Photo: UnitedHealthcare (archive photo)
UnitedHealthcare published a list of more than 2,000 pediatric procedure codes Monday, November 2, that will no longer require prior authorization for eligible patients under 18 starting December 1. The new detail follows the insurer’s May pledge to remove nearly two-thirds of pediatric prior authorizations; the changes are not yet in effect.
The company announcement said the changes apply to UnitedHealthcare commercial plans, Individual Exchange Plans and Community Plans where permitted by state law. For eligible members, the exemptions are not limited to care delivered at particular pediatric facilities.
The codes cover services including certain ear-tube and tonsil procedures, sleep studies, MRI and CT scans, joint and cardiac procedures, and some oncology and chemotherapy services. The list concerns specific billing codes, not a blanket waiver for every service in those categories.
Some complex services will still require prior authorization, including certain injectable medicines, genetic tests and surgical procedures, as well as services subject to state requirements. Some pediatric services will also continue to require advance notification, the company said.
The provider notice says code removals vary by state and plan. It excludes UnitedHealthcare Medicare Advantage plans, Dual Eligible Special Needs Plans, Health Plan of Nevada Medicaid and UMR plans that do not follow the UMR prior authorization list.
Clinicians should review the applicable code list and verify the requirements for the specific service, member and plan through the Prior Authorization and Notification tool in the UnitedHealthcare Provider Portal. Families should not assume that an exemption from prior authorization means every plan covers a service or that no other plan requirements apply.
The announcement follows UnitedHealthcare’s earlier pediatric prior-authorization commitment. Monday’s publication provides code-level information and a December 1 start date, rather than announcing that all pediatric reviews have already ended.
UnitedHealthcare said it selected services widely considered safe and effective in an effort to reduce administrative work for clinicians and families. The announcement describes a policy change; it does not provide measured results showing how much waiting time or administrative cost the December changes will save.
JBizNews Desk | New York
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