March 11, 2021
Area(s) of Interest: Payor Issues and Reimbursement
United Healthcare (UHC) recently announced plans to narrow its provider network for laboratory services beginning July 1, 2021. According to the notice UHC will limit outpatient laboratory services coverage to Designated Diagnostic Provider labs, which are freestanding or hospital outpatient labs that have met certain quality and efficiency requirements.
The change will take effect beginning with UHC commercial large group benefit plans in July 2021 followed by small group benefit plans in January 2022.
According to UHC, laboratory providers interested in becoming Designated Diagnostic Providers are required to complete an online quality questionnaire. Providers who meet UHC laboratory quality and efficiency requirements, will become a Designated Diagnostic Provider for laboratory services and will have an icon added to their provider directory listings identifying them as such.
The California Medical Association has inquired with UHC and awaits a response regarding the timing and notification to providers of their inclusion or exclusion in this narrowed network.
UHC will be utilizing a subset of its larger PPO laboratory network for these new benefit designs and patients with those products will be limited to accessing only Designated Diagnostic Providers for outpatient diagnostic lab services. Patients who utilize a non-Designated Diagnostic Provider will have services denied as non-covered and may be liable for charges. The Designated Diagnostic Provider benefit designs will not apply to lab services rendered as part of inpatient admissions, emergency room visits or outpatient surgery pre-operation testing that is billed as part of a global surgical package.
UHC has also said that in 2022 it plans to expand these Designated Diagnostic Provider benefit designs and limited access requirements to major radiology services (MR, CT, PET/Nuclear Medicine).
Providers with questions regarding the Designated Diagnostic Provider program can submit their inquiry to firstname.lastname@example.org. For more information on the Designated Diagnostic Provider program, UnitedHealthcare see the Frequency Asked Questions or visit the uhcprovider.com website.