These programs support the consistent use of evidence-based, professional guidelines for cardiology procedures. They were designed with the help of physician advisory groups to encourage appropriate and rational use of cardiology services. Using them helps reduce risks to patients and improves the quality, safety and appropriate use of cardiac procedures.
To submit and manage your prior authorizations, please sign in to the UnitedHealthcare Provider Portal.
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Basic Requirements and Process
Notification/prior authorization may be required for the following procedures in the service locations indicated.
Electrophysiology Implants, Diagnostic Catheterization, Echocardiogram*, Stress Echocardiogram: Required for outpatient and office visits. Not required for inpatient, emergency room, urgent care center or observation.
*Note: For Medicare Advantage benefit plans, prior authorization is not required for echocardiograms.
These requirements apply to all providers subject to the UnitedHealthcare Administrative Guide. To review the complete protocol, please refer to the Cardiology Notification/Prior Authorization Protocol section in that guide.
Special Notes for Congenital Heart Disease
- For congenital heart disease codes, notification is required for inpatient services only.
- For outpatient help, please refer members to Optum at 888-936-7246.
- For inpatient cases, please call the phone number on the back of the member's health care ID card.
Specific Cardiology Programs
Open the section below to view more information.
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Community Plan
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This program is effective in Arizona, Kentucky, Maryland, Minnesota, Mississippi, Missouri, New Jersey, New Mexico, New York, North Carolina, Pennsylvania, Rhode Island, Tennessee, Texas, Virginia and Washington.
- UnitedHealthcare Community Plan Cardiology Prior Authorization CPT Code List and Crosswalk
- UnitedHealthcare Community Plan Cardiology Prior Authorization Frequently Asked Questions
- UnitedHealthcare Community Plan Cardiology Prior Authorization Quick Reference Guide
- - Effective 08.19.2024
- - Effective 04.01.2024
- - Effective 03.01.2024
- - Effective 09.15.2023
- - Effective 07.01.2023
- - Effective 03.20.2023
Commercial
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The following Commercial resource materials are inclusive of UnitedHealthcare River Valley and NHP membership.
When you notify us of a planned service that is subject to the protocol, we’ll conduct a clinical review to decide if the service is medically necessary and covered, and will let you know our decision.
If the member's benefit plan does not require a clinical review and the service does not meet clinical guidelines, or if additional information is needed, we’ll let you know if you need to have a physician-to-physician discussion.
- Cardiology Notification / Prior Authorization CPT Code List and Crosswalk
- - Effective 08.19.2024
- - Effective 04.01.2024
- - Effective 03.01.2024
- - Effective 09.15.2023
- - Effective 07.01.2023
- - Effective 03.20.2023
- Commercial and Exchange Plans Cardiology Prior Authorization Frequently Asked Questions
- Commercial and Exchange Plans Cardiology Prior Authorization Quick Reference Guide
Exchange Plans
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- - Effective 08.19.2024
- - Effective 04.01.2024
- - Effective 03.01.2024
- - Effective 09.15.2023
- - Effective 07.01.2023
- - Effective 03.20.2023
- Commercial and Exchange Plans Cardiology Prior Authorization Frequently Asked Questions
- Commercial and Exchange Plans Cardiology Prior Authorization Quick Reference Guide
- Additional resource materials are included in the Commercial section above
Medicare Advantage and UnitedHealthcare Dual Special Needs Plan (DSNP)
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- Medicare Advantage Cardiology Prior Authorization Program Frequently Asked Questions
- Medicare Advantage Cardiology Prior Authorization Program Quick Reference Guide
- - Effective 08.19.2024
- - Effective 04.01.2024
- - Effective 03.01.2024
- - Effective 09.15.2023
- - Effective 07.01.2023
- - Effective 03.20.2023
Neighborhood Health Partnership
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Resources materials are included in the Commercial tab above.
UnitedHealthcare of the River Valley
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Resources materials are included in the Commercial tab above.
