Site of service medical necessity reviews for certain musculoskeletal surgeries

UnitedHealthcare aims to minimize out-of-pocket costs for UnitedHealthcare members and improve cost efficiencies for the overall health care system. Once prior authorization is requested for certain arthroscopic surgeries (of the elbow, ankle, wrist, hip, knee or shoulder and foot surgeries for bunions and hammertoes), UnitedHealthcare will also review the site of service for medical necessity if the procedure will be rendered in an outpatient hospital.

Where not already in place, these site of service reviews will begin for dates of service on or after Aug. 2, 2019, for fully insured groups in most states, on or after Sept. 3, 2019, for California and on or after Oct. 1, 2019, for Colorado, Connecticut, New Jersey and New York.

This review will occur where permitted by state law and by the terms of the member’s benefit plan. 

Medical necessity site of service reviews apply to providers in all states, except Alaska, Kentucky, Massachusetts and Texas due to regulations.

Review effective dates

The following table outlines when the review will go into effect: 

Line of Business

      Effective Dates (tied to 2019 COC)

Small Groups new and renewing on 2019 COC  

  • Begins on or after Aug. 2, 2019
  • Begins on or after Sept. 3, 2019 for California
  • Begins on or after Oct. 1, 2019 for Colorado, Connecticut, New Jersey and New York

Large Groups new or renewing on 2019 COC

  • Begins on or after Aug. 2, 2019
  • Begins on or after Sept. 3, 2019 for California
  • Begins on or after Oct. 1, 2019 for Colorado, Connecticut, New Jersey and New York

Key Account and National Account ASO clients may buy-up

  • National Accounts — Client selects date.
  • Key Accounts — On or after Jan. 1, 2020
  • Coverage and medical necessity review follow the state regulations based on provider place of service

Plans currently included and excluded for musculoskeletal surgical site of service review

UnitedHealthcare Plans Included in Review

      Plans Excluded from Review

  • UnitedHealthcare ― PRIME
  • UnitedHealthcare ― ACIS
  • UnitedHealthcare ― Oxford
  • Neighborhood Health Partnership
  • UnitedHealthcare of the River Valley
  • Legacy MAMSI
  • Exchange plans
  • ASO may buy-up
  • UMR and All Savers
  • Fully insured groups not on 2019 COC
  • UHC West
  • Sierra
  • Fully insured plans in Alaska, Kentucky, Massachusetts and Texas

 

Prior authorization requirements

As part of our prior authorization process, a coverage determination will be made as to whether the procedure and the outpatient hospital site of care are medically necessary. The outpatient hospital site will be determined to be medically necessary if certain criteria are met. 

If a medical necessity determination is made that either the procedure or site of service is not authorized, the member and the provider will receive an adverse determination letter that sets forth the determination. The provider may submit another request for approval by modifying the site of service to an ambulatory surgical center if that was the reason for the denial. 

If the outpatient hospital site of service is determined not to be medically necessary, the claim will be denied and the member is responsible for the cost of the service as long as the hospital obtained the member’s written consent to be billed in accordance with our protocols, prior to the service being rendered.

UnitedHealthcare protocols, codes and utilization guidelines

Medical necessity site of service reviews will apply to certain musculoskeletal surgical procedure codes for arthroscopy surgery on ankle, wrist, elbow, hip, knee, shoulder and foot surgeries for bunions or hammertoes as outlined in the Musculoskeletal Surgical Site of Service UR Guideline.

Please contact your UnitedHealthcare representative if you have questions.