its Outpatient Radiology Prior Authorization process is being implemented to “minimize out-of-pocket costs for its members.” The policy will impact all providers in all states, with three exceptions: Iowa, Kentucky and Utah.

“We understand some patients need more complex care because of factors like age or medical condition,” the provider’s website explained. “We review every plan member’s situation to evaluate a site of care according to their needs. We’ll consider any information you provide that shows whether there’s a reason for a procedure to be performed in an outpatient hospital setting.”

If a procedure is to be performed at a freestanding diagnostic radiology center or an office setting, a site of care review will not occur. Other than this site of care review, UnitedHealthcare has said its current MR and CT notification/prior authorization processes will remain the same. And if prior authorization has already been obtained, there is no need to take any additional action.

More urgent imaging exams are not impacted. Procedures performed in emergency rooms, urgent care centers and observation units, or during an inpatient hospital stay, do not need prior authorization.

More information on this policy update, including a full list of impacted procedure codes, is available on the UnitedHealthcare website.