Updated requirements for gastroenterology services
Last modified: June 1, 2023
To provide an opportunity for physician education and to allow UnitedHealthcare to collect more data on which providers should be eligible for our previously announced 2024 Gold Card administrative simplification program, we will be implementing an Advance Notification process, rather than Prior Authorization, for non-screening gastroenterology (GI) procedures.
Beginning June 1, 2023, UnitedHealthcare will be modifying our requirements for gastroenterology services. You will be asked to provide advance notification in lieu of prior authorization for gastroenterology endoscopy services for UnitedHealthcare commercial plan members, in accordance with the terms of their benefit plan. Please disregard communications that may reference prior authorization language, as it will take a few weeks for our systems to update to the new advance notification process. Please note that screening colonoscopy procedures are not subject to this advance notification process.
What is Advance Notification?
The Advance Notification process for non-screening GI procedures supports our efforts to ensure access to safe and affordable care. During 2023, we will collect the data received through advance notification to accelerate gold carding for eligible physician groups in early 2024. During this period, we will not issue medical necessity denials for procedures that are not aligned with clinical evidence. Additionally, we will not issue administrative denials for failure to submit advance notification. Rather, we will provide you the opportunity to engage in a comprehensive peer-to-peer discussion with a board-certified gastroenterologist around clinical guidelines. This approach also enables us to identify geographies where underutilization of GI procedures presents an opportunity for us to educate our members about the importance of screening colonoscopies and advanced diagnostic GI procedures.
Provider groups who do not submit advance notification during this period will not be considered for the UnitedHealthcare Gold Card program, scheduled to launch in 2024.
Affected procedures
The following procedures will now require advance notification:
- Esophagogastroduodenoscopies (EGD)
- Capsule endoscopies
- Diagnostic colonoscopies
- Surveillance colonoscopies
Please review the Preventive Care Services – Commercial and Individual Exchange Medical Policy for details regarding screening colonoscopies, which are not included in the advance notification process.
Providing Advance Notification
You can provide advance notification in one of the following ways:
- Online: Use the Prior Authorization and Notification tool on UHCprovider.com by following these steps:
- Sign in to the UnitedHealthcare Provider Portal using your One Healthcare ID
- Select Radiology, Cardiology, Oncology, Radiation Oncology and Gastroenterology Endoscopy Services Transactions
- Enter the required information on the submission site
- Phone: Call us at 866-889-8054 (Oxford 877-773-2884), Monday–Friday, 7a.m.–7p.m. in all time zones
Learn more
Please visit our frequently asked questions to learn more about how this change may affect you and your practice.
Review the guidelines:
Screening Colonoscopy Procedures – Commercial Medical Policy
Screening Colonoscopy Procedures – Oxford Policy
Outpatient Surgical Procedures – Commercial
Outpatient Surgical Procedures – Oxford
Gastrointestinal Colonoscopy Procedure Guidelines – Commercial
Gastrointestinal Endoscopy Procedure Guidelines – Commercial
Capsule Endoscopy Procedure Guidelines – Commercial
Questions?
Contact Provider Services at 866-416-6594 if you have any questions.
