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 such applicable federal and/or state law
network bulletinNetwork Bulletin: January 2014 - Volume 59
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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: January 2014 - Volume 59
Front & Center UnitedHealthcare Commercial
UnitedHealthcare Reimbursement Policy
UnitedHealthcare Medicare Solutions
UnitedHealthcare Community Plan
Doing Business Better
UnitedHealthcare Pharmacy
UnitedHealthcare Claims, Billing & Coding
UnitedHealthcare Affiliates
Front & Center• UnitedHealthcare Medicaid Policy Alignment
• 2014 UnitedHealthcare Administrative Guide Available –Effective April 1, 2014
• ImportantChangesinAdvanceNotificationandPriorAuthorizationRequirements for Home Health Services for Medicare Advantage Plans
• UnitedHealthcare Community Plan to Start Using NationalComprehensive Cancer Network Compendium
• InjectableChemotherapyPriorAuthorizationProgramforFloridaProviders
• UnitedHealthcare Shared Services Expansion for GEHA
• myHCE: Providing Cost Transparency for aMore Informed Health Care Consumer
• Prepare for UnitedHealthcareOnline.com LoginMigration to Optum Cloud Dashboard
• The CMS “Two Midnight Rule” – Effective Oct. 1, 2013
• 2014: The Year of the ICD-10 Code
• Enhanced HIPAA Edits to be Applied to Claim Submissions
• HIPPS Codes Requirement for Home Health Careand Skilled Nursing Facility Encounters
• MedicareAdvantagetoRequirePriorAuthorizationfor IMRT, SRS and SBRT as of April 1
• MedicareAdvantageRadiologyandCardiologyPriorAuthorizationProgram to Deploy for UnitedHealthcare West MedicareNon-Capitated Participating Providers on April 1, 2014
• Women’s Preventive Care Services Updates
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UnitedHealthcare Commercial
Network Bulletin: January 2014 - Volume 59 For more information call 877.842.3210, or visit UnitedHealthcareOnline.com3
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UnitedHealthcare Reimbursement Policy
Network Bulletin: January 2014 - Volume 59 For more information call 877.842.3210, or visit UnitedHealthcareOnline.com4
UnitedHealthcare Commercial
• UnitedHealthcare Medical Policy, Drug Policy, Coverage DeterminationGuidelineandUtilizationReviewGuidelineUpdates
• NewDisease-specificIMRTFormsforUnitedHealthcarePriorAuthorizationProcess
• The Preferred Payment Method for Your UnitedHealthcarePatients: Member Payments
HOME
UnitedHealthcare Reimbursement Policy
• UnitedHealthcare Reimbursement Policy
• Revision to CCI Editing Policy
• Revision to the Professional/Technical Component Policy - Denialof Drug Administration Codes and PC/TC Indicator 8
• Multiple Procedure Policy Revisions to Apply to Same Group
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UnitedHealthcare Medicare Solutions
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UnitedHealthcare Medicare Solutions
• 2013 Member Rewards Program – Better Health has its Rewards
• UnitedHealthcare Wins Bid for State of Illinois
• UnitedHealthcare Medicare Advantage Coverage Summary Updates
• ReminderforAdvanceNotificationandPriorAuthorization
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UnitedHealthcare Community Plan
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UnitedHealthcare Community Plan
• Important Reimbursement Policy Reminder
• Provider Disclosure of Ownership Form Now Online
• Changes to the UnitedHealthcare Community Plan of PennsylvaniaClaims Payer ID and Electronic Remittance Advice Payer ID
• Readmission Policy Frequently Asked Questions
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Doing Business Better
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UnitedHealthcare Pharmacy
Doing Business Better
• Important Change: Arriva Medical has Acquired Diabetes Care Club
• Medline Industries Joins Network
• UnitedHealthcare Preventive Plan Design
• Introducing COB Smart™: Receive Payments Accurately, Predictably and Reliably
• UnitedHealthcare’s Position on “Never Events”
• Navigate Products and Related Administrative Processes
• Physician and Provider Demographic Changes
• Training Sessions for Electronic Solutions
• Wellness Programs: Recommending Alternative Actions
• ElectronicInpatientAdmissionNotifications
• Checking Status of Claim Reconsideration Requests With Attachments
• CoverageDeterminationandUtilizationManagementDecisions
• All Savers Alternative Funding Product - New Portal
• UnitedHealth Premium® Results Available to Public Soon
• BMI Documentation in the Medical Record
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UnitedHealthcare Pharmacy
• Medicare Change to Physician-initiated Prescriptions at Mail Pharmacies
• EffectiveFeb.1,2014:NewPriorAuthorizationRequirementsforEnzymeReplacementMedications(ForUnitedHealthcareIntegratedCommercial Fully Insured and Self-funded Plans Only)
• New OptumRx Specialty Pharmacy Resource Guide
• Reminder: 25 Specialty Medications Added to Coupon Policy for Jan. 1, 2014
• UnitedHealthcareConsolidatedPharmacyBenefitProgram
For more information call 877.842.3210, or visit UnitedHealthcareOnline.com9 Network Bulletin: January 2014 - Volume 59
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UnitedHealthcare Claims, Billing & Coding
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UnitedHealthcare Claims, Billing & Coding
• AccurateBillingImprovesOfficeEfficiencyandDualSNPMemberSatisfaction
• AccessingExplanationsofBenefitsOnline
• Coding Update to Facility OPG Mapping – Effective Jan. 1, 2014
For more information call 877.842.3210, or visit UnitedHealthcareOnline.com10 Network Bulletin: January 2014 - Volume 59
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UnitedHealthcare Affiliates
UnitedHealthcareAffiliates
• Oxford Medical and Administrative Policy Updates
• UnitedHealthcareoftheRiverValleyPreauthorizationListandPolicyUpdates
• SignatureValue™BenefitInterpretationPolicyUpdates
• SignatureValue™ Medical Management Guideline Updates
• UnitedHealthcare of the River Valley and Neighborhood Health Partnership:Disease Management Programs
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Front & Center
Effective March 1, 2014, UnitedHealthcare Community Plan will align our medical policies with the rest of UnitedHealthcare’s medicalpolicies,toprovideastreamlined,simplifiedexperienceforproviders caring for members of our various health plans.
The policies are available at UnitedHealthcareOnline.com >Tools & Resources > Policies, Protocols and Guides > Medical & Drug Policies and Coverage Determination Guidelines.
Our medical policies, including established and new technologies, explain how we determine whether a service(e.g.,test,deviceorprocedure)is proven to be effective and/or to have abenefitonhealthoutcomesbasedonthe published clinical evidence. They are also used to decide whether a given health service is medically necessary. Services determined to be experimental, investigational, unproven, or not medically necessary by the clinical evidence are typically not covered.
Weunderstandthatthefirstlevelof review for medical policies is the determination of coverage which is basedonwhattheStatedefinesascoveredbenefits.Iftheserviceisnotacoveredbenefit,thenthemanagedcareorganizationdoesnothaveanyresponsibility to pay for the service. However, if the service is determined tobeacoveredbenefit,wehavetheresponsibility to determine if the service falls into the category of “medically necessary” based on clinical evidence and guidance.
UnitedHealthcare Medicaid Policy Alignment
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Front & Center
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Medical policies are developed as needed and represent one of the important resources used to support UnitedHealthcare’s coverage decision making. Policies are developed as needed and subject to change through regular review.
New and updated medical policy changes will be communicated in the Medical Policy Update Bulletin at UnitedHealthcareOnline.com > Tools & Resources > Policies, Protocols and Guides > Medical & Drug Policies and Coverage Determination Guidelines > Medical Policy Update Bulletin.
UnitedHealthcare Medicaid Policy Alignment
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2014 UnitedHealthcare Administrative Guide Available – Effective April 1, 2014
This essential resource for physicians, hospitals, facilities and other health care providers is now posted on UnitedHealthcareOnline.com. Download it today!
Important Updates in the 2014 Guide Include:
• AdvanceNotificationList-TheAdvanceNotificationlistofprocedurecodeshasmoved online for your convenience at UnitedHealthcareOnline.com > Clinician Resources > Advance & Admission Notification Requirements. Please reference the complete article for more details in the January Network Bulletin.
• Optum Cloud Dashboard - Is a cloud-based website that has new features and functionality which allows providers to submit claim reconsideration requests electronically with attachments.
• High Performing Networks - Expansion of new Commercial product offerings for UnitedHealthcare Compass.
• Exchanges - New product details on Individual Marketplace and/or Small Business HealthOptionsProgram(SHOP)Marketplacelanguage added in the Commercial Product section.
• Retroactive Eligibility Changes - Eligibility changes may occur retroactively if the member fails to pay their premium within a three monthgraceperiodforsubsidizedIndividual Exchange members.
Supplement Updates and Changes for 2014:
• Oxford Commercial Provider Reference Manual has been consolidated into a Supplement of the UnitedHealthcare Guide.
• OneNet Provider Manual has been consolidated into a Supplement of the UnitedHealthcare Guide.
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2014 UnitedHealthcare Administrative Guide Available – Effective April 1, 2014
• Medicare Advantage Capitated Provider Supplement - A new supplement for all non-UnitedHealthcare West capitated providers.
• Oxford Medicare Advantage Supplement has been removed and content has been integrated with the UnitedHealthcare standard Medicare Advantage section.
• UnitedHealthOne and All Savers Supplements are now two separate supplements to the Guide and have been revised in accordance with the current product offerings. Most notably, the Choice Plus product offered by Golden Rule is now subjecttothestandardAdmissionNotification requirements described in the Guide. New products offered by UnitedHealthcare Life Insurance Company(UHCLIC)arenowsubjecttothestandard Advance AND AdmissionNotificationrequirements described in the Guide.
Other Sections That Include Updates: WhenisAdvanceNotificationRequired,CardiologyNotification/PriorAuthorizationProtocolforCommercialCustomers,RadiologyNotification/PriorAuthorizationProtocol for Commercial Customers, Specialty Drug PriorAuthorizationforMedicalBenefit(forCommercialCustomers only), Self-Referral and Anti-Kickback, Claim reconsideration and appeals process and resolving disputes and UnitedHealth Premium Designation Program(forCommercialCustomersonly).
Please contact your Network Management representative, Physician Advocate, or Hospital & Facility Advocate for a hard copy of the UnitedHealthcare Administrative Guide orAdvanceNotificationList.
* Except as otherwise noted, the new Guide is effective on April 1, 2014 for currently contracted providers, and effective immediately for providers newly contracted on or after Jan. 1, 2014.
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ImportantChangesinAdvanceNotificationandPrior AuthorizationRequirementsforHomeHealthServices for Medicare Advantage Plans
EffectivefordatesofserviceonorafterFeb.1,2014,AdvancedNotificationfortheinitial60 days of home health services is no longer required for the following list of home health services.Notificationforthesecondandsubsequent60daysofcontinuoushomehealthservices will be required. Clinical documentation may be requested in order to determine coverage for these services. Home infusion services are not included.
• Nursing services in the home, including RN, LPN, and Home Health Aide
• Therapies in the home, including occupational, physical, speech and respiratory
• Social worker in the home
Authorization requests should include:
• Start of care date
• The date span for service being requested
• Home health service codes and diagnosis codes
• The number of units for each service requested, if applicable
The following documentation should be maintained for home health services in accordance with the Centers forMedicare&MedicaidServices(CMS)guidelinesand may be requested for clinical review:
• Current plan of care
• Face-to-faceencounter(documentationthephysician has seen the patient and written the order)
• Signed plan of care from previous 60 days (requiresphysiciansignature)
• Current nursing and therapy notes with brief clinical summary and assessment of the patient including homebound status
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Please remember that private duty nursing and hospice services are generally not a covered benefitforMedicareAdvantagePlans.Therearesomeexceptions.Forquestionsregardingbenefitcoverage please contact Customer Service at the # on the back of the member’s ID card.
ThereisnochangetotheAuthorizationrequirementsrelated to Enteral Feed Services.
Medicare coverage rules are still in effect for MedicareAdvantagemembersandspecificserviceswill continue to not be covered by Medicare, including but not limited to home health services furnished when the member is not in need of any other skilled service and part time or intermittent skillednursingorhomehealthaideservices(whencombined) greater than eight hours a day or more than28hoursperweekexceptwhenauthorizedona case-by-case basis to be more than eight hours a day and 35 hours or fewer hours per week.
ImportantChangesinAdvanceNotificationandPrior AuthorizationRequirementsforHomeHealthServices for Medicare Advantage Plans
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UnitedHealthcare Community Plan to Start Using National Comprehensive Cancer Network Compendium
Effective Feb. 15, 2014, UnitedHealthcare Community Plan will start using the National ComprehensiveCancerNetwork(NCCN)Compendiuminreviewingrequestsforcoverageforchemotherapyinjectabledrugs(J9000–J9999)administeredinanoutpatientsettingfor members ages 19 and older. The NCCN Compendium provides an independent resource for use in making chemotherapy coverage decisions.
There are some important details to note with this policy:
1. If the NCCN Compendium lists the drug with a recommendation level 1, 2A or 2B for the condition, the service is eligible for reimbursement basedonthemember’scertificateofcoverage.Ingeneral, we do not cover recommendations with Level 3 evidence.
2. NCCN updates its compendium as new drugs or changes are made.
3. This new drug policy requires that you always include the primary cancer diagnosis on the claim. Claims submitted with only a V58.1 diagnosis code may require additional information prior to a coverage decision.
4. Thispolicyappliestochemotherapydrugs(J9000– J9999). It does NOT apply to supportive care drugs(i.e.,erythropoiesis-stimulatingagents,antiemtics, colony stimulating factors).
5. The policy applies to members ages 19 and older. The majority of pediatric patients receive treatments on national pediatric protocols that are similar in concept to the NCCN patient care guidelines.
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InjectableChemotherapyPriorAuthorizationProgramfor Florida Providers
Effective second quarter 2014, providers in Florida billing for outpatient injectable chemotherapy for members being treated for a cancer diagnosis insured by Neighborhood HealthPartnership(NHP)orUnitedHealthcarewillberequiredtoobtainpriorauthorization.
UnitedHealthcare’s Injectable Chemotherapy Prior AuthorizationProgramwillbemanagedbyCareCoreNational’s Oncology Division and providers will be able toobtaininjectablechemotherapyauthorizationsonCareCore’s website.
AuthorizationsthatfollowNCCNregimenswillbe 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 thetimeofpriorauthorizationrequest.
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UnitedHealthcare Shared Services Expansion for GEHA
Through a shared services arrangement, UnitedHealthcare provides access to the UnitedHealthcare Options Preferred Provider Organizations(PPO)NetworktoGovernmentEmployeesHealthAssociation(GEHA)members in AL, AK, CO, DC, DE, ID, IA, LA, MD, MS, MT, MN, NE, NM, ND, OK, SD, TN, UT, VA, WV, WI and WY.
As of Jan. 1, 2014, GEHA will be accessing UnitedHealthcare Options PPO provider contracts in the state of Ohio. GEHA is the second-largest national health plan for civilian federal employees nationwide. Please check the back of the member’s ID card for contact information.
Foreligibility,summaryofbenefits,outpatientprecertificationrequirementsandclaim status, call the dedicated self-service line at 877-343-1887 or email [email protected].
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myHCE: Providing Cost Transparency for a More Informed Health Care Consumer
UnitedHealthcarelaunchedthemyHealthcareCostEstimator(myHCE)lastyearto assist members in making informed decisions regarding treatment options, providers and cost estimates.
myHCE is an integrated online tool providing quality rating information and cost estimates for common treatments and procedures for in-network hospitals andphysicians.Estimatesarepersonalizedtoreflectamember’sspecifichealthplanbenefits,includingtheir real-time copays and deductibles.
We continue to enhance myHealthcare Cost Estimator to empower members with relevant information about estimated health care costs and quality rating information. Changes in 2014 to myHCE include:
• Continued expansion of Care Paths to include inpatient and outpatient high volume services such as behavioral health
• Cost estimates for Optum business
• Effective Jan. 1, 2014, a limited offering to one MedicareNationalPreferredProviderOrganization(NPPO)RetireePlan(StateHealthPlanofNorthCarolina retirees). Currently the tool is not available to other Medicare members.
• Support for Executive Medical Plan
Resources for Network Hospitals and Physicians can be found on UnitedHealthcareOnline > Tools & Resources > Health Resources for Patients > Transparency (myHCE).
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Prepare for UnitedHealthcareOnline.com Login Migration to Optum Cloud Dashboard
If you haven’t already transitioned to the new UnitedHealthcareOnline.com login process, you will be transitioned early this year. Please watch for an email notifying you of your migration date.
When you login to UnitedHealthcareOnline.com on that date and after, you will automatically be redirected to the Optum Cloud Dashboard website.
If you are registered on Optum Cloud Dashboard, you will be able to return to UnitedHealthcareOnline.com or stay on Optum Cloud Dashboard to use the available applications. No further action is required for login migration.
If you aren’t registered, please follow the steps for Password Owners or Standard Users so that you can continue to use secure transactions on UnitedHealthcareOnline.com.
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The CMS “Two Midnight Rule” – Effective Oct. 1, 2013
TheCentersforMedicare&MedicaidServices(CMS)2014FiscalYearInpatientProspectivePaymentSystemFinalRulebecameeffectiveOct.1,2013andincludesclarificationaboutwhena patient should be admitted to the hospital.
This provision, known as the “Two Midnight Provision,” is intended to help you and auditors determine whether a MedicareclaimshouldbebilledunderPartA(inpatient) orPartB(outpatient).
UnitedHealthcare started implementing the CMS Two-Midnight Provision for our Medicare Advantage plans in October2013byincorporatingtheclarificationintoourconcurrent review programs. We plan to fully integrate the provision over the coming year.
Please review the links at the end of this article for details about the provision, which states that if a member requires medically necessary hospital care that is expected to span
two or more midnights, inpatient admission is appropriate. If you expect the member’s medically necessary treatment will span less than two midnights, assign it outpatient status.1
TheFinalRuleemphasizestheneedforaformalorder of inpatient admission to begin inpatient status, but permits the physician to consider all time a patient has already spent in the hospital as an outpatient receiving observation services, or in the emergency department, operating room, or other treatment area in guiding their two-midnight expectation.
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The CMS “Two Midnight Rule” – Effective Oct. 1, 2013
The Final Rule supports the continued use of evidence-based guidelines to help with deciding whether to admit a patient. Therefore, UnitedHealthcare will continue to use evidence-based guidelines to support consistent, clinically validated decision-making for hospital admissions which are medically necessary. We will review “the reasonableness of the physician’s expectation of the need for and duration of care based on complex medical factors such as history and comorbidities, the severity of signs and symptoms, current medical needs and the risk of an adverse event, which must be clearly documented.” 2 While CMS has delayed enforcing the Two Midnight Provision, they have not changed the effective date of Oct. 1, 2013. Rather, they are issuing guidance to MedicareAdministrativeContractors(MACs)abouthowto select hospital claims for review during a “Probe and Educate” program for admissions that occur between Oct. 1, 2013 and March 31, 2014. While this guidance is not directed towards Medicare Advantage plans, we will continue to monitor CMS publications while developing
our internal clinical review programs, and will continue to work collaboratively with you as we adapttotheseclarifications.
CMS resources: Federal Register/Vol. 78, No. 160/Monday, August 19, 2013:http://www.gpo.gov/fdsys/pkg/FR-2013-08-19/pdf/2013-18956.pdf
CMS FAQ: http://cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/Medical-Review/Downloads/QAsforWebsitePosting_110413-v2-CLEAN.pdf
Selecting claims for patient status reviews: http://cms.gov/Research-Statistics-Data-and-Systems/Monitoring-ProgramsMedical-Review/Downloads/SelectingHospitalClaimsfor ReviewForWebPostingCLEAN.pdf
Reviewing hospital claims for patient status: http://cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/Medical-Review/Downloads/ReviewingHospitalClaimsforAdmissionFINAL.pdf
1CMS Frequently Asked Questions: 2 Midnight Inpatient Admission Guidance and PatentStatusReviewsforAdmissionsafterOctober1,2013(“CMSFAQ”)(QuestionandAnswerNo.8):http://cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/Medical-Review/Downloads/QAsforWebsitePosting_110413-v2-CLEAN.pdf
2CMSFAQ(QuestionandAnswerNo.9)
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To support our providers during this transition, UnitedHealthcare offers the following tools at UnitedHealthcareOnline.com to assist you in becoming ICD-10 compliant:
• ICD-10 Education - on-demand educational resources designed to provide general information regarding ICD-10 and the implementation process.
• ICD-10 Tools - in collaboration with the American AcademyofProfessionalCoders(AAPC),thelargestcodingorganizationinthecountry,wehavecreateda suite of tools including ICD-10 code selection decision trees and detailed clinical documentation improvement webinars.
• ICD-10 Resources - a listing of industry-wide ICD-10 resources.
• ICD-10 Partnerships - in addition to AAPC, we are working with Optum to offer value-added solutions for cost-effective adoption of ICD-10.
For answers to your questions regarding ICD-10, please send your inquiry to [email protected].
2014: The Year of the ICD-10 Code
This year the health care industry will adopt and use International ClassificationofDisease, TenthRevision(ICD-10)codes. The Department of Health and Human Services mandates the use of ICD-10 codes for dates of service on or after Oct. 1, 2014.
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Effective April 23, 2014, UnitedHealthcare will apply an enhanced level of HIPAA edits to professional(837p)andinstitutional(837i)claimssubmitted electronically to most UnitedHealthcare andaffiliatepayer IDs.*
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 identify and correct rejected information prior to the claim’s acceptance into our adjudication system for processing.Thebenefitwillbefewerdeniedclaims and less interruption to revenue streams.
The primary impact to you will come from edits that willvalidatecodesets(suchasdiagnosis,procedure, modifierandnationaldrugcodes)atapre-adjudication level. The complete list of enhanced edits has been distributed to clearinghouses and software vendors.
It is important to check all of your claim submission reports regularly. Claims may be rejected by your clearinghouse or UnitedHealthcare; therefore, you may receive multiple reports per submission.
Visit UnitedHealthcareOnline.com for more information about tracking your electronic claims.
Rejections that may occur from the enhanced edits will appear at a clearinghouse level. Your Electronic Data Interchange(EDI)vendororclearinghouseshouldbeyourfirstpointofcontactforassistanceregardingtheseedits or to resolve rejections. For more information, please contact EDI Support:
* Exceptions:HarvardPilgrim(04271),MedicaHealthCarePlans(78857),PreferredCarePartners(65088),TheAlliance(88461)andTRICAREWest(99726)
Enhanced HIPAA Edits to be Applied to Claim Submissions
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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In the November 2013 Network Bulletin, we informed you of CMS’s new requirement for all Medicare Advantage OrganizationstobeginsubmittingHIPPScodesonallskillednursing facility and home health care encounter data. Since our last communication, CMS has delayed implementation of the requirement to July 1, 2014. You should continue to prepare your systems and processes to be able to provide HIPPS codes on claims for UnitedHealthcare Medicare Advantage members, however until further notice, please continue to submit claims to us as you have in the past. We will notify you in advance regarding when to begin submitting HIPPS codes on claims. IntheabsenceofspecificCMSguidance,atthistimepleasefollowthestandard Medicare process for identifying the appropriate HIPPS codes for your patients.
HIPPS Codes Requirement for Home Health Care and Skilled Nursing Facility Encounters
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EffectiveApr.1,2014,MedicareAdvantagehealthplanswillrequirepriorauthorizationforIntensityModulatedRadiationTherapy(IMRT),StereotaxicRadiosurgery(SRS)andStereotacticBodyRadiationTherapy(SBRT)whenadministeredinanoutpatientsetting.
Additional details about the program will be posted on our physician portal in two locations: UnitedHealthcareOnline.com > Clinical Resources > Cancer – Oncology > IMRT – Medicare Advantage. You can also go to: UnitedHealthcareOnline.com > Clinical Resources > Cancer – Oncology > SRS and SBRT – Medicare Advantage.
Medicare Advantage IMRT, SRS and SBRT Prior Authorizationtrainingandlivequestionandanswersessions will be hosted by WebEx in March 2014. Additionally, registration details will be posted on the websites in March 2014. See the above websites for specificscheduledates.
MedicareAdvantagetoRequirePriorAuthorization for IMRT, SRS and SBRT as of April 1
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MedicareAdvantageRadiologyandCardiologyPriorAuthorizationProgram to Deploy for UnitedHealthcare West Medicare Non-Capitated Participating Providers on April 1, 2014
UnitedHealthcare West Medicare Advantage Non-Capitated
Beginning April 1, 2014, participating physicians, facilities and other health care professionals who are subject to the Administrative Guide and the UnitedHealthcare West Non-Capitated Supplement and practice in Arizona,Oklahoma,Oregon,TexasandWashington,mustobtainpriorauthorizationforcertainoutpatientradiologyprocedures before they are rendered to UnitedHealthcare West Medicare Advantage members. Those states, as well as Colorado, must also do the same for cardiology procedures, beginning April 1, 2014.
Radiology Prior Authorization
Beginning April 1, 2014:
• Ordering providers who are subject to the Administrative Guide and the UnitedHealthcare West Non-CapitatedSupplementandpracticeinArizona,Oklahoma, Oregon, Texas and Washington will have a new phone number and website link that is to be used toobtainpriorauthorization
prior to scheduling certain CT, MRI, MRA, PET scan, Nuclear Medicine, and Nuclear Cardiology procedures for UnitedHealthcare West Medicare Advantage members. The advanced imaging proceduresrequiringpriorauthorizationarereferredto as advanced outpatient imaging procedures.
Ordering providers will need to obtain the required prior authorizationnumberbyusingthenewcontactmethods:
• Online: UnitedHealthcareOnline.com > Notifications/Prior Authorizations > Radiology Notification & Authorization - Submission & Status.
• Phone: 866-889-8054 - select the option for Medicare Advantage customers and then select the option for outpatient diagnostic imaging.
Onceapriorauthorizationrequestforaplannedadvanced outpatient imaging procedure is received, UnitedHealthcare will conduct a clinical coverage review to determine whether the service is medically necessary. The provider will be informed of the decision.
For a complete list of CPT Codes that require prior authorization,pleasevisitUnitedHealthcareOnline.com > Clinician Resources > Radiology > Medicare Advantage Radiology Prior Authorization Program > 2014 Radiology Prior Notification/Authorization CPT Code List.
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MedicareAdvantageRadiologyandCardiologyPriorAuthorizationProgram to Deploy for UnitedHealthcare West Medicare Non-Capitated Participating Providers on April 1, 2014
• Rendering providers who are subject to the Administrative Guide and the UnitedHealthcare West Non-Capitated Supplement and practice in Arizona,Oklahoma,Oregon,TexasandWashingtonmustconfirmthatthepriorauthorizationprocesshasbeencompleted and a coverage decision has been issued before rendering any advanced outpatient imaging procedure. If the ordering provider does not participate in UnitedHealthcare West’s network and is unwilling to completethepriorauthorizationprocess,therenderingprovidermustcompletethepriorauthorizationprocessandverify that a coverage decision has been issued prior to rendering the advanced outpatient imaging procedure.
Providersarenotrequiredtoobtainpriorauthorizationforanyadvanced imaging procedures rendered in an emergency room, urgent care center, observation unit or during an inpatient stay.
Cardiology Prior Authorization
Beginning April 1, 2014:
• Ordering providers who are subject to the Administrative Guide and the UnitedHealthcare West Non-CapitatedSupplementandpracticeinArizona,Colorado, Oklahoma, Oregon, Texas and Washington
mustobtainpriorauthorizationpriortoschedulingcertaindiagnosticcatheterizations,electrophysiologyimplants,echocardiograms and stress echocardiograms procedures for UnitedHealthcare West Medicare Advantage members.
For a complete list of CPT Codes that requirepriorauthorization,pleasevisit UnitedHealthcareOnline.com > Clinician Resources > Cardiology > Medicare Advantage Cardiology Prior Authorization Program > 2014 Cardiology Prior Authorization Table and CPT Code Crosswalk.
Onceapriorauthorizationrequestforaplannedcardiologyprocedure is received, UnitedHealthcare will conduct a clinical coverage review to determine whether the service is medically necessary. The provider will be informed of the decision.
• Rendering providers who are subject to the Administrative Guide and the UnitedHealthcare West Non-CapitatedSupplementandpracticeinArizona,Colorado,Oklahoma,Oregon,TexasandWashingtonmustconfirmthatthepriorauthorizationprocesshasbeencompletedand verify that a coverage decision has been issued before rendering any cardiology procedure.
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Priorauthorizationfordiagnosticcatheterizations,echocardiograms and stress echocardiograms is required for outpatientandoffice-basedservicesonly.Priorauthorizationforelectrophysiologyimplantsisrequiredforoutpatient,office-based and inpatient services.
Cardiology procedures rendered in and appropriately billed with any of the following places of service do not require prior authorization:emergencyroom,urgentcarecenterorinpatientsetting(exceptforelectrophysiologyimplants,whichrequirepriorauthorizationduringaninpatientstay).
Medicare Advantage Plans Subject to This Prior Authorization Process
As of the effective date of this communication, the prior authorizationrequirementssetforthabovewillapplytoUnitedHealthcare West’s Medicare Advantage plans that are subject to the Administrative Guide and UnitedHealthcare West Non-Capitated Supplement including but not limited to UnitedHealthcare® Medicare Complete®, UnitedHealthcare Dual Complete™, UnitedHealthcare® Chronic Complete and AARP® MedicareComplete® plans. Please note that excluded plans may have separate radiology or cardiology priorauthorizationrequirements.Pleaserefertotherespective
supplements in the Administrative Guide for details.For additional information, see the following Additional Resource Information section:
Additional Resource Information Prior Authorization Process
Providersmust(a)providenotificationandcompletethepriorauthorizationprocess,and(b)confirmthatacoveragedecision has been made as follows:
• Online at UnitedHealthcareOnline.com > Notifications/Prior Authorizations > Radiology Notification & Authorization – Submission & Status.
• Online at UnitedHealthcareOnline.com > Notifications/Prior Authorizations > Cardiology Notification & Authorization – Submission & Status.
• Call866-889-8054(7a.m.to7p.m.localtime, Monday – Friday).
Please note that payment for covered services is contingent uponcoverageunderthemember’sbenefitplan,the provider’s eligibility for payment, any claim processing requirements and the provider’s participation agreement with UnitedHealthcare West.
MedicareAdvantageRadiologyandCardiologyPriorAuthorizationProgram to Deploy for UnitedHealthcare West Medicare Non-Capitated Participating Providers on April 1, 2014
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MedicareAdvantageRadiologyandCardiologyPriorAuthorizationProgram to Deploy for UnitedHealthcare West Medicare Non-Capitated Participating Providers on April 1, 2014
Failure to Complete the Prior Authorization Process and Meet Medical Necessity Criteria
Failuretoprovidenotificationandcompletethepriorauthorizationprocess, or verify that a coverage determination has been issued, prior to rendering an advanced outpatient imaging procedure or cardiology procedure will result in an administrative claim reimbursement reduction, in part or in full. Members cannot be billed for claims that are administratively denied.
ForUnitedHealthcareWestMedicareAdvantagebenefitplans,anauthorizationnumberisissuedforbothapprovedandclinicallydeniedpriorauthorizations.Aclinicaldenialwillbeissuedifitisdetermined during the clinical coverage review process that the service does not meet medical necessity criteria. The clinical denial will be communicated via a letter faxed to the provider and a letter will be mailed to the Medicare Advantage member.
Members can be billed for requested services that are clinically denied, provided adequate written consent is obtained from the member prior to rendering the service.
Additional Information About Process
Additional information regarding the requirements you must follow, including requirements with respect to urgent requestsandtheretrospectivenotificationprocess,issetforthinthe(a)OutpatientRadiologyPriorAuthorizationProtocolforMedicareAdvantagemembers,and(b)CardiologyPriorAuthorizationProtocolfor Medicare Advantage members. These protocols are set forth in the Administrative Guide. We strongly encourage you to review the protocols.
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ContraceptiveServicesOnlyBenefit and Eligible Organizations
Under the Patient Protection and Affordable Care Act (PPACA),mosthealthinsuranceplansmustcovercertainbirthcontrolmethods(contraceptivesandsterilization)for women at no cost - when received from an in-network doctor, health care professional or pharmacy.
Somenonprofits,referredtoasEligibleOrganizations,don’t have to cover birth control as part of their group healthplanforreligiousreasons.EligibleOrganizationswill not contract, arrange, pay, or refer for contraceptive coverage, as part of their group health plan. Instead, UnitedHealthcare will pay for certain types of female birth control for members without cost-sharing through our“ContraceptiveServicesOnly”benefit,whichwearerequired by law to make available to members.
About the Contraceptive Services OnlyBenefit
Women who request the Contraceptive Services Only(CSO)benefitwillreceiveaCSOIDcard. This card is like a regular UnitedHealthcare member ID cardandmustbeusedatthedoctor’sofficeorpharmacyto ensure they don’t pay for the birth control drugs, products or services covered by the Contraceptive ServicesOnlybenefit.
Women’s Preventive Care Services Updates
Contraceptive
Services
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Health Plan (80840) 911-87726-04Member ID: Group Number:Member:
Payer ID 87726
Rx Bin: 610279Rx PCN: 9999Rx Grp: UHEALTH
DOI-0501UnitedHealthcare Choice
Underwritten by [Appropriate Legal Entity]
123456789 755733
EMPLOYEE SMITHContraceptive Services Only
DependentsSPOUSE SMITHCHILD1 SMITHCHILD2 SMITHCHILD3 SMITH
Health Plan (80840) 911-87726-04Member ID: Group Number:Member:
Payer ID 87726
Rx Bin: 610279Rx PCN: 9999Rx Grp: UHEALTH
DOI-0501UnitedHealthcare Choice
Underwritten by [Appropriate Legal Entity]
123456789 755733
EMPLOYEE SMITHContraceptive Services Only
DependentsSPOUSE SMITHCHILD1 SMITHCHILD2 SMITHCHILD3 SMITH
030829275950
000000000010000001260
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RUN_DATE 20130917 09:08:54DATA_SEQ_NO 0000001CLIENT_NUMBER 003082UHG_TYPE DIG2CARDDOC_ID DOC_SEQ_ID 0000001NAME SMITH ,EMPLOYEEMAILSET_NUMBER 0000001CUSTCES_KEY1 0000010000100000100001_KEY0 CARD1CUSTCES_KEY1 0000010000100000100001_KEY0 CARD2CUSTCES_KEY2 0755733CUSTCES_KEY2 0755733CUSTCES_KEY3 EMPLOYEECUSTCES_KEY3 EMPLOYEECUSTCES_KEY4 HCAC/MedicalCUSTCES_KEY4 HCAC/MedicalCUSTCES_KEY5 00CUSTCES_KEY5 01CUSTCES_KEY5 02CUSTCES_KEY5 03CUSTCES_KEY5 04CUSTCES_KEY5 00CUSTCES_KEY5 01CUSTCES_KEY5 02CUSTCES_KEY5 03CUSTCES_KEY5 04CUSTCES_KEY6 20130917CUSTCES_KEY6 20130917CUSTCES_KEY7 00000100001~00CARD1CUSTCES_KEY7 00000100001~01CARD1CUSTCES_KEY7 00000100001~02CARD1CUSTCES_KEY7 00000100001~03CARD1CUSTCES_KEY7 00000100001~04CARD1CUSTCES_KEY7 00000100001~00CARD2CUSTCES_KEY7 00000100001~01CARD2CUSTCES_KEY7 00000100001~02CARD2CUSTCES_KEY7 00000100001~03CARD2CUSTCES_KEY7 00000100001~04CARD2CUSTCES_KEY8 123456789CUSTCES_KEY8 123456789CUSTCES_KEY9 123456789~00CARD1CUSTCES_KEY9 123456789~01CARD1CUSTCES_KEY9 123456789~02CARD1CUSTCES_KEY9 123456789~03CARD1CUSTCES_KEY9 123456789~04CARD1CUSTCES_KEY9 123456789~00CARD2CUSTCES_KEY9 123456789~01CARD2CUSTCES_KEY9 123456789~02CARD2CUSTCES_KEY9 123456789~03CARD2CUSTCES_KEY9 123456789~04CARD2
Thereview
andapprovalofhealthcareservices,basedonmedicalnecessity,doesnotguaranteecoverage
underyourpolicy.Also,verificationofeligibilityforbenefitsandcoveragedoesnotguaranteecoverage.Actual
benefitsandcoveragewillbedeterminedunderthetermsandconditionsofyourpolicywhenaclaimis
submitted.ThisMedicalIDCardistobeusedsolelyinconnectionwithandissubjecttothetermsand
conditionsofyourhealthormedicalcoverageissuedoradministeredbyUnitedHealthcareoritsaffiliates.
UnitedHealthcareanditsaffiliatesreserveallrightsintheeventofimproperuse.
WelcometoUnitedHealthcare
Thankyouforchoosingusasyourhealthcarebenefitplanprovider.
AttachedisyourUnitedHealthcarehealthplanIDcard.Beginusingiton
thedayyourcoveragestarts.
Manageyourhealthcareonlineatmyuhc.com.Youwillfind
personalizedtoolsandinformationtohelpyou:
•Manageyourclaimsandseehowmuchyouowe
•Findadoctororhospital
•Estimateyourhealthcarecosts
•Researchhealthtopics
•Findanswerstoyourhealthcarequestions
Formorehelp,pleasecallusatthenumberonthebackofyourcard.
Graciasporelegirnoscomoproveedordesuplandebeneficiosde
atencióndelasalud.Adjuntamossutarjetadeidentificacióndelplande
saluddeUnitedHealthcare.Empieceausarlaeldíaenquecomiencesu
cobertura.Administresuatencióndelasaludenlíneaenmyuhc.com.
Encontraráinformaciónyherramientaspersonalizadasparaayudarlea
administrarsusreclamosyvercuántoadeuda,encontrarunmédicou
hospital,calcularsuscostosdeatencióndelasalud,investigartemasde
salud,yencontrarrespuestasasuspreguntasdeatencióndelasalud.
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reversodesutarjeta.
Printed: 09/17/13
This card does not guarantee coverage. To verify benefits, view claims, or finda provider, visit the websites or call.For Members: www.myuhc.com 123-456-7890
For Providers: www.unitedhealthcareonline.com 877-842-3210Medical Claims: PO Box 30555, Salt Lake City UT 84130-0555
Pharmacy Claims: OptumRx PO Box 29044 Hot Springs, AR 71903For Pharmacists: 888-290-5416
Printed: 09/17/13
This card does not guarantee coverage. To verify benefits, view claims, or finda provider, visit the websites or call.For Members: www.myuhc.com 123-456-7890
For Providers: www.unitedhealthcareonline.com 877-842-3210Medical Claims: PO Box 30555, Salt Lake City UT 84130-0555
Pharmacy Claims: OptumRx PO Box 29044 Hot Springs, AR 71903For Pharmacists: 888-290-5416
*117*
Shipper ID: 00000000 Insert #1 Insert #2Shipping Method: 2ND DAY Insert #3 Insert #4CARRIER: UPS Insert #5 Insert #6Address: Insert #7 Insert #8TO: Contraceptive Services Only Insert #9 Insert #10Contraceptive Services Only Insert #11 Insert #12ATTN: UHC123 Any Street Cycle Date: 20130917Hartford, CT 12345 PDF Date: Tue Sep 17, 2013 @ 09:08:54
MaxMover: NMailing/Meter Date: UHG JOB ID: 8782 GRP: 0755733 PV: 0001 RC: 0001 MKT: 77777
MT: 00 SA: 00 OI: 01 FORM: K20001 CPAY: BDALE BROWN: YESTEMPLATE: NEW FAMILY/IND : STD FAMILY : STANDARD : STANDARD
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HOME TABLE OF CONTENTS
Women’s Preventive Care Services Updates
Important Information About the CSOBenefit
• Only female birth control on the CSO list is availableat no cost. And includes many types of birth controlthat are covered, including: birth control pills, femalecondoms, and long-lasting birth control.
• Birth control services must be received at an in-networkpharmacyordoctor’soffice.
• Members must have a prescription for this birth controlto be covered at no cost - even for items that can bepurchased without a prescription.
For more information, please call your Provider Advocate or Provider Services.
Members Can Now Receive Breast Pumps Within 30 Days of Delivery
Under PPACA, breast-feeding services and equipment are covered without cost-sharing when received by a network provider, during pregnancy and/or in the postpartum period.
Members may purchase breast pumps without cost-share by contacting a network doctor or durable medicalequipment(DME)supplierwithin30daysoftheestimateddeliverydate.(Previously,mothershadtobelactating before receiving a breast pump.)
• For a list of breast pump suppliers, members maycall the number on the back of their ID card.
• If contacting the breast pump supplier directly, membersmay be asked for their doctor’s contact information, thebaby’s due date or the date the baby was delivered.The breast pump supplier may verify this and otherinformation with the member’s doctor before the breastpump is shipped.
• National breast pump suppliers ship the breastpump directly to the lactating mother.
• The doctor or DME supplier will bill UnitedHealthcaredirectly for reimbursement.
• Members do not need a prescription when contacting aDME breast pump supplier.
• Members will not be reimbursed for breast pumpspurchased at retail stores.
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HOME TABLE OF CONTENTS
Our Preventive Care Services Coverage Determination Guideline was updated Jan.1,2014toreflectthischange.
How Members Obtain a Breast Pump
For more information, contact your Physician Advocate or Provider Services; or visit the United for Reform Resource Center at uhc.com/reform and click the preventive services provision for the latest health reform news or review our Preventive Care Services Coverage Determination Guideline information about what preventive services must be covered under the health reform law is found at HealthCare.gov.
Women’s Preventive Care Services Updates
Next Article >
UnitedHealthcare Medical Policy, Drug Policy, Coverage Determination Guideline and UtilizationReviewGuidelineUpdates
For complete details on the new and/or revised policies and guidelines listed in the table on the following page, 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.
UnitedHealthcare Commercial
Network Bulletin: January 2014 - Volume 59 For more information call 877.842.3210, or visit UnitedHealthcareOnline.com36
HOME TABLE OF CONTENTS
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For more information call 877.842.3210, or visit UnitedHealthcareOnline.com37 Network Bulletin: January 2014 - Volume 59
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UnitedHealthcare Medical Policy, Drug Policy, Coverage Determination GuidelineandUtilizationReviewGuidelineUpdates
Policy Title Policy Type Effective Date Medical Policy Update Bulletin
TAKE NOTE
Annual CPT® and HCPCS Code Updates All Jan. 1, 2014 Jan. 2014
NEW
EnzymeReplacementTherapyfor Gaucher Disease
Drug Policy Feb. 1, 2014 Nov. 2013Dec. 2013Jan. 2014
MechanicalCirculatorySupportDevice(MCSD) Clinical Guideline Jan. 1, 2014 Nov. 2013 Dec. 2013
Next Article >
Medical Policy Jan. 1, 2014 Dec. 2013
UPDATED/REVISED
Abnormal Uterine Bleeding and Uterine Fibroids
UnitedHealthcare Commercial
For more information call 877.842.3210, or visit UnitedHealthcareOnline.com38 Network Bulletin: January 2014 - Volume 59
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Policy Title Policy Type Effective Date Medical Policy Update Bulletin
Apheresis Medical Policy Jan. 1, 2014 Dec. 2013
Bariatric Surgery Medical Policy Jan. 1, 2014 Dec. 2013
Blepharoplasty, Blepharoptosis, and Brow Ptosis Repair
Coverage Determination Guideline
Jan. 1, 2014 Dec. 2013
Campath(Alemtuzumab) Drug Policy Jan. 1, 2014 Dec. 2013
Cardiovascular Disease Risk Tests Medical Policy Jan. 1, 2014 Dec. 2013
Epidural Steroid and Facet Injections for Spinal Pain
Medical Policy Nov. 1, 2013 Nov. 2013
Hearing Aids and Devices Including Wearable, Bone-Anchored and Semi-Implantable
Medical Policy Dec. 1, 2013 Nov. 2013
Hip Resurfacing Arthroplasty Medical Policy Jan. 1, 2014 Dec. 2013
ImmuneGlobulin(IVIG) Drug Policy Dec. 1, 2013 Nov. 2013
Omnibus Codes Medical Policy Jan. 1, 2014 Dec. 2013
Oncology Medication Clinical Coverage Policy Drug Policy Jan. 1, 2014 Dec. 2013
Polysomnography and Portable Monitoring for Evaluation of Sleep Related Breathing Disorders
Medical Policy Dec. 1, 2013 Nov. 2013
Preventive Care Services Coverage Determination Guideline
Jan. 1, 2014 Dec. 2013
UnitedHealthcare Medical Policy, Drug Policy, Coverage Determination Guideline and UtilizationReviewGuideline Updates
UnitedHealthcare Medical Policy, Drug Policy, Coverage Determination Guideline and UtilizationReviewGuideline Updates
Next Article >
UnitedHealthcare Commercial
For more information call 877.842.3210, or visit UnitedHealthcareOnline.com39 Network Bulletin: January 2014 - Volume 59
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Policy Title Policy Type Effective Date Medical Policy Update Bulletin
Proton Beam Radiation Therapy Medical Policy Jan. 1, 2014 Dec. 2013
Repository Corticotropin Injection (H.P.ActharGel)
Drug Policy Dec. 1, 2013 Nov. 2013
Transcatheter Heart Valve Procedures Medical Policy Jan. 1, 2014 Dec. 2013
RETIRED
Breast Pump UtilizationReviewGuideline Jan. 1, 2014 Dec. 2013
Cardiac Outpatient Rehabilitation (ExerciseTraining)
Coverage Determination Guideline
Nov. 1, 2013 Nov. 2013
Complementary and Alternative Medicine Coverage Determination Guideline
Nov. 1, 2013 Nov. 2013
DefinitionofMedicallyNecessary Coverage Determination Guideline
Nov. 1, 2013 Nov. 2013
Dental Exclusion and Accidental Dental Coverage Determination Guideline
Jan. 1, 2014 Jan. 2014
Hearing Aids Coverage Determination Guideline
Dec. 1, 2013 Nov. 2013
Hyperbaric Oxygen Therapy and Topical Oxygen Therapy
Medical Policy Jan. 1, 2014 Jan. 2014
Maternity Services and Complications Coverage Determination Guideline
Dec. 1, 2013 Dec. 2013
UnitedHealthcare Medical Policy, Drug Policy, Coverage Determination Guideline and UtilizationReviewGuideline Updates
Next Article >
UnitedHealthcare Commercial
For more information call 877.842.3210, or visit UnitedHealthcareOnline.com40 Network Bulletin: January 2014 - Volume 59
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Policy Title Policy Type Effective Date Medical Policy Update Bulletin
Nutrition(Including:Counseling,Therapy,Enteral Nutrition, Infant Formula, Breast Milk, Supplements and Food)
Coverage Determination Guideline
Dec. 1, 2013 Dec. 2013
Physical Medicine and Rehabilitation Services-Inpatient and Outpatient
Coverage Determination Guideline
Nov. 1, 2013 Nov. 2013
Pulmonary Rehabilitation - Outpatient Coverage Determination Guideline
Nov. 1, 2013 Nov. 2013
Snoring Treatment Coverage Determination Guideline
Dec. 1, 2013 Nov. 2013
TotalAnkleReplacement(Arthroplasty) Medical Policy Jan. 1, 2014 Jan. 2014
Treatment of Complications Coverage Determination Guideline
Nov. 1, 2013 Nov. 2013
Wireless Capsule Endoscopy Medical Policy Jan. 1, 2014 Jan. 2014
UnitedHealthcare Medical Policy, Drug Policy, Coverage Determination Guideline and UtilizationReviewGuideline Updates
Note: The appearance of a service or procedure on this list does not imply that UnitedHealthcare provides coverage for the service or procedure. In the eventofaninconsistencyorconflictbetweentheinformationprovidedinthisbulletinandthepostedpolicy,theprovisionsofthepostedpolicywillprevail.
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For more information call 877.842.3210, or visit UnitedHealthcareOnline.com41 Network Bulletin: January 2014 - Volume 59
HOME TABLE OF CONTENTS
ThenewformsfortheUnitedHealthcareIntensityModulatedRadiationTherapy(IMRT)priorauthorizationprogramwillbepostedonourwebsiteinJanuary2014.Youcanfindtheformsat:UnitedHealthcareOnline > Clinician Resources > Cancer – Oncology > IMRT > Related Links.
We are changing the data collection form to enable therequestingphysiciantoprovidedisease-specificclinical details for the radiation oncologist reviewing the priorauthorizationrequest.Onourwebsite,underRelatedLinks,youwillfindthedisease-specificforms.Ifaformisnot available for the patient’s medical condition, a generic form will be available. Please note that incomplete forms may delay the review for IMRT services.
Questions can be forwarded to [email protected].
UnitedHealthcare Commercial
NewDisease-specificIMRTFormsforUnitedHealthcarePriorAuthorizationProcess
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For more information call 877.842.3210, or visit UnitedHealthcareOnline.com42 Network Bulletin: January 2014 - Volume 59
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The Preferred Payment Method for Your UnitedHealthcare Patients: Member Payments
Last summer, UnitedHealthcare implemented a new online payment capability for UnitedHealthcare members to make online payments directly to you and all their health care providers through myuhc.com. We are the firstnationalinsurancecarriertoofferourmembersonlinebillpaymentcapabilitiesthatarefullyintegratedwith online claim information.
Online Member Payments, designed in collaboration with InstaMed, a leading health care payments network, helps you get paid faster and easier than ever. Since the implementation, there has been a steady growth in patients using the service, averaging an additional 1,000 unique patients each day who are paying online at myuhc.com.
UnitedHealthcare members appreciate the capability because they can manage their claims and health care expenses all from one site.
How Online Member Payments Work:
Registered Providers:
• Providers register to receive patient payments electronically, which are then deposited directly into your designated bank accounts.
• Registered providers pay a low merchant transaction fee, similar to what you pay today when patients pay with credit/debit or bank withdrawals.
• Thefeeisaflatrateof2.99percentpertransaction when patients pay using credit/debit cards, and 1.5 percent when patients pay using their bank account.
• There are no sign-up fees, no monthly fees, and no minimum usage fees.
• InstaMed(thepaymentsprocessor)sendsemailnotificationstoproviderswhenpatientpaymentshavebeen made.
• Automatic posting of these payments can be made directly to your patient accounting system.
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Non-Registered Providers:
• If you haven’t registered, UnitedHealthcare members can still pay you online from their member portal.
• You will receive these patient payments by mail in the form of a one-time use MasterCard debit card.
• You incur normal costs to process these payments through your existing merchant account - no additional fee is charged.
• Payments are manually processed similar to a remittance and posted to your patients’ accounts.
Register to receive these payments directly deposited to your bank account by visiting www.uhcmemberpayments.com. If you have questions or want to learn more, sign up to attend a webinar training session. You can also contact [email protected], call 215-789-3682 or contact your UnitedHealthcare
Physician or Hospital Advocate.
The Preferred Payment Method for Your UnitedHealthcare Patients: Member Payments
Next Article >
Unless otherwise noted, these reimbursement policies apply to servicesreportedusingthe1500HealthInsuranceClaimForm(CMS-1500)oritselectronic equivalent or its successor form. UnitedHealthcare reimbursementpolicies do not address all factors that affect reimbursement for servicesrenderedtoUnitedHealthcaremembers,includingmemberbenefitplandocuments, UnitedHealthcare medical policies and the UnitedHealthcarePhysician, Health Care Professional, Facility and Ancillary ProviderAdministrative Guide. Meeting the terms of a particular reimbursement policy isnot a guarantee of payment. Once implemented the policies may be viewed intheir entirety at UnitedHealthcareOnline.com > Tools & Resources > Policiesand Protocols > Reimbursement Policies-Commercial. In the event ofaninconsistencyorconflictbetweentheinformationprovidedintheNetworkBulletin and the posted policy, the provisions of the posted policy prevail.
UnitedHealthcare Reimbursement Policy
Network Bulletin: January 2014 - Volume 59 For more information call 877.842.3210, or visit UnitedHealthcareOnline.com44
HOME TABLE OF CONTENTS
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UnitedHealthcare Reimbursement Policy
For more information call 877.842.3210, or visit UnitedHealthcareOnline.com45 Network Bulletin: January 2014 - Volume 59
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Revision to CCI Editing Policy
PreviouslyannouncedasarevisiontotheRebundlingPolicyandeffectiveinthefirstquarter of 2014, UnitedHealthcare will deny Preventive Medicine Evaluation and Management(E/M)services(CPTcodes99381-99397)whenreportedonthesamedateofserviceasanimmunizationadministrationservice(CPTcodes90460-90461and 90471-90474) through the CCI Editing Policy. This change aligns with the CMS NationalCorrectCodingInitiative(NCCI)andtheAmericanMedicalAssociationCurrentProceduralTerminology(CPT®)
Ifmodifier25isreportedwiththePreventiveMedicineE/MserviceandthedocumentationsupportsthatasignificantandseparatelyidentifiableE/Mservicewasprovidedonthesamedateastheadministration service, both would be reimbursed. It would not be appropriate to additionally report the Preventive Medicine E/M code for the counseling provided when a vaccine is administered.
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UnitedHealthcare Reimbursement Policy
For more information call 877.842.3210, or visit UnitedHealthcareOnline.com46 Network Bulletin: January 2014 - Volume 59
HOME TABLE OF CONTENTS
Revision to the Professional/Technical Component Policy- Denial of Drug Administration Codes and PC/TC Indicator 8
According to the CMS NCCI Policy Manual, drug administration codes (CPT96360-96379,96401-96425,and96521-96523) are considered included in the facility payment when reported in place ofservice(POS)24(ambulatorysurgicalcenter(ASC)).
Additionally, the CMS National Physician Fee Schedule guidelines advise that payment should not berecognizedforprofessional/technical(PC/TC)Indicator8codes,whicharedefinedasphysicianinterpretation codes, furnished to patients in the outpatient or non-hospital setting.
To better align with CMS, UnitedHealthcare will denydrugadministrationcodes(CPT96360-96379, 96401-96425, and 96521-96523) reported by a physician or other health care professional in a POS 24. We will also deny PCTC Indicator 8, CPT code 85060, when reported by a physician or other health care professional with a place of service code other than inpatient hospital (POS21).Thischangewilloccurinthesecondquarter of 2014.
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UnitedHealthcare Reimbursement Policy
For more information call 877.842.3210, or visit UnitedHealthcareOnline.com47 Network Bulletin: January 2014 - Volume 59
HOME TABLE OF CONTENTS
Multiple Procedure Policy Revisions to Apply to Same Group
The revision to the Multiple Procedure Policy, announced in the July 2013 Network Bulletin, was partially implemented for three weeks, from November 17, 2013 through December 7, 2013. The revision administered multiple procedure reductions to eligible surgical and medical procedures provided on the same day and reported by the same group practice, which included all physicians and other health care professionals with the same federaltaxidentificationnumber.
To allow for system enhancements, effective with dates of process beginning December 8, 2013, the Multiple Procedure Policy temporarily reverted to the previous method of applying multiple procedure reductions for secondary and subsequent eligible services only when provided on the same day to the same patient by the same individual physician or health care professional.
In February 2014, the Multiple Procedure Policy revision will be fully implemented to again apply multiple procedure reductions based on the same group practice. This revision will align the policy with CMS guidelines with application of multiple procedure reductions to all physicians and non-physicians in the same group practice, acting in the same capacity. Co-surgeon and team surgeon services will continue to be ranked separately from procedures reported by another physician.
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2013 Member Rewards Program – Better Health has its Rewards
At UnitedHealthcare, preventive screenings are an important part of our health promotion efforts and the basis of our Member Rewards program.
The 2013 Member Rewards program has ended. As a result of us working together, we sent out the following numbers of pre-paid debit cards as of mid-December:
• 103,864 Annual Wellness Visit/BMI rewards
• 10,718 Colorectal Screening rewards
• 14,442 Glaucoma Screening rewards
• 3,502 Breast Cancer Screening rewards
Please continue talking to your patients about the importance of scheduling and completing a health assessment and other preventive health screenings and exams. Also, be on the look-out for communication about the 2014 Member Rewards program in the coming months.
For more information, please call Provider Services at 877-842-3210 or visit Member Rewards.
UnitedHealthcare Medicare Solutions
Network Bulletin: January 2014 - Volume 59 For more information call 877.842.3210, or visit UnitedHealthcareOnline.com48
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UnitedHealthcare Medicare Solutions
For more information call 877.842.3210, or visit UnitedHealthcareOnline.com49 Network Bulletin: January 2014 - Volume 59
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UnitedHealthcare Wins Bid for State of Illinois
We will offer our UnitedHealthcare Group Medicare Advantage National PPO plan to the state’s 123,000 Medicare-eligible retirees. The plan is the only plan to be available across the entire service area including retirees who live outside of Illinois.
State retiree coverage is effective Feb. 1, 2014. The UnitedHealthcare Group Medicare Advantage National PPO Plan is open access with no referrals or gatekeeper. In addition, under this plan the member’s cost share is the same whether using an in-network or out-of-network provider.
• Providers who are in-network for UnitedHealthcare’s Medicare Advantage products will be paid according to their current agreement for these members.
• Out-of-network providers for UnitedHealthcare’s Medicare Advantage products will be paid according to Medicare’s allowable fee schedule.
The UnitedHealthcare Group Medicare Advantage NationalPPOplandoesnotrequirepriorauthorizations orpriornotificationsforout-of-networkphysicianswho see our members.
The State of Illinois Department of Central Management Services announced that UnitedHealthcare was one of three bidders awarded a competitive contract to offer a Medicare Advantage plan.
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UnitedHealthcare Medicare Solutions
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UnitedHealthcare Medicare Advantage Coverage Summary Updates
For complete details on the revised policies listed in the table below, 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.
Policy Title Approval Date Update Bulletin
REVISED
Bariatric Surgery Oct. 24, 2013 Nov. 2013
Blood, Blood Products and Related Procedures and Drugs Oct. 24, 2013 Nov. 2013
CardiacPacemakersandDefibrillators Oct. 24, 2013 Nov. 2013
Cosmetic and Reconstructive Procedures Oct. 24, 2013 Nov. 2013
Experimental Procedures and Items, Investigational Devices and Clinical Trials Oct. 24, 2013 Nov. 2013
GastroesophagealandGastrointestinal(GI)ServicesandProcedures Oct. 24, 2013 Nov. 2013
HospitalObservationCare(OutpatientHospital) Oct. 24, 2013 Nov. 2013
HospitalServices(InpatientandOutpatient) Oct. 24, 2013 Nov. 2013
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UnitedHealthcare Medicare Advantage Coverage Summary Updates
Policy Title Approval Date Update Bulletin
Laboratory Tests and Services Oct. 24, 2013 Nov. 2013
PositronEmissionTomography(PET)/CombinedPET-CT(ComputedTomography) Oct. 24, 2013 Nov. 2013
Rehabilitation-MedicalRehabilitation(PT,OT,andST,including Cognitive Rehabilitation)
Oct. 24, 2013 Nov. 2013
SkilledNursingFacility(SNF)CareandExhaustionofSNFBenefits Oct. 24, 2013 Nov. 2013
VentricularAssistDevice(VAD)andArtificialHeart Oct. 24, 2013 Nov. 2013
VeteranAdministration(VA)andIndianHealthServices(IHS) Oct. 24, 2013 Nov. 2013
Note: The appearance of a service or procedure on this list does not imply that UnitedHealthcare provides coverage for the service or procedure.
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ThisisareminderthatUnitedHealthcarerequiresadvancenotificationandprior authorizationforthestandardizedlistofinpatientandoutpatientproceduresacross Medicare plans for UB04 and HCFA billers.
Ifyoudonotobtainpriorauthorizationorverifytheauthorizationhasbeenobtainedbeforerenderingtheprocedure, it may result in an administrative claim denial. A clinical denial will be issued if it is determined during the priorauthorizationprocessthattherequestedservicedoesnot meet Medicare’s medical necessity criteria.
Follow this link for more information about the MedicareAdvantagepriorauthorizationprogramincluding medical, radiology, and cardiology: https://www.unitedhealthcareonline.com /b2c/CmaAction.do?channelId=12f8c79 58f5fa010VgnVCM100000c520720a____
ReminderforAdvanceNotificationandPriorAuthorization
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Important Reimbursement Policy Reminder
UnitedHealthcare Community Plan’s quality of care program factors readmission review to its reimbursements to participating and non-participating facilities based upon individual state and CMS published guidelines.*
Acute care admissions which occur within 30 days - or another time period depending on state guidelines or your provider agreement - of another acute care admission with the same or similar diagnosis will require a medical record review on a post service/prepayment basis. If a readmission undergoes clinical review because of a potential quality issue, the claim may be denied. Please note that if the claim is denied in full or part, providers cannot balance bill the member for a denied claim. Please note individual stateregulationsandcontractrequirementssupersedespecificpolicylanguage.
For more information, please refer to the UnitedHealthcare Community Plan ReadmissionPolicy(F7001).
Information That may be Requested for Medical Record Reviews
Patient medical records containing the admit through discharge information for thehospitalstaysbeginningonadmitdatesofservice(initialadmissiondateandsubsequent admission date) need to include:
• History and Physical
• Admission and Discharge Summary
• Physicians’ orders
• Emergency room records
• Progress notes
• Nurses’ notes
• Diagnostic and laboratory testing
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Important Reimbursement Policy Reminder
General Information Regarding Our Reimbursement Policies
Unless otherwise noted, our reimbursement policies apply to services reported using the CMS 1450 claim form (formerlyknownasUB-04),oritselectronicequivalent,orits successor form.
UnitedHealthcare Community Plan reimbursement policies do not address all issues related to reimbursement for services rendered to our members. Other resources that addressreimbursementincludethemember’sbenefitplandocuments, UnitedHealthcare Community Plan medical policies, and the UnitedHealthcare Community Plan Physician, Health Care Professional, Facility and Ancillary Provider Administrative Guide. Meeting the terms of a particular reimbursement policy is not a guarantee of payment. Likewise, retirement of a reimbursement policy affects only those system edits on claimsassociatedwiththespecificpolicybeingretired.
Retirement of a reimbursement policy is not a guarantee of payment. Other applicable reimbursement policies, medical policies and claims edits will continue to apply. Once implemented, the policies may be viewed in their entirety at UHCCommunityPlan.com > Find Plans By State (click on the appropriate state) > If you are a Health Professional > Reimbursement Policies.
Intheeventofaninconsistencyorconflictbetweentheinformationprovidedinthisnotificationandthepostedpolicy on UHCCommunityPlan.com, the provisions of the posted reimbursement policy will prevail.
If you have any questions please contact your Provider Advocate or call the number on your Provider Remittance Advice/ExplanationofBenefits.
* Note: This only applies to the states of TN, PA, DC, DE, OH, KS, MS, WA, IA, NJ, NY, WI, NM, and HI.
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Provider Disclosure of Ownership Form Now Online
UnitedHealthcareCommunityPlanisexcitedtorolloutanewonlineformforproviders(physician,facility and health care professionals) participating in UnitedHealthcare Community Medicaid plans. Providers can now complete the Disclosure of Ownership form securely online through a partnership with EchoSign.
The Disclosure of Ownership form is a federal regulation requirement applicable to all providers that contract with a State Medicaid agency. The launch of the new online form allows providers easy access to an electronic version of the requirement disclosure elements, needed to meet federal regulation.
The process is secure and complies with all federally requirement mandates to house personal information. EchoSignusesaKnowledgeBasedAuthentication(KBA)protection that allows a more advanced security around who is completing and signing the Disclosure of Ownership form. TheKBAisamethodthatisusedbyfinancialinstitutionsall over the world to ensure your personal information is transmitted securely.
Once the Disclosure of Ownership form has been successfully submitted you will receive an automated messageofconfirmation.
This form can be used in all UnitedHealthcare Community Plan markets. To complete the Disclosure of Ownership Form securely online, please visit UHCCommunityPlan.com and go to Health Care Professionals to select your state. The Disclosure of Ownership link is posted under Provider Forms at each state health plan site.
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Changes to the UnitedHealthcare Community Plan of Pennsylvania Claims Payer ID and Electronic Remittance Advice Payer ID
Enhancements to the enrollment and claims system for UnitedHealthcare Community Plan of Pennsylvania will become operational on or after March 1, 2014. Your claims payer ID will change to 87726 and your electronic remittance advice payer ID will change to 04567.
Readmission Policy Frequently Asked Questions
To learn more about UnitedHealthcare Community Plan’s Readmission Review policies, please go to UnitedHealthcare Community Plan Readmission Review Frequently Asked Questions *
* This only applies to the states of: TN, PA, DC, DE, NE, OH, WA, KS, MS, IA, NJ, NY, WI, HI, and NM.
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Important Change: Arriva Medical Has Acquired Diabetes Care Club
Diabetes Care Club, a national diabetic supply provider, has been acquired by Arriva Medical. Arriva Medical is now a nationally contracted provider for all lines of business. Arriva Medical provides diabetic test strips, lancets, testing monitors and supplies via mail order.
Nationally Contracted Diabetic Testing Supplies Providers Are:
Arriva Medical www.arrivamedical.com 800-580-1871 Byram www.byramhealthcare.com 877-902-9726 Edgepark www.edgepark.com 800-321-0591 Liberty www.libertymedical.com 800-695-2500
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Medline Industries Joins Network
Medline Industries has joined our network of medical supply providers effective Nov. 1, 2013 for all lines of business. Medline provides incontinence products such as diapers and urologicals, and woundcaresuppliessuchasgauze,tapes,andbandagestoourmembers.
Nationally Contracted Medical Supply Providers Are:
Byram www.byramhealthcare.com 877-902-9726 Edgepark www.edgepark.com 800-321-0591
Gordian www.amtwoundcare.com 800-568-5514 (Nursinghomeonly)
Medline www.medline.com 800-MEDLINE (800-633-5463)
Omnicare www.omnicare.com 800-990-6664 (Nursinghomeonly)
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UnitedHealthcare Preventive Plan Design
UnitedHealthcare has developed a limited plan design product called UnitedHealthcare Preventive. UnitedHealthcare Preventive will be indicated on the front of these members’ healthcareidentificationcards below where the patient’s employer/payer is located.
This limited plan design provides coverage for preventive care which includes all Patient Protection and Accountable CareAct(PPACA)-mandatedcoverage,includingwomen’spreventive health care. Other services covered include:
• One physical checkup every year
• OneOB/GYNcheckupeveryyear(Papsmear)
• One screening test for breast cancer every year
• Birth control pills or other forms of birth control
• Shots for measles or other childhood diseases
• Onecolonoscopyeveryfiveyears (colorectalcancerscreeningtest)
• Other preventive tests required by the Affordable Care Act
• Over-the-counter medications prescribed by physicians mandated by ACA including: Aspirin, Fluoride and Vitamin D supplements
UnitedHealthcare Preventive uses the UnitedHealthcare Options PPO network and services received outside of the network are not covered.
Costs for additional services, such as X-rays, blood tests, emergency department visits or other services to treat medical conditions, are not covered.
Some employers may choose to buy-up an additional optionandprovidetwosickofficevisitsandoneroutinevision exam.
• Thesickofficevisitscaneitherbeataspecialistorgeneralpractitionersofficebutthevisionexammust occur at a UnitedHealthcare vision provider location(Spectera).
• Thecoverageforsickofficevisitsincludesthechargefortheofficevisit.Relatedservicessuchasdiagnostic labs, x-rays, etc. are not covered.
To determine if your patient has preventive carewithsickofficevisitbenefits,contactCustomer Care at 877-842-3210 or go to UnitedHealthcareOnline.com and have the member’s information available to verify eligibility.
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Introducing COB Smart™: Receive Payments Accurately, Predictably and Reliably
Last fall, UnitedHealthcare, in collaboration with other payers and the Council for AffordableHealthcare(CAQH),anonprofitalliance of health plans and trade associations, introduced COB Smart. COB Smart helps improve the accuracy of Coordination of Benefits(COB)processesforproviders and members.
How Does COB Smart Work? COB Smart can assist providers in getting needed insurance information without the administrative hassle. UnitedHealthcare directly contributes to a registry of coverage information that can help providers and health planscorrectlyidentifywhichmembershavebenefitsthat should be coordinated in order for corresponding claimstobeprocessedcorrectlythefirsttime.Eachweek, UnitedHealthcare supplies coverage information to the registry, where it is compared with information
from other participating payers to identify individuals
with more than one form of coverage. Standard primacy
rules are then applied to determine the correct order
ofbenefits.
COB Smart can be integrated with most existing
health information tools and processes, such as
ElectronicHealthRecords,toconfirmapatient’s
eligibility, allowing providers to access complete
coordinationofbenefitsinformation,helpingincrease
payment accuracy and timeliness while reducing
paperworkandimprovingcashflow.
To learn more about COB Smart from CAQH,
click here.
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UnitedHealthcare’s Position on “Never Events”
In an ongoing effort to enhance the quality of care for its members, UnitedHealthcare continues to adopt the Never Event position of the Leapfrog Group. We ask physicians and other health care professionals to join us in the effort to eliminate preventable medical errors.
The Leapfrog Group’s Never Events position is based on the National Quality Forum’s list of serious reportable events. This list looks at medical errors that should never happen to a patient. The Leapfrog Group’s position in the case of a Never Event occurrence is for hospitals to:
• Apologizetothepatientandfamily
• Report the event to at least one reporting programsuch as the Joint Commission on Accreditation ofHealthcareOrganizations,astatereportingprogramorapatientsafetyorganization
• Perform root cause analysis
• Waive all costs directly related to the event and refrainfrom seeking reimbursement from the patient or athird-party payer
In the instance a Never Event has not been reported, we willattempttodetermineifanyclaimsfiledwithusmeetthe criteria, as outlined by the NQF and adopted by CMS and The Leapfrog Group, as a Serious Reportable Adverse Event. To the extent that a provider does not comply with these requirements, that provider’s claim will be denied and will be a provider’s liability. The provider may not bill the member for these charges.
For more information, tools, articles and resources
on patient safety and the Leapfrog Group, visit
UnitedHealthcareOnline.com >
Clinician Resources > Patient Safety
Resources. For coding guidance, also visit
UnitedHealthcareOnline.com > Tools &
Resources > Policies, Protocols and Guides >
Reimbursement Policies - Commercial > Wrong
Surgical or Other Invasive Procedures Policy.
If you have questions about UnitedHealthcare’s
Patient Safety Program, contact Rebecca Lankford
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Navigate Products and Related Administrative Processes
UnitedHealthcare Navigate® is a gated product that meets member needs around access and cost with an emphasis on primary care and referrals to network specialists. Navigate enrollment continues to grow as more UnitedHealthcare members are seeking lower cost options.
As the Navigate product continues to expand, we will continuetosharestate/market-specificinformationand requirements.
For more information about Navigate, please go to UnitedHealthcareOnline.com > Tools & Resources > Products & Services > UnitedHealthcare Navigate.
Here is a Checklist of Reminders When Seeing UnitedHealthcare Navigate Members:
• Check the member’s ID card to identify theirspecificbenefitproduct.
• Verifythemember’sbenefitsandeligibilityonUnitedHealthcareOnline.com.
• Checkforpriornotification/authorizationrequirements on UnitedHealthcareOnline.com(e.g.radiology,cardiology).
• When making referrals, please ensure you’re referring to participating network specialists. Refer to the Referral Requirements Quick Reference Guide for more information on what requires a referral.
• Submit referrals using our secure physician websiteby logging in at UnitedHealthcareOnline.com >Notifications/Prior Authorizations > ReferralSubmission prior to the specialist servicebeing received. Referrals cannot be accepted byphone, fax or paper.
• Submit claims to the address on the back of themember ID card.
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Training Sessions for Electronic Solutions
We offer instructor-led webcast training sessions that can help automate and streamline administrative processes. Session topics include:
• UnitedHealthcareOnline.com
• UnitedHealthcareOnline.com Password Owner
• UnitedHealthcareOnline.comNotification/PriorAuthorizationFunctionOverview
• Electronic Payments and Statements
• Electronic Data Interchange 101
• OxfordHealth.com Overview
• Post-n-Track® Demonstration
• PNC Remittance Advantage for ElectronicOxford Payments and EOBs
Physician and Provider Demographic Changes
To ensure that we have the most current information for our participating physicians and health care providers, please update your practice information at UnitedHealthcareOnline.com > Contact us. Or call 877-842-3210. For any tax ID updates, please use the Provider Demographic Change Form and include a W-9. If you have questions, please call your local UnitedHealthcare Physician Advocate.
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Click to learn more about UnitedHealthcare and Oxford sessions and how to register.
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Wellness Programs: Recommending Alternative Actions
One of the requirements of PPACA relates to wellness programs. PPACA regulations build on existing wellness program policies to help promote good health through wellness rewards.
The new regulations, which affect group health plans for plan years beginning on or after Jan. 1, 2014, increase the maximum reward allowed under certain wellness programsandprovideotherclarificationsregardingreasonable design of health-contingent wellness programs and the reasonable alternatives that must be offered to avoid prohibited discrimination.
Wellness programs should be reasonably designed to promote health or prevent disease. In the rare case when a health-contingent wellness program’s reasonable alternative is not medically appropriate for one of your patients, the regulations allow you to recommend an alternative action.
To learn more, please click here.
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Checking Status of Claim Reconsideration Requests With Attachments
Now you can check the status of your requests submitted via Optum Cloud Dashboard without making a phone call.
Simply log into Optum Cloud Dashboard to view information about your existing claim reconsideration requests with attachments. Statuses include In-Progress,Closed(completed)andRejected. You can read reviewer comments and update your request if needed. Reconsideration requests are reviewed within 30 days.
Please refer to the Claim Reconsideration with Attachment Quick Reference Guide for instructions.
Electronic Inpatient AdmissionNotifications
Please use the Electronic Data Interchange278Ntosubmitnotificationsfrom your practice management system for UnitedHealthcare, UnitedHealthcare Medicare Solutions and UnitedHealthcare Community Plan. For more information, go to AdmissionNotification(278N), contact your clearinghouse/vendor or UnitedHealthcare at 888-804-0663 or [email protected].
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CoverageDeterminationandUtilizationManagementDecisions
Other resources used during the coverage decision process include:
• Federal and state requirements as applicable to commercial, Medicare and Medicaid members.
• For commercial plan members we use the applicable definitionsinthemember-specificdocumenttodetermine coverage.
• ForMedicaremembers,weusetheCMSdefinitionof“reasonable and necessary” within Medicare coverage rules and regulations.
Please note that UnitedHealthcare does not offer incentives tophysicianstoencourageunder-utilizationofcareorservices, or to encourage barriers to care and service. The coverage determination process is focused on ensuring that UnitedHealthcare members receive the most appropriate care based on applicable law, evidence-based medicine and theirbenefitplandesign.
Our health care coverage decisions are based on applicable federal and state regulations, thepatient’sspecificbenefitplandesignand applicable clinical policies and/or guidelines.
All Savers Alternative Funding Product - New Portal
The All Savers Alternate Funding plan is an innovative product designed specificallyforsmallbusinesses. All Savers plans give members access to the UnitedHealthcare Choice Plus network, which today includes nearly 705,000 health care professionals and 56,000 hospitals across the nation.
Health care professions and hospitals can obtain eligibility, claim payment, EOB and additional information at www.myallsaversprovider.com
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UnitedHealth Premium® Results Available to Public Soon
NotificationsofnewUnitedHealthPremiumdesignationsforqualityandcostefficiencyweresent by mail to physicians in November 2013. The physicians’ letters included instructions on how to access their full suite of UnitedHealth Premium assessment reports online at UnitedHealthcareOnline.com. Physicians may also submit reconsideration requests online through this site.
Most physician designations will be published to our online websites such as myuhc.com on Jan. 8, 2014. The publication date for physicians in Connecticut, Delaware, New Jersey, New York, Pennsylvania and Rhode Island will be on April 2, 2014.
The public designation display date allowed time for physicians to submit reconsiderations before the results were available to the public. Of course, as is our practice, physicians may submit a reconsideration request at any time during the review cycle. All requests will be reviewed expeditiously.
Further Information: Go to UnitedHealthcareOnline.com and select “UnitedHealth Premium” on the top navigation bar tofindresourcesandtoolsthatexplaintheprogram. Send us an email though the Contact Premium Program link or call 866-270-5588.
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BMI Documentation in the Medical Record
Supporting members in their efforts to maintain a healthy body weight is crucial to our commitment to “helping people live healthier lives.”
The National Institutes of Health and the World Health Organizationhaveadoptedthemeasurementofabodymassindex(BMI)of30oraboveasamethodforidentifyingobesity in adults. BMI measurement is also a HEDIS measure that the National Committee for Quality Assurance is using in 2014 to evaluate health plan quality.
Patients with a high BMI have a higher risk for chronic health problems, which includes high blood pressure, type 2 diabetes, coronary heart disease, stroke, gallbladder disease, osteoarthritis, respiratory problems and endometrial, breast, prostate and colon cancer. Conditions caused or exacerbated by obesity are the second leading cause of preventable death in our country.
It is important to note that BMI measurement is calculated differently for children than it is for adults. BMI calculations for adults are based strictly on the patient’s height and weight information. BMI calculations for children also include gender, age and use of growth charts. The Centers for Disease Control and Prevention have BMI graphs and charts available for both adults and children at www.cdc.gov. Your EMR programs may already have BMI calculations available, making documentation easy in the medical record. Make sure your electronic medical record (EMR)BMIcalculationprogramisturnedon.
Further detail and information on how to incorporate BMI documentation into your medical records can be found at www.cdc.gov.
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Medicare Change to Physician-initiated Prescriptions at Mail Pharmacies
Starting in 2014, mail order pharmacies are required to get your patient’sconfirmationandapprovalforanyprescriptionordersthatyou send directly to the mail pharmacy.
Any new prescription or renewal that you send to a mail order pharmacy will require yourpatienttoconfirmtheirorderwiththe pharmacy. This includes both new andrefillmedicationsthatyoufax,phoneor e-prescribe for your patients and send to a mail order pharmacy.
Beginning Jan. 1, 2014, OptumRx and all other mail order pharmacies will contact your patients for any prescription you send to the mail order pharmacy.
UnitedHealthcare has informed your patients who are currently using mail order by providing a note in all existing prescriptions since October 1, 2013. Any help you can provide your patients by mentioning this change when you are discussing prescriptions you will send to a mail order pharmacy will help to ensure that there are no delays in any therapies you are prescribing.
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EffectiveFeb.1,2014:NewPriorAuthorizationRequirementsforEnzymeReplacementMedications(forUnitedHealthcareIntegratedCommercialFully Insured and Self-funded Plans Only)
Effective Feb. 1, 2014, UnitedHealthcare will require all participating network providersbillingunderthemedicalbenefittoobtain priorauthorizationbeforeadministeringenzymereplacementmedications,Cerezyme® and Elelyso®, to treat Gaucher disease for UnitedHealthcare commercial plan members. This requirement will affect both new and existing members.
RequestforcoverageofCerezymeandElelysomay be subject to medical necessity review. As a result, you may be required to switch patients to VPRIV®, a lower-cost clinically similar medication, in order to continuebenefitcoverage.Priorauthorizationwillnotbe required for VPRIV.
Please review the FAQ for information on the medical necessityreviewandhowtorequestpriorauthorizationfor your patient.
If you have questions, please contact your local network manager or call the provider services phone number on the back of the member’s health care ID card.
ThisprotocolappliesonlytoUnitedHealthcaremembersincommercialbenefitplans insured or administered by UnitedHealthcare, Mid-Atlantic Medical Services, Neighborhood Health Partnership, Oxford and River Valley. This protocol does not apply to the State of New York Empire Plan, UnitedHealthcare West or UnitedHealthcare Community Plan.
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New OptumRx Specialty Pharmacy Resource Guide
To give your patients the best experience and help make their transition to our specialty pharmacy as easy as possible, we encourage you to use our new OptumRx Specialty Pharmacy Resource Guide for access to:
• Direct phone numbers
• Howtosubmitpriorauthorizations–includingonline(theeasiestandfastestway)
• Howtogetyourpatient(s)set-upwiththeSpecialtyPharmacy Program
• Information on what we offer to your patients
To download and print the Resource Guide, go to UnitedHealthcareOnline.com > Tools and Resources > Pharmacy Resources > Specialty Pharmacy Program.
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Our coupon policy limits pharmacies participating in UnitedHealthcare’ s Designated Specialty Pharmacy Program from facilitating redemption of manufacturer-sponsored coupons or cards as payment of the member’s cost share in the following instances:
• ForTiers3or4(highestmembercost)medicationslisted in this comprehensive drug list.
• For any new specialty medications released to the market in a therapeutic class currently on the list.
Coupons can encourage use of higher-cost medications, despite availability of lower-cost, clinically similar options, resultinginsignificantcosttomembersandemployergroups. This policy change is meant to reinforce our PrescriptionDrugList(PDL)design,whichencouragesuse of lower tier, lower-cost options. Our effort follows the U.S. government’s long-time practice of not allowing coupons to be redeemed for patients covered by Medicare, Medicaid and other federal health care programs.
Physicianscanhelpminimizetheimpacttopatientsby: 1. PrescribingTiers1or2optionsfirst:Fora
comprehensive drug list with alternatives included, visit UnitedHealthcareOnline.com >Tools & Resources > Pharmacy Resources.
2. Working with pharmacies: Pharmacists from our Designated Specialty Pharmacies may contact your officeonbehalfofamemberinterestedinswitchingto a lower cost option. They will review with you the lower cost options available to your patient. If you agree to change the patient’s prescription to aTier2medication,pleaseauthorizethis change by speaking to a pharmacist directly or by faxing a new prescription or e-prescribing to the specialty pharmacy.
If you have questions about the policy for these specialty medications, please call the provider services phone number on your patient’s health plan ID card. This protocol applies only to UnitedHealthcare members in commercial benefitplansinsuredoradministeredbyUnitedHealthcare.ItalsoappliestoNeighborhood Health Partnership, Oxford, River Valley, and Sierra. This protocol does not apply to the State of New York Empire Plan, Mid-Atlantic Medical Services, UnitedHealthcare West or UnitedHealthcare Community Plan.
Reminder: 25 Specialty Medications Added to Coupon Policy for Jan. 1, 2014
Effective Jan. 1, 2014, UnitedHealthcare will add 25 new specialty medications to our coupon policy.
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UnitedHealthcareisconsolidatingandmanagingitspharmacybenefitprogramsinternallythroughOptumRx and in 2013 all services for our commercial members currently handled by Medco were transferred to OptumRx.
Thefinaltransition,includingmembersfromUnitedHealthcareEmployer & Individual, UnitedHealth One, Golden Rule, and All Savers, will occur on Jan. 1, 2014.
Bringing all our pharmacy services in-house will enhance our ability to partner with you and your patients to improve health outcomes and better manage total health care costs.
Itisimportanttonotethatprescriptiondruglists,benefitplan designs, specialty pharmacy and clinical programs will continue to be managed within UnitedHealthcare. Members will continue to have access to more than 64,000 retail network pharmacies. These essential elements will not require any action on your part or that of your patients. We will simply transition information to OptumRx.
You and Your Patients
Most existing mail service prescriptions will transfer to OptumRx. Prescriptions for certain medications, like painkillers, and expired prescriptions will not transfer, and your patient will receive a letter from UnitedHealthcare instructing them to contact your officeforanewprescription.
OnceyourpatientstransitiontoOptumRx,you’llfindthattheonlinepriorauthorizationtool(availablethroughUnitedHealthCareOnline.com) is easy to use. The majority of onlinepriorauthorizationsareapprovedinrealtime,andanauto-population feature provides 95 percent of a member’s information.(TheOptumRxPriorAuthorizationteamisalsoavailable by phone at 800-711-4555.)
UnitedHealthcareConsolidatedPharmacyBenefitProgram
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UnitedHealthcareConsolidatedPharmacyBenefitProgram
In addition to members of UnitedHealthcare Employer & Individual,thischangeappliestopriorauthorizationsfor Oxford, Medica, Harvard Pilgrim, River Valley and Neighborhood HealthPlan(OnlinePriorAuthorizationtoolavailablethroughOptumRx.com). For members of the Health Plan of Nevada and Sierra Health & Life, please continue to use the current prior authorizationprocess.IfyouE-prescribethroughSureScripts,the NCPDP ID for OptumRx is #0556540.
Timing Considerations
To ensure that members experience seamless service and access to the covered full range of pharmacy benefits,thetransitionoccurredonastagedbasisthroughout2013(seechart).ThefinalgroupsofmemberswilltransitiononJanuary 1, 2014. We’ve provided the adjacent schedule (seechart,subjecttochange),butyoumayalsowant to ask patients to present their new ID card, which will contain the updated information.
Date Region PlansJan. 1, 2013 UnitedHealthcare
Employees and select clients
UnitedHealthcare commercial, Harvard Pilgrim.
Apr. 1, 2013 West region and Northeast region
UnitedHealthcare commercial, Medica, Harvard Pilgrim.
June 1, 2013 Central region UnitedHealthcare commercial, Medica, Harvard Pilgrim.
July 1, 2013 National Account clients across all regions
UnitedHealthcare commercial, Medica, Harvard Pilgrim.
Sept. 1, 2013 Southeast region UnitedHealthcare commercial, Medica, Harvard Pilgrim.
Oct. 1, 2013 All regions Oxford, Sierra, River Valley, Neighborhood Health Plan.
Jan 1, 2014 All regions UnitedHealthcare commercial, UnitedHealth One, Golden Rule, All Savers.
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Inaccurate billing can lead to member dissatisfaction, confusion and frustration. Billing errors also generate workflowinefficienciesthatleadtounnecessaryadministrative costs for providers.
To help prevent billing errors, please ask members in the Dual SpecialNeedsPlan(D-SNP)residinginAZ,MI,NJ,NY,PA,TNand WI to show their state Medicaid card and UnitedHealthcare Community PlanIDcardateveryvisit.Verificationofdualcoveragewhenservices are rendered expedites claim payments and reduces patient calls to youroffice.
D-SNPmemberswillalsoreceiveeducationaboutthebenefitsofpresentingbothcardsateachofficevisit.
UnitedHealthcare Claims, Billing & Coding
AccurateBillingImprovesOfficeEfficiency and Dual SNP Member Satisfaction
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AccessingExplanationsofBenefitsOnline
Plan Option 1 Option 2UnitedHealthcare Commercial, Medicare Solutions and UnitedHealthcare Community Plan in some states.
Single EOB Search
• Register or log on to UnitedHealthcareOnline.com
• Select Claims & Payments > Electronic Payments and Statements (EPS) > Single EOB Search
• You may locate EOBs by payment number or status and date.
A Quick Reference guide is available.
With additional enrollment in Electronic Payments & Statements (EPS) you can:
• Search for EOBs using additional options
• View, save or print EOBs and consolidated payment summaries
• Receive payments by direct deposit
Learn more on our website or call 866-842-3278, option 5, for more information.
Oxford Commercial Claim Status
• Register or log on to OxfordHealth.com
• Select Claims in the Check column on the Transaction tab
• You may locate claims and EOBs using several search options.
Provider and Facility Quick Reference guides are available.
With additional enrollment in PNC Remittance Advantage you can:
• Search for EOBs using additional options
• View, save or print EOBs
• Receive payments by direct deposit
Learn more on our website or call 877-597-5489, option 1, for more information or to request a demonstration.
YoucanreducethetimeyouspendrequestingcopiesofExplanationsofBenefits(EOBs)byusingourwebsitesrather than calling. Please see the following table for information about obtaining UnitedHealthcare and Oxford EOBs online:
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UnitedHealthcare Claims, Billing & Coding
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Coding Update to Facility OPG Mapping – Effective Jan. 1, 2014
Effective Jan. 1, 2014, the following code updates were made to the current UnitedHealthcare 2013 Outpatient Procedure Grouper (OPG)mapping:
• 77 codes that are new for Jan. 1, 2014 were added to the applicable 0-10 grouper levels.
• 40 codes that expired effective Dec. 31, 2013 were removed from the mapping.
There are no other grouper level assignment changes to existing codes. Please remember that for reimbursement under OPG, UnitedHealthcare requires the appropriate line level CPT/Healthcare Common Procedure Coding System (HCPCS)codeinadditiontotherevenuecodewhenbillingfor outpatient procedures.
A list of the new and deleted codes is below:
NEW CODES ADDED TO OPG
Description 1/1/2014 OPG Group
0335T Extraosseousjointstblztion 3
0336T Lapablatuterinefibroids 7
0338T Trnscth renal symp denrv unl 4
0339T Trnscth renal symp denrv bil 4
0340T Ablate pulm tumors + extnsn 6
0342T Thxp apheresis w/hdl delip 5
10030 Guidecathetfluiddrainage 0
19081 Bx breast 1st lesion strtctc 2
19082 Bx breast add lesion strtctc 0
19083 Bx breast 1st lesion us imag 2
19084 Bx breast add lesion us imag 0
19085 Bx breast 1st lesion mr imag 2
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UnitedHealthcare Claims, Billing & Coding
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Coding Update to Facility OPG Mapping – Effective Jan. 1, 2014
Description 1/1/2014 OPG Group
19086 Bx breast add lesion mr imag 0
19281 Perq device breast 1st imag 0
19282 Perq device breast ea imag 0
19283 Perq dev breast 1st strtctc 0
19284 Perq dev breast add strtctc 0
19285 Perq dev breast 1st us imag 0
19286 Perq dev breast add us imag 0
19287 Perq dev breast 1st mr guide 0
19288 Perq dev breast add mr guide 0
23333 Remove shoulder fb deep 1
23334 Shoulder prosthesis removal 3
37236 Open/perq place stent 1st 7
37237 Open/perq place stent ea add 6
Description 1/1/2014 OPG Group
37238 Open/perq place stent same 7
37239 Open/perq place stent ea add 6
37241 Vascembolize/occludevenous 7
37242 Vascembolize/occludeartery 7
37243 Vascembolize/occludeorgan 7
37244 Vascembolize/occludebleed 7
43191 Esophagoscopy rigid trnso dx 1
43192 Esophagoscp rig trnso inject 2
43193 Esophagoscp rig trnso biopsy 2
43194 Esophagoscp rig trnso rem fb 2
43195 Esophagoscopy rigid balloon 2
43196 Esophagoscp guide wire dilat 2
43197 Esophagoscopyflexdxbrush 1
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Description 1/1/2014 OPG Group
43198 Esophagoscflextrnsnbiopy 1
43211 Esophagoscop mucosal resect 1
43212 Esophagoscop stent placement 4
43213 Esophagoscopy retro balloon 2
43214 Esophagosc dilate balloon 30 2
43229 Esophagoscopy lesion ablate 3
43233 Egd balloon dil esoph30 mm/> 2
43253 Egd us transmural injxn/mark 2
43254 Egd endo mucosal resection 1
43266 Egd endoscopic stent place 4
43270 Egd lesion ablation 2
43274 Ercp duct stent placement 3
43275 Ercp remove forgn body duct 3
Description 1/1/2014 OPG Group
43276 Ercp stent exchange w/dilate 3
43277 Ercp ea duct/ampulla dilate 3
43278 Ercp lesion ablate w/dilate 3
49405 Imagecathfluidcolxnvisc 2
49406 Imagecathfluidperi/retro 2
49407 Imagecathfluidtrns/vgnl 2
52356 Cysto/uretero w/lithotripsy 5
64616 Chemodenerv musc neck dyston 0
64617 Chemodener muscle larynx emg 1
64642 Chemodenerv 1 extremity 1-4 1
64643 Chemodenerv 1 extrem 1-4 ea 0
64644 Chemodenerv 1 extrem 5/> mus 1
64645 Chemodenerv 1 extrem 5/> ea 0
Coding Update to Facility OPG Mapping – Effective Jan. 1, 2014
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UnitedHealthcare Claims, Billing & Coding
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Coding Update to Facility OPG Mapping – Effective Jan. 1, 2014
Description 1/1/2014 OPG Group
64646 Chemodenerv trunk musc 1-5 1
64647 Chemodenerv trunk musc 6/> 1
66183 Insert ant drainage device 5
93582 Perq transcath closure pda 8
C5271 Low cost skin substitute app 1
C5272 Low cost skin substitute app 0
C5273 Low cost skin substitute app 3
C5274 Low cost skin substitute app 0
C5275 Low cost skin substitute app 1
C5276 Low cost skin substitute app 0
C5277 Low cost skin substitute app 1
C5278 Low cost skin substitute app 0
C9737 Lap esoph augmentation 7
CODES DELETED FROM THE OPG
Code Description
0124T CONJUNCTIVAL DRUG PLACEMENT
0186T SUPRACHOROIDAL DRUG DELIVERY
0192T INSERT ANT SEGMENT DRAIN EXT
13150 REPAIR OF WOUND OR LESION
19102 BX BREAST PERCUT W/IMAGE
19103 BX BREAST PERCUT W/DEVICE
19290 PLACE NEEDLE WIRE BREAST
19291 PLACE NEEDLE WIRE BREAST
19295 PLACE BREAST CLIP PERCUT
23331 REMOVE SHOULDER FOREIGN BODY
32201 DRAIN PERCUT LUNG LESION
37204 TRANSCATHETER OCCLUSION
37205 TRANSCATH IV STENT PERCUT
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Coding Update to Facility OPG Mapping – Effective Jan. 1, 2014
Code Description
37206 TRANSCATH IV STENT/PERC ADDL
37207 TRANSCATH IV STENT OPEN
37208 TRANSCATH IV STENT/OPEN ADDL
37210 EMBOLIZATIONUTERINEFIBROID
42802 BIOPSY OF THROAT
43219 ESOPHAGUS ENDOSCOPY
43228 ESOPH ENDOSCOPY ABLATION
43256 UPPR GI ENDOSCOPY W/STENT
43258 OPERATIVE UPPER GI ENDOSCOPY
43267 ENDO CHOLANGIOPANCREATOGRAPH
43268 ENDO CHOLANGIOPANCREATOGRAPH
43269 ENDO CHOLANGIOPANCREATOGRAPH
43271 ENDO CHOLANGIOPANCREATOGRAPH
Code Description
43272 ENDO CHOLANGIOPANCREATOGRAPH
43456 DILATE ESOPHAGUS
43458 DILATE ESOPHAGUS
44901 DRAIN APP ABSCESS PERCUT
47011 PERCUT DRAIN LIVER LESION
48511 DRAIN PANCREATIC PSEUDOCYST
49021 DRAIN ABDOMINAL ABSCESS
49041 DRAIN PERCUT ABDOM ABSCESS
49061 DRAIN PERCUT RETROPER ABSC
50021 RENAL ABSCESS PERCUT DRAIN
58823 DRAIN PELVIC ABSCESS PERCUT
64613 DESTROY NERVE NECK MUSCLE
64614 DESTROY NERVE EXTREM MUSC
C9736 LAP SURG RF ABLAT UT FIBROIDS IO GD MON WHEN PER
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UnitedHealthcare Affiliates
Oxford® Medical and Administrative Policy Updates
Network Bulletin: January 2014 - Volume 59 For more information call 877.842.3210, or visit UnitedHealthcareOnline.com82
For complete details on the new and/or revised policies listed in the table on the following page, refer to the monthly Policy Update Bulletin at OxfordHealth.com > Providers > Tools & Resources > Practical Resources > Medical and Administrative Policies > Policy Update Bulletin.
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Oxford® Medical and Administrative Policy Updates
Policy Title Policy Type Effective Date
Policy Update Bulletin
UPDATED/REVISED
Annual CPT® and HCPCS Code Updates All Jan. 1, 2014 Jan. 2014
NEW
Brilinta(Ticagrelor) Clinical Policy Jan. 1, 2014 Dec. 2013
CystaranTM(Cysteamine)OphthalmicSolution Clinical Policy Jan. 1, 2014 Dec. 2013
EnzymeReplacementTherapyforGaucherDisease Clinical Policy Feb. 1, 2014 Nov. 2013Dec. 2013 Jan. 2014
GilotrifTM(Afatinib) Clinical Policy Jan. 1, 2014 Dec. 2013
Lotronex(Alosteron) Clinical Policy Jan. 1, 2014 Dec. 2013
MechanicalCirculatorySupportDevice(MCSD) Administrative Policy Jan. 1, 2014 Nov. 2013Dec. 2013
Mekinist(Trametinib) Clinical Policy Jan. 1, 2014 Dec. 2013
TAKE NOTE
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For more information call 877.842.3210, or visit UnitedHealthcareOnline.com84 Network Bulletin: January 2014 - Volume 59
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Oxford Medical and Administrative Policy Updates
Policy Title Policy Type Effective Date
Policy Update Bulletin
UPDATED/REVISED
Pulmozyme®(DornaseAlfa Clinical Policy Jan. 1, 2014 Dec. 2013
StribildTM(Elvitegravir/Cobicistat/Emtricitabine/TenofovirDisoproxil Fumarate)
Clinical Policy Dec. 1, 2013 Nov. 2013
Tafinlar(Dabrafenib) Clinical Policy Jan. 1, 2014 Dec. 2013
TobiTMNebulizerSolution(TobramycinInhalationSolution)andTobi®Podhaler™(TobramycinInhalationPowder)
Clinical Policy Jan. 1, 2014 Dec. 2013
UPDATED/REVISED
Agents for Migraine-Triptans Clinical Policy Jan. 1, 2014 Dec. 2013
Anticonvulsants - Depakote ER®, Keppra®, Keppra XR®, Lamictal®, Lamictal XR®, Generic Levetiracetam XR, Lamictal ODT®, Lamotrigine Extended-Release, Oxtellar XR™, Topamax®, Stavzor®,Banzel®, Potiga™, Vimpat® , Trokendi XR and Lamotrigine Oral Disintegrating Tablets
Clinical Policy Jan. 1, 2014 Dec. 2013
Apheresis Clinical Policy Jan. 1, 2014 Dec. 2013
Autism Clinical Policy Dec. 1, 2013 Nov. 2013
Autologous Chondrocyte Transplantation in the Knee Clinical Policy Dec. 1, 2013 Nov. 2013
Bariatric Surgery Clinical Policy Jan. 1, 2014 Dec. 2013
Bosulif®(Bosutinib) Clinical Policy Jan. 1, 2014 Dec. 2013
NEW
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UnitedHealthcare Affiliates
For more information call 877.842.3210, or visit UnitedHealthcareOnline.com85 Network Bulletin: January 2014 - Volume 59
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Oxford Medical and Administrative Policy Updates
Policy Title Policy Type Effective Date
Policy Update Bulletin
UPDATED/REVISED
Breast Reconstruction Post Mastectomy Clinical Policy Dec. 1, 2013 Nov. 2013
BreastRepair/Reconstruction(NotFollowingaMastectomy) Clinical Policy Dec. 1, 2013 Nov. 2013
Cardiovascular Disease Risk Tests Clinical Policy Jan. 1, 2014 Dec. 2013
Clinical Trials Clinical Policy Jan. 1, 2014 Dec. 2013
Compounds and Bulk Powders Clinical Policy Jan. 1, 2014 Dec. 2013
Connecticut Clinical Trials Clinical Policy Jan. 1, 2014 Dec. 2013
Core Decompression for Avascular Necrosis Clinical Policy Jan. 1, 2014 Dec. 2013
Daliresp®(Roflumilast) Clinical Policy Jan. 1, 2014 Dec. 2013
Discogenic Pain, Treatment Clinical Policy Jan. 1, 2014 Dec. 2013
DPP4Inhibitors(Janumet,Januvia,JanumetXR)CheckTitle Clinical Policy Jan. 1, 2014 Dec. 2013
Drug Coverage Criteria - New and Therapeutic Equivalent Medications
Clinical Policy Dec. 1, 2013 Jan. 1, 2014
Nov. 2013 Dec. 2013
Drug Coverage Guidelines Clinical Policy Jan. 1, 2014 Dec. 2013
Durable Medical Equipment, Orthotics and Prosthetics Multiple Frequency
Reimbursement Policy Dec. 1, 2013 Nov. 2013
Erivedge(Vismodegib) Clinical Policy Jan. 1, 2014 Dec. 2013
Genetic Testing for Hereditary Breast and/or Ovarian CancerSyndrome(HBOC)
Clinical Policy Dec. 1, 2013 Nov. 2013
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UnitedHealthcare Affiliates
For more information call 877.842.3210, or visit UnitedHealthcareOnline.com86 Network Bulletin: January 2014 - Volume 59
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Oxford Medical and Administrative Policy Updates
Policy Title Policy Type Effective Date
Policy Update Bulletin
UPDATED/REVISED
Home Health Care Clinical Policy Feb. 1, 2014 Jan. 2014
Iclusig(Ponatinib) Clinical Policy Dec. 1, 2013 Jan. 1, 2014
Dec. 2013
ImmuneGlobulin(IVIGandSCIG) Clinical Policy Dec. 1, 2013 Nov. 2013 Dec. 2013
In-OfficeLaboratoryTestingandProceduresList Reimbursement Policy Dec. 1, 2013 Jan. 1, 2014
Nov. 2013 Dec. 2013
Lyme Disease Clinical Policy Dec. 1, 2013 Nov. 2013
Isotretinoin Oral Products Clinical Policy Jan. 1, 2014 Dec. 2013
Kuvan(SapropterinDihydrochloride) Clinical Policy Jan. 1, 2014 Dec. 2013
Maximum Frequency Per Day Reimbursement Policy Dec. 1, 2013 Nov. 2013
Modafinil(Provigil)andArmodafinil(Nuvigil) Clinical Policy Jan. 1, 2014 Dec. 2013
ModifierSUPolicy Reimbursement Policy Dec. 1, 2013 Nov. 2013
MultipleSclerosis:InterferonB-1A(Avonex,Rebif),InterferonB-1BBetaseron,Extavia,Glatiramer(Copaxone),Fingolimod(Gilenya),andTeriflunomide(Aubagio)
Clinical Policy Dec. 1, 2013 Nov. 2013
MultipleSclerosis:InterferonB-1A(Avonex,Rebif), InterferonB-1BBetaseron,Extavia,Glatiramer(Copaxone),Fingolimod(Gilenya),Teriflunomide(Aubagio),andDimethylFumarate(Tecfidera)
Clinical Policy Jan. 1, 2014 Dec. 2013
Omnibus Codes Clinical Policy Jan. 1, 2014 Dec. 2013
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UnitedHealthcare Affiliates
For more information call 877.842.3210, or visit UnitedHealthcareOnline.com87 Network Bulletin: January 2014 - Volume 59
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Oxford Medical and Administrative Policy Updates
Policy Title Policy Type Effective Date
Policy Update Bulletin
UPDATED/REVISED
Opioid Dependence Agents: Buprenorphine HCL and Naloxone (Suboxone)andBuprenorphineHCL
Clinical Policy Jan. 1, 2014 Dec. 2013
Oral and Nasal Fentanyl Medications Clinical Policy Jan. 1, 2014 Dec. 2013
Oral Chemotherapy Drugs: Application of NCCN Clinical Practice Guidelines
Clinical Policy Jan. 1, 2014 Dec. 2013
Osteochondral Grafting of Knee Clinical Policy Jan. 1, 2014 Dec. 2013
Oxford’s Outpatient Imaging Self-Referral Policy Clinical Policy Dec. 1, 2013 Nov. 2013
Plagiocephaly and Craniosynostosis Treatment Clinical Policy Dec. 1, 2013 Nov. 2013
Polysomnography and Portable Monitoring for Evaluation of Sleep Related Breathing Disorders
Clinical Policy Jan. 1, 2014 Dec. 2013
Presacral Neurectomy and Uterine Nerve Ablation for Pelvic Pain
Clinical Policy Dec. 1, 2013 Nov. 2013
Preventive Care Clinical Policy Jan. 1, 2014 Dec. 2013
ProgesteroneProducts:Crinone(ProgesteroneGel),Endometrin(ProgesteroneVaginalInsert)andFirstProgesteroneVGS(ProgesteroneVaginalSuppositoryUSPCompounding Kit) for Non-Fertility Use
Clinical Policy Jan. 1, 2014 Dec. 2013
PulmonaryArterialHypertension(PAH)DrugTherapy Clinical Policy Jan. 1, 2014 Dec. 2013
Radiopharmaceuticals and Contrast Media Clinical Policy Dec. 1, 2013 Nov. 2013
Rectiv(NitroglycerinOintment) Clinical Policy Jan. 1, 2014 Dec. 2013
Routine Foot Care Clinical Policy Jan. 1, 2014 Dec. 2013
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Policy Title Policy Type Effective Date
Policy Update Bulletin
UPDATED/REVISED
Sedative Hypnotic Agents Clinical Policy Jan. 1, 2014 Dec. 2013
Speech Therapy and Early Intervention Programs/Birth to Three Clinical Policy Dec. 1, 2013 Nov. 2013
Sprycel®(Dasatinib) Clinical Policy Jan. 1, 2014 Dec. 2013
Subcutaneous Leuprolide Acetate Clinical Policy Jan. 1, 2014 Dec. 2013
TopicalRetinoids(PharmaceuticalTreatmentofAcne) Clinical Policy Jan. 1, 2014 Dec. 2013
Transcatheter Heart Valve Procedures Clinical Policy Jan. 1, 2014 Dec. 2013
Unicondylar Spacer Devices for Treatment of Pain or Disability Clinical Policy Dec. 1, 2013 Nov. 2013
Vaccines Clinical Policy Jan. 1, 2014 Dec. 2013
Vagus Nerve Stimulation Clinical Policy Jan. 1, 2014 Dec. 2013
Virtual Upper Gastrointestinal Endoscopy Clinical Policy Dec. 1, 2013 Nov. 2013
Visual Information Processing Evaluation and Orthoptic and Vision Therapy
Clinical Policy Dec. 1, 2013 Nov. 2013
Warming Therapy and Ultrasound Therapy for Wounds Clinical Policy Jan. 1, 2014 Dec. 2013
Xtandi®(Enzalutamide) Clinical Policy Jan. 1, 2014 Dec. 2013
Oxford Medical and Administrative Policy Updates
Note: The appearance of a service or procedure on this list does not imply that Oxford provides coverage for the service or procedure. In the event ofaninconsistencyorconflictbetweentheinformationprovidedinthisbulletinandthepostedpolicy,theprovisionsofthepostedpolicywillprevail.
OxfordHMOproductsareunderwrittenbyOxfordHealthPlans(NY),Inc.,OxfordHealthPlans(NJ),Inc.andOxfordHealthPlans(CT),Inc. Oxford insurance products are underwritten by Oxford Health Insurance, Inc.
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UnitedHealthcareoftheRiverValleyPreauthorizationList and Policy Updates
For complete details on the new and/or revised policies and guidelines listed in the table below, refer to the monthly Policy Update Bulletin at UHCRiverValley.com > Providers > Coverage Policy Library > Policy Update Bulletin. These updates apply to UnitedHealthcare of the River Valley commercial and hawk-i plan membership only; they do not apply to members enrolled in a River Valley Ohio product or South Carolina product.
Policy Title Effective Date Coverage Policy Update Bulletin
TAKE NOTE
Annual CPT® and HCPCS Code Updates Jan. 1, 2014 Jan. 2014
NEW
EnzymeReplacementTherapyforGaucherDisease Feb. 1, 2014 Nov. 2013 Dec. 2013Jan. 2014
MechanicalCirculatorySupportDevice(MCSD) Jan. 1, 2014 Nov. 2013 Dec. 2013
UPDATED/REVISED
Abnormal Uterine Bleeding and Uterine Fibroids Jan. 1, 2014 Dec. 2013
Apheresis Jan. 1, 2014 Dec. 2013
Bariatric Surgery Jan. 1, 2014 Dec. 2013
Blepharoplasty, Blepharoptosis and Brow Ptosis Repair Jan. 1, 2014 Dec. 2013
Breast Reconstruction Post Mastectomy Dec. 1, 2013 Nov. 2013
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UnitedHealthcare of the River Valley Prior AuthorizationListandPolicy Updates
Policy Title Effective Date Coverage Policy Update Bulletin
BreastRepair/Reconstruction(NotFollowingMastectomy) Dec. 1, 2013 Nov. 2013
Cardiovascular Disease Stress Tests Jan. 1, 2014 Dec. 2013
Cochlear Implants Dec. 1, 2013 Nov. 2013
Computed Tomographic Colonography Jan. 1, 2014 Nov. 2013 Dec. 2013
Core Decompression for Avascular Necrosis Dec. 1, 2013 Nov. 2013
Deep Brain Stimulation Jan. 1, 2014 Dec. 2013
Hip Resurfacing Arthroplasty Jan. 1, 2014 Dec. 2013
Hyperbaric Oxygen Therapy and Topical Oxygen Therapy Jan. 1, 2014 Dec. 2013
ImmuneGlobulin(IVIGandSCIG) Jan. 1, 2014 Dec. 2013
Implantable Beta-Emitting Microspheres for Treatment of Malignant Tumors Jan. 1, 2014 Dec. 2013
Intensity-Modulated Radiation Therapy Jan. 1, 2014 Dec. 2013
Nerve Graft to Restore Erectile Function During Radical Prostatectomy Jan. 1, 2014 Dec. 2013
Noninvasive Prenatal Diagnosis of Fetal Aneuploidy Using Cell-Free Fetal Nucleic Acids in Maternal Blood
Feb. 1, 2014 Dec. 2013 Jan. 2014
Omnibus Codes Jan. 1, 2014 Nov. 2013 Dec. 2013
Orencia®(Abatacept) Dec. 1, 2013 Nov. 2013
Polysomnography and Portable Monitoring For Evaluation of Sleep Related Breathing Disorders
Dec. 1, 2013 Nov. 2013
Preventive Care Services Jan. 1, 2014 Dec. 2013
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Policy Title Effective Date Coverage Policy Update Bulletin
Proton Beam Radiation Therapy Jan. 1, 2014 Dec. 2013
RepositoryCorticotropinInjection(HPActharGel) Jan. 1, 2014 Dec. 2013
Transcatheter Heart Valve Procedures Jan. 1, 2014 Dec. 2013
Vaccines Jan. 1, 2014 Dec. 2013
Vagus Nerve Stimulation Dec. 1, 2013 Nov. 2013
RETIRED
TotalAnkleReplacementSurgery(Arthroplasty) Jan. 1, 2014 Dec. 2013
Wireless Capsule Endoscopy Jan. 1, 2014 Dec. 2013
Xyntha-FactorVIII(AntihemophilicFactor,Recombinant) Jan. 1, 2014 Dec. 2013
UnitedHealthcare of the River Valley Prior AuthorizationListandPolicy Updates
Note: The appearance of a service or procedure on this list does not imply that UnitedHealthcare provides coverage for the service or procedure. In the eventofaninconsistencyorconflictbetweentheinformationprovidedinthisbulletinandthepostedpolicy,theprovisionsofthepostedpolicywillprevail.
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For complete details on the revised policy listed below, refer to the monthly SignatureValue™BenefitInterpretation Policy Update Bulletin at UHCWest.com > Provider Log In > Library > Resource Center > Guidelines & Interpretation Manuals.
SignatureValue™BenefitInterpretation Policy Updates
Policy Title Applicable State(s) Effective Date
Policy Update Bulletin
UPDATED/REVISED
Biofeedback All Jan. 1, 2014 Dec. 2013
Clinical Trials: Routine Costs in Clinical Trials All Dec. 1, 2013 Nov. 2013
Jan. 1, 2014 Dec. 2013
Complementary and Alternative Medicine All Jan. 1, 2014 Dec. 2013
Detoxification:ChemicalDependency/Substance AbuseDetoxification
Oregon Dec. 1, 2013 Nov. 2013
All Jan. 1, 2014 Dec. 2013
DurableMedicalEquipment(DME),Prosthetics,CorrectiveAppliances/Orthotics(Non-FootOrthotics)and Medical Supplies Grid
All Jan. 1, 2014 Dec. 2013
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Policy Title Applicable State(s) Effective Date
Policy Update Bulletin
Hearing: Hearing Screening, Hearing Examinations and Hearing Aids and Hearing Devices
All Jan. 1, 2014 Dec. 2013
Hospice Care and Services California Jan. 1, 2014 Dec. 2013
Maternity and Newborn Care Oregon Jan. 1, 2014 Dec. 2013
Nutritional Therapy: Enteral and Oral Nutritional Therapy All Jan. 1, 2014 Dec. 2013
Ostomy: Ostomy Supplies All Jan. 1, 2014 Dec. 2013
Ostomy: Ostomy Supplies Grid All Jan. 1, 2014 Dec. 2013
Physician Services: Primary Care and Specialist Visits California, Oregon & Washington
Jan. 1, 2014 Dec. 2013
Radiology: Diagnostic and Therapeutic Radiology Services
All Jan. 1, 2014 Dec. 2013
SignatureValue™ BenefitInterpretation Policy Updates
Note: The appearance 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 inconsistencyorconflictbetweentheinformationprovidedinthisbulletinandthepostedpolicy,theprovisionsofthepostedpolicywillprevail.
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For complete details on the new and/or revised policies listed in the table below, refer to the monthly SignatureValue™ Medical Management Guidelines Update Bulletin at UHCWest.com > Provider Log In > Library > Resource Center > Guidelines & Interpretation Manuals.
SignatureValue™ Medical Management Guideline Updates
Title Effective Date Update Bulletin
TAKE NOTE
Annual CPT® and HCPCS Code Updates Jan. 1, 2014 Jan. 2014
NEW
Clinical Trials Jan. 1, 2014 Nov. 2013 Dec. 2013
Hospital Readmissions: Quality of Care Guideline Dec. 1, 2014 Nov. 2013
MechanicalCirculatorySupportDevice(MCSD) Jan. 1, 2014 Nov. 2013 Dec. 2013
UPDATED/REVISED
Abnormal Uterine Bleeding and Uterine Fibroids Jan. 1, 2014 Dec. 2013
Apheresis Jan. 1, 2014 Dec. 2013
Autism Spectrum Disorder Nov. 1, 2013 Nov. 2013
Bariatric Surgery Jan. 1, 2014 Dec. 2013
Cardiovascular Disease Risk Tests Jan. 1, 2014 Dec. 2013
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Title Effective Date Update Bulletin
Hearing Aids and Devices Including Wearable, Bone-Anchored and Semi-Implantable
Jan. 1, 2014 Dec. 2013
Hip Resurfacing Arthroplasty Jan. 1, 2014 Dec. 2013
Omnibus Codes Jan. 1, 2014 Dec. 2013
Polysomnography and Portable Monitoring for Evaluation of Sleep Related Breathing Disorders
Dec. 1, 2013 Nov. 2013
Preventive Care Services Jan. 1, 2014 Dec. 2013
Proton Beam Radiation Therapy Jan. 1, 2014 Dec. 2013
Transcatheter Heart Valve Procedures Jan. 1, 2014 Dec. 2013
RETIRED
Hyperbaric Oxygen Therapy and Topical Oxygen Therapy Jan. 1, 2014 Jan. 2014
TotalAnkleReplacement(Arthroplasty) Jan. 1, 2014 Jan. 2014
Wireless Capsule Endoscopy Jan. 1, 2014 Jan. 2014
SignatureValue™ Medical Management Guideline Updates
Note: The appearance of a service or procedure on this list does not imply that coverage is provided for the service or procedure. In the event of aninconsistencyorconflictbetweentheinformationprovidedinthisbulletinandthepostedpolicy,theprovisionsofthepostedpolicywillprevail.
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UnitedHealthcareAffiliates
UnitedHealthcare of the River Valley and Neighborhood Health Partnership:Disease Management Programs
UnitedHealthcare of the River Valley (UnitedHealthcareRiverValley)diseasemanagement programs serve members in the UnitedHealthcare River Valley and Neighborhood Health Partnership (NHP)plans.Servicesavailablefor members include:
• Educational materials
• Periodicdisease-specificnewsletters
• Notificationofcareopportunitiessuchasmissedtests, medication compliance, and emergentorinpatient admissions for an exacerbation
• Case management interventions for membersidentifiedathighestrisk
Providers receive quarterly reports and notificationsregardingcareopportunitiesfor patients. The UnitedHealthcare River Valley website at UHCrv.com provides information about the programs and disease management member and provider rights and responsibilities. Providers may contact the disease management staff to request information about the programs, refer patients for services or communicate a complaint or offer feedback.
Normal business hours are from 8 a.m. to 4:30 p.m., Monday through Friday, with voicemail options after hours.To contact us, call 800-369-2704, Option 4; Fax: 866-950-7759; or send an email to [email protected].
Insurance coverage provided by UnitedHealthcare Insurance Company or its affiliates.HealthplancoverageprovidedbyUnitedHealthcareofCalifornia,UnitedHealthcare of Colorado, Inc., UnitedHealthcare of Oregon, Inc., and UnitedHealthcareofWashington,Inc.orotheraffiliates.AdministrativeservicesprovidedbyUnitedHealthCareServices,Inc.oritsaffiliates.