Beginning June 1, 2023, UnitedHealthcare modified our process for gastroenterology (GI) services. You are 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 note that screening colonoscopy procedures are not subject to this advance notification process.
Affected states
- All states, except Kentucky, New Mexico and Rhode Island
- Iowa effective: Aug. 1, 2023
- U.S. territories (U.S. Virgin Islands, Guam and Puerto Rico) are excluded
Affected plans
This requirement pertains to patients with UnitedHealthcare commercial plans, including:
- UnitedHealthcare Plan of the River Valley
- Neighborhood Health Partnership
- UnitedHealthcare Level Funded
- Oxford Health Plans
Additional information
The Advance Notification process for non-screening GI procedures supports our efforts to ensure access to safe and affordable care. During 2023, we will use 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.
Screening colonoscopy procedures only require prior authorization for site of service medical necessity review if the service is planned at an outpatient hospital.
Specific gastroenterology programs
All commercial plans
- Capsule Endoscopy Procedure Guidelines — Commercial - Effective June 1, 2023
- Capsule Endoscopy Procedure Guidelines — Commercial - Effective March 15, 2024
- Capsule Endoscopy Procedure Guidelines — Commercial - Effective May 1, 2025
- Gastrointestinal Colonoscopy Procedure Guidelines — Commercial - Effective June 1, 2023
- Gastrointestinal Colonoscopy Procedure Guidelines — Commercial - Effective March 15, 2024
- Gastrointestinal Colonoscopy Procedure Guidelines — Commercial - Effective August 1, 2024
- Gastrointestinal Colonoscopy Procedure Guidelines — Commercial - Effective May 1, 2025
- Gastrointestinal Endoscopy Procedure Guidelines — Commercial - Effective June 1, 2023
- Gastrointestinal Endoscopy Procedure Guidelines — Commercial - Effective September 15, 2023
- Gastrointestinal Endoscopy Procedure Guidelines — Commercial - Effective March 15, 2024
- Gastrointestinal Endoscopy Procedure Guidelines — Commercial - Effective May 1, 2025
- Outpatient Surgical Procedures — Site of Service — Commercial Utilization Review Guideline
- Screening Colonoscopy Procedures — Site of Service — Commercial Medical Policy
- Outpatient Surgical Procedures — Site of Service — Commercial Utilization Review Guideline
Oxford plans
- Capsule Endoscopy Procedure Guidelines — UnitedHealthcare Oxford Plan - Effective June 1, 2023
- Capsule Endoscopy Procedure Guidelines — UnitedHealthcare Oxford Plan - Effective March 15, 2024
- Capsule Endoscopy Guidelines — Version 1.0.2025 - UnitedHealthcare Oxford Plan - Effective May 1, 2025
- Gastrointestinal Colonoscopy Procedure Guidelines — UnitedHealthcare Oxford Plan - Effective June 1, 2023
- Gastrointestinal Colonoscopy Procedure Guidelines — UnitedHealthcare Oxford Plan - Effective March 15, 2024
- Gastrointestinal Colonoscopy Procedure Guidelines — UnitedHealthcare Oxford Plan - Effective August 1. 2024
- Gastrointestinal Colonoscopy Procedure Guidelines — UnitedHealthcare Oxford Plan - Effective May 1, 2025
- EGD Procedure Guidelines — UnitedHealthcare Oxford Plan - Effective June 1, 2023
- EGD Procedure Guidelines — UnitedHealthcare Oxford Plan - Effective September 15, 2023
- EGD Procedure Guidelines — UnitedHealthcare Oxford Plan - Effective March 15, 2024
- EGD Guidelines Version — Version 1.0.2025 - UnitedHealthcare Oxford Plan - Effective May 1, 2025
- Screening Colonoscopy Procedures — Site of Service — Oxford Clinical Policy
- Outpatient Surgical Procedures — Site of Service — Oxford Clinical Policy
FAQ and CPT code list crosswalk table
CPT® is a registered trademark of the American Medical Association