Site of service medical necessity reviews for certain surgeries
- Fully Insured
- Products and Services
- Select States
UnitedHealthcare continues to work toward the Triple Aim of improved health and patient experience while reducing cost of care, including minimizing out-of-pocket costs for UnitedHealthcare members. As part of this effort, we are working together with providers to achieve better health outcomes, improve patient experience and lower the cost of care.
Site of service medical necessity reviews will begin for certain surgeries when surgery is performed in an outpatient hospital setting. These reviews will begin on or after Nov. 1, 2019 for fully insured groups in most states.
- In California, Colorado, Connecticut, New Jersey and New York, reviews will begin for certain surgeries happening on or after Dec. 1, 2019.
Through site of service medical necessity reviews, we are focused on helping to further minimize out-of-pocket costs for our plan members and to improve cost efficiencies for the overall health care system, while still providing access to safe, quality health care.
This review will occur where permitted by state law and by the terms of the member’s benefit plan. Site of service medical necessity reviews apply to providers in all states except Alaska, Kentucky, Massachusetts, Maryland and Texas.
The UnitedHealthcare Outpatient Surgical Procedures – Site of Service Utilization Review Guideline used to facilitate medical necessity site of service reviews will be available on uhcprovider.com on Nov. 1, 2019. The guideline includes the criteria used to facilitate our site of service medical necessity reviews.
Plans currently included and excluded for surgical site of service medical necessity review
UnitedHealthcare plans included in review
Plans excluded from review at initial launch
Working on site of service review for Oxford and ASO. Talk to your UnitedHealthcare representative.
How prior authorization for surgical procedures and site of service works
- Site of service medical necessity reviews are conducted during the prior authorization process.
- Prior authorization is required only for planned procedures.
- UnitedHealthcare will issue a medical necessity determination for the service and site of service, if applicable, under the terms of the member’s benefit plan, if permitted by state law. Site of service medical necessity reviews are conducted only if the procedure will be performed in an outpatient hospital setting.
- If the site of service is determined to be not medically necessary, the outpatient hospital claim will be denied. The member is responsible for the cost of the services if, prior to the service being rendered, the hospital obtained the member’s written consent to be billed for the service in accordance with UnitedHealthcare’s requirements.
Please contact your broker or UnitedHealthcare representative if you have questions