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UHC Announces Designated Diagnostic Provider Requirements for Coverage

  • Director of Anatomic Pathology Development

On February 24, 2021, XIFIN learned that UHC has delayed the application deadline from February 28, 2021 to March 10, 2021. The go-live date of July 1, 2021 is still in place. Additional requests to confirm how places of service 81, 11, 19, 22 are impacted has been requested from UHC. XIFIN will provide additional updates as they are received.


UHC recently announced plans to implement the Designated Diagnostic Provider benefit designs. For fully insured commercial plan members, outpatient laboratory services will only be covered when delivered by freestanding or hospital lab providers who meet certain quality and efficiency requirements.

The plans are set to go into place on July 1, 2021, and participating labs must complete the Lab Quality Questionnaire by March 10, 2021. While this currently only impacts pathology groups and laboratories (hospital-based and independent labs), Designated Diagnostic Provider requirements will be expanded to include major radiology services, such MR, CT, PET/Nuclear Medicine, in 2022.

Per the UHC website:

Designated Diagnostic Providers are designed to support our members in choosing cost-effective and high-value care providers. Outpatient diagnostic lab services will only be covered for members with UnitedHealthcare Designated Diagnostic Provider benefit designs if delivered by Designated Diagnostic Providers.

Non-Designated Diagnostic Providers will remain in network with UnitedHealthcare, but outpatient diagnostic lab services will deny as non-covered for members with Designated Diagnostic Provider benefit designs and your patients 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.

Provider Requirements

To become a lab Designated Diagnostic Provider and participate in the benefit designs, you need to meet certain quality and efficiency requirements by March 10, 2021. You can verify your lab Designated Diagnostic Provider status by contacting your dedicated network representative.

To participate, you must meet certain quality and efficiency requirements as follows:

  • Complete the Designated Diagnostic Provider lab quality questionnaire by March 10, 2021
  • If you meet the lab quality and efficiency requirements, you will become a Designated Diagnostic Provider for lab services and be notified accordingly
  • If you do not meet the lab Designated Diagnostic Provider requirements for lab services, a dedicated network representative will reach out to follow up and support the process

It is noted throughout the website that these benefit designs are subject to state regulatory approval. XIFIN recommends you reach out to the College of American Pathologists (CAP), your UHC representative, and/or or state Insurance Commissioner to address any concerns you may have about this program. 

AHA Protest

In a letter dated February 4th, AHA urged CMS to disallow the implementation of the DPP policy in products that it oversees. The letter emphasized Under UnitedHealthcare’s DPP program, a lab may be listed as being in-network but, in reality, the plan will not cover services provided by the lab. This undermines the patient’s understanding of their network and likely the contractual agreement they have signed with the insurer. It also could mislead state and federal regulators about the sufficiency of the health plan’s network. You can read the full letter here.

Sources:


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