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Prior Authorization for Outpatient Therapeutic Radiopharmaceuticals

Starting in 2019, Optum will start managing the online request process for outpatient therapeutic radiopharmaceuticals. This change will apply to UnitedHealthcare commercial plan members effective April 1, 2019 and for select Community & State members effective May 1, 2019. As an affiliate of UnitedHealthcare, Optum offers solutions to help improve the care provider experience for transactions such as prior authorization requests.

Now, when you use the Prior Authorization and Notification tool on Link to submit your prior authorization request, you’ll click on Oncology and enter the member’s state and product details as prompted. You’ll be directed to the Optum website to complete your request.

Overview

To help ensure our member benefit coverage is medically appropriate, we regularly evaluate our medical policies, clinical programs and health benefits based on the latest scientific evidence and specialty society guidance. To support these goals, we require notification/prior authorization for therapeutic radiopharmaceuticals administered to UnitedHealthcare commercial plan members in an outpatient setting. 

To view our entire medical policy on therapeutic radiopharmaceuticals, please see the Therapeutic Radiopharmaceuticals-Commercial Medical Policy.

For more information about UnitedHealthcare commercial plan policies, go to UHCprovider.com/policies > Commercial Policies.

Prior authorization is required for the following:

  • Lutetium Lu 177 (Lutathera®)
  • Radium RA-233 dichloride (Xofigo®)
  • All therapeutic radiopharmaceuticals that have not yet received an assigned code and will be billed under a miscellaneous Healthcare Common Procedure Coding System (HCPCS) code

Therapeutic radiopharmaceuticals billed under the following HCPCS codes require prior authorization:

  • A9513 Lutetium Lu 177, dotatate, therapeutic, 1 mCi
  • A9606 Radium RA-223 dichloride, therapeutic, per microcurie
  • A9699 Radiopharmaceutical, therapeutic, not otherwise classified
  1. Use the Prior Authorization and Notification Tool on Link. Sign in to Link by clicking on the Link button in the top right corner of UHCprovider.com.
  2. Select the Prior Authorization and Notification tile on your Link dashboard.
  3. Click on Oncology and enter the member’s state and product details as prompted. You’ll be directed to the Optum website to complete your request.

Please complete all prior authorization requests online. The online system will identify the members who need a prior authorization request submitted. To learn more about using Link to request prior authorization, go to UHCprovider.com/paan. If you have questions, please call 888-397-8129, 8 a.m. to 5 p.m. local time, Monday through Friday.

The following UnitedHealthcare Commercial plans require prior authorization for therapeutic radiopharmaceuticals:

  • Golden Rule Insurance Company (select group numbers1)
  • Neighborhood Health Partnership
  • UnitedHealthcare Commercial plans, excluding Indemnity/Options PPO
  • UnitedHealthcare Life Insurance Company (select groups1

The following UnitedHealthcare Community & State plans require prior authorization for therapeutic radiopharmaceuticals:

  • UnitedHealthcare Community Plan in Arizona
    • Arizona Health Care Cost Containment System/Medicaid
    • Developmentally Disabled
  • UnitedHealthcare Community Plan of California
    • Medi-Cal Managed Care
  • UnitedHealthcare Community Plan in Florida
    • Florida Healthy Kids
    • Medicaid
  • UnitedHealthcare Community Plan in Maryland
    • HealthChoice
  • UnitedHealthcare Community Plan in Michigan
    • Medicaid
    • Excludes Children’s Special Health Care Services and UnitedHealthcare Dual Complete (HMO SNP)
  • UnitedHealthcare Community Plan in Nebraska
    • UnitedHealthcare Community Plan-Heritage Health
  • •UnitedHealthcare Community Plan in Ohio
    • Medicaid
  • UnitedHealthcare Community Plan in Rhode Island
    • Rhode Island Children with Special Health Care Needs
    • Rhode Island UnitedHealthcare Rhody Health Partners ACA Adult Expansion
    • Rhode Island UnitedHealthcare Rhody Health Partners
    • Rhode Island UnitedHealthcare RIte Care
  • UnitedHealthcare Community Plan in Texas
    • CHIP
    • STAR, STAR+PLUS, and STAR Kids
    • Excludes UnitedHealthcare Connected® (Medicare and Medicaid Plan) and UnitedHealthcare Dual Complete (HMO SNP)
  • UnitedHealthcare Community Plan in Washington
    • Apple Health
  • UnitedHealthcare Community Plan in Wisconsin
    • Badger Care

We’re Here to Help

If you have questions, please email unitedoncology@uhc.com.


Footnotes

  1.  Some member benefit plans require a primary care physician to initiate a referral to a specialist. Members may also have a specific network service area that reflects the needs of the targeted population.
Insurance coverage provided by or through UnitedHealthcare Insurance Company, All Savers Insurance Company, Oxford Health Insurance, Inc. or their affiliates. Health Plan coverage provided by UnitedHealthcare of Arizona, Inc., UHC of California DBA UnitedHealthcare of California, UnitedHealthcare Benefits Plan of California, UnitedHealthcare of Colorado, Inc., UnitedHealthcare of Oklahoma, Inc., UnitedHealthcare of Oregon, Inc., UnitedHealthcare of Texas, LLC, UnitedHealthcare Benefits of Texas, Inc., UnitedHealthcare of Utah, Inc. and UnitedHealthcare of Washington, Inc., Oxford Health Plans (NJ), Inc. and Oxford Health Plans (CT), Inc. or other affiliates. Administrative services provided by United HealthCare Services, Inc., OptumRx, OptumHealth Care Solutions, LLC, Oxford Health Plans LLC or their affiliates. Behavioral health products are provided by U.S. Behavioral Health Plan, California (USBHPC), United Behavioral Health (UBH) or its affiliates.. 

On April 1, 2019, Optum will start managing the online request process for outpatient therapeutic radiopharmaceuticals. This change will apply to UnitedHealthcare commercial plan members. As an affiliate of UnitedHealthcare, Optum offers solutions to help improve the care provider experience for transactions such as prior authorization requests.

Now, when you use the Prior Authorization and Notification tool on Link to submit your prior authorization request, you’ll click on Oncology and enter the member’s state and product details as prompted. You’ll be directed to the Optum website to complete your request.

We invite you to attend an upcoming webinar to learn more about this new process. Each one-hour session will give you an overview of the request process and show you the online tool you’ll use to submit your notification/prior authorization request. Please see the 2019 Q2 Care Provider Training Schedule to register for one of these sessions