Frequently Asked Questions Cardiology Prior Authorization Program Applies to UnitedHealthcare Community Plan Members.

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1 Frequently Asked Cardiology Prior Authorization Program Applies to UnitedHealthcare Community Plan Members. Overview Prior authorization is required for select cardiology procedures provided to certain UnitedHealthcare Community Plan members. Working with external physician advisory groups, UnitedHealthcare has developed the Cardiology Prior Authorization Protocol to support a more consistent application of current scientific clinical evidence and professional society guidance to diagnostic and interventional cardiology procedures. The protocol is based on efforts to help improve compliance with evidence-based guidelines, reduce medical risk and align our business processes to simplify the administrative experience for physicians, other health care providers, hospitals and facilities. It also may improve care experiences, outcomes and total cost of care of UnitedHealthcare Community Plan members. The clinical guidelines used for the protocol are current with best practices and reflect guidance from our external Cardiac Scientific Advisory Board, which is comprised of leading clinical and academic board-certified cardiologists. The clinical criteria are reviewed annually. The evidence-based clinical guidelines are posted on UnitedHealthcareOnline.com, and serve as a detailed reference tool to support ordering providers in selecting the appropriate procedure. To access these guidelines go to UnitedHealthcareOnline > Clinician Resources > Cardiology > UnitedHealthcare Community Plan Cardiology Prior Authorization Program. You may access other related resources online including the protocol, quick reference guide and provider education. If you have questions, please contact your Provider Advocate or UnitedHealthcare Network Management representative. 1. What medical care providers are affected by the prior authorization requirement for select cardiac procedures? 2. If UnitedHealthcare Community Plan is the secondary plan, is prior authorization required on cardiac procedures? 3. Who is responsible for obtaining prior authorization of a cardiac procedure? The Cardiology Prior Authorization Program is required for UnitedHealthcare Community Plan participating providers, facilities and other health care professionals for certain inpatient, outpatient and officebased cardiac procedures prior to performance for UnitedHealthcare Community Plan members. No. Prior authorization is not required when UnitedHealthcare Community Plan is secondary to any other payer, including Medicare. The ordering physician s office is responsible for obtaining a prior authorization number before scheduling the cardiac procedure. Since cardiac procedures are not always performed by the same ordering and rendering physician, the ordering physician must obtain the prior authorization and communicate it to the rendering physician. If the rendering physician determines there is no prior authorization on file, they should submit the prior authorization request. The member may have authorization requirements for specific benefit plans as well as specific requirements when using non-participating care providers. page 1 of 5

2 4. How can providers obtain and verify a prior authorization number? 5. Which cardiac procedures require prior authorization? 6. What are the place of service requirements for cardiology prior authorization? To obtain or verify a prior authorization number: Online: UHCCommunityPlan.com or Use the UnitedHealthcareOnline application on Link for prior authorization. Sign into Link using your Optum ID. Select UnitedHealthcareOnline.com > Notifications/Prior Authorizations > Cardiology Notification & Authorization - Submission & Status. Phone: from 7 a.m. to 7 p.m., local time Monday - Friday A Prior Authorization number is required for each procedure, is CPT code-specific and valid for 45-days. Prior authorization is required for the following CPT codes: Diagnostic Catheterization CPT codes: 93452, 93453, 93454, 93455, 93456, 93457, 93458,93459, 93460, Electrophysiology Implants Pacemaker Implant CPT codes: 33206, 33207, 33208, 33212, 33213, 33214, 33227, CRT (Cardiac Resynchronization Therapy) CPT device codes: 33221, 33224, 33229, 33231, 33264, CPT Lead Code Defibrillator (AICD) Implant CPT codes: 33230, 33240, 33249, 33262, 33263, Echocardiogram CPT codes: 93303, 93304, 93306, 93307, Stress Echo CPT codes: 93350, Failure to obtain prior authorization or verify that it has been obtained before rendering cardiac procedures may result in administrative claim denial. Care providers cannot balance bill members for the services. Prior authorization is required for each of the following procedures in the place of service identified: Cardiac Procedure Outpatient Office Inpatient Diagnostic Catheterization Required Required Not Required Electrophysiology Implants Required Required Required Echocardiogram Required Required Not Required Stress Echo Required Required Not Required Cardiac services performed at the following places of service DO NOT require prior authorization: Emergency rooms Urgent care centers Hospital observation units Inpatient settings (except for electrophysiology implants). page 2 of 5

3 7. What information may be requested to obtain a cardiology prior authorization? 8. Will any professional component(s) be affected by prior authorization? Information that may be requested before a prior authorization is considered include: Member s plan name, member name, date of birth, telephone and address, member identification (ID) and group number Ordering provider s name, NPI, tax ID number, address, telephone and fax number Rendering provider s name and address (if different than the ordering provider) The cardiac procedure(s) being requested, with the CPT code(s) The working diagnosis with the appropriate ICD code(s) The member s clinical condition, which may include any symptoms, listed in detail, with severity and duration; treatments that have been received, including dosage and duration for drugs; and dates for other therapies. Any other information that the provider believes will help in evaluating whether the service ordered meets current evidence-based clinical guidelines, including but not limited to, prior diagnostic tests and consultation reports. If the rendering provider is different from the ordering provider, the prior authorization number should be obtained and communicated by the ordering provider to the rendering provider. For echocardiograms and stress echocardiograms, the professional component (modifier 26) will not be subject to administrative denial for lack of prior authorization. For cardiac catheterization and electrophysiology implants, the full claim, including the professional component modifier 26, will be subject to administrative denial for lack of prior authorization. For all cardiology services, if a procedure is not approved and it is still performed the, global, technical and professional components will be subject to denial for lack of medical necessity, including professional claims billed with modifier 26. page 3 of 5

4 9. When is retrospective authorization used rather than prior authorization? 10. Is retrospective authorization available for cases where the electrophysiology implant is done during the course of an inpatient admission but is not the reason for the admission? 11. Can the CPT code for the procedure to be performed be modified under the Cardiology Prior Authorization Program? Retrospective authorization is completed after a procedure has been rendered and is only allowed in two situations: (1) when a service subject to the prior authorization requirement is required on an emergent basis; and (2) when a service subject to the prior authorization requirement, such as electrophysiology implants, is performed during the course of an inpatient stay. In these situations, the service may be performed, and authorization can be requested retrospectively. Retrospective authorization requests for electrophysiology implants and diagnostic catheterizations must be requested within 15 calendar days of the service. For echocardiogram and stress echo procedures, retrospective authorization must be requested within two business days of the service. Documentation must include an explanation as to why the procedure was required on an emergent basis or that it was performed during the course of an inpatient stay. Retrospective authorization is not available for outpatient elective procedures. Yes. In order to help ensure that patient care is not delayed while in the inpatient setting, retrospective authorization is available for procedures performed during the course of an inpatient admission. For example, if a patient is admitted for a reason other than the procedures subject to this program (e.g., heart failure), and it is determined during a cardiac consult that an electrophysiology implant is required, then the physician should proceed with the procedure and submit the authorization on a retrospective basis within 15 calendar days of the date of service. The retrospective authorization process does not apply to the facility s separate admission authorization requirement. Yes. Certain specified CPT Code combinations can be modified. You will not be required to contact UnitedHealthcare to modify the existing prior authorization record. The Crosswalk Table maps CPT codes that are interchangeable for prior authorization. A complete listing of codes and the CPT Code Crosswalk Table is available at UnitedHealthcareOnline. com > Clinician Resources > Cardiology > UnitedHealthcare Community Plan Cardiology Prior Authorization Program. If a CPT Code combination is not listed on the CPT Code Crosswalk Table, the Cardiology Prior Authorization Protocol for additional cardiac procedures still applies and a modification to the authorized procedure would need to occur. page 4 of 5

5 12. How does the CPT Code Crosswalk Table work? 13. What is the difference between a case number and a prior authorization number? 14. Does receipt of a prior authorization number guarantee that UnitedHealthcare Community Plan will pay the claim? 15. Who performs the medial necessity review for prior authorization requests? 16. What happens if a prior authorization request is not approved? 17. Is there an appeal process if the prior authorization request is not approved? The CPT Code Crosswalk Table includes a mapping of CPT codes that are interchangeable for prior authorization: If a provider calls to obtain prior authorization for a left heart catheterization and provides the CPT code and ultimately bills a CPT code, the code substitution is appropriate if these codes are mapped as interchangeable on the Crosswalk Table. CPT code substitutions are not appropriate, however, if the codes are not mapped as interchangeable on the table. For example, if a provider calls to obtain prior authorization for a pacemaker insertion (CPT Code 33206) and instead implants a defibrillator (CPT Code 33240) and these codes are not mapped as interchangeable on the Crosswalk Table, then this code substitution is inappropriate. A case number is a 10-digit number assigned for each prior authorization request (e.g ). A case number is used for reference purposes when a case is initiated and remains open due to missing information. Case numbers are not valid for purposes of claim payment. Once the prior authorization process has been completed, and it is determined that the requested procedure is consistent with evidencebased clinical guidelines, a prior authorization number is issued. A prior authorization number begins with A followed by a nine-digit number. No. Receipt of a prior authorization number does not guarantee or authorize payment. Payment for covered services is contingent upon various factors including coverage within the member s benefit plan and the care provider s Participation Agreement with UnitedHealthcare Community Plan. Board-certified cardiologists will perform the medical review for prior authorization requests. Ordering or rendering providers may request a clinical discussion with the reviewing cardiologist. To initiate a physicianto-physician discussion, call , then: select prompt #3 and provide the 10-digit case number. If there is no case number or it is invalid, press* If a prior authorization request is not approved, the ordering care provider and member will be informed in writing of the reason for the denial, including the clinical rationale, as well as how to initiate an appeal. Yes. Appeal rights are sent to the ordering providers and member with each adverse determination. All appeals will be managed by UnitedHealthcare. An authorized representative, including a care provider acting on behalf of his/her patient with their written consent, may file an appeal on behalf of their patient per appeals guidelines. M54876-I 9/ United HealthCare Services, Inc. Doc#: PCA _ page 5 of 5