Network Bulletin: February 2015 network bulletin

An important message from UnitedHealthcare to health care professionals and facilities

UnitedHealthcare respects the expertise of the physicians, health care professionals and their staff who participate in our network. Our goal is to support you and your patients in making the most informed decisions regarding the choice of quality and cost-effective care, and to support practice staff with a simple and predictable administrative experience. The Network Bulletin was developed to share important updates regarding UnitedHealthcare procedure and policy changes, as well as other useful administrative and clinical information.*

*Where information in this bulletin conflicts with applicable state and/or federal law, UnitedHealthcare follows suchapplicable federal and/or state law

network bulletinNetwork Bulletin: February 2015

enter

Network Bulletin: November 2013 - Volume 58 For more information call 877.842.3210, or visit UnitedHealthcareOnline.com2

Table of Contents

For more information call 877.842.3210, or visit UnitedHealthcareOnline.com2 Network Bulletin: February 2015

In order to save you time as you go about your busy day, you can click on any of the articles below and be taken directly to that article. You can also return to the Table of Contents from any page in the Network Bulletin by simply clicking “Table of Contents” in the top right-hand corner of any page.

Front & Center

• Update to Global Surgery Reimbursement Policy

• Injectable Chemotherapy Prior Authorization Program

• Credentialing Plan Changes Effective April 1, 2015

• IMRT Prior Authorization Requirementfor Commercially Insured Members

• Preauthorization List Additions for UnitedHealthcareof the River Valley Commercial Members Delayed

• Enhanced HIPAA Claim Edits Planned for March 2015

UnitedHealthcare Commercial

• UnitedHealthcare Medical Policy, Drug Policy,Coverage Determination Guideline andUtilization Review Guideline Updates

UnitedHealthcare Medicare Solutions

• UnitedHealthcare Medicare AdvantageCoverage Summary Updates

UnitedHealthcare Community Plan

• Medical Policy & CoverageDetermination Guideline Updates

UnitedHealthcare Military & Veterans

• E-Prescribing – Now Availableat Military Pharmacies

UnitedHealthcare Commercial Reimbursement Policy

• Revision to the Nonphysician HealthCare Professionals Billing Evaluationand Management Codes Policy

• ModifiersBeingAddedtoServicesandModifiersNotReimbursabletoHealth Care Professionals Policy

Doing Business Better

• Claim Reconsideration andAppeal Process Summary

UnitedHealthcare Affiliates

• UnitedHealthcare of the River ValleyPreauthorization List and Policy Updates

• SignatureValue™BenefitInterpretation Policy Updates

• SignatureValue™ Medical ManagementGuideline Updates

• UnitedHealthcare Oxford® Medical andAdministrative Policy Updates

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Network Bulletin: November 2013 - Volume 58 For more information call 877.842.3210, or visit UnitedHealthcareOnline.com33 For more information call 877.842.3210,

or visit UnitedHealthcareOnline.comNetwork Bulletin: February 2015

To further align with the Centers for Medicare and Medicaid Services (CMS), UnitedHealthcare will adopttheCMSprocessformodifier78forMedicareAdvantage plans effective April 1, 2015.

Whenmodifier78isreportedforaprocedurehavingaGlobalDaysValue of 010 or 090, UnitedHealthcare will reimburse only for the intraoperativepercentageofthemodifiedprocedure,determinedby the intraoperative percentage listed on the CMS Medicare Physician Fee Schedule (MPFS). This will result in payment reductions accordingly.

According to the CMS Medicare Claims Processing Manual, Chapter 12, Section 40.4C: “When a CPT code billed with modifier‘-78’describestheservicesinvolvingareturntriptotheoperating room to deal with complications, pay the value of the intra-operative services of the code that describes the treatment of the complications. Refer to Field 18 of the MPFS to determine the percentage of the global package for the intra-operative services.”

Policy updates to include this information will be published to UnitedHealthcareOnline.com, and the reductions noted above will become effective beginning April 1, 2015.

To view the policy, please go to:

UnitedHealthcareOnline.com > Tools & Resources > Policies, Protocols and Guides > Medicare Advantage Reimbursement Policies > Global Surgery.

Update to Global Surgery Reimbursement Policy

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Effective June 1, 2015, providers billing for outpatient injectable chemotherapy for UnitedHealthcare Commercial members* being treated for a cancer diagnosis are required to obtain prior authorization for services.

UnitedHealthcare’sInjectableChemotherapyPriorAuthorization Program will be managed by CareCore National’sOncologyDivisiononourbehalfandproviders will be able to obtain injectable chemotherapy authorizationsonCareCore’swebsite.

Authorizations that follow the National Comprehensive Cancer Network (NCCN) regimens will be approved at the time of the request online. Requests for pediatric chemotherapy regimens, rare cancers, or chemotherapy regimens that are not NCCN-recommended, can also receive a timely response if necessary supporting documentation is provided at the time of the prior authorization request.

UnitedHealthcare Injectable Chemotherapy Prior Authorization training and live question and answer sessions will be held by WebEx.

Registration details will be posted on our website in April at: UnitedHealthcareOnline.com > Clinician Resources > Cancer – Oncology > Chemotherapy Prior Authorization Program.

*UnitedHealthcare Fully Insured and select ASO membership will require chemotherapy prior authorization. The CareCore National website will assist providers in identifying members that require prior authorization for chemotherapy.

Injectable Chemotherapy Prior Authorization Program

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UnitedHealthcare reviews and updates our Credentialing Plan at least every two years to ensure continued compliance with all State and Federal regulatory requirements and National Committee for Quality Assurance (NCQA) accreditation requirements.

The 2015-2016 Credentialing Plan and State and Federal Regulatory Addendum will become effective April 1, 2015. The following are some of the key changes:

Section 2.0 Definitions • MaterialRestriction:Clarificationthatarestrictionon

or prohibition from performing a service or proceduretypically provided by other practitioners in the sameor a similar specialty is a material restriction that willresult in termination of participation.

Section 4.0 Initial Credentialing of Licensed Independent Practitioner Applicants• Clarifieslanguageregardingtheimpactofalicense

sanction from a state where the practitioner islicensed but is no longer in active practice. Licenseactions from non-practice states may result in denial/termination unless the license action is based onadministrative issues or as a result of action taken byanother state licensing board.

Section 9.5 Ongoing Monitoring• NewSectionE:QualityandEfficiencyPerformance

Management. UnitedHealthcare has committed to ourmembers and care providers to support the Triple Aimof improving the patient care experience, improvinghealth outcomes, and reducing the cost of health care.

To drive continuous improvement in quality through Healthcare Effectiveness Data and Information Set (HEDIS) and Centers for Medicare and Medicaid Services’StarRatingsmeasuresandefficiencyofhealth care models, the credentialing entity may, from time to time, send reports to participating licensed independent physicians (LIPs) regarding their performance as compared to peers. To support physicians in their efforts, when practice patterns areidentifiedthatmayrepresentopportunitiestoimprove quality and reduce unwarranted variation, UnitedHealthcare will identify those practice patterns andprovideidentifiedphysicianswiththetoolsandinformation to improve resource utilization in a way consistent with evidence-based medicine guidelines. In the event that unwarranted variation does not improve, UnitedHealthcare may take actions up to and including termination of participation status

The Credentialing Plan will be posted to UnitedHealthcareOnline.com by April 1, 2015.

Credentialing Plan Changes Effective April 1, 2015

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For several years, prior authorization for Intensity Modulated Radiation Therapy (IMRT) CPT codes 77418 and 0073T has been required. On Jan. 1, 2015, the American Medical Association (AMA) released CPT code changes affecting the billing for IMRT services and codes 77418 and 0073T were deleted. Prior authorization will, as a result, be required for the following codes, effective Jan. 1, 2015:

• G6015: Intensity modulated treatment delivery,singleormultiplefields/arcs,vianarrowspatiallyandtemporally modulated beams, binary, dynamic mlc, pertreatment session

• G6016: Compensator-based beam modulationtreatment delivery of inverse planned treatmentusing 3 or more high resolution (milled or cast)compensator,convergentbeammodulatedfields,per treatment session

• 77385: Intensity modulated radiation treatmentdelivery, includes guidance and tracking, whenperformed; simple

• 77386: Intensity modulated radiation treatmentdelivery, includes guidance and tracking, whenperformed; complex

These codes impact Commercial members of the following health plans:• UnitedHealthcare

• UnitedHealthcare West

• UnitedHealthcare of the Mid-Atlantic

• UnitedHealthcare Plan of the River Valley

• Neighborhood Health Partnership

Please use the G6015 and G6016 codes when billing for IMRT services in 2015.

Prior authorization requests approved in 2014 with an authorized date range, including services in 2015, are not affected. A claims crosswalk table will be used to process claims for CPT codes G6015, G6016, 77385 and 77386, when an authorization is in place for 77418 and/or 0073T for authorized dates of service in 2015. Services that are billed that do not fall within the authorized date range will require prior authorization.

Revised IMRT fax cover sheets that include the new CPT codes for IMRT services (G6015, G6016, 77385 and 77386) are available on at UnitedHealthcareOnline.com > Clinician Resources > Oncology > Intensity Modulated Radiation Therapy > Related Links.

The clinical questions and list of diagnosis codes that do not require additional clinical information have been updatedtoreflectourrevisedIMRTclinicalpolicy. Prior authorization requests submitted after Jan. 1, 2015 will not be accepted if submitted on the 2014 IMRT fax cover sheets.

ThemostefficientwaytorequestpriorauthorizationforIMRT is to complete the appropriate IMRT clinical form and fax cover sheet and fax your request.

You may also request prior authorization for IMRT at UnitedHealthcareOnline.com.

IMRT Prior Authorization Requirement for Commercially Insured Members

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Previously announced changes have been delayed until further notice for UnitedHealthcare of the River Valley commercial members and participating providers that are subject to the River Valley Entities Supplement. Updates regarding the changes will be included in a future issue of the Network Bulletin.

In the November 2014 Network Bulletin, we announced a new requirement with respect to certain radiology services that would become effective Feb. 16, 2015 for River Valley commercial members and participating providers that are subject to the River Valley Entities Supplement.

Given the delay and until further notice, providers will not be required to obtain preauthorization prior to rendering certain advanced imaging procedures provided to River Valley Commercial members, including: Computerized Tomography (CT), Magnetic Resonance Imaging (MRI), Magnetic Resonance Angiography (MRA), Positron-Emission Tomography (PET), Nuclear Medicine and Nuclear Cardiology.

Youcanfindinformationaboutthe preauthorization requirements at UHCRiverValley.com > Preauthorizations > Procedures, DME, and Other Services

Preauthorization List Additions for UnitedHealthcare of the River Valley Commercial Members Delayed

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Enhanced HIPAA Claim Edits Planned for March 2015

Effective March 25, 2015, UnitedHealthcare will apply additional WEDI Strategic National Implementation Process (SNIP) HIPAA edits to professional (837p) and institutional (837i) claimssubmittedelectronicallytomostUnitedHealthcareandaffiliatepayer IDs.* These are new edits that were not applied with the edit enhancements released in 2014. For more information on current and previous edit releases, visit the Enhanced Claim Edits section of UnitedHealthcareOnline.

Because the new edits will be applied on a pre-adjudication basis, an increase in the number of claim rejections may occur. This will enable you to identifyandcorrectrejectedinformationpriortotheclaim’sacceptance into our adjudication system for processing. Thebenefitwillbefewerdeniedclaimsandlessinterruptionto revenue streams.

The primary impact to you will come from edits that will validate code sets (such as diagnosis, procedure andmodifiercodes)atapre-adjudicationlevel.The new edits have been distributed to clearinghouses and software vendors.

It’simportanttocheckallofyourclaimsubmissionreportsregularly. Claims may be rejected by your clearinghouse or UnitedHealthcare; therefore, you may receive multiple reports per submission. View tracking your electronicclaims to learn more about reports and rejections.

Rejections that may occur from the enhanced edits will appear at a clearinghouse level. Your Electronic Data Interchange (EDI) vendor or clearinghouse should be your firstpointofcontactforassistanceregardingtheseeditsorto resolve rejections. For assistance from UnitedHealthcare, please contact EDI Support:

* Excluded: Harvard Pilgrim (04271), Medica HealthCare Plans (78857), Preferred Care Partners (65088), the Alliance (88461) and TRICARE West (99726)

UnitedHealthcare Commercial, UnitedHealthcare Medicare Solutions and UnitedHealthcare West

EDI issue reporting form or 800-842-1109

UnitedHealthcare Community Plan [email protected] or 800-210-8315

UnitedHealthcare Oxford [email protected] or 800-599-4334

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UnitedHealthcare Medical Policy, Drug Policy, Coverage Determination Guideline and Utilization Review Guideline Updates


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For complete details on the policy updates listed in the table on the following page, please refer to the monthly Medical Policy Update Bulletin at UnitedHealthcareOnline.com > Tools & Resources > Policies, Protocols and Guides > Medical & Drug Policies and Coverage Determination Guidelines > Medical Policy Update Bulletin.


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Policy Title Policy Type Effective Date

Medical Policy Update Bulletin

NEW

Balloon Sinus Ostial Dilation Medical Policy April 1, 2015 Jan. 2015Feb. 2015

Entyvio (Vedolizumab) Drug Policy March 1, 2015 Dec. 2014Jan. 2015Feb. 2015

Hysterectomy for Benign Conditions Medical Policy April 1, 2015 Jan. 2015Feb. 2015

Simponi Aria (Golimumab) Drug Policy March 1, 2015 Dec. 2014Jan. 2015Feb. 2015

UPDATED/REVISED

Deep Brain Stimulation Medical Policy Feb. 1, 2015 Jan. 2015

Electrical Stimulation and Electromagnetic Therapy for Wounds

Medical Policy Feb. 1, 2015 Jan. 2015

Epiduroscopy, Epidural Lysis of Adhesions and Functional Anesthetic Discography


Hip Resurfacing Arthroplasty Medical Policy Feb. 1, 2015 Jan. 2015

Implantable Beta-Emitting Microspheres for Treatment of Malignant Tumors


Infertility Diagnosis and Treatment Medical Policy Feb. 1, 2015 Jan. 2015

Mechanical Stretching and Continuous Passive Motion Devices


Nerve Graft to Restore Erectile Function Medical Policy Feb. 1, 2015 Jan. 2015

Obstructive Sleep Apnea Treatment Medical Policy Feb. 1, 2015 Jan. 2015

Omnibus Codes Medical Policy Feb. 1, 2015 Jan. 2015

Preventive Care Services Coverage Determination Guideline

Feb. 15, 2015 Jan. 2015

Prosthetic Devices, Wigs, Specialized, Microprocessor or Myoelectric Limbs

Coverage Determination Guideline

Feb. 1, 2015 Jan. 2015


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Radiofrequency Therapy and Tibial Nerve Stimulation for Urinary Disorders


Sensory Integration Therapy and Auditory Integration Training


Surgical Treatment for Spine Pain Medical Policy Feb. 1, 2015 Jan. 2015

Temporomandibular Joint Disorders Medical Policy Jan. 1, 2015 Jan. 2015

Transcranial Magnetic Stimulation Medical Policy Feb. 1, 2015 Jan. 2015

RETIRED

Autism Spectrum Disorder UtilizationReviewGuideline

Jan. 1, 2015 Jan. 2015

Intrastromal Corneal Ring Segments Medical Policy Jan. 1, 2015 Jan. 2015


Note: The inclusion of a service or procedure on this list does not imply that UnitedHealthcare provides coverage for the service or procedure. In the event

of an inconsistency between the information provided in this Network Bulletin and the posted policy, the posted policy prevails.

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UnitedHealthcare Medicare Advantage Coverage Summary Updates

For complete details on the updated/revised policies listed in the table on the following page, please refer to the Medicare Advantage Coverage Summary Update Bulletin at UnitedHealthcareOnline.com> Tools & Resources > Policies, Protocols and Guides > UnitedHealthcare Medicare Advantage Coverage Summaries > Update Bulletin.


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Policy Title Approval Date Update Bulletin

UPDATED/REVISED

Chemotherapy, and Associated Drugs and Treatments Dec. 16, 2014 Jan. 2015

Family Planning (Birth Control) Dec. 16, 2014 Jan. 2015

Foot Care Services Dec. 16, 2014 Jan. 2015

Hearing Aids, Auditory Implants and Related Procedures Dec. 16, 2014 Jan. 2015

Hyperbaric Oxygen Therapy Dec. 16, 2014 Jan. 2015

Nasal and Sinus Procedures Dec. 16, 2014 Jan. 2015

Orthopedic Procedures, Devices and Products Dec. 16, 2014 Jan. 2015

Ostomy Supplies Dec. 16, 2014 Jan. 2015

Positron Emission Tomography (PET)/Combined PET-CT (Computed Tomography)

Dec. 16, 2014 Jan. 2015

ServicesWhileConfined/Incarcerated Dec. 16, 2014 Jan. 2015

Spine Procedures Dec. 16, 2014 Jan. 2015

Transplants – Organ and Tissue Transplants Dec. 16, 2014 Jan. 2015

Uterine Services and Procedures Dec. 16, 2014 Jan. 2015

Vertebral Artery Surgery Dec. 16, 2014 Jan. 2015

UnitedHealthcare Medicare Advantage Coverage Summary Updates




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Medical Policy & Coverage Determination Guideline Updates

For complete details on the policy updates listed in the table on the following page, please refer to the monthly Medical Policy Update Bulletin at UHCCommunityPlan.com > Provider Information > Medical Policies and Coverage Determination Guidelines for Community Plan.


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UPDATED/REVISED

Deep Brain Stimulation Medical Policy March 1, 2015 Jan. 2015Feb. 2015


Medical Policy March 1, 2015 Jan. 2015Feb. 2015



Hip Resurfacing Arthroplasty Medical Policy March 1, 2015 Jan. 2015Feb. 2015





Nerve Graft to Restore Erectile Function During Radical Prostatectomy


Obstructive Sleep Apnea Treatment Medical Policy March 1, 2015 Jan. 2015Feb. 2015

Omnibus Codes Medical Policy March 1, 2015 Jan. 2015Feb. 2015





Surgical Treatment for Spine Pain Medical Policy March 1, 2015 Jan. 2015Feb. 2015




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Transcranial Magnetic Stimulation Medical Policy March 1, 2015 Jan. 2015Feb. 2015

RETIRED

Intrastromal Corneal Ring Segments Medical Policy Jan. 1, 2015 Jan. 2015

Temporomandibular Joint Disorders Medical Policy Jan. 1, 2015 Jan. 2015



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E-Prescribing – Now Available at Military Pharmacies

On Dec. 31, 2014, the Military Health System (MHS) deployed electronic prescribing capability. TRICARE providers can now send prescriptions electronically to military pharmacies, offering a new option for their patients.

To send a prescription electronically to a military pharmacy, providersonlyneedtofindthelocalmilitarypharmacynameintheir existing e-prescribing software application. Military pharmacy namesusuallystartwiththeprefix“DOD”.TRICAREpatientswhofillmedicationsatamilitarypharmacycangetuptoa90-daysupply for most medications, compared to a 30-day supply through a retail network pharmacy. They also have no copay or cost share for medications from military pharmacies.

One thing to keep in mind is that military pharmacies may have more limited formularies than some retail pharmacies. All pharmaciesintheMHSstockmedicationsthatareonTRICARE’s

“basic core formulary” can also carry additional medications based on the needs of the military population they serve. Military pharmacies will not be able to accept electronic prescriptions for controlled substances. You will still need a hand written prescription for these medications.

For the latest information on electronic prescribing at military pharmacies, you can visit the Defense Health Agency Pharmacoeconomic Branch website. For more information ontheTRICAREmembersfillingprescriptionsatmilitarypharmacies,ortofindamilitarypharmacynearyouthatyourTRICARE patients might want to use, please visit the TRICARE Pharmacy page.

UnitedHealthcare Military & Veterans

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Unless otherwise noted, these reimbursement policies apply to services reported using the 1500 Health Insurance Claim Form (CMS-1500) or its electronic equivalent or its successor form. UnitedHealthcare reimbursement policies do not address all factors that affect reimbursement for services rendered to UnitedHealthcare members,includinglegislativemandates,enrolleebenefitcoveragedocuments, UnitedHealthcare medical or drug policies, and the UnitedHealthcare Physician, Health Care Professional, Facility and Ancillary Provider Administrative Guide. Meeting the terms of a particular reimbursement policy is not a guarantee of payment. Once implemented the policies may be viewed in their entirety at UnitedHealthcareOnline.com > Tools & Resources > Policies and Protocols > Reimbursement Policies-Commercial. In the event ofaninconsistencyorconflictbetweentheinformationprovidedin the Network Bulletin and the posted policy, the provisions of the posted policy prevail.


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UnitedHealthcare does not currently reimburse Evaluation and Management (E/M) CPT codes 99201-99499whensubmittedbyspecificnonphysicianhealthcareprofessionals.Accordingtothe Centers for Medicare and Medicaid Services (CMS), E/M services are reimbursable to certain nonphysicianpractitioners,limitedtonursepractitioners,clinicalnursespecialists,certifiednursemidwives, and physician assistants.

Effective in the second quarter of 2015, UnitedHealthcare will expand the scope of this policy to not reimburse E/M CPT 99201-99499 when reported by the following nonphysician health care professionals:

• Licensed practical nurse

• Licensed vocational nurse

• Home health/private duty nurse

• Visiting nurse

• Behavioral analyst

• Genetic counselor

• Alcohol and drug counselor

• Crisis diversion

• Employee assistance program (EAP) counselor

• Empowerment coach

• Marriage & family therapy/licensed marriageand family therapy

• Licensed professional counselor

• Substance abuse services, alcohol & drug

• Other mental health counselor

• Christian science practitioner

• Registered social worker

• Marriage and family social worker

• Pharmacist

These professionals should review the CPT and healthcare common procedure coding system (HCPCS) national code sets to select a more accurate code that describes the services they are providing.

Revision to the Nonphysician Health Care Professionals Billing Evaluation and Management Codes Policy


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UnitedHealthcarewillnotreimbursemodifiersH9,HU-HZ, QJ or TR, effective in the second quarter of2015.Theuseofthefollowingmodifiersindicates that a service has been funded by a county, state or federal agency; therefore, no cost has been incurred requiring reimbursement:

ModifiersBeingAddedtoServicesandModifiersNot Reimbursable to Health Care Professionals Policy

Modifier Description

H9 Court-ordered

HU Funded by child welfare agency

HV Funded state addictions agency

HW Funded by state mental health agency

HX Funded by county/local agency

HY Funded by juvenile justice agency

HZ Funded by criminal justice agency

QJ Services/items provided to a prisoner or patient in state or local custody, however the state or local government, as applicable, meets the requirements in 42 CFR 411.4 (B)

TR School-based individualized education program services provided outside the public school district responsible for the student

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We continue to monitor and review our processes to provide the best service to our constituents. We completed our annual review of the claim reconsideration and appeal process for our Provider Administrative Guide for 2015 and wanted to take this opportunity to highlight the following summary*:

The Two-Step Process Step one is the reconsideration level: Requests for reconsideration must be submitted within 12 months of the date ontheinitialExplanationofBenefits(EOB).Itisimportanttosubmit the reconsideration level early in the process since the reconsideration level and the appeal level share one 12-month timeframe. The request must include the Claim Reconsideration Form located online and all supporting documentation.

For more information on how to obtain the form, please see the Provider Administrative Guide located at UnitedHealthcareOnline.com > Policies, Protocols and Administrative Guides > UnitedHealthcare Administrative Guide for 2015.

If the reconsideration does not result in an overturned decision, the EOB or response letter will include next level rights and where to submit a request for further review.

Step two is the appeal level: Appeals must be submitted within the same 12-month time period as stated above. Please submit all supporting materials that you wish to have reviewed in the

Claim Reconsideration and Appeal Process Summary


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appeal including a letter requesting a formal appeal. Please submit to the appropriate address located in the Provider Administrative Guide. Appeals must be submitted in writing. If the appeal does not result in an overturned decision, the provider must review their contract for further dispute resolution steps.

If you have additional questions on the claim reconsideration or appeal process, please reference the Provider Administrative Guide under the applicable section.

* Claim reconsideration does not apply to California or ColoradoCommercial, or as required by state law, refer to ProviderDispute Resolution (PDR).

Claim Reconsideration and Appeal Process Summary

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For complete details on the policy updates listed in the table on the following page, please refer to the monthly Policy Update Bulletin at UHCRiverValley.com > Providers > Coverage Policy Library > Policy Update Bulletin.

UnitedHealthcare AffiliatesUnitedHealthcare of the River Valley Preauthorization List and Policy Updates

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UnitedHealthcare of the River Valley Preauthorization List and Policy Updates

These updates apply to UnitedHealthcare of the River Valley commercial and hawk-i plan members only.

Policy Title Effective Date Coverage Policy Update Bulletin

TAKE NOTE

New Preauthorization Requirements for Radiology/Advanced Outpatient Imaging Procedures *Implementation delayed

To be decided Feb. 2015

NEW

Balloon Sinus Ostial Dilation April 1, 2015 Jan. 2015Feb. 2015

Clotting Factors and Coagulant Blood Products April 1, 2015 Jan. 2015Feb. 2015

Entyvio™ (vedolizumab) April 1, 2015 Jan. 2015Feb. 2015

Hysterectomy for Benign Conditions April 1, 2015 Jan. 2015Feb. 2015

Radiology/Advanced Outpatient Imaging Procedures

*Implementation delayed; previously announced with an effective date of Feb. 16, 2015

To be decided Feb. 2015

Simponi® Aria™ (golimumab) April 1, 2015 Jan. 2015Feb. 2015

UPDATED/REVISED

Alemtuzumab March 1, 2015 Jan. 2015Feb. 2015

Anemia Drugs: Darbepoetin Alfa, Epoetin Alfa and Peginesatide Feb. 1, 2015 Jan. 2015

Deep Brain Stimulation Feb. 1, 2015 Jan. 2015

DME, Orthotics, Ostomy Supplies, Medical Supplies and Repairs/Replacements

Feb. 1, 2015 Jan. 2015

Electrical Stimulation and Electromagnetic Therapy for Wounds Feb. 1, 2015 Jan. 2015


Feb. 1, 2015 Jan. 2015

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UnitedHealthcare of the River Valley Prior Authorization List and Policy Updates

Policy Title Effective Date Coverage Policy Update Bulletin

Hip Resurfacing Arthroplasty Feb. 1, 2015 Jan. 2015

Immune Globulin (IVIG and SCIG) Feb. 1, 2015 Jan. 2015


Feb. 1, 2015 Jan. 2015

Infertility Diagnosis and Treatment Feb. 1, 2015 Jan. 2015

Mechanical Stretching and Continuous Passive Motion Devices Feb. 1, 2015 Jan. 2015


Feb. 1, 2015 Jan. 2015

Obstructive Sleep Apnea Treatment Feb. 1, 2015 Jan. 2015

Omnibus Codes Feb. 1, 2015 Jan. 2015

Preventive Care Services Feb. 15, 2015 Jan. 2015


Feb. 1, 2015 Jan. 2015

Sandostatin®/Sandostatin LAR® (Octreotide Acetate) Feb. 1, 2015 Jan. 2015

Sensory Integration Therapy and Auditory Integration Training Feb. 1, 2015 Jan. 2015

Stelara (Ustekinumab) Feb. 1, 2015 Jan. 2015

Surgical Treatment for Spine Pain Feb. 1, 2015 Jan. 2015

Temporomandibular Joint Disorders Feb. 1, 2015 Jan. 2015

Transcranial Magnetic Stimulation Feb. 1, 2015 Jan. 2015

RETIRED

Intrastromal Corneal Ring Segments Feb. 1, 2015 Feb. 2015




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Policy Title Applicable State(s) Effective Date

Update Bulletin

UPDATED/REVISED

Complementary and Alternative Medicine All (California, Oklahoma, Oregon, Texas, & Washington)

Feb. 1, 2015 Jan. 2015

Medical Necessity All Jan. 1, 2015 Jan. 2015

Nutritional Therapy: Enteral and Oral Nutritional Therapy

All Feb. 1, 2015 Jan. 2015

Member Initiated Second and Third Opinion All Feb. 1, 2015 Jan. 2015

Post Mastectomy Surgery All Feb. 1, 2015 Jan. 2015

Telemedicine/Telehealth Services All Feb. 1, 2015 Jan. 2015

SignatureValue™BenefitInterpretationPolicyUpdates

For complete details on the policy updates listed in the following table, please refer to the monthly SignatureValue™ Benefit Interpretation Policy Update Bulletin at UHCWest.com > Provider Log In > Library > Resource Center > Guidelines & Interpretation Manuals.

Note: The inclusion of a service or procedure on this list does not imply that coverage is provided for the service or procedure. In the event of an

inconsistency between the information provided in this Network Bulletin and the posted policy, the posted policy prevails.

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Policy Title Effective Date Update Bulletin

NEW

Balloon Sinus Ostial Dilation April 1, 2015 Jan. 2015

Hysterectomy for Benign Conditions April 1, 2015 Jan. 2015

UPDATED/REVISED

Deep Brain Stimulation Feb. 1, 2015 Jan. 2015


Feb. 1, 2015 Jan. 2015


Feb. 1, 2015 Jan. 2015

Hip Resurfacing Arthroplasty Feb. 1, 2015 Jan. 2015


Feb. 1, 2015 Jan. 2015

Mechanical Circulatory Support Device (MCSD) Jan. 1, 2015 Jan. 2015


Feb. 1, 2015 Jan. 2015


Feb. 1, 2015 Jan. 2015

Obstructive Sleep Apnea Treatment Feb. 1, 2015 Jan. 2015

Omnibus Codes Feb. 1, 2015 Jan. 2015

Preventive Care Services Feb. 15, 2015 Jan. 2015


Feb. 1, 2015 Jan. 2015

SignatureValue™ Medical Management Guideline Updates

For complete details on the policy updates listed in the following table, please refer to the monthly SignatureValue™ Medical Management Guidelines Update Bulletin at UHCWest.com > Provider Log In > Library > Resource Center > Guidelines & Interpretation Manuals.

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SignatureValue™ Medical Management Guideline Updates

Policy Title Effective Date Update Bulletin


Feb. 1, 2015 Jan. 2015

Surgical Treatment for Spine Pain Feb. 1, 2015 Jan. 2015

Temporomandibular Joint Disorders Jan. 1, 2015 Jan. 2015

Transcranial Magnetic Stimulation Feb. 1, 2015 Jan. 2015

RETIRED

Intrastromal Corneal Ring Segments Jan. 1, 2015 Jan. 2015


inconsistency between the information provided in this Network Bulletin and the posted policy, the posted policy prevails.


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Oxford® Medical and Administrative Policy Updates


Policy Update Bulletin

UPDATED/REVISED

Balloon Sinus Ostial Dilation Clinical Policy April 1, 2015 Jan. 2015Feb. 2015

Hysterectomy for Benign Conditions Clinical Policy April 1, 2015 Jan. 2015Feb. 2015

UPDATED/REVISED

Accreditation Requirements for Radiologists and Radiology Centers

Administrative Policy Feb. 1, 2015 Jan. 2015

Agents for Migraine - Triptans Clinical Policy Feb. 1, 2015 Jan. 2015

Alemtuzumab Clinical Policy Feb. 1, 2015 Jan. 2015

Ambulance Policy Reimbursement Policy

Jan. 1, 2015 Jan. 2015

Assistant Surgeon Policy Reimbursement Policy

Jan. 1, 2015 Jan. 2015

Bilateral Procedures Reimbursement Policy

Jan. 1, 2015 Jan. 2015

Contraceptives Clinical Policy Feb. 1, 2015 Jan. 2015

Co-Surgeons; Team Surgeon Policy Reimbursement Policy

Jan. 1, 2015 Jan. 2015

Drug Coverage Criteria - New and Therapeutic Equivalent Medications

Clinical Policy Feb. 1, 2015 Jan. 2015

Drug Coverage Guidelines Clinical Policy Feb. 1, 2015 Jan. 2015

Femoroacetabular Impingement Syndrome Treatment


Global Days Policy Reimbursement Policy

Jan. 1, 2015 Jan. 2015

For complete details on the new and/or revised policies listed in the following table, refer to the monthly Policy Update Bulletin at OxfordHealth.com > Providers > Tools & Resources > Medical Information > Medical and Administrative Policies > Policy Update Bulletin.

TAKE NOTE

- Oxford®


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Network Bulletin: November 2013 - Volume 58 For more information call 877.842.3210, or visit UnitedHealthcareOnline.com3030 Insurance coverage provided by UnitedHealthcare Insurance Company or its affiliates. Health plan coverage provided by UnitedHealthcare of

Arizona, Inc., UnitedHealthcare of California, UnitedHealthcare of Colorado, Inc., UnitedHealthcare of Oregon, Inc., UnitedHealthcare of Utah, Inc. and UnitedHealthcare of Washington, Inc. or other affiliates. Administrative services provided by UnitedHealthcare Services, Inc. or its affiliates.

Network Bulletin: February 2015Doc#: PCA15610_20150120

Oxford Medical and Administrative Policy Updates


Policy Update Bulletin

UPDATED/REVISED

Hearing Aids And Devices Including Wearable, Bone-Anchored and Semi-Implantable


Immune Globulin (IVIG and SCIG) Clinical Policy Feb. 1, 2015 Jan. 2015

Injectable Chemotherapy Drugs: Application of NCCN Clinical Practice Guidelines


Injection and Infusion Services Policy Reimbursement Policy

Jan 1, 2015 Jan. 2015

Inpatient Consultations Reimbursement Policy

Jan. 1, 2015 Jan. 2015

Multiple Imaging Rules Reimbursement Policy

Feb. 1, 2015 Jan. 2015

Multiple Procedures Policy Reimbursement Policy

Jan. 1, 2015 Jan. 2015

Oral Anti-Diabetic Agents (Janumet, Januvia, JanumetXR,Invokana,Farxiga,Empaglifloxin/Metformin, Jardiance, Xigduo XR)


Practitioner/Provider Administrative Claim Reconsideration and Appeal Process

Administrative Policy Jan. 1, 2015 Jan. 2015

Preventive Care Services Clinical Policy Feb. 15, 2015 Jan. 2015

Preventive Medicine and Screening Policy Reimbursement Policy

Jan. 1, 2015 Jan. 2015

Prolonged Services Policy Reimbursement Policy

Feb. 1, 2015 Jan. 2015

RadiologyProceduresRequiringPrecertification Clinical Policy Feb. 1, 2015 Jan. 2015

Sandostatin Lar Depot (Octreotide Acetate) Clinical Policy Feb. 1, 2015 Jan. 2015

Stelara (Ustekinumab) Clinical Policy Feb. 1, 2015 Jan. 2015

Telemedicine Policy Reimbursement Policy

Jan. 1, 2015 Jan. 2015

Temporomandibular Joint Disorders Clinical Policy Jan. 1, 2015 Jan. 2015

Time Span Codes Policy Reimbursement Policy

Jan. 20, 2015 Jan. 2015

Treatment of Infertility for New York Large and Small Groups



inconsistency between the information in this Network Bulletin and the posted policy, the posted policy will prevail.

Oxford HMO products are underwritten by Oxford Health Plans (NY), Inc., Oxford Health Plans (NJ), Inc. and Oxford Health Plans (CT), Inc. Oxford

insurance products are underwritten by Oxford Health Insurance, Inc.

Documents

Network Bulletin: February 2015 network bulletin