Posted in #Medicareadvantage, #unitedhealthcare, Training, Updates

UHC Commercial and Exchange Plans: update to Radiology Prior Auth List

As of December 1,2021 the following codes will be added to the radiology prior authorization list. These codes will require an authorization for DOS 12/01/2021 and thereafter.

The prior authorization for these codes WILL NOT APPLY TO The following situations: if the advanced imaging is done in-

  • Emergency room
  • Urgent care center
  • Observation unit
  • Inpatient stay

In case you missed it:

In June 2021, UHC also added more Radiology and Cardiology codes on the Prior Authorization List. These codes apply to UnitedHealthCare Community Plan, Medicare Advantage, commercial and exchange Plans


For complete details on the radiology protocol, refer to the current UnitedHealthcare Administrative Guide


Find this type of information useful? Follow my blog for more insurance payer updates, medical coding and medical billing guideline changes, reimbursement and medical policy updates.


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UHC Exchange Plans: no ref needed for chiropractic services

According to UHC latest announcement for their exchange plans: patients that have individual or family UHC exchange plans will NO LONGER need a referral for chiropractor.

If you are provider in any following states, then this change will take affect for DOS 09/01/2021 and thereafter:

  • Arizona
  • Maryland
  • North Carolina
  • Oklahoma
  • Tennessee
  • Virginia
  • Washington State

Starting Jan 1, 2022, this change will also apply to new 2022 Individual and Family Exchange plans in these states:

  • Alabama
  • Florida
  • Georgia
  • Illinois
  • Louisiana
  • Michigan
  • Texas

If you are a provider and have a question regarding this change, please contact your provider relations advocate.


Find this content useful? Follow my blog for more Payer updates, medical coding and medical billing guideline changes, reimbursement and medical policy updates.


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Empire NYSHIP Plans and member cost-sharing for diagnostic allergy and asthma testing: year 2020 and beyond

This post is for Allergy & Asthma providers that accept Empire NYSHIP (TPA UHC) patients and perform diagnostic asthma/allergy testing in the office setting (POS 11).

Commonly used CPT codes in Office Setting (w/ short description)

1. 95004- skin prick allergy testing

2. 95024- intradermal allergy testing

3. 95044- patch allergy testing

4.95018- Medication (Penicillin) allergy testing

5. 94200- Peak flow

6. 95012- NIOX or FENO

Member cost-sharing/patient co-pays for year 2020 and beyond:

Most of the Empire NYSHIP plans (there are various types), have updated their co-pay to $25 per office visit (specialist) Please click here to visit my post on the updated Empire NYSHIP co-pays.

However, as recent as last year, the Empire NYSHIP plans also started to add, an extra $25 member cost-sharing fee, to the above mentioned CPT codes. In order for your office not to leave this uncollected revenue on the table, please make sure to inform your front office staff of this change!  

Now  let’s take a look at 2 (TWO) examples.

Ex. 1. Patient comes in for the first time and has the environmental skin prick testing done the same day. The billing would be:  99204 25 with 95004X40 -the total patient financial responsibility would be $50: $25 for OV and $25 for testing.

Ex. 2. Patient with DX of Allergic Asthma (J45.30) is coming in for a follow up visit. The billing would be: 99213 25 with 94200 59 and 95012 59. In this instance the second co-pay would be applied to 94200 and 95012 would be paid. So, the patient will still pay only $50 co-pay.

Now, If you have any more questions about this post, Empire NYSHIP patients cost-sharing or something else, please go on my (SERVICES) page and contact me for a free 30-min Evaluation ($250 Value).