CurrentUnitedHealthcarePolicy N/A

UHC-Exchange-MRI-CT-Site-of-Service-Reviews-for-Individual-and-Family-Exchange-Plans-FAQs.pdf

Defines UnitedHealthcare's site-of-service medical necessity review process for MRI and CT procedures planned in outpatient hospital settings for Individual & Family Exchange (ACA Marketplace) plans in specified states, including prior authorization/notification expectations, exceptions, and provider obligations.

Policy Summary

PayerUnitedHealthcare

PolicyUHC-Exchange-MRI-CT-Site-of-Service-Reviews-for-Individual-and-Family-Exchange-Plans-FAQs.pdf

Policy CodePolicy N/A

Change TypeNo material change

Effective Date

Next Review Date

Key ActionProviders must complete the prior authorization/notification process before performing MRI/CT in an outpatient hospital setting; failure to do so may result in claim denial and inability to bill the member.

SourceLink

POLICY UPDATE CHANGES

No material changes to clinical coverage or policy provisions.

16States where policy applies

Coverage Summary

UnitedHealthcare's site-of-service medical necessity review process applies to MRI and CT procedures that are planned to be performed in an outpatient hospital setting for members covered by UnitedHealthcare Individual & Family (ACA Marketplace) plans in the following states: Alabama, Arizona, Florida, Georgia, Illinois, Kansas, Louisiana, Michigan, Mississippi, Missouri, North Carolina, Ohio, Oklahoma, Tennessee, Virginia, and Washington. The process defines prior authorization/notification expectations, exceptions, and provider obligations for those plans.

Medical-Necessity Criteria and Decision Logic

Site of Service Medical Necessity Review Decision Logic

Reviews are conducted for MRI/CT procedures planned in outpatient hospital settings using the applicable MRI/CT Site of Service medical policy criteria:

ALL of the following

Procedure is MRI or CT
Procedure is planned to be performed in an outpatient hospital setting
AND the member's plan is one of the following
- UnitedHealthcare Individual & Family ACA Marketplace plan in Alabama
- UnitedHealthcare Individual & Family ACA Marketplace plan in Arizona
- UnitedHealthcare Individual & Family ACA Marketplace plan in Florida
- UnitedHealthcare Individual & Family ACA Marketplace plan in Georgia
- UnitedHealthcare Individual & Family ACA Marketplace plan in Illinois
- UnitedHealthcare Individual & Family ACA Marketplace plan in Kansas
- UnitedHealthcare Individual & Family ACA Marketplace plan in Louisiana
- UnitedHealthcare Individual & Family ACA Marketplace plan in Michigan
- UnitedHealthcare Individual & Family ACA Marketplace plan in Mississippi
- UnitedHealthcare Individual & Family ACA Marketplace plan in Missouri
- UnitedHealthcare Individual & Family ACA Marketplace plan in North Carolina
- UnitedHealthcare Individual & Family ACA Marketplace plan in Ohio
- UnitedHealthcare Individual & Family ACA Marketplace plan in Oklahoma
- UnitedHealthcare Individual & Family ACA Marketplace plan in Tennessee
- UnitedHealthcare Individual & Family ACA Marketplace plan in Virginia
- UnitedHealthcare Individual & Family ACA Marketplace plan in Washington
Coverage determination for outpatient hospital site requires meeting criteria in the applicable MRI/CT Site of Service medical policy or clinical policy

Exceptions and Non-Applicability

Situations where site of service review or prior authorization is not required:

ANY of the following

Procedures performed in an emergency room
Procedures performed in an urgent care center
Procedures performed in an observation unit
Procedures done during an inpatient stay

Circumstances Allowing Outpatient Hospital Approval Despite Default Preference

Outpatient hospital site may be authorized when one or more of the following are documented:

ANY of the following

Member has medical condition(s) (e.g., age, comorbidities) that require outpatient hospital resources
Nearest participating freestanding diagnostic radiology center or office is a long distance for the member to travel
Nearest participating freestanding diagnostic radiology center or office lacks equipment or resources needed for the planned procedure

Provider Actions & Requirements

Prior Authorization

Prior authorization/notification required for outpatient hospital MRI/CT

Providers must complete UnitedHealthcare's prior authorization/notification process before performing MRI or CT procedures in an outpatient hospital setting. 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.

Documentation Required

Document clinical justification for outpatient hospital site

Submit clinical information to support authorization of the outpatient hospital site when applicable. Relevant documentation includes the patient's clinical condition (for example age, comorbidities), distance to the nearest participating freestanding imaging center, and whether the freestanding center lacks the equipment or resources needed for the planned MRI/CT. UnitedHealthcare will review the submitted clinical information against the applicable MRI/CT Site of Service medical policy.

Billing Rule

Billing when site of service denied

If UnitedHealthcare determines the outpatient hospital site is not medically necessary, providers may bill the member only if they obtain the member's written consent in accordance with UnitedHealthcare protocols prior to the service.

Documentation Required

ACO providers must follow authorization protocols

Providers who are part of an ACO are expected to notify UnitedHealthcare and request prior authorization in accordance with UnitedHealthcare protocols. There are no special exceptions for ACO providers at this time.

Background

UnitedHealthcare conducts site-of-service reviews to encourage more cost-efficient locations for MRI and CT services while preserving access to safe, quality care. Reviews use the criteria in the underlying Magnetic Resonance Imaging (MRI) and Computed Tomography (CT) Scan - Site of Service - Commercial and Individual Exchange Medical Policy and are performed only when the procedure is planned in an outpatient hospital setting. The policy supports exceptions and approval of outpatient hospital sites when documentation shows medical necessity (for example, patient age or comorbidities), when a participating freestanding center is not reasonably accessible, or when necessary equipment/resources are unavailable at lower-cost settings. Providers must complete prior authorization/notification before performing the service to avoid claim denial, and may bill a member only if they obtain the member’s written consent consistent with UnitedHealthcare protocols when site of service is denied.

Site of service medical necessity review

Site of service medical necessity review: A review to determine whether an MRI or CT procedure should be performed at an outpatient hospital site versus a lower-cost setting based on medical necessity and plan terms.

Frequently Asked Questions

Question	Answer
Which plans does the policy apply to?	UnitedHealthcare Individual & Family ACA Marketplace plans in AL, AZ, FL, GA, IL, KS, LA, MI, MS, MO, NC, OH, OK, TN, VA, and WA.
When is prior authorization not required?	For procedures performed in an emergency room, urgent care center, observation unit, or during an inpatient stay.
What happens if prior authorization is not completed?	UnitedHealthcare may deny the claim and the provider cannot bill the member unless written consent is obtained prior to service per protocols.
How can providers find participating freestanding imaging centers?	Use the UnitedHealthcare Medical Care Directory: select Employer and Individual Plans, choose the plan, go to Places > Labs, Imaging and Screenings > Imaging Centers, and look for Freestanding Facility indicator.

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