Effective July 1, 2021, and subject to state regulatory approval, the insurer UnitedHealthcare is launching a new benefit design where outpatient diagnostic laboratory services will only be covered for fully insured commercial plan members when they are delivered by a “Designated Diagnostic Provider.” The CAP initially met with UnitedHealthcare leaders on February 19 to discuss the insurer’s upcoming plan changes and address a number of concerns. In response to CAP member questions, the CAP met again with UnitedHealthcare on March 22 to secure additional clarification on the Designated Diagnostic Provider program.

During the March 22 meeting, UnitedHealthcare confirmed to the CAP that there is no hard deadline to complete the required questionnaire and that evaluations will be on an ongoing process. The insurer did state that completing the questionnaire earlier is better: UnitedHealthcare is currently suggesting providers who complete it online by May 15 will ensure inclusion in current beneficiary plan materials/education.

Further, UnitedHealthcare shared that they are making adjustments to the questionnaire to make it easier for all pathology groups to apply, and completion should be done by/at the taxpayer identification number (TIN) level. The Designated Diagnostic Provider benefit design applies to any provider billing laboratory services using POS codes 19, 22, or 81, and includes the entire laboratory and pathology suite of CPT codes. Invitations to apply were sent out based on claims. CAP members can email the insurer for help.

To become a Designated Diagnostic Provider, providers will need to meet certain quality and efficiency requirements. In response to concerns raised by the CAP, UnitedHealthcare clarified they would not expect a hospital laboratory to meet the same efficiency requirements that they would for freestanding laboratories, and that they want to work with all in-network providers to make sure they meet efficiency standards. UnitedHealthcare also commented that they recognize health care is local and that community-based pathology is important, so there will be some room for adjustments/variability in efficiency standards with that in mind. The CAP will continue to engage with the insurer to ensure access to pathology and laboratory services across all settings.

For more information, visit the UnitedHealthcare Designated Diagnostic Provider page.