CurrentUnitedHealthcarePolicy PCA-2-25-00137-POE-FAQ 03142025

Outpatient Radiology Prior Authorization Program for Medicare Advantage — Frequently asked questions

This document describes UnitedHealthcare's prior authorization requirements and processes for certain advanced outpatient imaging procedures for most Medicare Advantage plans and explains responsibilities for ordering and rendering providers.

Policy Summary

PayerUnitedHealthcare

PolicyOutpatient Radiology Prior Authorization Program for Medicare Advantage — Frequently asked questions

Policy CodePolicy PCA-2-25-00137-POE-FAQ 03142025

Change TypeNo material change

Effective Date

Next Review Date

Key ActionSubmit prior authorization requests online via UHCprovider.com (Prior Authorizations & Notifications > Create a new request; select Radiology and Medicare) or by phone at 866-889-8054 during business hours.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

3procedure categories

2submission methods

3-hoururgent response time

866-889-8054phone

45 daysauth validity

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2 business daysmodification window

Coverage and Authorization Criteria

Outpatient radiology prior authorization criteria

Prior authorization is required for specified advanced outpatient imaging procedures for most UnitedHealthcare Medicare Advantage plans; exclusions and places-of-service exceptions apply.

Authorization required for the following advanced outpatient imaging procedures when performed in outpatient or office-based settings: Positron-emission tomography (PET); Nuclear medicine; Nuclear cardiology.

Plan and provider exclusions

Protocol does not apply to listed plans (Preferred Care Network/Partners of Florida, Erickson Advantage, certain Nursing Home/Assisted Living SNPs, UnitedHealthcare Medicare Direct, Sierra).
Protocol does not apply to delegated provider groups and UnitedHealthcare West capitated providers.

Places of service not subject to prior authorization

Services rendered in emergency rooms, urgent care centers, hospital observation units, and inpatient settings are not subject to prior authorization when appropriately billed.
If a freestanding clinic bills outpatient place of service, prior authorization is required even when the patient originated from inpatient/ER/observation/urgent care.

Failure to request prior authorization before performing an advanced outpatient imaging procedure may result in an administrative claim denial; providers may not bill members for administratively denied services.

Ordering health care professional is responsible for requesting prior authorization; if the ordering provider is non‑participating or unwilling, the rendering provider must complete the authorization process.

Each authorization is specific to the individual CPT code; complete the prior authorization process for each CPT code to be performed.

Information required for requests: Requests must include member demographics, ordering provider identifiers, diagnosis/ICD codes, requested CPT codes, clinical details, prior treatments/tests, and other information needed to evaluate against evidence‑based guidelines.

Urgent requests: Ordering providers may request urgent prior authorizations; UnitedHealthcare will respond within 3 hours during business hours; outside business hours submit within 2 business days after the date of service with an explanation of urgency.

Authorization receipt does not guarantee payment; payment depends on plan benefits, provider participation, federal regulations, and Medicare Advantage policies.

Providers receive notification of completed prior authorizations by fax (electronic notification available if elected); if a service fails medical necessity review, clinical denial and appeal instructions are issued to the member and ordering provider.

Prior authorization operational criteria

Operational criteria for authorization validity, code changes, and required actions:

A prior authorization is valid for 45 calendar days from the date the prior authorization number is issued for one procedure on one date of service; request a new authorization if the procedure is not performed within 45 days.

CPT code modification when crosswalk lists change: If the CPT code change is listed in the Radiology Prior Authorization Crosswalk Table, the rendering health care professional is not required to contact UnitedHealthcare or update the original prior authorization.

CPT code modification when crosswalk does not list change: If the CPT code combination is not listed in the Crosswalk Table, the ordering or rendering health care professional must modify the original prior authorization online or by phone within 2 business days after the procedure when the procedure is for a contiguous body part; if the procedure is for a noncontiguous body part, the ordering health care professional must obtain a new prior authorization before the procedure.

When modification is required, follow portal steps or call UnitedHealthcare; modifications must occur within 2 business days after the procedure is rendered.

CPT Codes, Crosswalks, and Authorization per Procedure

Radiology CPT codes requiring prior authorizationCPT

See UHCprovider.com/radiology

Current listing of CPT codes requiring prior authorization

CPT crosswalk examplesCPT

70450-70470,70460,76380 (examples in crosswalk)	Example CT head/brain CPT codes and crosswalked equivalents referenced in Crosswalk Table examples
78012 -> 78014	If prior authorization obtained for 78012 and procedure changes to 78014 (listed in crosswalk), no further action required
78070 -> 78072	If prior authorization obtained for 78070 and change to 78072 is not listed in crosswalk, ordering or rendering provider must modify the authorization within 2 business days

inv-05: Authorization per CPT

RequirementComplete prior authorization for each individual CPT code; each authorization number is specific to the CPT code.

Claim form noteAuthorization numbers are not required to appear on the claim form.

Where to find code listFor the most current listing of radiology CPT codes that require prior authorization, visit UHCprovider.com/radiology.

inv-06: modification window

Modification windowModify the original prior authorization request within 2 business days when the Radiology Crosswalk Table does not list the CPT code combination (for contiguous body parts either ordering or rendering provider may modify).

How to modify

How Providers Request Authorizations and Operational Steps

Prior Authorization

Provider responsibilities for requesting authorization

There are specific provider responsibilities when requesting prior authorization. The ordering health care professional who determines the need for an advanced outpatient imaging procedure is generally responsible for requesting authorization before scheduling the procedure. If the ordering professional is non‑participating and unwilling to complete authorization, the rendering health care professional must complete the process. Failure to follow the outpatient radiology authorization protocol may result in an administrative claim denial; you may not bill members for administratively denied claims.

Ordering provider is the primary responsible party for prior authorization.
Rendering provider must initiate authorization if ordering provider will not or is non‑participating.

Prior Authorization

Per‑procedure / CPT authorization requirement

Prior authorization is required for each individual CPT code for advanced outpatient imaging procedures. Obtain a separate authorization for each procedure/CPT code before the service is rendered. Each authorization number is specific to the CPT code requested; we do not require the authorization number to be submitted on the claim form, but failure to obtain prior authorization may result in administrative denial.

Key Terms and Identifiers

inv-20: List of advanced outpatient imaging procedure categories (PET, Nuclear medicine, Nuclear cardiology)

Procedure categoriesPositron-emission tomography (PET)

Procedure categoriesNuclear medicine

Procedure categoriesNuclear cardiology

inv-21: case number — 10-digit identifier assigned when process initiated

FormatA case number is a 10-digit numeric identifier assigned when the prior authorization process is initiated (e.g., 1041401245).

PurposeUsed to access case details during physician-to-physician discussions or to provide missing clinical information when a request cannot be completed.

Policy Summary

PayerUnitedHealthcare

PolicyOutpatient Radiology Prior Authorization Program for Medicare Advantage — Frequently asked questions

Policy CodePolicy PCA-2-25-00137-POE-FAQ 03142025

Change TypeNo material change

Effective Date

Next Review Date

SourceLink

On This Page

A case number (10-digit numeric) is assigned when the prior authorization process is initiated for reference; an authorization number (alphanumeric) is issued when the prior authorization process is completed; case numbers are not valid for claim payment.

Completed prior authorizations are faxed to the ordering provider (or sent electronically if elected); clinical denials include notice with appeal instructions to the member and ordering provider.

Modify online via UHCprovider.com: Sign in with One Healthcare ID > Prior Authorizations & Notifications > Create a new request > select Radiology and Medicare > Continue.

Noncontiguous body partsIf the procedure is for a noncontiguous body part, the ordering provider must obtain a new prior authorization before the procedure.

Obtain prior authorization per individual CPT code.
Authorization number is specific to the CPT and valid for the authorized CPT only.

Denial Risk

Effect of incomplete prior authorization on professional component

If you do not complete the prior authorization process, the professional component (modifier 26) is not subject to administrative denial solely for missing authorization. However, if you receive a clinical denial for lack of medical necessity and still perform the procedure, the professional component of the claim is subject to denial for lack of medical necessity.

Missing prior authorization alone will not cause an administrative denial of the professional component (modifier 26).
A clinical denial for medical necessity may result in denial of the professional component if the procedure was performed despite denial.

Documentation Required

Appeals for denials due to incorrect member insurance information

If a claim is denied because the member provided incorrect insurance information to the ordering health care professional (resulting in a missing prior authorization), the rendering health care professional may submit an appeal. Appeals can be filed by contacting UnitedHealthcare and follow the Claims Appeals and Reconsideration Process in the Provider Administrative Guide. An authorized representative, including a health care professional acting on behalf of the patient with the member's written consent, may file an appeal on the member's behalf.

Rendering provider may appeal denials due to incorrect member insurance information.
Follow the Provider Administrative Guide for the Claims Appeals and Reconsideration Process.
Authorized representatives may file appeals with the member's written consent.

Case numbers are not valid for claim payment.

inv-22: prior authorization number — alphanumeric identifier issued on completion

FormatPrior authorization numbers are alphanumeric identifiers issued when the prior authorization process is completed.

TimingIssued upon completion of the prior authorization process (distinct from the case number assigned at initiation).

Distinct from case numberUnlike case numbers, authorization numbers are alphanumeric and indicate completion of the authorization decision.