UHC Prior Authorization & Site of Service Update for Colonoscopy

November 24, 2020

The October 2020 edition of United Healthcare’s (UHC) Network Bulletin indicated a plan to expand the Notification and Prior Authorization requirements and Site of Service Medical Necessity review, to include two screening colonoscopy procedures/HCPCS codes G0105 and G0121 which will take effect January 1, 2021. UHC will only require Notification/Prior Authorization and conduct Site of Service medical necessity reviews when services are performed in an outpatient hospital setting. These new guidelines are implemented to redirect patients to a much less expensive “non-hospital” facility for this type of service as part of a cost-savings.

The expansion will affect UHC’s commercial benefit plans including Oxford, Neighborhood Health Partnership and UHC of the River Valley. In addition, UHC is also implementing a new Utilization Review Guideline (URG) to support site of service medical necessity reviews for the above HCPCS codes and other colonoscopy procedures/CPT codes (45378, 45380, 45381, 45384 and 45385), which are already subjected to the notification/prior authorization requirements and site of service medical necessity reviews. It is unclear whether pathology work in a hospital outpatient setting will be denied for lack of authorization. It is important that you are aware and understand the new guidelines, as it may affect your practice. Beginning January 2021, the new guidelines will be redacted and expected to provide much stricter guidelines to follow.

•    This will apply to IA and IL beginning February 1, 2021
•    AK, KY, MA, RI, TX, UT and WI are excluded from these updates (at this time)
•    United Healthcare West or Sierra are excluded and will not apply (at this time)

Beginning January 1, 2021 the Utilization Review Guidelines (URG) will be available here.

For Oxford, on January 1, 2021, the URG will be available here.