UnitedHealthcare aims to minimize out-of-pocket costs for UnitedHealthcare members and to improve cost efficiencies for the overall health care system. For certain Magnetic Resonance Imaging (MRI), Magnetic Resonance Angiograms (MRA) or Computerized Tomography (CT) procedures, a medical necessity review for the site of care will be issued under the terms of the member’s benefit plan, as part of our prior authorization process, if the procedure will be performed in an outpatient hospital. Site of care reviews will apply to dates of service on or after March 1 for fully insured small groups and on or after July 1 for fully insured large groups.
The review will occur where permitted by state law and by the terms of the member’s benefit plan.
Medical necessity site of care reviews will be conducted for fully insured membership covered under the 2019 Certificate of Coverage (COC).
The following chart outlines when the medical necessity site of care reviews will go into effect.
Line of Business |
Date of Service Site of Care Reviews Begin |
Small Groups new and renewing on 2019 COC in Jan. 1 through March 1, 2019 |
Begins on March 1, 2019
|
Small Groups renewing and new business on 2019 COC after March 1, 2019 |
Begins on renewal or new business effective date |
Rhode Island Small and Large Groups renewing or new Jan. 1 through March 1, 2019 |
Begins March 1, 2019 |
Rhode Island Small and Large Groups renewing or new after March 1, 2019 |
Begins on renewal or new business effective date |
Large Groups renewing or new on 2019 COC |
Begins July 1, 2019 on renewal |
Plans excluded from medical necessity site of care reviews at this time include any plans not on a 2019 COC, self-funded plans including UMR, all National Account plans, Oxford, legacy MAMSI, UHC West, and Sierra. In addition, fully insured plans in Alaska, Connecticut, Iowa, Kentucky, Maine, Utah, Vermont and Wisconsin are excluded.
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 of care will be determined to be medically necessary if certain criteria are met.
Once a medical necessity determination is made, the member and the ordering provider will receive a determination letter that sets forth the determination. If the outpatient hospital site of care is determined not to be medically necessary, the outpatient hospital’s 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.
Please contact your broker or UnitedHealthcare representative if you have questions.
This update is not applicable to AK, CT, IA, KY, ME, UT, VT and WI.