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Prior Authorization Requirements to Change for UHC Community Plans

Effective February 1, 2019, United Healthcare’s (UHC) Community Plan (Medicaid HMO) will require prior authorization for Genetic and Molecular Lab Testing provided in an outpatient setting.  The change will be effective for UHC Community Plans in the following states: FL, MD, MI, MO, NJ, NY, PA, RI, TN and TX.  This is per the carrier’s November 2018 Provider Newsletter.  Prior to this date, UHC only has prior authorization requirements on its commercial plans.  This affects tests such as:

• Tier 1 Molecular Pathology Procedures
• Tier 2 Molecular Pathology Procedures
• Genomic Sequencing Procedures
• Multianalyte Assays with Algorithmic Analysis that include Molecular Pathology Testing

The CPT code set affected by this change is:

0001U 0009M
0018U-0019U 0011M,-0013M
0022U-0023U 81105-81111
0026U-0034U 81120-81121
0036U-0037U 81161-81420
0040U 81425-81479
0045U-0050U 81507
0055U-0057U 81519
0060U 81545
0004M 81595-81599
0006M-0007M S3870

Care providers will use the Genetic and Molecular Lab Test tool on Link to submit the notification/prior authorization request.  More information on this tool can be found at www.UHCprovider.com/genetics.  All determinations of coverage will be subject to the carrier’s clinical policy requirements, which are found at www.uhcproviders.com/policies.   These prior authorization numbers will need to be included in claims data received by APS for claims submission and ultimately payment by UHC Community Plan.

APS will continue to monitor United Healthcare and all payer policies to help ensure you receive payment for all services rendered.

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