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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: March 2014
enter
Network Bulletin: November 2013 - Volume 58 For more information call 877.842.3210, or visit UnitedHealthcareOnline.com2
Table of Contents
For more information call 877.842.3210, or visit UnitedHealthcareOnline.com2 Network Bulletin: March 2014
Front & Center UnitedHealthcare Commercial
UnitedHealthcare Reimbursement Policy
UnitedHealthcare Medicare Solutions
UnitedHealthcare Community Plan
Doing Business BetterUnitedHealthcare Pharmacy
UnitedHealthcare Claims, Billing & Coding
UnitedHealthcare Affiliates
UnitedHealthcare Military & Veterans
Clinical Updates
Front & Center• Creating a Path for Greater Care
• UnitedHealthcare Code Lookup Tool Now Available
• UnitedHealthcare West Network: Notice of New 2014 Physician, Health Care Professional, Facility and Ancillary Provider Capitated Administrative Guide – Effective July 1, 2014
• Medicare Advantage to Require Prior Authorization for IMRT, SRS and SBRT as of April 1
• Enhanced HIPAA Edits to be Applied to Claim Submissions, Effective April 23
• Injectable Chemotherapy Prior Authorization Program for Florida Providers Effective May 17
• HelpingImproveProviders’AccesstotheAdvanceNotificationList
• Credentialing Plan Changes Effective April 1, 2014
• Women’s Preventive Health Care FAQ Now Available
• Phasing Out Mail Delivery of PRA
• UnitedHealthcare West Medicare Advantage Radiology and Cardiology Prior Authorization Program Update
NEXT SECTION>
UnitedHealthcare Commercial
Network Bulletin: March 2014 For more information call 877.842.3210, or visit UnitedHealthcareOnline.com3
HOME
NEXT SECTION>
UnitedHealthcare Reimbursement Policy
Network Bulletin: March 2014 For more information call 877.842.3210, or visit UnitedHealthcareOnline.com4
UnitedHealthcare Commercial
• UnitedHealthcare Oncology Clinical Trial Reviews
• UnitedHealthcare Medical Policy, Drug Policy, Coverage Determination Guideline and Utilization Review Guideline Updates
HOME
UnitedHealthcare Reimbursement Policy
• Revision to Anesthesia Policy – Alternate Anesthesia Codes Reported by the Surgeon
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UnitedHealthcare Medicare Solutions
For more information call 877.842.3210, or visit UnitedHealthcareOnline.com5 Network Bulletin: March 2014
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UnitedHealthcare Medicare Solutions
• Rights and Responsibilities for Medicare Members
• Advance Directives
• Claim Liability Changes for All UnitedHealthcare Medicare Advantage Plans
• UnitedHealthcare Medicare Advantage Coverage Summary Updates
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UnitedHealthcare Community Plan
For more information call 877.842.3210, or visit UnitedHealthcareOnline.com6 Network Bulletin: March 2014
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UnitedHealthcare Community Plan
• Sleep Test Optimization Program - Phase 2
• Provider Disclosure of Ownership Form Now Online
For more information call 877.842.3210, or visit UnitedHealthcareOnline.com7 Network Bulletin: March 2014
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UnitedHealthcare Military & Veterans
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UnitedHealthcare Military & Veterans
• Updated 2014 UnitedHealthcare Military & Veterans TRICARE Provider Handbook Available April 1, 2014
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Doing Business Better
8
HOME
Network Bulletin: March 2014 For more information call 877.842.3210, or visit UnitedHealthcareOnline.com
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UnitedHealthcare Pharmacy
Doing Business Better
• UnitedHealthcare Expands Provider Relationship With Linkia, LLC/Hanger, Inc.: Provider for Orthotic and Prosthetic Services
• UnitedHealth Premium® Results Available to Public
• MPPR for Diagnostic Cardiovascular and Ophthalmology Services
• ManageYourReceivablesMoreEfficientlyOnline
• Learn About Optum Cloud Dashboard’s New Features
• ElectronicInpatientAdmissionNotifications
• UnitedHealthcareOnline.com Training
For more information call 877.842.3210, or visit UnitedHealthcareOnline.com9 Network Bulletin: March 2014
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UnitedHealthcare Pharmacy
• Pharmacy Summary of PDLs
• UnitedHealthcare Pharmacy Tiering Update
For more information call 877.842.3210, or visit UnitedHealthcareOnline.com10 Network Bulletin: March 2014
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UnitedHealthcare Claims, Billing & Coding
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UnitedHealthcare Claims, Billing & Coding
• ClarificationofProcessforProviderReimbursementRequestsAfter Members Use Consumer Account Cards
For more information call 877.842.3210, or visit UnitedHealthcareOnline.com11 Network Bulletin: March 2014
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Clinical Updates
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12
Clinical Updates• Mid-Atlantic Health Plan Pre-authorization Submissions
on UnitedHealthcareOnline.com
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UnitedHealthcare Affiliates
HOME
Network Bulletin: March 2014 For more information call 877.842.3210, or visit UnitedHealthcareOnline.com
UnitedHealthcareAffiliates
• SignatureValue™BenefitInterpretationPolicyUpdates
• SignatureValue™ Medical Management Guideline Updates
• Oxford® Medical and Administrative Policy Updates
• UnitedHealthcare of the River Valley Preauthorization List and Policy Updates
For more information call 877.842.3210, or visit UnitedHealthcareOnline.com13 Network Bulletin: March 2014
<< FIRST SECTION
Front & Center
HOME
According to the Centers for Disease Control, many of the 90 percentofMedicarebeneficiarieswhovisitaphysicianatleastoncea year are not receiving their full range of recommended covered preventive services.1
These preventive exams, tests and screenings can often catch health problems early, when they may be easier and less expensive to treat. And with the Patient Protection and Affordable Care Act, Medicare beneficiariesarenowentitledtoan annual wellness visit, with no out-of-pocket costs, that includes a schedule of recommended preventive services.1
We know you’re busy, so we’re here to help.
Like you, we want your patients to be as healthy as possible. But we know it often takes extra time and effort to make sure they come in for their annual wellness visit and complete their preventive services. That’s why UnitedHealthcare is introducing a program to help keep our
members engaged and encourage them to take action on your treatment plan.The program is designed to encourage greater use of preventive health care services by supporting and working with our Medicare Advantage members to get engaged with their physicians. And it all starts by encouraging them to set up an annual wellness visit. Here’s how it works:
1. Your patients who are our members will receive ongoing communication and be offered an incentive to complete their annual wellness visit. We will communicate directly with our Medicare Advantage members about the importance of taking proactive steps to keep their health on track.
Creating a Path for Greater Care Front & Center
Network Bulletin: March 2014 For more information call 877.842.3210, or visit UnitedHealthcareOnline.com14
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Front & Center
For more information call 877.842.3210, or visit UnitedHealthcareOnline.com15 Network Bulletin: March 2014
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2. You will have easy access to actionable patient data and reporting. Our reports will provide you with meaningful data when you need it, with simple access to both patient-level and practice-level data.
3. Physicians can earn additional compensation.Your practice may be eligible for additional incentives compensation for exceeding quality-based performance targets. And since we know it takes extra time for you to review patient health and complete assessment forms, we also offer additional administrative compensation
4. You can take advantage of tools and resources designed to support your practice. Our practice-based support solutions may help save time and effort for your administrative staff. We’ll provide tools, resources and support to maximize your efforts to help improve patient outcomes, while encouraging patients to take a more proactive role in their health.
Let’s team up to get members on the right path to wellness.
Better health starts with taking steps in the right direction. UnitedHealthcare is committed to helping you improve the health of our Medicare Advantage members through the rewards and support offered through the program.
To learn more, contact your local UnitedHeathcare Network team today.
1 “Enhancing Use of Clinical Preventive Services Among Older Adults,” Center for Disease Prevention, 2011. http://www.cdc.gov/aging/pdf/clinical_preventive_services_closing_the_gap_report.pdf
Creating a Path for Greater Care
Front & Center
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UnitedHealthcare Code Lookup Tool Now Available
The UnitedHealthcare Code Lookup Tool is now available. It enables providers to map an ICD-9 code to an ICD-10 code, and map an ICD-10 code to an ICD-9 code.
The tool was developed using the Centers for Medicare and Medicaid Services (CMS) General Equivalence Mappings (GEMs) as a baseline, focusing on the high volume codes most frequently submitted to UnitedHealthcare claim platforms. UnitedHealthcare used the knowledgeofateamofcertifiedcoders,nurses,physicians and other representatives across all areas of UnitedHealthcare to identify additional mappings from a broader clinical context than the CMS GEMs.
The Code Lookup Tool can be accessed from the UnitedHealthcareOnline.com ICD-10 Outreach site in the “Tools” section. NOTE: The UnitedHealthcare Code Lookup Tool is not a substitute for native coding (i.e. using the most current ICD-10 manual to remediate).
Send questions regarding the Code Look-up Tool to ICD10Questions@uhc.com.
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Front & Center
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UnitedHealthcare West Network: Notice of New 2014 Physician, Health Care Professional, Facility and Ancillary Provider Capitated Administrative Guide – Effective July 1, 2014
The UnitedHealthcare West Capitated Administrative Guide is being updated for 2014, and will be published and available on uhcwest.com as of April 1, 2014.
The Guide will be effective July 1, 2014, for all physicians, health care professionals, facilities and ancillary providers participating in the UnitedHealthcare West network. For those providers joining the network on or after April 1, 2014, the Guide will be effective immediately.
The 2013 UnitedHealthcare West Provider Capitated Administrative Guide will continue to be available to view and print at uhcwest.com. A summary list of important updates to the 2014 version of the Guide will be posted in the May Network Bulletin. To distinguish between administrative rules applicable to UnitedHealthcare products and products formerly knownasPacifiCareCommercialandPacifiCare/SecureHorizons Medicare products, we will
use a reference to UnitedHealthcare West. The following legal entities are included in the reference to UnitedHealthcare West: UHC of California doing business as UnitedHealthcare of California, UnitedHealthcare of Oklahoma, Inc., UnitedHealthcare ofOregon,Inc.,UnitedHealthcareBenefitsofTexas,Inc.,UnitedHealthcareofWashington,Inc.,PacifiCareofArizona,Inc.,PacifiCareofColorado,Inc.,PacifiCareof Nevada, Inc., and UnitedHealthcare Services, Inc. The products offered by these legal entities have been rebranded.PacifiCareHealthSystems,LLCremainsasa stand-alone legal entity. Behavioral health products are provided by U.S. Behavioral Health Plan, California or United Behavioral Health.
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Front & Center
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Medicare Advantage health plans will require prior authorization for Intensity Modulated Radiation Therapy (IMRT), Stereotaxic Radiosurgery (SRS) and Stereotactic Body Radiation Therapy (SBRT) when administered in an outpatient setting, effective April 1, 2014.
Additional details about the program will be posted at UnitedHealthcareOnline.com > Clinical Resources > Cancer – Oncology > Medicare Advantage Therapeutic Radiation.
Medicare Advantage IMRT, SRS and SBRT prior authorization training and live question and answer sessions will be hosted by WebEx in March. See theabovewebsitesforspecificscheduledatesandregistration details.
Medicare Advantage to Require Prior Authorization for IMRT, SRS and SBRT as of April 1
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Front & Center
For more information call 877.842.3210, or visit UnitedHealthcareOnline.com19 Network Bulletin: March 2014
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Enhanced HIPAA Edits to be Applied to Claim Submissions, Effective April 23
Effective April 23, 2014, UnitedHealthcare will apply an enhanced level of Health Insurance Portability and Accountability Act (HIPAA) edits to professional (837p) and institutional (837i)claimssubmittedelectronicallytomostUnitedHealthcareandaffiliatepayer IDs.*
Please review the complete list of enhanced edits periodically for modifications that may occur prior to implementation. 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. The goal will be fewer denied claims and less interruption to revenue streams.
The primary impact to you will come from edits that will validate code sets (such as diagnosis, procedure, modifierandnationaldrugcodes)atapre-adjudicationlevel. 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) vendor or clearinghouse should beyourfirstpointofcontactforassistanceregardingthese edits or to resolve rejections.
For more information, please contact EDI Support:
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UnitedHealthcare Commercial, UnitedHealthcare Medicare Solutions and UnitedHealthcare West
EDI issue reporting form or 800-842-1109
UnitedHealthcare Community Plan ac_edi_ops@uhc.com or 800-210-8315
UnitedHealthcare Oxford ediproviderassistance@oxhp.com or 800-599-4334
* Exceptions: Harvard Pilgrim (04271), Medica HealthCare Plans (78857), Preferred Care Partners (65088), The Alliance (88461) and TRICARE West (99726)
Front & Center
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Injectable Chemotherapy Prior Authorization Program for Florida Providers Effective May 17
Effective May 17, 2014, providers in Florida who are billing for outpatient injectable chemotherapy for members being treated for a cancer diagnosis insured by one of the following health plans are required to obtain prior authorization for services:
• Neighborhood Health Partnership (NHP)
• UnitedHealthcare – excluding indemnity/preferred partners organization (PPO) members
• UnitedHealthcare Community Plan – excluding UnitedHealthcare at Home and UnitedHealthcare Health & Home Connection members
UnitedHealthcare’s Injectable Chemotherapy Prior Authorization program will be managed by CareCore National’s Oncology Division and providers will be able to obtain injectable chemotherapy authorizations on CareCore’s website.
Authorizations that follow the National Comprehensive Cancer Network (NCCN) regimens will be approved at the time of the request online. Requests for pediatric chemotherapy regimens, rare cancers, or chemotherapy regimens that are not NCCN recommended, can also receive a timely response if necessary supporting documentation is provided at the time of the prior authorization request.
UnitedHealthcare Injectable Chemotherapy prior authorization training and live question and answer sessions will be held via WebEx.
Registration details will be posted in April to: UnitedHealthcareOnline.com > Clinician Resources > Cancer – Oncology > Florida Chemotherapy Prior Authorization Program.
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Front & Center
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HelpingImproveProviders’AccesstotheAdvanceNotificationList
Advancenotification/Priorauthorizationisnolongerrequiredforcapsuleendoscopyorhyperbaric oxygen treatment for UnitedHealthcare Commercial and Medicare Advantage members. In addition, more than 100 codes were removed from the UnitedHealthcare Commercial list and more than 200 codes were removed from the Medicare Advantage list.
ManyotherimprovementstotheAdvanceNotificationprocess have been implemented as well:
• Last November, UnitedHealthcareOnline.com wasenhancedtoonlyacceptnotificationforservicesthat are only on the prior authorization list, as wellas providing an automated way to provide approvaldecisions for certain services.
• TheAdministrativeGuide’sAdvanceNotificationListmoved online.
• To ensure that the most up-to-date codes are alwayseasily available at any time without the need for aphone call, UnitedHealthcare has posted the AdvanceNotificationrequirementsforUnitedHealthcareCommercial and Medicare Advantage plans to our
website at UnitedHealthcareOnline.com > Clinician Resources > Advance & Admission Notification Requirements. UnitedHealthCareOnline.com canacceptthenotificationsonline.
• On Jan. 1, 2014, additional enhancements weremade to expand services that can be approved inan effort to improve turnaround time in decisions.
• In 2015, we will make additional improvementsthat will continue to help improve turnaround timesfor decisions. Some of those changes will consistof additional procedure codes being removedfromtheAdvanceNotificationListandcontinuedenhancements to UnitedHealthcareOnline.comthat will provide automated decisions on anexpanded set of services.
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Front & Center
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UnitedHealthcare reviews and updates our Credentialing Plan at least every two years to ensure continued compliance with all state and federal regulatory requirements and NCQA Accreditation requirements.
The 2014 Credentialing Plan and State and Federal Regulatory Addendum will be effective April 1, 2014. Here are some of the key changes:
• Removed references to the Healthcare Integrity and Protection Data Bank as it has been merged into the National Practitioner Data Bank;
• Revised composition of the Credentialing Committee to match current practice;
• Added Medical Directors as Committee members;
• Clarifiedlanguagerelatedtolicensurerequirementsto further align with contract language; and
• Added a reference to possible denial of credentialing/recredentialing based on history of Quality of Care concerns and/or history of malpractice settlements.
Credentialing Plan Changes Effective April 1, 2014
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Front & Center
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Inordertocontinueeffortstoidentifyandimplementadministrativesimplificationsforyourpractice, we will phase out mail delivery of paper remittance advice (PRA) and only distribute remittance advice electronically. You will continue to receive electronic remittance advice (ERA) via an electronic transaction as usual, but you will no longer receive PRAs beginning 31 days afterthefirstpaymentwassenttoyouafterDec.15,2013.
Forexample,ifthefirstpaymentwesentyouafter Dec. 15, 2013 was on Jan. 10, 2014, your last day to receive PRAs would be Feb. 10, 2014 (31 calendar days later).
Only providers who have signed up for electronic remittance advice (ERA) will no longer receive PRAs. If you did not enroll in ERA, you will continue to receive PRAs as usual.
This will be effective only in the states of Kansas, Maryland, Michigan, Nebraska, New Jersey, New York, Ohio, Texas, Washington and Wisconsin.
You can, however, always view, save and print PRA at UnitedHealthcareOnline.com at any time.
If you do not have a user ID and password to access the site, click here: UnitedHealthcareOnline.com or call 866-842-3278.
Phasing Out Mail Delivery of PRA
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Front & Center
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Women’s Preventive Health Care FAQ Now Available
To view up-to-date frequently asked questions (FAQ) regarding women’s preventive health care, please go to:
https://www.unitedhealthcareonline.com/ccmcontent/ProviderII/UHC/en-US/Assets/ProviderStaticFiles/ProviderStaticFilesPdf/Clinician%20Resources/Womens%20Health/FAQ_Womens_Preventive_Care_Services.pdf
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Front & Center
For more information call 877.842.3210, or visit UnitedHealthcareOnline.com25 Network Bulletin: March 2014
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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, Texas and Washington, must obtain prior authorization for certain outpatient radiology procedures before they are rendered to UnitedHealthcare West Medicare Advantage members. Those states, as well as Colorado, must also do the same for cardiology procedures before they are rendered to UnitedHealthcare West Medicare Advantage members.
Important points to remember, effective April 1, 2014:
• Radiology Prior Authorization Requirements - Effective April 1, 2014, ordering providers who are subject to the Administrative Guide and the UnitedHealthcare West Non-Capitated Supplement and practice in Arizona, Oklahoma, Oregon, Texas and Washington health care providers will use a new phone number and website to
obtain a prior authorization number and notify UnitedHealthcare prior to scheduling certain CT, MRI, MRA, PET scan, Nuclear Medicine, and Nuclear Cardiology procedures for UnitedHealthcare West Medicare Advantage members. Rendering providers mustconfirmthatacoveragedecisionhasbeenmadebefore rendering these procedures or payment for their services may be denied.
A complete listing of CPT codes for which prior authorization is required is available at UnitedHealthcareOnline.com > Clinician Resources > Radiology > Medicare Advantage Radiology Prior Authorization Program >Authorization Resources: Reference Materials > Radiology Prior Notification/Authorization CPT Code List.
UnitedHealthcare West Medicare Advantage Radiology and Cardiology Prior Authorization Program Update
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UnitedHealthcare is standardizing our radiology and cardiology prior authorization requirements.
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Please note that prior authorization is not required for any advanced imaging procedure that is rendered in the emergency room, urgent care center, observation unit or during an inpatient stay.
• Cardiology Prior Authorization Requirements - Effective April 1, 2014, ordering providers who are subject to the Administrative Guide and the UnitedHealthcare West Non-Capitated Supplement and practice in Arizona, Colorado, Oklahoma, Oregon, Texas and Washington must obtain prior authorization before scheduling diagnostic catheterizations, electrophysiology implants, echocardiograms and stress echocardiograms for UnitedHealthcare West Medicare Advantage members. Rendering providers must confirmthatacoveragedecisionhasbeenissuedbeforerendering the cardiology procedure or payment for the services may be denied.
A complete listing of CPT codes for which prior authorization is required is available at UnitedHealthcareOnline.com > Clinician Resources > Cardiology > Medicare Advantage Cardiology Prior Authorization Program > Important Program Information: 2014 Cardiology Prior Authorization Table and CPT Code Crosswalk.
Prior authorization for diagnostic catheterizations, echocardiograms and stress echocardiograms is required foroutpatientandoffice-basedservicesonly.Priorauthorization for electrophysiology implants is required for outpatient,office-basedandinpatientservices.Cardiologyprocedures rendered and appropriately billed in an emergency room, urgent care center or inpatient setting, except for electrophysiology implants, which requires prior authorization during an inpatient stay, do not require prior authorization.
UnitedHealthcare West Medicare Advantage Radiology and Cardiology Prior Authorization Program Update
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Additionally, effective April 1, 2014:• Providers must complete the prior authorization
processandconfirmthatacoveragedecisionhas 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; or
• Call 866-889-8054, 7 a.m. to 7 p.m. local time, Monday through Friday
• Failure to complete the prior authorization process or verify that a coverage determination has been issued before rendering an advanced outpatient imaging or cardiology procedure that is subject to prior authorization requirements will result in an administrative claim reimbursement reduction, in part or in full. Members cannot be billed for administratively denied services.
• An authorization number is issued for both approved and clinically denied prior authorizations. A clinical denial will be issued if it is determined during the clinical coverage review process that the service does not meet medical necessity criteria.
• The clinical denial will be communicated by a letter faxed to the provider and a letter mailed to the UnitedHealthcare West Medicare Advantage member. Members can be billed for claims that are clinically denied if you obtain adequate written consent from the member prior to rendering the service.
• Additional information regarding the requirements to follow can be found in the Outpatient Radiology Prior Authorization Protocol for Medicare Advantage Customers and the Cardiology Prior Authorization Protocol for Medicare Advantage Customers. These protocols are outlined in the Administrative Guide as well.
The guide is available at UnitedHealthcareOnline.com > Tools & Resources > Policies, Protocols & Guides > Administrative Guides.
UnitedHealthcare West Medicare Advantage Radiology and Cardiology Prior Authorization Program Update
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UnitedHealthcare West Medicare Advantage Radiology and Cardiology Prior Authorization Program Update
Training Opportunity
If you still have questions after reviewing this information, please join us for a live question and answer telephone conference
• 12 p.m. (CST) on March 18, 2014
• 2 p.m. (CST) on March 20, 2014
• 4 p.m. (CST) on March 26, 2014
Please register to attend the conference at:
• UnitedHealthcareOnline.com > Clinician Resources > Radiology > Medicare Advantage Radiology Prior Authorization Program or
• UnitedHealthcareOnline.com > Clinician Resources > Cardiology > Medicare Advantage Cardiology Prior Authorization Program
If you have questions, please contact your UnitedHealthcare Network Management representative, or Provider Services at 800-637-5792, or email radiology@customerelation.com, or cardiology@customerelation.com.
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UnitedHealthcare Oncology Clinical Trial Reviews
UnitedHealthcare requires prior authorization for participation in oncology clinical trials and we have assigned a dedicated team to review these requests. A provider can use one of the following ways to contact us to request coverage for an oncology clinical trial:
Phone: 866-936-6002Email: cancer_resource_services@optum.com Fax: 855-250-2102
All requests for a clinical trial require review of the clinical trial and the member’s coverage document. The coverage document may allow coverage for the clinical trial – covering the costs of routine care, but may exclude costs for the investigational item, device or service. The provider will be informed in writing of the coverage review outcome. A brief summary of the member’s clinical condition, clinical trial details, documents showing institutional review board approval and sponsorship by the approved source is necessary for a clinical trial review.
UnitedHealthcare Commercial
Network Bulletin: March 2014 For more information call 877.842.3210, or visit UnitedHealthcareOnline.com29
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UnitedHealthcare Commercial
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UnitedHealthcare Medical Policy, Drug Policy, Coverage Determination Guideline and Utilization Review Guideline Updates
Policy Title Policy Type Effective Date Medical Policy Update Bulletin
CLARIFICATION
Abnormal Uterine Bleeding and Uterine Fibroids Medical Policy Jan. 1, 2014 Feb. 2014
UPDATED/REVISED
Bone and Soft Tissue Healing and Fusion Enhancement Products
Medical Policy Apr. 1, 2014 Mar. 2014
Botulinum Toxins A and B Drug Policy Feb. 1, 2014 Jan. 2014
Clotting Factors and Coagulant Blood Products Drug Policy Feb. 1, 2014 Jan. 2014
Deep Brain Stimulation Medical Policy Feb. 1, 2014 Jan. 2014
Durable Medical Equipment, Orthotics, Ostomy Supplies, Medical Supplies, and Repairs/Replacements
Coverage Determination Guideline
Feb. 1, 2014 Jan. 2014
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For complete details on the new and/or revised policies and guidelines listed in the following table, please refer to the monthly Medical Policy Update Bulletin at UnitedHealthcareOnline.com > Tools & Resources > Policies, Protocols and Guides > Medical & Drug Policies and Coverage Determination Guidelines > Medical Policy Update Bulletin.
UnitedHealthcare Commercial
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Policy Title Policy Type Effective Date Medical Policy Update Bulletin
Electrical Stimulation and Electromagnetic Therapy for Wounds
Medical Policy Feb. 1, 2014 Jan. 2014
Electrical Stimulation for the Treatment of Pain and Muscle Rehabilitation
Medical Policy Feb. 1, 2014 Jan. 2014
Emergency Health Services and Urgent Care Center Services
Coverage Determination Guideline
Apr. 1, 2014 Feb. 2014Mar. 2014
Gastrointestinal Motility Disorders, Diagnosis and Treatment
Medical Policy Feb. 1, 2014 Jan. 2014
Genetic Testing for Hereditary Breast and/or Ovarian Cancer Syndrome (HBOC)
Medical Policy Feb. 1, 2014 Jan. 2014
Infertility Diagnosis and Treatment Medical Policy Feb. 1, 2014 Jan. 2014
Manipulation Under Anesthesia Medical Policy Mar. 1, 2014 Feb. 2014
Occipital Neuralgia and Cervicogenic, Cluster and Migraine Headaches
Drug Policy Feb. 1, 2014 Jan. 2014
Ophthalmologic Policy: Vascular Endothelial Growth Factor (VEGF) Inhibitors
Drug Policy Feb. 1, 2014 Jan. 2014
Orthognathic (Jaw) Surgery Coverage Determination Guideline
Jan. 1, 2014 Jan. 2014
Sandostatin (Octreotide Acetate) Drug Policy Feb. 1, 2014 Jan. 2014
Sensory Integration Therapy and Auditory Integration Training
Medical Policy Mar. 1, 2014 Feb. 2014
UnitedHealthcare Medical Policy, Drug Policy, Coverage Determination Guideline and Utilization Review Guideline Updates
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UnitedHealthcare Commercial
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Policy Title Policy Type Effective Date Medical Policy Update Bulletin
Sodium Hyaluronate Medical Policy Mar. 1, 2014 Feb. 2014
Standing Systems Medical Policy Mar. 1, 2014 Feb. 2014
Stelara (Ustekinumab) Drug Policy Feb. 1, 2014 Jan. 2014
Surgical and Ablative Procedures for Venous InsufficiencyandVaricoseVeins
Medical Policy Mar. 1, 2014 Feb. 2014
Temporomandibular Joint Disorders Medical Policy Mar. 1, 2014 Feb. 2014
Vagus Nerve Stimulation Medical Policy Feb. 1, 2014 Jan. 2014
REPLACED
Auditory Integration Training Medical Policy Mar. 1, 2014 Feb. 2014
Durable Medical Equipment and Related Supplies, Prosthetics and Orthotics
Utilization Review Guideline Feb. 1, 2013 Jan. 2014
High Ligation and Endomechanical Ablation for Varicose Veins
Medical Policy Mar. 1, 2014 Feb. 2014
Mandibular Disorders Medical Policy Mar. 1, 2014 Feb. 2014
Sensory Integration Therapy Medical Policy Mar. 1, 2014 Feb. 2014
Surgical and Ablative Procedures for Venous InsufficiencyandVaricoseVeins
Coverage Determination Guideline
Mar. 1, 2014 Feb. 2014
UnitedHealthcare Medical Policy, Drug Policy, Coverage Determination Guideline and Utilization Review Guideline Updates
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UnitedHealthcare Commercial
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Policy Title Policy Type Effective Date Medical Policy Update Bulletin
Temporomandibular Joint Services Coverage Determination Guideline
Mar. 1, 2014 Feb. 2014
RETIRED
Experimental, Investigational, and Unproven Services
Coverage Determination Guideline
Feb. 1, 2014 Feb. 2014
Home Health Care Coverage Determination Guideline
Jan. 1, 2014 Jan. 2014
Infertility Services Coverage Determination Guideline
Jan. 1, 2014 Jan. 2014
UnitedHealthcare Medical Policy, Drug Policy, Coverage Determination Guideline and Utilization Review Guideline Updates Note: The inclusion of a service or procedure on this list does not imply that UnitedHealthcare provides coverage for the service or procedure. In the
eventofaninconsistencyorconflictbetweentheinformationinthisBulletinandthepostedpolicy,theprovisionsofthepostedpolicyprevail.
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Unless otherwise noted, these reimbursement policies apply to servicesreported using the 1500 Health Insurance Claim Form (CMS-1500) or itselectronic 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: March 2014 For more information call 877.842.3210, or visit UnitedHealthcareOnline.com34
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UnitedHealthcare Reimbursement Policy
35 Network Bulletin: March 2014
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For more information call 877.842.3210, or visit UnitedHealthcareOnline.com
The current Anesthesia Policy denies anesthesia current procedure terminology (CPT) codes 00100-01999 (excluding 01953 and 01996) when reported by the physician who also reports the surgical or medical procedure. Effective Q2 of 2014, edits will be added to deny anesthesia CPT codes identifiedasalternateanesthesiacodeswithintheAmericanSocietyofAnesthesiologists (ASA) Guide for Surgery/Anesthesia CPT Codes 2014 Crosswalk®, when reported by the physician who also reports the surgical or medical procedure. Alternate anesthesia codes are used to specify the anatomic locationoftheprocedure,theageofthepatientorotherfactorsthatinfluencethecode selection. Per the American Medical Association (AMA), if a physician personally performs the regional or general anesthesia for a surgical procedure that they alsoperform,modifier47shouldbeappendedtothesurgicalcode,andnocodesfrom the Anesthesia section of the CPT code book should be used. Please refer to theAMApublication,CodingwithModifiers,fourthedition,forfurtherinformation.
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Revision to Anesthesia Policy – Alternate Anesthesia Codes Reported by the Surgeon
Rights and Responsibilities for Medicare Members
UnitedHealthcare members have certain rights and responsibilities which are intended to help uphold the quality of care and services they receive from you.
If your patient has questions or concerns about their rights as a Medicare member, or needs help with communication, such as assistance from a language interpreter, please refer them to the Customer Service phone number listed on the back of their health plan member ID card. Members receive information about their Rights and Responsibilities upon enrollment and annually thereafter.
UnitedHealthcare Medicare Solutions
Network Bulletin: March 2014 For more information call 877.842.3210, or visit UnitedHealthcareOnline.com36
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These rights and responsibilities can be found at: https://www.uhcmedicaresolutions.com/health-plans/medicare-advantage-plans/resources-plan-material/ma-medicare-forms/medicare-rights-center.html
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UnitedHealthcare Medicare Solutions
For more information call 877.842.3210, or visit UnitedHealthcareOnline.com37 Network Bulletin: March 2014
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Advance Directives
The federal Patient Self-Determination Act (PSDA) gives individuals the legal right to make choices about their medical care in advance of an incapacitating illness or injury through an advance directive.
Under this act, physicians and other health care professionals, including hospitals, skilled nursing facilities, hospices, home health agencies and others must provide written information to patients about state law, advance treatment directives, the patients’ right to accept or refuse treatment, and your own policies regarding advance directives. Whenever possible, please suggest your patients execute an advance directive and a limited durable power of attorney. UnitedHealthcare also informs our members about advance directives through our member handbooks and other communications.
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UnitedHealthcare Medicare Solutions
For more information call 877.842.3210, or visit UnitedHealthcareOnline.com38 Network Bulletin: March 2014
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Claim Liability Changes for All UnitedHealthcare Medicare Advantage Plans
Tohelpmembersunderstandtheirfinancialresponsibilityfornon-coveredservices,UnitedHealthcare has taken steps to help ensure Medicare claims processing procedures are more consistently administered. As referenced in UnitedHealthcare’s provider administrative manuals, members are not responsible when not given appropriate Advanced Notice for non-covered services.
In February 2012, these changes were enacted on a go-forward basis with no related retroactive claims processing.Pleasecheckthemember’sspecificbenefittoidentify if a particular service is covered. If a service is not covered, member liability is appropriate when an Advanced Notice of Non-coverage (ANN) has been provided to the member prior to service delivery. When the ANN has been properly executed and providers are submitting charges on behalf of the member, the related claim(s) mustbesubmittedwitheitheraGAorGYmodifiertodemonstrate to UnitedHealthcare that the provider has informed the member of the non-covered service and that the member has agreed to take responsibility for charges related to the service. It is important to remember prior to providing the service or submitting a claim with eitherofthesemodifiers,physiciansandotherhealthcareprofessionalsmustobtainwrittenaffirmationfromthemember acknowledging that the service to be rendered is
not covered and that the member will accept responsibility for these charges. UnitedHealthcare has posted a sample template of this form on UnitedHealthcareOnline.com >Tools & Resources > Policies, Protocols and Guides > Protocols to guide providers in establishing appropriate documentation of member responsibility for charges.
Effective on or after March 19, 2014, non-covered servicesappendedwiththeGYModifierwillfollowthesamelogicastheGAModifier,totheextentpossible. UnitedHealthcare now requires an ANN for UnitedHealthcare Medicare Advantage members for all non-covered services.
The form and instructions can be found at UnitedHealthcareOnline.com. Please contact the Provider Service Center at 877-837-1882 or your Physician Advocate with questions.
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UnitedHealthcare Medicare Solutions
For more information call 877.842.3210, or visit UnitedHealthcareOnline.com39 Network Bulletin: March 2014
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UnitedHealthcare Medicare Advantage Coverage Summary Updates
For complete details on the revised policies listed in the following table, please refer to the Medicare Advantage Coverage Summary Update Bulletin at UnitedHealthcareOnline.com > Tools & Resources > Policies, Protocols and Guides > UnitedHealthcare Medicare Advantage Coverage Summaries > Update Bulletin.
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Policy Title Approval Date Update Bulletin
REVISED
Gastroesophageal and Gastrointestinal (GI) Services and Procedures Dec. 17, 2013 Jan. 2014
Medications/Drugs (Outpatient/Part B) Dec. 17, 2013 Jan. 2014
Mental Health Services and Procedures Dec. 17, 2013 Jan. 2014
Neurologic Services and Procedures Dec. 17, 2013 Jan. 2014
Respiratory Therapy, Pulmonary Rehabilitation and Pulmonary Services Dec. 17, 2013 Jan. 2014
Speech Generating Devices Dec. 17, 2013 Jan. 2014
Spine Procedures Dec. 17, 2013 Jan. 2014
RETIRED
Percutaneous Vertebroplasty and Percutaneous Kyphoplasty Dec. 17, 2013 Jan. 2014
Note: The appearance of a service or procedure on this list does not imply that UnitedHealthcare provides coverage for the service or procedure.
Sleep Test Optimization Program - Phase 2
Effective April, 15 2014, new prior authorization requirements will take effect for polysomnography and portable monitoring for sleep-related breathing disorders for UnitedHealthcare Community Plan members in the states of: Arizona, Delaware, Mississippi, Pennsylvania, and Wisconsin. For Massachusetts and Washington, these new requirements will become effective May 15, 2014.
Prior authorization will be required for attended sleep testing performed in a health care facility. Unattended sleep testing performed out of center will NOT require prior authorization.
Whether the requested sleep test requires prior authorization with medical necessity review is based on the site of service. Procedure codes for attended sleep testing which would require prior authorization include CPT 95805, 95807, 95808, 95810 and 95811.
Details on how to arrange home sleep testing:
UnitedHealthcare has contracted with Sleep Central, a division of Rotech Healthcare Inc., to deliver the home
sleep testing device to the member’s home, provide instructions and phone support, and deliver the test result usinganetworkofboard-certifiedsleepmedicine physicians who perform the test interpretation. Sleep Central has clinicians on staff 24 hours a day, seven days a week to assist with home sleep testing questions.
Contact Sleep Central Monday through Friday, 9 a.m. to 7 p.m. (CST) at 866-688-2981. If you have prior authorization questions, please contact your local network management representative or Provider Services at 877-842-3210 or go to UHCCommunityPlan.com.
UnitedHealthcare Community Plan
Network Bulletin: March 2014 For more information call 877.842.3210, or visit UnitedHealthcareOnline.com40
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UnitedHealthcare Community Plan
For more information call 877.842.3210, or visit UnitedHealthcareOnline.com41 Network Bulletin: March 2014
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Provider Disclosure of Ownership Form Now Online
The online disclosure form went live in the following UnitedHealthcare Community Plan markets on Jan. 1, 2014: Tennessee, New Mexico, Hawaii, Mississippi, New Jersey, Washington, Florida, Nebraska, Kansas, Rhode Island, Maryland, New York, Iowa, Michigan and Massachusetts.
UnitedHealthcare Community Plan continues to monitor state Medicaid requirements for managed care collection of the disclosure forms. If your state is not listed, collection of the form by managed Medicaid plans is not a requirement at this time.
Online completion of this form allows UnitedHealthcare Community Plan providers in these states an easier way to accessandcompletethenecessarydatafieldsaccurately. EchoSign is a web-based application that provides deliverytracking,confirmationandeSignaturecapabilities.
The application: • Requires no software installation to receive or sign
important notices, network communications, contracts and amendments; and
• Provides a convenient online audit trail that is safe, private and secure.
Knowledge Based Authentication (KBA) will be used when a signature is required. KBA protection, which is used by financialinstitutionsallovertheworld,allowsadvancedsecurity as to who opens and signs a contract or amendment.
With KBA, you will be asked for basic personal information, including the last four digits of your social security number, then a series of question pages will appear that are related to who the signer is and what property may have been owned. Once the signer has answered all the KBA questions correctly, they will see the page to continue with the signing process. Once the Disclosure of Ownership has been successfully submitted you will receive an automated messageofconfirmation.
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Disclosure of Ownership Forms can now be completed securely online through a partnership with EchoSign. The Disclosure of Ownership form is a federal requirement applicable to all providers that contract with a State Medicaid Agency.
Updated 2014 UnitedHealthcare Military & Veterans TRICARE Provider Handbook Available April 1, 2014
The UnitedHealthcare Military & Veterans TRICARE Provider Handbook is being updated and the new edition will be available on April 1, 2014. Once published, the changes in the Handbook will be effective on July 1, 2014 for currently contracted providers and immediately for providers newly contracted on or after April 1, 2014.
The TRICARE Handbook is located on UnitedHealthcareOnline.com > Tools & Resources > Policies, Protocols and Guides > TRICARE Provider Handbook; as well as on UHCMilitaryWest.com > Providers > Provider Handbook.
A summary list of changes to the Handbook will also be posted once it is published on April 1, 2014 for your convenience.
UnitedHealthcare Military & Veterans
Network Bulletin: March 2014 For more information call 877.842.3210, or visit UnitedHealthcareOnline.com42
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UnitedHealthcare Expands Provider Relationship With Linkia, LLC/Hanger, Inc.: Provider for Orthotic and Prosthetic Services
As part of the UnitedHealthcare effort to improve and expand the orthotic and prosthetic (O&P) network of providers, UnitedHealthcare has contracted with Linkia, LLC. Linkia, a subsidiary of Hanger, Inc. is a specialty health care company dedicated to O&P management and care. UnitedHealthcare has developed a strategic relationship with Linkia, LLC/Hanger, Inc. to help reduce out-of-network services, reduce member out-of-pocket expenses, while maintaining quality and consistency of O&P services for the member. Due tothestructureofmanybenefitplans,members who receive services provided by an out-of-network O&P provider may incurincreasedfinancialliabilityandbe exposed to higher out-of-pocket expenses, and no quality requirements. By referring members to Linkia, LLC/Hanger, Inc., members can be assured quality and cost savings.
Communications have been developed to educate referring physicians and members on the advantages and requirements of utilizing O&P services to in-network providers. Referring physicians who have referred patients for O&P services from non-participating providers will receive letters notifying them of in-network O&P options. Services can be directed to Linkia, LLC/Hanger, Inc., UnitedHealthcare’s strategic O&P provider.
Please contact Linkia, LLC/Hanger, Inc. at: www.linkia.com or call 877-754-6542 to locate a clinic location in your area. Orthotic and Prosthetic providers, including regional and local providers for your area may be found by visiting UnitedHealthcareOnline.com.
Doing Business Better
Network Bulletin: March 2014 For more information call 877.842.3210, or visit UnitedHealthcareOnline.com43
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Doing Business Better
44 Network Bulletin: March 2014
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For more information call 877.842.3210, or visit UnitedHealthcareOnline.com
UnitedHealth Premium® Results Available to Public
Most UnitedHealth Premium physician designations were 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 April 2, 2014.
NotificationsofnewUnitedHealthPremium designationsforqualityandcostefficiencywere mailed to physicians in November 2013. The physicians’ letters included instructions on how to access their full suite of UnitedHealth Premium assessment reports at UnitedHealthcareOnline.com. Physicians may also submit reconsideration requests through the site.
The public designation display date allowed time for physicians to submit reconsiderations before the results were available to the public. As is our practice, physicians may submit a reconsideration request at any time during the review cycle.
For more information, go to UnitedHealthcareOnline.com and select “UnitedHealth Premium®” onthetopnavigationbartofindresources and tools that explain the program, send us an email though the Contact Premium Program link, or call 866-270-5588.
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45 Network Bulletin: March 2014
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For more information call 877.842.3210, or visit UnitedHealthcareOnline.com
MPPR for Diagnostic Cardiovascular and Ophthalmology Services
The Centers for Medicare & Medicaid Services (CMS) expanded its Multiple Procedure Payment Reduction (MPPR) policy to cover diagnostic cardiovascular and ophthalmology procedures. The MPPRs on diagnostic cardiovascular and ophthalmology procedures apply when multiple services are provided to the same patient on the same day.
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The MPPRs apply independently to cardiovascular and ophthalmology services, as well as technical component services, and the technical component of global services. ThepolicyappliestoproceduresidentifiedwithaMultipleProcedure (MP) indicator 6 (diagnostic cardiovascular) and 7 (diagnostic ophthalmology) on the CMS National Physician Fee Schedule. UnitedHealthcare Medicare plans will align with CMS guidance and implement the new MPPR for Diagnostic Cardiovascular and Ophthalmology Services Policy, effective with claims reported with dates of service on and after May 1, 2014. For cardiovascular services, full payment is made for the technical component service with the highest payment under the Medicare Physician Fee Schedule (MPFS). Payment is made at 75 percent for subsequent technical component services provided by the same physician or multiple physicians in the same group practice to the same patient on the same day.
For ophthalmology services, full payment is made for the technical component service with the highest payment under the MPFS. Payment is made at 80 percent for subsequent technical component services provided by the same physician or by multiple physicians in the same group practice to the same patient on the same day. For more information, go to:
For more information, go to: UnitedHealthcare reimbursement policyhttps://www.unitedhealthcareonline.com/ccmcontent/ProviderII/UHC/en-US/Main%20Menu/Tools%20&%20Resources/Policies%20and%20Protocols/Medicare%20Advantage%20Reimbursement%20Policies/M/MPPRDiagnosticHeartEye.pdf
CMS MLNhttp://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM7848.pdf
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46 Network Bulletin: March 2014
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For more information call 877.842.3210, or visit UnitedHealthcareOnline.com
ManageYourReceivablesMoreEfficientlyOnline
With Electronic Payments and Statements (EPS)youcanreceivepaymentsfivetoseven days faster through direct deposit and eliminate trips to the bank.
Enroll your practice or facility in EPS for faster claim payments.It’snocosttoprovideroffices,healthcarefacilitiesandbillingoffices.Onceyou’reenrolled, you’ll receive your reimbursement electronically for all EPS-supported UnitedHealthcare products.
Read an overview of EPS, watch a short video or attend a live webcast to learn more. For answers to your questions or assistance with registration, call the EPS Help Desk at 866-842-3278, option 5 to speak with a representative.
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47 Network Bulletin: March 2014
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For more information call 877.842.3210, or visit UnitedHealthcareOnline.com
Learn About Optum Cloud Dashboard’s New Features
We’llintroduceyoutotheEligibility&BenefitsCenter and the Claims Management Application in one convenient webinar. Webinars are offered every Wednesday and Thursday. In these 30 minute instructor-led webinars, you will learn about:
Eligibility&BenefitsCenter• Check eligibility for all lines of business
• Getin-andout-of-networkbenefitinformationformostUnitedHealthcare members. You will be linked to other websites as needed.
• ReviewCoordinationofBenefitsinformation
• Select additional copay and coinsurance categories to display
Claims Management• Flag claims to view them automatically each
time you login
• View line level and claim level remark codes
• Getacleardefinitionofpaymentallocation
Time is available after the webinar for questions and answers.
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48 Network Bulletin: March 2014
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For more information call 877.842.3210, or visit UnitedHealthcareOnline.com
UnitedHealthcareOnline.com Training
Learn how you can accomplish more with less time and effort using UnitedHealthcareOnline.com.
In our 60–minute webinar, you will:
• Learnhowtonavigatethewebsite,andfindreferencematerials and resources such as medical andreimbursement policies and quick reference guides
• Get an overview of our most-used functions suchascheckingeligibilityandbenefits,statusupdates,submittingnotifications,aswellasclaimsandreconsideration requests
• Receive best practice examples, tips and shortcuts tomakedoingbusinesswithusmoreefficient
• Get answers to your questions.
Space is limited, so register today for one of the live sessions.
Electronic Inpatient AdmissionNotifications
You can use the Electronic Data Interchange (EDI) 278N to submit notificationsfromyourpracticemanagement system for UnitedHealthcare, UnitedHealthcare Medicare Solutions and UnitedHealthcare Community Plan.
For more information, go to Admission Notification(278N), contact your clearinghouse/vendor or UnitedHealthcare at 888-804-0663 or 278n@uhc.com.
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Pharmacy Summary of PDLs
UnitedHealthcare is providing a new tool that cansimplifyfindingmedicationsthatprovidea good value at a lower cost to members.
Unlike traditional Prescription Drug Lists (PDLs) and formularies, this summary of PDLs details information from all four UnitedHealthcare pharmacy groups - Medicare, Medicaid, Commercial and OptumRx. Medications that are preferred across all four groups are highlighted and should provide members lower costs, even if members switch from one group to another.
UnitedHealthcare Pharmacy
Network Bulletin: March 2014 For more information call 877.842.3210, or visit UnitedHealthcareOnline.com49
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UnitedHealthcare Pharmacy
50 Network Bulletin: March 2014
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For more information call 877.842.3210, or visit UnitedHealthcareOnline.com
The summary of PDLs has at least one common preferred medication in many of the top treatment classes.
Guide to symbols:
* Value to end member or government (either federal or state)
Here is a sample showing the guide and a representative class:
Pharmacy Summary of PDLs
Medicare Commercial Medicaid OptumRxCholesterol Lowering AgentsAtorvastatin
Lovastatin
Pravastatin
Simvastatin
Crestor
Livalo
Niacin ext-rel (Niaspan) B/G
Vytorin
The Summary of PDLs can be found at UnitedHealthcareOnline.com > Tools and Resources > Pharmacy Resources > UnitedHealthcare or the Optum Cloud.
The PDL for the Texas UnitedHealthcare Community Plan for CHIP and Medicaid members is available at the Vendor Drug Program at txvendordrug.com/pdl.Updates. The PDL and prior authorization process were posted in January 2014 and further updates are slated for July 2014.
Preferred across all four UnitedHealthcare lines of business.
Best value* in class Least value* in class
Good value* in class NotonPDL/formularyorexcludedfrombenefitcoverage.
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UnitedHealthcare Pharmacy
51 Network Bulletin: March 2014
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For more information call 877.842.3210, or visit UnitedHealthcareOnline.com
UnitedHealthcare Pharmacy Tiering Update
Olysio, a new protease inhibitor used in combination therapy to treat members with Hepatitis C infection, has moved from Tier 3 to Tier 2 on both the Advantage and Traditional Commercial Prescription Drug Lists (PDLs), effective Feb. 7, 2014.
Olysio is a specialty medication included in the designated specialty pharmacy network program which requires the use of OptumRx specialty pharmacy for most members to receive in-network coverage. In addition, Olysio requires priorauthorizationtodeterminebenefitcoverageand ensure appropriate use.
This information only applies to UnitedHealthcare integrated commercialclientswhosepharmacybenefitadministration has moved or is moving from Medco/ESI to OptumRx in 2013 aswellasnewpharmacybenefitbusinessbeginningin2013.It does not apply to direct commercial business (OptumRx direct business without UnitedHealthcare medical coverage) ornon-HMOlegacyPacifiCareorUnitedHealthcarepublicsector integrated commercial business that has been administered by OptumRx prior to Jan. 1, 2013.
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Before submitting requests for reimbursement on claims after a member has used the Consumer Account Card (CAC) for the claim, please check your billing systems to determine what partial payment you may have already received from the member.
This will help us to pay you more promptly. Please note on the submittal what the payment was for, such as copay, coinsurance, deductible, etc. Include debit card transaction information (transaction number, etc.) with the claim submission.
When processing claims, we compare the business name from the card swipe terminal and the provider name on the claim. Please check these names to see if they match and adjust the card swipe terminal as needed.
If you have questions, please review claim submission protocol at UnitedHealthcareOnline.com under the Claims & Payment menu or call us at 877-842-3210.
UnitedHealthcare Claims, Billing & Coding
ClarificationofProcessforProvider Reimbursement Requests After Members Use Consumer Account Cards
Network Bulletin: March 2014 For more information call 877.842.3210, or visit UnitedHealthcareOnline.com52
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Mid-Atlantic Health Plan (M.D.IPA & Optimum Choice) network physicians, health care professionals and their staff can now submit and check the status of a preauthorization request on UnitedHealthcareOnline.com.
The exception is for physical, occupational, speech, and other therapy-related services. Preauthorization requests for these services cannot be submitted at this time through UnitedHealthcareOnline.com.
For more information, please visit UnitedHealthcareOnline.com > Tools & Resources > Training & Education > UnitedHealthcareOnline.com Notification/Preauthorization Function Overview
Clinical Updates
Mid-Atlantic Health Plan Pre-authorization Submissions on UnitedHealthcareOnline.com
Network Bulletin: March 2014 For more information call 877.842.3210, or visit UnitedHealthcareOnline.com53
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Continued >
Clinical Update
For more information call 877.842.3210, or visit UnitedHealthcareOnline.com54 Network Bulletin: March 2014
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Mid-Atlantic Health Plan Pre-authorization Submissions on UnitedHealthcareOnline.com
The following list of services will requirement preauthorization for the Mid Atlantic Health Plan (M.D.IPA and Optimum Choice) effective for dates of service on or after April 15, 2014.
Category CPT code Notes
Cosmetic & Resonstructive 11922 Effective 4/15/14
Cosmetic & Resonstructive 11960 Effective 4/15/14
Cosmetic & Resonstructive 11971 Effective 4/15/14
Cosmetic & Resonstructive 15830 Effective 4/15/14
Cosmetic & Resonstructive 17999 Effective 4/15/14
Cosmetic & Resonstructive 21137 Effective 4/15/14
Cosmetic & Resonstructive 21138 Effective 4/15/14
Cosmetic & Resonstructive 21139 Effective 4/15/14
Cosmetic & Resonstructive 21172 Effective 4/15/14
Cosmetic & Resonstructive 21175 Effective 4/15/14
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Clinical Update
For more information call 877.842.3210, or visit UnitedHealthcareOnline.com55 Network Bulletin: March 2014
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Category CPT code Notes
Cosmetic & Resonstructive 21179 Effective 4/15/14
Cosmetic & Resonstructive 21180 Effective 4/15/14
Cosmetic & Resonstructive 21181 Effective 4/15/14
Cosmetic & Resonstructive 21182 Effective 4/15/14
Cosmetic & Resonstructive 21183 Effective 4/15/14
Cosmetic & Resonstructive 21184 Effective 4/15/14
Cosmetic & Resonstructive 21230 Effective 4/15/14
Cosmetic & Resonstructive 21235 Effective 4/15/14
Cosmetic & Resonstructive 21256 Effective 4/15/14
Cosmetic & Resonstructive 21260 Effective 4/15/14
Cosmetic & Resonstructive 21261 Effective 4/15/14
Cosmetic & Resonstructive 21263 Effective 4/15/14
Cosmetic & Resonstructive 21267 Effective 4/15/14
Cosmetic & Resonstructive 21268 Effective 4/15/14
Cosmetic & Resonstructive 21275 Effective 4/15/14
Cosmetic & Resonstructive 21280 Effective 4/15/14
Cosmetic & Resonstructive 21282 Effective 4/15/14
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Clinical Update
For more information call 877.842.3210, or visit UnitedHealthcareOnline.com56 Network Bulletin: March 2014
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Category CPT code Notes
Cosmetic & Resonstructive 21295 Effective 4/15/14
Orthognathic Surgery 21299 Effective 4/15/14
Cosmetic & Resonstructive 21740 Effective 4/15/14
Cosmetic & Resonstructive 21742 Effective 4/15/14
Cosmetic & Resonstructive 21743 Effective 4/15/14
Joint Replacement 23473 Effective 4/15/14
Joint Replacement 23474 Effective 4/15/14
Joint Replacement 24360 Effective 4/15/14
Joint Replacement 24361 Effective 4/15/14
Joint Replacement 24362 Effective 4/15/14
Joint Replacement 24363 Effective 4/15/14
Joint Replacement 24371 Effective 4/15/14
Cosmetic & Resonstructive 28344 Effective 4/15/14
Septoplasty/Rhinoplasty 30400 Effective 4/15/14
Septoplasty/Rhinoplasty 30410 Effective 4/15/14
Septoplasty/Rhinoplasty 30420 Effective 4/15/14
Septoplasty/Rhinoplasty 30430 Effective 4/15/14
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Clinical Update
For more information call 877.842.3210, or visit UnitedHealthcareOnline.com57 Network Bulletin: March 2014
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Category CPT code Notes
Septoplasty/Rhinoplasty 30435 Effective 4/15/14
Septoplasty/Rhinoplasty 30450 Effective 4/15/14
Septoplasty/Rhinoplasty 30460 Effective 4/15/14
Septoplasty/Rhinoplasty 30462 Effective 4/15/14
Septoplasty/Rhinoplasty 30520 Effective 4/15/14
33369 Effective 4/15/14
69320 Effective 4/15/14
Potentially Unproven Services
Cosmetic & Resonstructive
Bariatric Surgery 0312T Effective 4/15/14
Bariatric Surgery 0313T Effective 4/15/14
Bariatric Surgery 0314T Effective 4/15/14
Bariatric Surgery 0315T Effective 4/15/14
Bariatric Surgery 0316T Effective 4/15/14
Bariatric Surgery 0317T Effective 4/15/14
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Clinical Update
For more information call 877.842.3210, or visit UnitedHealthcareOnline.com58 Network Bulletin: March 2014
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Category CPT code Notes
A0436
E0601
E2511
Effective 4/15/14
Effective 4/15/14
Effective 4/15/14
Non-Emergency Transport-Air
Durable Medical Equipment
Durable Medical Equipment
Prosthetics L5990
Prosthetics L6010
Q2026
Q2027 Effective 4/15/14Cosmetic & Resonstructive
Cosmetic & Resonstructive S2202 Effective 4/15/14
Home Care – Nutritional, Skilled Nursing, Private Duty Nursing S9208 Effective 4/15/14
Home Care – Nutritional, Skilled Nursing, Private Duty Nursing S9433 Effective 4/15/14
Home Care – Nutritional, Skilled Nursing, Private Duty Nursing T1000 Effective 4/15/14
Home Care – Nutritional, Skilled Nursing, Private Duty Nursing T1002 Effective 4/15/14
T1003
T1005Home Care – Nutritional, Skilled Nursing, Private Duty Nursing
Prosthetic V2629
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Cosmetic & Resonstructive
Home Care – Nutritional, Skilled Nursing, Private Duty Nursing
Effective 4/15/14. Purchase cost or a cumulative rental cost over $1000.00
Effective 4/15/14. Purchase cost or a cumulative rental cost over $1000.00
Effective 4/15/14
Effective 4/15/14
Effective 4/15/14
Effective 4/15/14. Purchase cost or a cumulative rental cost over $1000.00
Network Bulletin: March 2014 For more information call 877.842.3210, or visit UnitedHealthcareOnline.com59
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ForcompletedetailsontherevisedSignatureValueBenefitInterpretation Policy listed in the following table, please refer to the monthly SignatureValue™BenefitInterpretationPolicy Update Bulletin at UHCWest.com > Provider Log In > Library > Resource Center > Guidelines & Interpretation Manuals.
UnitedHealthcare Affiliates
SignatureValue™BenefitInterpretationPolicy Updates
UnitedHealthcareAffiliates
For more information call 877.842.3210, or visit UnitedHealthcareOnline.com60 Network Bulletin: March 2014
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Policy Title Applicable State(s) Effective Date Policy Update Bulletin
NEW
Transgender: Gender Identity Disorder/Gender Dysphoria California Jan. 1, 2014 Jan. 2014
UPDATED/REVISED
Autism Spectrum Disorder Texas Feb. 1, 2014 Jan. 2014
Complementary and Alternative Medicine All (California, Oklahoma, Oregon, Texas, & Washington)
Feb. 1, 2014 Jan. 2014
Dental Care and Oral Surgery All Feb. 1, 2014 Jan. 2014
Maternity and Newborn Care California Feb. 1, 2014 Jan. 2014
Mental Health: Inpatient Mental Health All Feb. 1, 2014 Jan. 2014
Mental Health: Outpatient Mental Health California Mar. 1, 2014 Feb. 2014
Pervasive Developmental Disorder California Feb. 1, 2014 Jan. 2014
SignatureValue™BenefitInterpretationPolicyUpdates
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UnitedHealthcareAffiliates
For more information call 877.842.3210, or visit UnitedHealthcareOnline.com61 Network Bulletin: March 2014
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Policy Title Applicable State(s) Effective Date Policy Update Bulletin
Physician Services: Primary Care and Specialist Visits California Mar. 1, 2014 Feb. 2014
Rehabilitation: Medical Rehabilitation (Physical, Occupational and Speech Therapy)
All Feb. 1, 2014 Jan. 2014
Surgery: Cosmetic, Reconstructive or Plastic Surgery California Feb. 1, 2014 Jan. 2014
REPLACED/RETIRED
TransgenderReassignmentSupplementalBenefit California Jan. 1, 2014 Jan. 2014
Note:Theappearanceofaserviceorprocedureonthislistdoesnotimplythatcoverageisprovidedfortheserviceorprocedure.Intheeventofaninconsistencyorconflict between the information provided in this Bulletin and the posted policy, the provisions of the posted policy prevail.
SignatureValue™BenefitInterpretationPolicyUpdates
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Policy Title Effective Date Policy Update Bulletin
UPDATED/REVISED
Abnormal Uterine Bleeding and Uterine Fibroids Feb. 1, 2014 Feb. 2014
Autism Spectrum Disorder Feb. 1, 2014 Feb. 2014
Blepharoplasty, Blepharoptosis, and Brow Ptosis Repair Mar. 1, 2014 Feb. 2014
Bone or Soft Tissue Healing and Fusion Enhancement Products Mar. 1, 2014 Feb. 2014
Cosmetic and Reconstructive Procedures Mar. 1, 2014 Feb. 2014
Custodial and Skilled Care Services Mar. 1, 2014 Feb. 2014
Deep Brain Stimulation Mar. 1, 2014 Feb. 2014
Electrical Stimulation and Electromagnetic Therapy for Wounds Feb. 1, 2014 Jan. 2014
Electrical Stimulation for the Treatment of Pain and Muscle Rehabilitation Feb. 1, 2014 Jan. 2014
Gastrointestinal Motility Disorders, Diagnosis and Treatment Feb. 1, 2014 Jan. 2014
SignatureValue™ Medical Management Guideline Updates
For complete details on the new and/or revised SignatureValue Medical Management Guidelines policies listed in the following table, please refer to the monthly SignatureValue™ Medical Management Guidelines Update Bulletin at UHCWest.com > Provider Log In > Library > Resource Center > Guidelines & Interpretation Manuals.
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For more information call 877.842.3210, or visit UnitedHealthcareOnline.com63 Network Bulletin: March 2014
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Policy Title Effective Date Policy Update Bulletin
Genetic Testing for Hereditary Breast and/or Ovarian Cancer Syndrome (HBOC)
Feb. 1, 2014 Jan. 2014
Home Health Mar. 1, 2014 Feb. 2014
Infertility Diagnosis and Treatment Feb. 1, 2014 Jan. 2014
Manipulation Under Anesthesia Mar. 1, 2014 Feb. 2014
Occipital Neuralgia and Headache Feb. 1, 2014 Feb. 2014
Orthognathic (Jaw) Surgery Mar. 1, 2014 Feb. 2014
Panniculectomy and Body Contouring Procedures Mar. 1, 2014 Feb. 2014
Private Duty Nursing Mar. 1, 2014 Feb. 2014
Sensory Integration Therapy and Auditory Integration Training Mar. 1, 2014 Feb. 2014
Sodium Hyalurononate Mar. 1, 2014 Feb. 2014
Standing Systems Mar. 1, 2014 Feb. 2014
SurgicalandAblativeProceduresforVenousInsufficiency and Varicose Veins
Mar. 1, 2014 Feb. 2014
Vagus Nerve Stimulation Mar. 1, 2014 Feb. 2014
REPLACED/RETIRED
Gender Identity Disorder Treatment (Sex Transformation) 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 an inconsistencyorconflictbetweentheinformationprovidedinthisBulletinandthepostedpolicy,theprovisionsofthepostedpolicyprevail.
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For more information call 877.842.3210, or visit UnitedHealthcareOnline.com64 Network Bulletin: March 2014
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Oxford® Medical and Administrative Policy Updates
For complete details on the new and/or revised policies listed in the table below, refer to the monthly Policy Update Bulletin at OxfordHealth.com > Providers > Tools & Resources > Practical Resources > Medical and Administrative Policies > Policy Update Bulletin.
Policy Title Policy Type Effective Date
Policy Update Bulletin
UPDATED/REVISED
Drug Policy Format & Indexing Changes Clinical Policy Mar. 1, 2014 Feb. 2014
Actimmune (Interferon Gamma-1b) Clinical Policy Mar. 1, 2014 Feb. 2014
Requests for In-Network Exceptions Administrative Policy Feb. 1, 2014 Jan. 2014
UPDATED/REVISED
Abnormal Uterine Bleeding and Uterine Fibroids Clinical Policy Feb. 1, 2014 Jan. 2014Feb. 2014
Agents for Migraine - Triptans Clinical Policy Feb. 1, 2014 Jan. 2014
Assistant Surgeon Policy Reimbursement Policy Jan. 1, 2014 Jan. 2014
TAKE NOTE
NEW
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Oxford Medical and Administrative Policy Updates
Policy Title Policy Type Effective Date
Policy Update Bulletin
UPDATED/REVISED
Assisted Administration of Clotting Factors and Coagulant Blood Products
Clinical Policy Mar. 1, 2014 Feb. 2014
Autism Administrative Policy Feb. 1, 2014 Jan. 2014
B Bundle Code Policy Reimbursement Policy Jan. 1, 2014 Jan. 2014
Bilateral Procedures Reimbursement Policy Jan. 1, 2014 Jan. 2014
Biologics in the Treatment of Skin, Joint and Gastrointestinal Conditions
Clinical Policy Feb. 1, 2014 Jan. 2014
Blepharoplasty, Blepharoptosis and Brow Ptosis Repair Clinical Policy Feb. 1, 2014 Jan. 2014
Botulinum Toxins A and B Clinical Policy Feb. 1, 2014 Jan. 2014
Campath (Alemtuzumab) Clinical Policy Feb. 1, 2014 Jan. 2014
Cardiology Procedures for CareCore National Arrangement Clinical Policy Apr. 1, 2014 Jan. 2014 Feb. 2014Mar. 2014
CardiologyProceduresRequiringPrecertification Clinical Policy Apr. 1, 2014 Jan. 2014 Feb. 2014Mar. 2014
Clotting Factors and Coagulant Blood Products Clinical Policy Feb. 1, 2014 Jan. 2014
Mar. 1, 2014 Feb. 2014
Compounds and Bulk Powders Clinical Policy Feb. 1, 2014 Jan. 2014
Contraceptives Clinical Policy Feb. 1, 2014 Jan. 2014
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Oxford Medical and Administrative Policy Updates
Policy Title Policy Type Effective Date
Policy Update Bulletin
UPDATED/REVISED
Co-Surgeons; Team Surgeon Policy Reimbursement Policy Jan. 1, 2014 Jan. 2014
Deep Brain Stimulation Clinical Policy Feb. 1, 2014 Jan. 2014
Drug Coverage Criteria - New and Therapeutic Equivalent Medications
Clinical Policy Feb. 1, 2014 Jan. 2014
Mar. 1, 2014 Feb. 2014
Drug Coverage Guidelines Clinical Policy Feb. 1, 2014 Jan. 2014
Mar. 1, 2014 Feb. 2014
Electrical Stimulation and Electromagnetic Therapy for Wounds Clinical Policy Mar. 1, 2014 Feb. 2014
Electrical Stimulation for the Treatment of Pain and Muscle Rehabilitation
Clinical Policy Feb. 1, 2014 Jan. 2014
Mar. 1, 2014 Feb. 2014
Elidel® (Pimecrolimus) and Protopic® (Tacrolimus) Clinical Policy Feb. 1, 2014 Jan. 2014
Forteo (Teriparatide) Clinical Policy Feb. 1, 2014 Jan. 2014
Fulyzaq (Crofelemer) Clinical Policy Feb. 1, 2014 Jan. 2014
Gastrointestinal Motility Disorders, Diagnosis and Treatment Clinical Policy Mar. 1, 2014 Feb. 2014
Gattex (Teduglutide [Rdna Origin]), for Injection, for Subcutaneous Use
Clinical Policy Feb. 1, 2014 Jan. 2014
Genetic Testing for Hereditary Breast and/or Ovarian Cancer Syndrome (HBOC)
Clinical Policy Mar. 1, 2014 Feb. 2014
Global Days Policy Reimbursement Policy Jan. 1, 2014 Jan. 2014
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Oxford Medical and Administrative Policy Updates
Policy Title Policy Type Effective Date
Policy Update Bulletin
UPDATED/REVISED
Hearing Aids and Devices Including Wearable, Bone-Anchored and Semi-Implantable
Clinical Policy Feb. 1, 2014 Jan. 2014
Hip Resurfacing Arthroplasty Clinical Policy Feb. 1, 2014 Jan. 2014
Home Health Care Clinical Policy Mar. 1, 2014 Feb. 2014
Icatibant (Firazyr) and C1 Esterase Inhibitors Human (Berinert and Cinryze)
Clinical Policy Feb. 1, 2014 Jan. 2014
Implantable Beta-Emitting Microspheres for Treatment of Malignant Tumors
Clinical Policy Feb. 1, 2014 Jan. 2014
InfertilityProceduresRequiringNotification and/orPrecertification
Clinical Policy Feb. 1, 2014 Jan. 2014
Injectable Chemotherapy Drugs: Application of NCCN Clinical Practice Guidelines
Clinical Policy Feb. 1, 2014 Jan. 2014
Inpatient Consultations Reimbursement Policy Feb. 1, 2014 Jan. 2014
Maximum Frequency Per Day Reimbursement Policy Jan. 21, 2014 Jan. 2014
Feb. 1, 2014 Jan. 2014
Moderate Sedation Policy Reimbursement Policy Jan. 1, 2014 Jan. 2014
Mar. 1, 2014 Feb. 2014
Multiple Procedures Policy Reimbursement Policy Jan. 1, 2014 Jan. 2014
Occipital Neuralgia and Cervicogenic Cluster and Migraine Headaches
Clinical Policy Feb. 1, 2014 Jan. 2014
Onfi(Clobazam) Clinical Policy Feb. 1, 2014 Jan. 2014
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Oxford Medical and Administrative Policy Updates
Policy Title Policy Type Effective Date
Policy Update Bulletin
UPDATED/REVISED
Oral Chemotherapy Drugs: Application of NCCN Clinical Practice Guidelines
Clinical Policy Feb. 1, 2014 Jan. 2014
Orthognathic (Jaw) Surgery Clinical Policy Mar. 1, 2014 Feb. 2014
PrecertificationExemptionsforOutpatientServices Administrative Policy Apr. 1, 2014 Jan. 2014Feb. 2014Mar. 2014
Preexisting Condition Administrative Policy Feb. 1, 2014 Jan. 2014
Prolonged Services Policy Reimbursement Policy Feb. 1, 2014 Jan. 2014
Protocol for Providing Advance Notice to Commercial Customers when Involving Non-Participating Providers in Customers’ Care
Administrative Policy Apr. 1, 2014 Jan. 2014Feb. 2014Mar. 2014
Radiopharmaceuticals and Contrast Media Clinical Policy Feb. 1, 2014 Jan. 2014
Repository Corticotropin Injection (H.P. Acthar Gel) Clinical Policy Mar. 1, 2014 Feb. 2014
Sandostatin LAR Depot (Octreotide Acetate) Clinical Policy Feb. 1, 2014 Jan. 2014
Sandostatin Subcutaneous Formulation (Octreotide Acetate) Clinical Policy Feb. 1, 2014 Jan. 2014
Selzentry (Maraviroc) Clinical Policy Feb. 1, 2014 Jan. 2014
Sensory Integration Therapy and Auditory Integration Training Clinical Policy Mar. 1, 2014 Feb. 2014
Signifor (Pasireotide Diaspartate) Clinical Policy Feb. 1, 2014 Jan. 2014
Stelara (Ustekinumab) Clinical Policy Feb. 1, 2014 Jan. 2014
Stribild™ (Elvitegravir/Cobicistat/Emtricitabine/Tenofovir Disoproxil Fumarate)
Clinical Policy Feb. 1, 2014 Jan. 2014
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For more information call 877.842.3210, or visit UnitedHealthcareOnline.com69 Network Bulletin: March 2014
HOME TABLE OF CONTENTS
Policy Title Policy Type Effective Date
Policy Update Bulletin
UPDATED/REVISED
Telemedicine Policy Reimbursement Policy Jan. 1, 2014 Jan. 2014
Temporomandibular Joint Disorders Clinical Policy Mar. 1, 2014 Feb. 2014
Topical Retinoids (Pharmaceutical Treatment of Acne) Clinical Policy Feb. 1, 2014 Jan. 2014
Transcranial Magnetic Stimulation Clinical Policy Feb. 1, 2014 Jan. 2014
Transportation Services Clinical Policy Feb. 1, 2014 Jan. 2014
Treatment of Infertility Clinical Policy Feb. 1, 2014 Jan. 2014
Treatment of Infertility for Connecticut Groups Clinical Policy Feb. 1, 2014 Jan. 2014
Treatment of Infertility for New Jersey Large Groups Clinical Policy Feb. 1, 2014 Jan. 2014
Treatment of Infertility for New Jersey Small Groups Clinical Policy Feb. 1, 2014 Jan. 2014
Treatment of Infertility for New York Large and Small Group Clinical Policy Feb. 1, 2014 Jan. 2014
Truvada (Emtricitabine/Tenofovir Disoproxil Fumarate) Clinical Policy Feb. 1, 2014 Jan. 2014
Vagus Nerve Stimulation Clinical Policy Feb. 1, 2014 Jan. 2014
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 of an inconsistencyorconflictbetweentheinformationprovidedinthisBulletinandthepostedpolicy,theprovisionsofthepostedpolicyprevail.
Oxford HMO products are underwritten by Oxford Health Plans (NY), Inc., Oxford Health Plans (NJ), Inc. and Oxford Health Plans (CT), Inc. Oxford insurance products are underwritten by Oxford Health Insurance, Inc.
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UnitedHealthcare of the River Valley Preauthorization List 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
NEW
Ophthalmologic Policy - Vascular Endothelial Growth Factor (VEGF) Inhibitors
May 1, 2014 Mar. 2014
Routine Foot Care Mar. 1, 2014 Feb. 2014
UPDATED/REVISED
Bone and Soft Tissue Fusion Enhancement Products Apr. 1, 2014 Mar. 2014
Botulinum Toxins A and B Mar. 1, 2014 Feb. 2014
Campath Feb. 1, 2014 Jan. 2014
Deep Brain Stimulation Feb. 1, 2014 Jan. 2014
Electrical Stimulation and Electromagnetic Therapy for Wounds Mar. 1, 2014 Feb. 2014
Electrical Stimulation for the Treatment of Pain and Muscle Rehabilitation Feb. 1, 2014 Jan. 2014
Mar. 1, 2014 Feb. 2014
Epiduroscopy, Epidural Lysis of Adhesions and Functional Anesthetic Discorgraphy
Feb. 1, 2014 Jan. 2014
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UnitedHealthcare of the River Valley Prior Authorization List and Policy Updates
Policy Title Effective Date Coverage Policy Update Bulletin
Femoroacetabular Impingement Syndrome Feb. 1, 2014 Jan. 2014
Gastrointestinal Motility Disorders, Diagnosis and Treatment Feb. 1, 2014 Jan. 2014
Genetic Testing for Hereditary Breast and/or Ovarian Cancer Syndrome (HBOC)
Feb. 1, 2014 Jan. 2014
Hearing Aids and other Devices Including Wearable, Bone Anchored and Semi-Implantable
Mar. 1, 2014 Feb. 2014
Home Health Care Mar. 1, 2014 Feb. 2014
Manipulation Under Anesthesia Mar. 1, 2014 Feb. 2014
Occipital Neuralgia and Cervicogenic, Cluster and Migraine Headaches Feb. 1, 2014 Jan. 2014
Oncology Medication Clinical Coverage Policy Feb. 1, 2014 Jan. 2014
Orthognathic and Jaw Surgery Mar. 1, 2014 Feb. 2014
Sandostatin®/ Sandostatin LAR® Depot (Octreotide Acetate) Mar. 1, 2014 Feb. 2014
Sensory Integration Therapy and Auditory Integration Training Mar. 1, 2014 Feb. 2014
Sodium Hyaluronate Mar. 1, 2014 Feb. 2014
Standing Systems Mar. 1, 2014 Feb. 2014
Stelara® (Ustekinumab) Mar. 1, 2014 Feb. 2014
SurgicalandAblativeProceduresforVenousInsufficiency and Varicose Veins
Mar. 1, 2014 Feb. 2014
Surgical Treatment for Spine Pain Feb. 1, 2014 Jan. 2014
Temporomandibular Joint Disorders Mar. 1, 2014 Feb. 2014
Vagus Nerve Stimulation Feb. 1, 2014 Jan. 2014
UnitedHealthcare Affiliates
For more information call 877.842.3210, or visit UnitedHealthcareOnline.com72 Network Bulletin: March 2014
HOME TABLE OF CONTENTS
Policy Title Effective Date Coverage Policy Update Bulletin
REPLACED/RETIRED
Biologics (Injection) for the Treatment of Skin, Joint and Gastrointestinal Conditions
Feb. 1, 2014 Feb. 2014
Cimizia (Certolizumab Pegol) Jan. 1, 2014 Jan. 2014
Compounded Medications Feb. 1, 2014 Feb. 2014
UnitedHealthcare of the River Valley Prior Authorization List and Policy 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,theprovisionsofthepostedpolicyprevail.
InsurancecoverageprovidedbyUnitedHealthcareInsuranceCompanyoritsaffiliates.HealthplancoverageprovidedbyUnitedHealthcareofCalifornia,UnitedHealthcareofColorado,Inc.,UnitedHealthcareofOregon,Inc.,andUnitedHealthcareofWashington,Inc.orotheraffiliates.AdministrativeservicesprovidedbyUnitedHealthCareServices,Inc.oritsaffiliates.
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