may 2019 empire plan network news · network news may 2019 unitedhealthcare empire plan medical...

NETWORK NEWSMay 2019

UnitedHealthcare

Empire Plan Medical Program CopaymentsAs you’ve seen in prior issues of Network News and via standalone Empire Plan Medical Copayment Guide mailings, there have been Empire Plan copayment changes for 2019. However, those changes apply only to certain Empire Plan employee groups as noted in the Copayment Guide. Not all Empire Plan employee groups have the same copayment requirements. Some have changed, but some have not.

Over the last few months, UnitedHealthcare and the State of New York have received complaints from Empire Plan enrollees indicating they had been charged an incorrect copayment. Please be sure to review the Guide carefully and/or verify the patient’s copayment liability via UHCprovider.com or by calling 1-877-7NYSHIP (1-877-769-7447). Changes to date have been outlined below.

The following employee groups continue to have a $20 copay for office visits and have NOT had copayment changes at this time:

• APSU

• Council 82

• PEF

• PIA (NYS Police Investigators Unit)

• Unified Court System – COBANC

The following employee groups have an office visit copay of $25 and experienced other copayment changes effective January 1, 2019:

• CSEA

• District Council 37

• NYS Retirees

• Participating Agencies – The Empire Plan (primarily local governments)

• Participating Employers (primarily public authorities)

• PBA – Supervisors

• PBA – Troopers

• Unified Court System – All Others

• UUP (Including Lifeguards)

On June 1, 2019, the following groups will experience an increase in the office visit copayment from $20 to $25 and experience other copayment changes:

• Management/Confidential

• NYSCOPBA

Enrollees in the Excelsior Plan continue to have an office visit copayment of $30.

Enrollees in the Student Employee Health Plan (SEHP) continue to have an office visit copayment of $10.

FEBRUARY 2019Front & Center

UHCTransitions Will Become UHCCareConnect and Be Available through Link Informational

Reminder: Non-Participating Providers Consent Form No

Win $500 in Our Go Paperless Sweepstakes Yes

Link Self-Service Updates and Enhancements Yes

Changes in Advance Notification and Prior Authorization Requirements No

Pharmacy Update: Notice of Changes to Prior Authorization Requirements and Coverage Criteria for UnitedHealthcare Commercial and Oxford No

MiniMed™ 670G System from Medtronic More Widely Available No

Updates to Requirements for Specialty Medical Injectable Drugs for UnitedHealthcare No

Commercial and Community Plan Members No

Next Phase Announced: More Fax Numbers Used for Medical Prior Authorization Retiring May 6, 2019 No

Prior Authorization Required for Therapeutic Radiopharmaceuticals No

Tell Us What You Think of Our Communications Informational

Dental Clinical Policy & Coverage Guideline Updates No

UnitedHealthcare Commercial

Peer Comparison Reports Sent to Select Specialists No

UnitedHealthcare Medical Policy, Medical Benefit Drug Policy and Coverage Determination Guideline Updates See Specific Policy

TAKE NOTE: Annual CPT® and HCPCS Code Updates

Bone or Soft Tissue Healing and Fusion Enhancement Products <Medical> Yes

Breast Imaging for Screening and Diagnosing Cancer <Medical> Yes

Brineura™ (Cerliponase Alfa) <Drug> Yes

Cardiovascular Disease Risk Tests <Medical> Yes

Carrier Testing for Genetic Diseases <Medical> No

Chemosensitivity and Chemoresistance Assays in Cancer <Medical> Yes

Clotting Factors, Coagulant Blood Products & Other Hemostatics <Drug> Yes

Crysvita® (Burosumab-Twza) <Drug> Yes

UnitedHealthcare Network Bulletin Articles & The Empire PlanThe following articles are included in the February 2019, March 2019, and April 2019 issues of UnitedHealthcare’s Network Bulletin. The table below denotes which articles apply to The Empire Plan and/or our Empire Plan Network providers. To access Network Bulletin, sign on to UHCprovider.com and select “News and Network Bulletin” in the “Resource Library” section (or select News and Network Bulletin in Quick Links at the bottom of the home page). Be sure to read the applicable articles and direct any questions you may have regarding Empire Plan impact to your Empire Plan network representative.

IMPORTANT NOTE: Starting with the April 2019 issue of UnitedHealthcare’s Network Bulletin, this article outlining The Empire Plan impact is being posted monthly on UHCprovider.com. To view The Empire Plan impact article, go to: UHCprovider.com MENU Resource Library News and Network Bulletin Latest Care Provider News

Network Bulletin: Article Topic Applies toThe Empire Plan?

2 The Empire Plan Network News - May 2019

Deep Brain and Cortical Stimulation <Medical> Yes

Enzyme Replacement Therapy <Drug> Yes

Extracorporeal Shock Wave Therapy (ESWT) <Medical> Yes

Genetic Testing for Hereditary Cancer <Medical> No

Gonadotropin Releasing Hormone Analogs <Drug> Yes

Habilitative Services and Outpatient Rehabilitation Therapy <CDG> No

Hearing Aids and Devices Including Wearable, Bone-Anchored and Semi-Implantable <Medical> Yes

Hepatitis Screening <Medical> Yes

High Frequency Chest Wall Compression Devices <Medical> Yes

Home Health Care <CDG> No

Ilumya™ (Tildrakizumab-Asmn) <Drug> Yes

Infliximab (Remicade®, Inflectra™, Renflexis™) <Drug> Yes

Intensity-Modulated Radiation Therapy <Medical> Yes

Luxturna™ (Voretigene Neparvovec-Rzyl) <Drug> Yes

Macular Degeneration Treatment Procedures <Medical> Yes

Maximum Dosage <Drug> Yes

Molecular Oncology Testing for Cancer Diagnosis, Prognosis, and No

Treatment Decisions <Medical> Yes

Neurophysiologic Testing and Monitoring <Medical> No

Neuropsychological Testing Under the Medical Benefit <Medical> No

Omnibus Codes <Medical> Yes

Onpattro™ (Patisiran) <Drug> Yes

Preventive Care Services <CDG> Yes

Proton Beam Radiation Therapy <Medical> Yes

Radicava™ (Edaravone) <Drug> Yes

Respiratory Interleukins (Cinqair®, Fasenra®, and Nucala®) <Drug> Yes

Rituxan® (Rituximab) <Drug> Yes

Self-Administered Medications List <Drug> No

Skin and Soft Tissue Substitutes <Medical> Yes

Sodium Hyaluronate <Medical> Yes

Surgical Treatment for Spine Pain <Medical> Yes

Therapeutic Radiopharmaceuticals <Medical> Yes

Trogarzo™ (Ibalizumab-Uiyk) <Drug> Yes

White Blood Cell Colony Stimulating Factors <Drug> Yes

NEW

Magnetic Resonance Imaging (MRI) and Computed Tomography (CT) Scan-Site Of Care <URG> No


The Empire Plan Network News - May 2019 3

UPDATED/REVISED

Ablative Treatment for Spinal Pain <Medical> Yes

Ambulance Services <CDG> No

Autologous Chondrocyte Transplantation in the Knee <Medical> Yes

Bone or Soft Tissue Healing and Fusion Enhancement Products <Medical> Yes

Botulinum Toxins A and B <Drug> Yes


Breast Repair/Reconstruction Not Following Mastectomy <CDG> Yes

Cardiovascular Disease Risk Tests <Medical> Yes

Clotting Factors, Coagulant Blood Products & Other Hemostatics <Drug> Yes

Cochlear Implants <Medical> Yes

Deep Brain and Cortical Stimulation <Medical> Yes

Durable Medical Equipment, Orthotics, Ostomy Supplies, Medical Supplies and Repairs/Replacements <CDG> Yes

Electric Tumor Treatment Field Therapy <Medical> Yes

Electrical Stimulation and Electromagnetic Therapy for Wounds <Medical> Yes

Fetal Aneuploidy Testing Using Cell-Free Fetal Nucleic Acids in Maternal Blood <Medical> No

Hearing Aids and Devices Including Wearable, Bone-Anchored and Semi-Implantable <Medical> Yes

Hepatitis Screening <Medical> Yes

Home Health Care <CDG> No

Implantable Beta-Emitting Microspheres for Treatment of Malignant Tumors <Medical> Yes

Infertility Diagnosis and Treatment <Medical> Yes

Infertility Services <CDG> Yes

Intensity-Modulated Radiation Therapy <Medical> Yes

Intraoperative Hyperthermic Intraperitoneal Chemotherapy (HIPEC) <Medical> Yes

Intravenous Enzyme Replacement Therapy (ERT) for Gaucher Disease <Drug> Yes

Macular Degeneration Treatment Procedures <Medical> Yes

Magnetic Resonance Spectroscopy (MRS) <Medical> Yes

Maximum Dosage <Drug> Yes

Mechanical Stretching Devices <Medical> Yes

Meniscus Implant and Allograft <Medical> Yes

Molecular Oncology Testing for Cancer Diagnosis, Prognosis, and Treatment Decisions <Medical> Yes

Omnibus Codes <Medical> Yes



Osteochondral Grafting <Medical> Yes

Percutaneous Vertebroplasty and Kyphoplasty <Medical> Yes

Private Duty Nursing Services (PDN) <CDG> Yes

Proton Beam Radiation Therapy <Medical> Yes

Respiratory Interleukins (Cinqair®, Fasenra®, and Nucala®) <Drug> Yes

Skilled Care and Custodial Care Services <CDG> Yes

Skin and Soft Tissue Substitutes <Medical> Yes

Speech Language Pathology Services <CDG> No

Spinal Ultrasonography <Medical> Yes

Surgical Treatment for Spine Pain Eff 1/1/2019 <Medical> Yes

Surgical Treatment for Spine Pain Eff 2/1/2019 <Medical> Yes

Temporomandibular Joint Disorders <Medical> Yes

Total Artificial Heart <Medical> Yes

Transpupillary Thermotherapy <Medical> Yes

Umbilical Cord Blood Harvesting and Storage for Future Use <Medical> Yes

Unicondylar Spacer Devices for Treatment of Pain or Disability <Medical> Yes

Vagus Nerve Stimulation <Medical> Yes

Xolair® (Omalizumab) <Drug> Yes

UnitedHealthcare Reimbursement Policies

Coordinated Reimbursement Policy Announcement See Specific Policy

Reminder: Clinical Laboratory Improvement Amendments (CLIA) ID Requirement Policy Yes

UnitedHealthcare Community Plan Reimbursement Policy No

UnitedHealthcare Community Plan ~This section does not apply to The Empire Plan~

UnitedHealthcare Medicare Advantage ~This section does not apply to The Empire Plan~

Doing Business Better

Coverage Determinations and UM Decisions (Financial Incentives) Yes

UnitedHealthcare Affiliates ~This section does not apply to The Empire Plan~

MARCH 2019Front & Center

Webinar Series on Adverse Childhood Experiences (ACEs) Yes

Congratulations to the First Two $500 Winners in the Go Paperless Sweepstakes Yes




Clinical Practice Guidelines Updated on UHCprovider.com Informational



More Fax Numbers for Medical Prior Authorization Will Retire No


Link Self-Service Updates and Enhancements Yes


Peer Comparison Reports to be Mailed in April No

UnitedHealth Premium® Updated Methodology and Version 12 Mailing No

Participating Provider Laboratory and Pathology Protocol No


NEW Yes

Electroencephalographic (EEG) Monitoring and Video Recording Medical Yes

Gamifant™ (Emapalumab-Lzsg) Drug Yes

Subcutaneous Implantable Hormone Pellets Drug No

Subcutaneous Implantable Naltrexone Pellets Drug Yes

UPDATED/REVISED Yes

Apheresis Medical Yes

17-Alpha-Hydroxyprogesterone Caproate (Makena™ and 17P) Drug Yes

Chromosome Microarray Testing (Non-Oncology Conditions) Medical Yes

Clinical Trials CDG No

Clotting Factors, Coagulant Blood Products & Other Hemostatics Drug Yes

Cognitive Rehabilitation Medical No

Collagen Crosslinks and Biochemical Markers of Bone Turnover Medical Yes

Electrical Stimulation for the Treatment of Pain and Muscle Rehabilitation Medical Yes

Habilitative Services and Outpatient Rehabilitation Therapy CDG No

Home Hemodialysis Medical Yes

Hospital Readmissions QOC No

Infertility Services CDG Yes

Light and Laser Therapy for Cutaneous Lesions and Pilonidal Disease Medical Yes

Magnetic Resonance Imaging (MRI) and Computed Tomography (CT) Scan — Site of Care URG No

Manipulation Under Anesthesia Medical Yes

Molecular Oncology Testing for Cancer Diagnosis, Prognosis, and Treatment Decisions Medical Yes

Negative Pressure Wound Therapy Medical Yes

Neurophysiologic Testing and Monitoring Medical Yes

Neuropsychological Testing Under the Medical Benefit Medical No



Outpatient Cardiac Telemetry Medical Yes

Pharmacogenetic Testing Medical Yes

Provider Administered Drugs — Site of Care Review Guidelines URG No

Sodium Hyaluronate Medical Yes

Surgical and Ablative Procedures for Venous Insufficiency and Varicose Veins Medical Yes

Total Artificial Disc Replacement for the Spine Medical Yes

Transcatheter Heart Valve Procedures Medical Yes

Transcranial Magnetic Stimulation Medical Yes

White Blood Cell Colony Stimulating Factors Drug Yes

Whole Exome and Whole Genome Sequencing Medical Yes


Revision to the Consultation Services Policy No




Doing Business Better

UnitedHealthcare Credentialing Plan 2019 – 2021 Summary of Changes Yes


APRIL 2019

Front & Center

Updates to Requirements for Specialty Medical Injectable Drugs for UnitedHealthcare Commercial, Community Plan and Medicare Advantage Members No


More Fax Numbers Used for Medical Prior Authorization Will Retire July 1, 2019 No


Congratulations to Our Go Paperless Sweepstakes Winners! Enter Today for Your Chance to Win $500 Yes

New Prior Authorization Requirement for In Patient Cerebral Seizure Video EEG Monitoring No




UnitedHealthcare Genetic and Molecular Lab Testing Notification/Prior Authorization Requirement No

2019 UnitedHealthcare Outpatient Procedure Grouper Exhibit Update — Effective July 1, 2019 Yes



108068_Network_News.indd 7108068_Network_News.indd 7 5/8/19 11:05 AM5/8/19 11:05 AM


TAKE NOTE

Medical Benefit Drug Policy Template Update Yes

UPDATED/REVISED

Abnormal Uterine Bleeding and Uterine Fibroids <Medical> Yes

Attended Polysomnography for Evaluation of Sleep Disorders <Medical> No

Blepharoplasty, Blepharoptosis and Brow Ptosis Repair <CDG> Yes


Breast Reduction Surgery <CDG> Yes

Buprenorphine (Probuphine® & Sublocade™) <Drug> Yes

Chelation Therapy for Non-Overload Conditions <Medical> Yes

Chemotherapy Observation or Inpatient Hospitalization <URG> No

Complement Inhibitors (Soliris® & Ultomiris™) <Drug> Yes

Continuous Glucose Monitoring and Insulin Delivery for Managing Diabetes <Medical> Yes

Cytological Examination of Breast Fluids for Cancer Screening <Medical> Yes

Elbow Replacement Surgery (Arthroplasty) <Medical> No

Electrical and Ultrasound Bone Growth Stimulators <Medical> Yes

Emergency Health Care Services and Urgent Care Center Services <CDG> No

Epidural Steroid and Facet Injections for Spinal Pain <Medical> Yes

Exondys 51® (Eteplirsen) <Drug> Yes

Extracorporeal Shock Wave Therapy (ESWT) <Medical> Yes

Glaucoma Surgical Treatments <Medical> Yes

Gonadotropin Releasing Hormone Analogs <Drug> Yes

Hip Resurfacing and Replacement Surgery (Arthroplasty) <Medical> No

Hospital Readmissions <QOC> No

Hysterectomy for Benign Conditions <Medical> No

Ilumya™ (Tildrakizumab-Asmn) <Drug> Yes

Immune Globulin (IVIG and SCIG) <Drug> Yes

Immune Globulin Site of Care Review Guidelines for Medical Necessity of Hospital Outpatient Facility Infusion <URG> No

Implanted Electrical Stimulator for Spinal Cord <Medical> Yes

Inpatient Pediatric Feeding Programs <URG> No

Knee Replacement Surgery (Arthroplasty), Total and Partial <Medical> No



Obstructive Sleep Apnea Treatment <Medical> Yes

Office Based Program <URG> No

Orthognathic (Jaw) Surgery <CDG> Yes

Panniculectomy and Body Contouring Procedures <CDG> Yes

Platelet Derived Growth Factors for Treatment of Wounds <Medical> Yes

Pneumatic Compression Devices <Medical> Yes

Preventive Care Services <CDG> Yes

Propranolol Treatment for Infantile Hemangiomas: Inpatient Protocol <URG> No

Rhinoplasty and Other Nasal Surgeries <CDG> Yes

Shoulder Replacement Surgery (Arthroplasty) <Medical> No

Speech Language Pathology Services <CDG> No

Surgical Treatment for Spine Pain <Medical> Yes

Temporomandibular Joint Disorders <Medical> Yes

Vagus Nerve Stimulation <Medical> Yes


Coordinated Commercial Reimbursement Policy Announcement See Specific Policy

Procedure to Modifier Policy, Professional Yes

Maximum Frequency per Day (MFD) Policy, Professional Yes

Consultation Services Policy, Professional No

Reimbursement Policy Name Change for UnitedHealthcare Medicare Advantage No





State News

New Prior Authorization Requirement for In Patient Cerebral Seizure Video EEG Monitoring No


Neonatal Resource Services Clinical Guideline: Inhaled Nitric Oxide (iNO) No

Outpatient Injectable Drug Prior Authorization Requirements for UnitedHealthcare Community Plan Kansas No

UnitedHealthcare Genetic and Molecular Lab Testing Notification/Prior Authorization Requirement No




Empire Plan Network AcupuncturistsAs noted in our February 2019 issue of Network News, The Empire Plan has expanded its participating provider network to include licensed acupuncturists. Visits to network acupuncture providers are subject to the applicable office visit copayment. To locate a network acupuncturist, visit the online provider directory at www.empireplanproviders.com or call 1-877-7-NYSHIP (1-877-769-7447) and press or say 1 for the Medical/Surgical Program.

Network acupuncture providers may not be available in all geographic regions; however, the network will continue to expand throughout 2019.

Does your practice include a licensed acupuncturist? Let us know by writing to Empire Plan Network Management at PO Box 2300, Kingston, NY 12402-2300, or reaching out to your Empire Plan Network contact.

Don’t Forget … We’re here for you! And, we’re listening. The Empire Plan Network News is here to keep you informed on all things related to The Empire Plan and your network participation. Have a topic that you’d like us to cover in Network News? Just let us know! Write to us at Empire Plan Network News, UnitedHealthcare, 505 Boices Ln, Kingston, NY 12401. Or, shoot us an email at [email protected]!


June 2019Medical Program Copayment Guide

Employee Group Drug List +

APSU Flexible Formulary $201 $201 $201 $201 $30

Council 82 Flexible Formulary $201 $201 $201 $201 $30

CSEA Advanced Flexible Formulary $251 $251 $301 $301 $50

District Council 37 Advanced Flexible Formulary $251 $251 $301 $301 $50

Management/Confidential Advanced Flexible Formulary $251 $251 $301 $301 $50

NYS Retirees Flexible Formulary $251 $251 $301 $301 $50

NYSCOPBA Advanced Flexible Formulary $251 $251 $301 $301 $50

Participating Agencies – The Empire Plan(primarily local governments)

Flexible Formulary $251 $251 $301 $301 $50

Participating Employers(primarily public authorities) Flexible Formulary $251 $251 $301 $301 $50

PBA – Supervisors Advanced Flexible Formulary $251 $251 $301 $301 $50

PBA – Troopers Advanced Flexible Formulary $251 $251 $301 $301 $50

PEF Flexible Formulary $201 $201 $201 $201 $30

PIA(NYS Police Investigators Unit) Flexible Formulary $201 $201 $201 $201 $30

Unified Court System – COBANC Flexible Formulary $201 $201 $201 $201 $30

Unified Court System – All Others Advanced Flexible Formulary $251 $251 $301 $301 $50

UUP (Including Lifeguards) Advanced Flexible Formulary $251 $251 $301 $301 $50

Participating Agencies –The Excelsior Plan(primarily local governments)

The Excelsior Plan Drug List $302 $302

($753) $302 $302

($753) $75

Student Employee Health Plan (SEHP) Flexible Formulary $102 $102 $10

There are NO COPAYMENTS due for: • Allergy Immunizations/Serum (except SEHP which has no coverage for allergy immunizations/serum)• Chemotherapy• Hemodialysis Prenatal Care• Radiation Therapy• Well Child Care• Services defined as Essential Preventive Services by the Patient Protection and Affordable Care Act (PPACA), also known as Federal Health Care Reform.

These services are summarized on the 2019 EMPIRE PLAN PREVENTIVE CARE COVERAGE CHART. Additional information regarding Preventive Care Services can be found at: UHCprovider.com • Policies and Protocols • Commercial Policies • Medical & Drug Policies and Coverage Determination Guidelines • Preventive Care Services

+ Medicare-primary enrollees and Medicare-primary dependents enrolled in Empire Plan Medicare Rx utilize a Part D drug list (Abridged Formulary) and Non-Part D drug list (Bonus Drug List). Enrollees and dependents who do not have Medicare as primary coverage utilize the drug lists noted in this column.

1 – Maximum of 2 copayments per service date. Combine Visit & Surgery or Radiology Service & Laboratory Service. 2 – Maximum of 1 copayment per service date.3 – Copayment for Diagnostic Radiology and Imaging Services subject to Prospective Procedure Review (MRI, MRA, CT, PET, Nuclear Medicine Tests).

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Empire Plan Network ManagementUnitedHealthcarePO Box 2300Kingston, NY 12402-2300

ADDRESS SERVICE REQUESTED

The Empire Plan Network News is published and privately distributed by UnitedHealthcare Insurance Company ofNew York for informational use by the physicians and providers of The Empire Plan Network. The information contained herein does not supersede any pertinent state or federal regulations. Network News does not offer financialor medical advice. In the event of discrepancies, healthbenefit plan documents are controlling.

INSIDE THIS ISSUE:

• Empire Plan Medical Program Copaymentspage #1

• UHC Network Bulletin – February, March & April 2019 pages #2-9

• Empire Plan Network Acupuncturists page #10

• Don’t Forget page #10

• Medical Program Copayment Guide page #11

Send your Empire Plan claims and written inquiries regarding claims issues to:

Empire Plan ClaimsPO Box 1600Kingston, NY 12402-1600

Send written inquiries regarding Empire Plan Network participation issues and changes to your contractual identifiers, such as tax identification number(s) or practitioners joining/leaving your practice, to:

Empire Plan Network Management505 Boices LnKingston, NY 12401

Send changes to your practice demographic information, such as address(es), telephone number(s), etc., to:

• UHCprovider.com;

• Fax# (855) 773-3156; or

• The Empire Plan Network Management address above (only if you do not have internet or fax access).

If you are unsure regarding any aspect of The Empire Plan, please call 1-877-7NYSHIP (1-877-769-7447).


may 2019 empire plan network news · network news may 2019 unitedhealthcare empire plan medical...

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