Posted in #unitedhealthcare, Training, Updates

UHC Community Health, Medicaid (Multiple States): Radiation therapy Prior Auth requirement

This policy will affect DOS (dates of services) on 10/07/2021 and thereafter, and will apply to UnitedHealthcare Community Plan members in the following states:

  • California
  • Florida
  • Maryland
  • Mississippi
  • Ohio
  • Rhode Island
  • Washington
  • Wisconsin

The prior authorization requirement will apply to the following outpatient radiation therapies, for UnitedHealthcare Community Plan Medicaid members, in the above mentioned states:

  • Intensity modulated radiation
  • Stereotactic body radiation therapy
  • Fractionation for breast cancer, prostate cancer, lung cancer and bone metastasis
  • Image guided radiation therapy
  • Special and associated radiation therapy services
  • Implantable beta emitting microspheres (Y90)

Authorization requirement for proton beam therapy (PBT):

If prior authorization for these services is already approved for administered treatment prior to Oct. 7, 2021, you do not need to submit a new prior authorization request for that approved treatment plan.

Authorization requirement for intensity-modulated radiation therapy (IMRT), image-guided radiation therapy (IGRT), special services Y90/SIRT or SBRT, including SRS:

Services started between Aug. 1–Oct. 6, 2021, you do not need to submit a prior authorization request. UHC Community Health will authorize the radiation therapy service(s) the member was receiving prior to Oct. 7, 2021, and the authorization will be effective for 90 days from the treatment start date. Any further radiation therapy services that extend after 90 days from the treatment start date prior authorization would be required prior to the start of services.

Completing Authorization requests:

Please complete prior authorization requests on the UnitedHealthcare Provider Portal using your One Healthcare ID and the Prior Authorization and Notification tool. Once you’re in the tool, select Radiology, Cardiology, Oncology and Radiation Oncology Transactions  > Service Type of Radiation Oncology > Product Type of Medicaid > member state.

Where to find the Prior Authorization Criteria:

Prior to Oct. 1, 2021, the new medical policies (Radiation Therapy: Fractionation, Image-Guidance and Special Services and Stereotactic Body Radiation Therapy and Stereotactic Radiosurgery) can be accessed from the UnitedHealthcare Community Plan Medical Policy Update Bulletin: July 2021.

On Oct. 1, 2021, medical policies for all radiation therapy services will be available at UnitedHealthcare Community Plan Medical & Drug Policies and Coverage Determination Guidelines.

Direct Link to the medical policy for Radiation Therapy: Fractionation, Image-Guidance, and Special Services, please click here.

Direct Link to the medical policy for Proton Beam Radiation Therapy, please click here.

Direct Link to the medical policy for Intensity-Modulated Radiation Therapy, please click here.





My name is Kate Patskovska, CPB. I am an Independent Medical Biller CPB (AAPC) and an owner of KR2 Medical Billing. KR2 Medical Billing is a full service Consulting/Medical Billing Business that is dedicated to educating, consulting, and overall improving the "financial health" of your medical practice.

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