Site-of-service (SOS) considerations — certain procedures and codes require prior authorization when performed in specific settings (outpatient hospital or ambulatory surgical center). When performed in an office setting prior authorization is often not required. The plan reviews SOS as part of prior authorization and may deny or redirect services to a more appropriate setting. Submit SOS-related prior authorization requests via the UnitedHealthcare Provider Portal or call the number on the member's ID card.
Prior authorization is required if the listed procedures are performed in an outpatient hospital setting or ambulatory surgical center (ASC); prior authorization may not be required when those same procedures are billed as performed in an office setting.
Site-of-service review applies to multiple service categories including (but not limited to) arthroscopy, reconstructive/cosmetic procedures, foot surgery, and certain dermatologic and ENT procedures; the plan will review the site of service during the prior authorization process.
For codes listed with a site-of-service restriction, prior authorization is required when the service is performed in an outpatient hospital or ASC except where explicitly noted (for specific state exceptions see related policy notes).
Providers must submit prior authorization and SOS notifications online using the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal (UHCprovider.com) or call 866-889-8054. Follow the portal instructions to select the Prior Authorization and Notification tab.
Examples of codes subject to site-of-service review (partial list): 29805, 29806, 29807, 29819, 29820, 29821, 29822, 29823, 29824, 29825, 29827, 29828, 29830, 29834, 29835, 29836, 29837, 29838, 29840, 29844, 29845, 29846, 29847, 29848, 29860, 29861, 29862, 29863, 29870, 29873, 29874, 29875.
Additional examples of codes where SOS review may apply (partial list): 30400, 30410, 30420, 30430, 30435, 30450, 30460, 30462, 30465; dermatologic office-based codes: 11402, 11403, 11404, 11406, 11420, 11421, 11422, 11423.
Radiology/advanced outpatient imaging: Certain CT, MRI, MRA, PET, nuclear medicine and nuclear cardiology procedures require prior authorization before scheduling when performed as advanced outpatient imaging; providers must notify UnitedHealthcare and complete prior authorization prior to scheduling (see Radiology Prior Authorization and Notification > Commercial).