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:

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.