United Healthcare Expanding Designated Diagnostic Provider Program to Imaging Providers

United Healthcare has launched the Designated Diagnostic Provider (DDP) program for laboratory and major imaging services. In 2021, the program was implemented for laboratory facilities and is now expanding to include major imaging services in 2022. According to United Healthcare, the program is designed to help improve member access to quality care and reduce member healthcare costs.  

As part of this new benefits design, major imaging services, which include MRI, CT, PET scan, MRA, and nuclear medicine, must be performed by a Designated Diagnostic Provider for the members to receive the highest benefit level and lowest out-of-pocket cost. Modalities such as X-ray, ultrasound, and mammography are outside the scope of this program. 

This new benefit plan was available to UHC’s fully insured small group commercial plan members on January 1, 2022. Large group commercial members will have access beginning July 1, 2022. 

Provider Requirements

Free-standing and outpatient hospitals currently contracted with United Healthcare to provide major imaging services must meet certain quality and efficiency standards to become Designated Diagnostic Providers. Facilities must first complete the DDP Quality Questionnaire which asks questions relating to whether the facility is accredited, provides timely services, and submits electronic images.

Facilities that do not meet the requirements to be a Designated Diagnostic Provider will remain in-network, but members who utilize a non-Designated Diagnostic provider will pay a higher out-of-pocket cost.

Member Benefits

Members with this benefit who receive services from a Designated Diagnostic Provider will pay a lower cost share than members who received services from a facility that is not a Designated Diagnostic Provider. According to the UHC Frequently Asked Questions the higher cost share, “may include a $500 per-occurrence deductible and 50% coinsurance subject to their annual deductible”.

An icon identifying providers as a Designated Diagnostic Provider for imaging will be added to UHC’s provider and member directories. Referring providers will be able to identify Designated Diagnostic Providers for imaging directly through their electronic medical records (EMR) or by signing in to the UnitedHealthcare Provider Portal. 

Referring Patient to a Designated Diagnostic Provider

The UnitedHealthcare Designated Diagnostic Provider website has individual sections for lab facilities, imaging facilities, and referring providers. The referring provider’s section encourages providers to refer patients to a Designated Diagnostic Provider to:

Optimize Patient
Health

Improve
Transparency

Lower Cost

The major imaging services (MRI, CT, PET scan, MRA, and nuclear medicine) covered under this program require prior authorization.  According to the website, if a referring provider refers a patient to a non-Designated Diagnostic Provider facility, United Healthcare will notify the member and referring physician and help them locate a Designated Diagnostic Provider. If the non-Designated Diagnostic Provider is still chosen, the member will be subject to a higher cost-share. 

Subject to State and Regulatory Approval

United Healthcare notes throughout its website that these benefit designs are subject to state regulatory approval. According to their website, as of January 2022, fewer than 50% of states have received Designated Diagnostic Provider approval for laboratory. 

UHC’s frequently asked questions document lists several exclusions, including the Medicare and Medicaid plans, the state of Hawaii, outpatient surgery pre-op testing billed as part of the global service package, and imaging services performed on an admitted inpatient, in an emergency room, or at a specialty or primary care provider office. Modalities such as X-ray, ultrasound, and mammography are also outside the program’s scope.

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Additional Resources

American Academy of Radiology Advocacy in Action

UHC Provider DDP Homepage

DDP Frequently Asked Questions

DDP Provider Lab State Map as of January 2022