CurrentColorado Rocky Mountain Health PlansPolicy N/A

Site of service reviews for MRI/CT services

Governs UnitedHealthcare's site-of-service medical necessity review and prior authorization expectations for MRI and CT procedures performed in outpatient hospital settings for commercial and individual exchange plans; affects ordering providers and members covered under applicable UnitedHealthcare commercial plans.

Policy Summary

PayerColorado Rocky Mountain Health Plans

PolicySite of service reviews for MRI/CT services

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionObtain prior authorization/site-of-service medical necessity review for MRI and CT procedures scheduled in outpatient hospital settings.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

outpatient onlyApplicable setting

commercial plansApplies to

some segments/statesExclusions

prior auth requiredAuthorization risk

Coverage Criteria

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Outpatient hospital approval

Covered at outpatient hospital site only when applicable policy criteria are met or when specific exceptions apply.

Approval conditions: Outpatient hospital site is approved if ALL criteria in the applicable medical policy or clinical policy are met OR if the member cannot reasonably access a participating freestanding center or the freestanding center lacks necessary equipment/resources.

Uses clinical information submitted to evaluate exceptions such as travel distance or equipment availability.

Denial and member billing

Site-of-service denial and member billing

Denial-related conditions: If prior authorization/notification is not completed before the procedure, the claim may be denied; if outpatient hospital site is determined to be not medically necessary, the provider may bill the member only with the member's prior written consent consistent with UnitedHealthcare protocols.

Providers cannot bill members for services when prior authorization/notification was not completed and the claim is denied.

This policy does not apply to certain UnitedHealthcare segments and to members in specified states. Excluded segments are UnitedHealthcare West and UnitedHealthcare Sierra. Excluded states are Alaska, Connecticut, Iowa, Maine, Maryland, Massachusetts, New Hampshire, Rhode Island (effective June 1, 2023), Texas, Utah, Vermont, and Wisconsin.

Approval of an outpatient hospital site of service is based on whether the applicable MRI/CT medical policy or clinical policy criteria are met. If those criteria are not met, the outpatient hospital location will be determined to be not medically necessary. Procedures performed in an emergency department, urgent care center, observation unit, or during an inpatient stay are not subject to the outpatient hospital prior authorization/notification requirement.

When Outpatient Hospital Site is Indicated

Outpatient hospital site indication when clinical criteria or member circumstances necessitate hospital-level resources

Indications for outpatient hospital site: Use outpatient hospital when applicable clinical policy criteria require hospital-level resources (e.g., patient medical condition or complexity) OR when member circumstances such as unreasonable travel distance to a participating freestanding center or lack of necessary equipment/resources at the freestanding center justify the hospital site.

Exact clinical criteria are detailed in the linked MRI/CT clinical policy; clinical information submitted by the provider will be used to evaluate these circumstances.

Provider Actions and Authorization Requirements

Prior Authorization

Prior authorization/site-of-service review required

Prior authorization/site-of-service medical necessity review is required for MRI and CT procedures scheduled in outpatient hospital settings; an outpatient hospital site will be approved only if the criteria in the applicable medical policy or clinical policy are met.

Step Therapy

Authorization expectation for ACO providers

Providers, including those in ACO arrangements, must notify UnitedHealthcare and request prior authorization in accordance with UnitedHealthcare protocols.

Documentation Required

Scheduling and member consent documentation

When the ordering physician completes prior authorization, scheduling begins: the member receives a phone call to schedule the procedure and, after the member selects a location, the ordering physician is faxed the chosen facility details and the member's authorization number.

Denial Risk

Failure to obtain prior authorization

If prior authorization/notification is not completed before the procedure is rendered, UnitedHealthcare may deny the claim and the provider cannot bill the member for the service.

Prior Authorization Details

Prior Authorization

MRI | CT — Prior authorization for outpatient hospital procedures

Site-of-service medical necessity review is required for MRI and CT procedures scheduled in outpatient hospital settings; approvals are only issued when the applicable medical or clinical policy criteria are met. Prior authorization/notification is not required for procedures performed in the emergency room, urgent care, observation unit, or during an inpatient stay.

Required only when the procedure is scheduled in an outpatient hospital setting.
Emergency, urgent care, observation, and inpatient procedures are excluded from the prior authorization/site-of-service requirement.

Definitions

Site-of-service medical necessity review definition — inv-11

DefinitionSite-of-service medical necessity review is the process used to determine whether an MRI or CT procedure should be performed at an outpatient hospital versus a lower-cost freestanding facility based on clinical criteria and member circumstances.

When conductedReviews are performed only when the MRI or CT procedure is scheduled to be performed in an outpatient hospital setting.

Decision factorsDetermination uses applicable medical or clinical policy criteria and clinical information submitted by the provider, including member-specific factors such as travel distance and equipment or resource availability at freestanding centers.

Exception handlingIf the nearest participating freestanding center is a long distance away or lacks necessary equipment/resources, the procedure may be authorized at a participating outpatient hospital site per the applicable medical/clinical policy.

Related policiesUses criteria in the linked MRI and CT site-of-service medical policy (Commercial and Individual Exchange) or the Oxford site-of-service clinical policy for Oxford plans.

Frequency Limits

MRI | CT frequency limits — inv-13

Modalities coveredMRI and CT procedures scheduled in outpatient hospital settings are subject to frequency and site-of-service review.

Frequency limits presentNo specific numeric frequency limits are stated in this document; frequency rules and any limits are those in the referenced MRI/CT clinical policy.

Prior authorization implicationPrior authorization/site-of-service medical necessity review is required for MRI and CT procedures scheduled in outpatient hospital settings unless performed in emergency, urgent, or inpatient settings.

Where to find exact limitsRefer to the linked Magnetic Resonance Imaging (MRI) and Computed Tomography (CT) Scan - Site of Service medical policy (commercial) or the Oxford clinical policy for modality-specific frequency guidance.

Background

The intent of this policy is to identify MRI and CT procedures that can be performed safely outside the outpatient hospital setting to improve cost-effectiveness while preserving access to necessary care. Site-of-service determinations require that the applicable clinical policy criteria be met for approval of an outpatient hospital; if criteria are unmet, the outpatient hospital site is considered not medically necessary.