Network Bulletin: January 2014 - Volume 59 network bulletin · te t nre en rern te e t n teete re n...

An important message from UnitedHealthcare to health care professionals and facilities

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

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

network bulletinNetwork Bulletin: January 2014 - Volume 59

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: January 2014 - Volume 59

Front & Center UnitedHealthcare Commercial

UnitedHealthcare Reimbursement Policy

UnitedHealthcare Medicare Solutions

UnitedHealthcare Community Plan

Doing Business Better

UnitedHealthcare Pharmacy

UnitedHealthcare Claims, Billing & Coding

UnitedHealthcare Affiliates

Front & Center• UnitedHealthcare Medicaid Policy Alignment

• 2014 UnitedHealthcare Administrative Guide Available –Effective April 1, 2014

• ImportantChangesinAdvanceNotificationandPriorAuthorizationRequirements for Home Health Services for Medicare Advantage Plans

• UnitedHealthcare Community Plan to Start Using NationalComprehensive Cancer Network Compendium

• InjectableChemotherapyPriorAuthorizationProgramforFloridaProviders

• UnitedHealthcare Shared Services Expansion for GEHA

• myHCE: Providing Cost Transparency for aMore Informed Health Care Consumer

• Prepare for UnitedHealthcareOnline.com LoginMigration to Optum Cloud Dashboard

• The CMS “Two Midnight Rule” – Effective Oct. 1, 2013

• 2014: The Year of the ICD-10 Code

• Enhanced HIPAA Edits to be Applied to Claim Submissions

• HIPPS Codes Requirement for Home Health Careand Skilled Nursing Facility Encounters

• MedicareAdvantagetoRequirePriorAuthorizationfor IMRT, SRS and SBRT as of April 1

• MedicareAdvantageRadiologyandCardiologyPriorAuthorizationProgram to Deploy for UnitedHealthcare West MedicareNon-Capitated Participating Providers on April 1, 2014

• Women’s Preventive Care Services Updates

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UnitedHealthcare Commercial

Network Bulletin: January 2014 - Volume 59 For more information call 877.842.3210, or visit UnitedHealthcareOnline.com3

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• UnitedHealthcare Medical Policy, Drug Policy, Coverage DeterminationGuidelineandUtilizationReviewGuidelineUpdates

• NewDisease-specificIMRTFormsforUnitedHealthcarePriorAuthorizationProcess

• The Preferred Payment Method for Your UnitedHealthcarePatients: Member Payments

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• UnitedHealthcare Reimbursement Policy

• Revision to CCI Editing Policy

• Revision to the Professional/Technical Component Policy - Denialof Drug Administration Codes and PC/TC Indicator 8

• Multiple Procedure Policy Revisions to Apply to Same Group

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• 2013 Member Rewards Program – Better Health has its Rewards

• UnitedHealthcare Wins Bid for State of Illinois

• UnitedHealthcare Medicare Advantage Coverage Summary Updates

• ReminderforAdvanceNotificationandPriorAuthorization

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• Important Reimbursement Policy Reminder

• Provider Disclosure of Ownership Form Now Online

• Changes to the UnitedHealthcare Community Plan of PennsylvaniaClaims Payer ID and Electronic Remittance Advice Payer ID

• Readmission Policy Frequently Asked Questions


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• Important Change: Arriva Medical has Acquired Diabetes Care Club

• Medline Industries Joins Network

• UnitedHealthcare Preventive Plan Design

• Introducing COB Smart™: Receive Payments Accurately, Predictably and Reliably

• UnitedHealthcare’s Position on “Never Events”

• Navigate Products and Related Administrative Processes

• Physician and Provider Demographic Changes

• Training Sessions for Electronic Solutions

• Wellness Programs: Recommending Alternative Actions

• ElectronicInpatientAdmissionNotifications

• Checking Status of Claim Reconsideration Requests With Attachments

• CoverageDeterminationandUtilizationManagementDecisions

• All Savers Alternative Funding Product - New Portal

• UnitedHealth Premium® Results Available to Public Soon

• BMI Documentation in the Medical Record


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• Medicare Change to Physician-initiated Prescriptions at Mail Pharmacies

• EffectiveFeb.1,2014:NewPriorAuthorizationRequirementsforEnzymeReplacementMedications(ForUnitedHealthcareIntegratedCommercial Fully Insured and Self-funded Plans Only)

• New OptumRx Specialty Pharmacy Resource Guide

• Reminder: 25 Specialty Medications Added to Coupon Policy for Jan. 1, 2014

• UnitedHealthcareConsolidatedPharmacyBenefitProgram


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• AccurateBillingImprovesOfficeEfficiencyandDualSNPMemberSatisfaction

• AccessingExplanationsofBenefitsOnline

• Coding Update to Facility OPG Mapping – Effective Jan. 1, 2014


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UnitedHealthcareAffiliates

• Oxford Medical and Administrative Policy Updates

• UnitedHealthcareoftheRiverValleyPreauthorizationListandPolicyUpdates

• SignatureValue™BenefitInterpretationPolicyUpdates

• SignatureValue™ Medical Management Guideline Updates

• UnitedHealthcare of the River Valley and Neighborhood Health Partnership:Disease Management Programs


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<< FIRST SECTION

Front & Center

Effective March 1, 2014, UnitedHealthcare Community Plan will align our medical policies with the rest of UnitedHealthcare’s medicalpolicies,toprovideastreamlined,simplifiedexperienceforproviders caring for members of our various health plans.

The policies are available at UnitedHealthcareOnline.com >Tools & Resources > Policies, Protocols and Guides > Medical & Drug Policies and Coverage Determination Guidelines.

Our medical policies, including established and new technologies, explain how we determine whether a service(e.g.,test,deviceorprocedure)is proven to be effective and/or to have abenefitonhealthoutcomesbasedonthe published clinical evidence. They are also used to decide whether a given health service is medically necessary. Services determined to be experimental, investigational, unproven, or not medically necessary by the clinical evidence are typically not covered.

Weunderstandthatthefirstlevelof review for medical policies is the determination of coverage which is basedonwhattheStatedefinesascoveredbenefits.Iftheserviceisnotacoveredbenefit,thenthemanagedcareorganizationdoesnothaveanyresponsibility to pay for the service. However, if the service is determined tobeacoveredbenefit,wehavetheresponsibility to determine if the service falls into the category of “medically necessary” based on clinical evidence and guidance.

UnitedHealthcare Medicaid Policy Alignment

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Medical policies are developed as needed and represent one of the important resources used to support UnitedHealthcare’s coverage decision making. Policies are developed as needed and subject to change through regular review.

New and updated medical policy changes will be communicated in the Medical Policy Update Bulletin at UnitedHealthcareOnline.com > Tools & Resources > Policies, Protocols and Guides > Medical & Drug Policies and Coverage Determination Guidelines > Medical Policy Update Bulletin.

UnitedHealthcare Medicaid Policy Alignment

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2014 UnitedHealthcare Administrative Guide Available – Effective April 1, 2014

This essential resource for physicians, hospitals, facilities and other health care providers is now posted on UnitedHealthcareOnline.com. Download it today!

Important Updates in the 2014 Guide Include:

• AdvanceNotificationList-TheAdvanceNotificationlistofprocedurecodeshasmoved online for your convenience at UnitedHealthcareOnline.com > Clinician Resources > Advance & Admission Notification Requirements. Please reference the complete article for more details in the January Network Bulletin.

• Optum Cloud Dashboard - Is a cloud-based website that has new features and functionality which allows providers to submit claim reconsideration requests electronically with attachments.

• High Performing Networks - Expansion of new Commercial product offerings for UnitedHealthcare Compass.

• Exchanges - New product details on Individual Marketplace and/or Small Business HealthOptionsProgram(SHOP)Marketplacelanguage added in the Commercial Product section.

• Retroactive Eligibility Changes - Eligibility changes may occur retroactively if the member fails to pay their premium within a three monthgraceperiodforsubsidizedIndividual Exchange members.

Supplement Updates and Changes for 2014:

• Oxford Commercial Provider Reference Manual has been consolidated into a Supplement of the UnitedHealthcare Guide.

• OneNet Provider Manual has been consolidated into a Supplement of the UnitedHealthcare Guide.

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2014 UnitedHealthcare Administrative Guide Available – Effective April 1, 2014

• Medicare Advantage Capitated Provider Supplement - A new supplement for all non-UnitedHealthcare West capitated providers.

• Oxford Medicare Advantage Supplement has been removed and content has been integrated with the UnitedHealthcare standard Medicare Advantage section.

• UnitedHealthOne and All Savers Supplements are now two separate supplements to the Guide and have been revised in accordance with the current product offerings. Most notably, the Choice Plus product offered by Golden Rule is now subjecttothestandardAdmissionNotification requirements described in the Guide. New products offered by UnitedHealthcare Life Insurance Company(UHCLIC)arenowsubjecttothestandard Advance AND AdmissionNotificationrequirements described in the Guide.

Other Sections That Include Updates: WhenisAdvanceNotificationRequired,CardiologyNotification/PriorAuthorizationProtocolforCommercialCustomers,RadiologyNotification/PriorAuthorizationProtocol for Commercial Customers, Specialty Drug PriorAuthorizationforMedicalBenefit(forCommercialCustomers only), Self-Referral and Anti-Kickback, Claim reconsideration and appeals process and resolving disputes and UnitedHealth Premium Designation Program(forCommercialCustomersonly).

Please contact your Network Management representative, Physician Advocate, or Hospital & Facility Advocate for a hard copy of the UnitedHealthcare Administrative Guide orAdvanceNotificationList.

* Except as otherwise noted, the new Guide is effective on April 1, 2014 for currently contracted providers, and effective immediately for providers newly contracted on or after Jan. 1, 2014.

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ImportantChangesinAdvanceNotificationandPrior AuthorizationRequirementsforHomeHealthServices for Medicare Advantage Plans

EffectivefordatesofserviceonorafterFeb.1,2014,AdvancedNotificationfortheinitial60 days of home health services is no longer required for the following list of home health services.Notificationforthesecondandsubsequent60daysofcontinuoushomehealthservices will be required. Clinical documentation may be requested in order to determine coverage for these services. Home infusion services are not included.

• Nursing services in the home, including RN, LPN, and Home Health Aide

• Therapies in the home, including occupational, physical, speech and respiratory

• Social worker in the home

Authorization requests should include:

• Start of care date

• The date span for service being requested

• Home health service codes and diagnosis codes

• The number of units for each service requested, if applicable

The following documentation should be maintained for home health services in accordance with the Centers forMedicare&MedicaidServices(CMS)guidelinesand may be requested for clinical review:

• Current plan of care

• Face-to-faceencounter(documentationthephysician has seen the patient and written the order)

• Signed plan of care from previous 60 days (requiresphysiciansignature)

• Current nursing and therapy notes with brief clinical summary and assessment of the patient including homebound status

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Please remember that private duty nursing and hospice services are generally not a covered benefitforMedicareAdvantagePlans.Therearesomeexceptions.Forquestionsregardingbenefitcoverage please contact Customer Service at the # on the back of the member’s ID card.

ThereisnochangetotheAuthorizationrequirementsrelated to Enteral Feed Services.

Medicare coverage rules are still in effect for MedicareAdvantagemembersandspecificserviceswill continue to not be covered by Medicare, including but not limited to home health services furnished when the member is not in need of any other skilled service and part time or intermittent skillednursingorhomehealthaideservices(whencombined) greater than eight hours a day or more than28hoursperweekexceptwhenauthorizedona case-by-case basis to be more than eight hours a day and 35 hours or fewer hours per week.

ImportantChangesinAdvanceNotificationandPrior AuthorizationRequirementsforHomeHealthServices for Medicare Advantage Plans

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UnitedHealthcare Community Plan to Start Using National Comprehensive Cancer Network Compendium

Effective Feb. 15, 2014, UnitedHealthcare Community Plan will start using the National ComprehensiveCancerNetwork(NCCN)Compendiuminreviewingrequestsforcoverageforchemotherapyinjectabledrugs(J9000–J9999)administeredinanoutpatientsettingfor members ages 19 and older. The NCCN Compendium provides an independent resource for use in making chemotherapy coverage decisions.

There are some important details to note with this policy:

1. If the NCCN Compendium lists the drug with a recommendation level 1, 2A or 2B for the condition, the service is eligible for reimbursement basedonthemember’scertificateofcoverage.Ingeneral, we do not cover recommendations with Level 3 evidence.

2. NCCN updates its compendium as new drugs or changes are made.

3. This new drug policy requires that you always include the primary cancer diagnosis on the claim. Claims submitted with only a V58.1 diagnosis code may require additional information prior to a coverage decision.

4. Thispolicyappliestochemotherapydrugs(J9000– J9999). It does NOT apply to supportive care drugs(i.e.,erythropoiesis-stimulatingagents,antiemtics, colony stimulating factors).

5. The policy applies to members ages 19 and older. The majority of pediatric patients receive treatments on national pediatric protocols that are similar in concept to the NCCN patient care guidelines.

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InjectableChemotherapyPriorAuthorizationProgramfor Florida Providers

Effective second quarter 2014, providers in Florida billing for outpatient injectable chemotherapy for members being treated for a cancer diagnosis insured by Neighborhood HealthPartnership(NHP)orUnitedHealthcarewillberequiredtoobtainpriorauthorization.

UnitedHealthcare’s Injectable Chemotherapy Prior AuthorizationProgramwillbemanagedbyCareCoreNational’s Oncology Division and providers will be able toobtaininjectablechemotherapyauthorizationsonCareCore’s website.

AuthorizationsthatfollowNCCNregimenswillbe approved at the time of the request online. Requests for pediatric chemotherapy regimens, rare cancers, or chemotherapy regimens that are not NCCN recommended, can also receive a timely response if necessary supporting documentation is provided at thetimeofpriorauthorizationrequest.

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UnitedHealthcare Shared Services Expansion for GEHA

Through a shared services arrangement, UnitedHealthcare provides access to the UnitedHealthcare Options Preferred Provider Organizations(PPO)NetworktoGovernmentEmployeesHealthAssociation(GEHA)members in AL, AK, CO, DC, DE, ID, IA, LA, MD, MS, MT, MN, NE, NM, ND, OK, SD, TN, UT, VA, WV, WI and WY.

As of Jan. 1, 2014, GEHA will be accessing UnitedHealthcare Options PPO provider contracts in the state of Ohio. GEHA is the second-largest national health plan for civilian federal employees nationwide. Please check the back of the member’s ID card for contact information.

Foreligibility,summaryofbenefits,outpatientprecertificationrequirementsandclaim status, call the dedicated self-service line at 877-343-1887 or email [email protected].

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myHCE: Providing Cost Transparency for a More Informed Health Care Consumer

UnitedHealthcarelaunchedthemyHealthcareCostEstimator(myHCE)lastyearto assist members in making informed decisions regarding treatment options, providers and cost estimates.

myHCE is an integrated online tool providing quality rating information and cost estimates for common treatments and procedures for in-network hospitals andphysicians.Estimatesarepersonalizedtoreflectamember’sspecifichealthplanbenefits,includingtheir real-time copays and deductibles.

We continue to enhance myHealthcare Cost Estimator to empower members with relevant information about estimated health care costs and quality rating information. Changes in 2014 to myHCE include:

• Continued expansion of Care Paths to include inpatient and outpatient high volume services such as behavioral health

• Cost estimates for Optum business

• Effective Jan. 1, 2014, a limited offering to one MedicareNationalPreferredProviderOrganization(NPPO)RetireePlan(StateHealthPlanofNorthCarolina retirees). Currently the tool is not available to other Medicare members.

• Support for Executive Medical Plan

Resources for Network Hospitals and Physicians can be found on UnitedHealthcareOnline > Tools & Resources > Health Resources for Patients > Transparency (myHCE).

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Prepare for UnitedHealthcareOnline.com Login Migration to Optum Cloud Dashboard

If you haven’t already transitioned to the new UnitedHealthcareOnline.com login process, you will be transitioned early this year. Please watch for an email notifying you of your migration date.

When you login to UnitedHealthcareOnline.com on that date and after, you will automatically be redirected to the Optum Cloud Dashboard website.

If you are registered on Optum Cloud Dashboard, you will be able to return to UnitedHealthcareOnline.com or stay on Optum Cloud Dashboard to use the available applications. No further action is required for login migration.

If you aren’t registered, please follow the steps for Password Owners or Standard Users so that you can continue to use secure transactions on UnitedHealthcareOnline.com.

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The CMS “Two Midnight Rule” – Effective Oct. 1, 2013

TheCentersforMedicare&MedicaidServices(CMS)2014FiscalYearInpatientProspectivePaymentSystemFinalRulebecameeffectiveOct.1,2013andincludesclarificationaboutwhena patient should be admitted to the hospital.

This provision, known as the “Two Midnight Provision,” is intended to help you and auditors determine whether a MedicareclaimshouldbebilledunderPartA(inpatient) orPartB(outpatient).

UnitedHealthcare started implementing the CMS Two-Midnight Provision for our Medicare Advantage plans in October2013byincorporatingtheclarificationintoourconcurrent review programs. We plan to fully integrate the provision over the coming year.

Please review the links at the end of this article for details about the provision, which states that if a member requires medically necessary hospital care that is expected to span

two or more midnights, inpatient admission is appropriate. If you expect the member’s medically necessary treatment will span less than two midnights, assign it outpatient status.1

TheFinalRuleemphasizestheneedforaformalorder of inpatient admission to begin inpatient status, but permits the physician to consider all time a patient has already spent in the hospital as an outpatient receiving observation services, or in the emergency department, operating room, or other treatment area in guiding their two-midnight expectation.

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The CMS “Two Midnight Rule” – Effective Oct. 1, 2013

The Final Rule supports the continued use of evidence-based guidelines to help with deciding whether to admit a patient. Therefore, UnitedHealthcare will continue to use evidence-based guidelines to support consistent, clinically validated decision-making for hospital admissions which are medically necessary. We will review “the reasonableness of the physician’s expectation of the need for and duration of care based on complex medical factors such as history and comorbidities, the severity of signs and symptoms, current medical needs and the risk of an adverse event, which must be clearly documented.” 2 While CMS has delayed enforcing the Two Midnight Provision, they have not changed the effective date of Oct. 1, 2013. Rather, they are issuing guidance to MedicareAdministrativeContractors(MACs)abouthowto select hospital claims for review during a “Probe and Educate” program for admissions that occur between Oct. 1, 2013 and March 31, 2014. While this guidance is not directed towards Medicare Advantage plans, we will continue to monitor CMS publications while developing

our internal clinical review programs, and will continue to work collaboratively with you as we adapttotheseclarifications.

CMS resources: Federal Register/Vol. 78, No. 160/Monday, August 19, 2013:http://www.gpo.gov/fdsys/pkg/FR-2013-08-19/pdf/2013-18956.pdf

CMS FAQ: http://cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/Medical-Review/Downloads/QAsforWebsitePosting_110413-v2-CLEAN.pdf

Selecting claims for patient status reviews: http://cms.gov/Research-Statistics-Data-and-Systems/Monitoring-ProgramsMedical-Review/Downloads/SelectingHospitalClaimsfor ReviewForWebPostingCLEAN.pdf

Reviewing hospital claims for patient status: http://cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/Medical-Review/Downloads/ReviewingHospitalClaimsforAdmissionFINAL.pdf

1CMS Frequently Asked Questions: 2 Midnight Inpatient Admission Guidance and PatentStatusReviewsforAdmissionsafterOctober1,2013(“CMSFAQ”)(QuestionandAnswerNo.8):http://cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/Medical-Review/Downloads/QAsforWebsitePosting_110413-v2-CLEAN.pdf

2CMSFAQ(QuestionandAnswerNo.9)

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To support our providers during this transition, UnitedHealthcare offers the following tools at UnitedHealthcareOnline.com to assist you in becoming ICD-10 compliant:

• ICD-10 Education - on-demand educational resources designed to provide general information regarding ICD-10 and the implementation process.

• ICD-10 Tools - in collaboration with the American AcademyofProfessionalCoders(AAPC),thelargestcodingorganizationinthecountry,wehavecreateda suite of tools including ICD-10 code selection decision trees and detailed clinical documentation improvement webinars.

• ICD-10 Resources - a listing of industry-wide ICD-10 resources.

• ICD-10 Partnerships - in addition to AAPC, we are working with Optum to offer value-added solutions for cost-effective adoption of ICD-10.

For answers to your questions regarding ICD-10, please send your inquiry to [email protected].

2014: The Year of the ICD-10 Code

This year the health care industry will adopt and use International ClassificationofDisease, TenthRevision(ICD-10)codes. The Department of Health and Human Services mandates the use of ICD-10 codes for dates of service on or after Oct. 1, 2014.

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Effective April 23, 2014, UnitedHealthcare will apply an enhanced level of HIPAA edits to professional(837p)andinstitutional(837i)claimssubmitted electronically to most UnitedHealthcare andaffiliatepayer IDs.*

Because the new edits will be applied on a pre-adjudication basis, an increase in the number of claim rejections may occur. This will enable you to identify and correct rejected information prior to the claim’s acceptance into our adjudication system for processing.Thebenefitwillbefewerdeniedclaims and less interruption to revenue streams.

The primary impact to you will come from edits that willvalidatecodesets(suchasdiagnosis,procedure, modifierandnationaldrugcodes)atapre-adjudication level. The complete list of enhanced edits has been distributed to clearinghouses and software vendors.

It is important to check all of your claim submission reports regularly. Claims may be rejected by your clearinghouse or UnitedHealthcare; therefore, you may receive multiple reports per submission.

Visit UnitedHealthcareOnline.com for more information about tracking your electronic claims.

Rejections that may occur from the enhanced edits will appear at a clearinghouse level. Your Electronic Data Interchange(EDI)vendororclearinghouseshouldbeyourfirstpointofcontactforassistanceregardingtheseedits or to resolve rejections. For more information, please contact EDI Support:

* Exceptions:HarvardPilgrim(04271),MedicaHealthCarePlans(78857),PreferredCarePartners(65088),TheAlliance(88461)andTRICAREWest(99726)

Enhanced HIPAA Edits to be Applied to Claim Submissions

UnitedHealthcare Commercial, UnitedHealthcare Medicare Solutions and UnitedHealthcare West

EDI issue reporting form or 800-842-1109

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

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

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In the November 2013 Network Bulletin, we informed you of CMS’s new requirement for all Medicare Advantage OrganizationstobeginsubmittingHIPPScodesonallskillednursing facility and home health care encounter data. Since our last communication, CMS has delayed implementation of the requirement to July 1, 2014. You should continue to prepare your systems and processes to be able to provide HIPPS codes on claims for UnitedHealthcare Medicare Advantage members, however until further notice, please continue to submit claims to us as you have in the past. We will notify you in advance regarding when to begin submitting HIPPS codes on claims. IntheabsenceofspecificCMSguidance,atthistimepleasefollowthestandard Medicare process for identifying the appropriate HIPPS codes for your patients.

HIPPS Codes Requirement for Home Health Care and Skilled Nursing Facility Encounters

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EffectiveApr.1,2014,MedicareAdvantagehealthplanswillrequirepriorauthorizationforIntensityModulatedRadiationTherapy(IMRT),StereotaxicRadiosurgery(SRS)andStereotacticBodyRadiationTherapy(SBRT)whenadministeredinanoutpatientsetting.

Additional details about the program will be posted on our physician portal in two locations: UnitedHealthcareOnline.com > Clinical Resources > Cancer – Oncology > IMRT – Medicare Advantage. You can also go to: UnitedHealthcareOnline.com > Clinical Resources > Cancer – Oncology > SRS and SBRT – Medicare Advantage.

Medicare Advantage IMRT, SRS and SBRT Prior Authorizationtrainingandlivequestionandanswersessions will be hosted by WebEx in March 2014. Additionally, registration details will be posted on the websites in March 2014. See the above websites for specificscheduledates.

MedicareAdvantagetoRequirePriorAuthorization for IMRT, SRS and SBRT as of April 1

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MedicareAdvantageRadiologyandCardiologyPriorAuthorizationProgram to Deploy for UnitedHealthcare West Medicare Non-Capitated Participating Providers on April 1, 2014

UnitedHealthcare West Medicare Advantage Non-Capitated

Beginning April 1, 2014, participating physicians, facilities and other health care professionals who are subject to the Administrative Guide and the UnitedHealthcare West Non-Capitated Supplement and practice in Arizona,Oklahoma,Oregon,TexasandWashington,mustobtainpriorauthorizationforcertainoutpatientradiologyprocedures before they are rendered to UnitedHealthcare West Medicare Advantage members. Those states, as well as Colorado, must also do the same for cardiology procedures, beginning April 1, 2014.

Radiology Prior Authorization

Beginning April 1, 2014:

• Ordering providers who are subject to the Administrative Guide and the UnitedHealthcare West Non-CapitatedSupplementandpracticeinArizona,Oklahoma, Oregon, Texas and Washington will have a new phone number and website link that is to be used toobtainpriorauthorization

prior to scheduling certain CT, MRI, MRA, PET scan, Nuclear Medicine, and Nuclear Cardiology procedures for UnitedHealthcare West Medicare Advantage members. The advanced imaging proceduresrequiringpriorauthorizationarereferredto as advanced outpatient imaging procedures.

Ordering providers will need to obtain the required prior authorizationnumberbyusingthenewcontactmethods:

• Online: UnitedHealthcareOnline.com > Notifications/Prior Authorizations > Radiology Notification & Authorization - Submission & Status.

• Phone: 866-889-8054 - select the option for Medicare Advantage customers and then select the option for outpatient diagnostic imaging.

Onceapriorauthorizationrequestforaplannedadvanced outpatient imaging procedure is received, UnitedHealthcare will conduct a clinical coverage review to determine whether the service is medically necessary. The provider will be informed of the decision.

For a complete list of CPT Codes that require prior authorization,pleasevisitUnitedHealthcareOnline.com > Clinician Resources > Radiology > Medicare Advantage Radiology Prior Authorization Program > 2014 Radiology Prior Notification/Authorization CPT Code List.

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• Rendering providers who are subject to the Administrative Guide and the UnitedHealthcare West Non-Capitated Supplement and practice in Arizona,Oklahoma,Oregon,TexasandWashingtonmustconfirmthatthepriorauthorizationprocesshasbeencompleted and a coverage decision has been issued before rendering any advanced outpatient imaging procedure. If the ordering provider does not participate in UnitedHealthcare West’s network and is unwilling to completethepriorauthorizationprocess,therenderingprovidermustcompletethepriorauthorizationprocessandverify that a coverage decision has been issued prior to rendering the advanced outpatient imaging procedure.

Providersarenotrequiredtoobtainpriorauthorizationforanyadvanced imaging procedures rendered in an emergency room, urgent care center, observation unit or during an inpatient stay.

Cardiology Prior Authorization

Beginning April 1, 2014:

• Ordering providers who are subject to the Administrative Guide and the UnitedHealthcare West Non-CapitatedSupplementandpracticeinArizona,Colorado, Oklahoma, Oregon, Texas and Washington

mustobtainpriorauthorizationpriortoschedulingcertaindiagnosticcatheterizations,electrophysiologyimplants,echocardiograms and stress echocardiograms procedures for UnitedHealthcare West Medicare Advantage members.

For a complete list of CPT Codes that requirepriorauthorization,pleasevisit UnitedHealthcareOnline.com > Clinician Resources > Cardiology > Medicare Advantage Cardiology Prior Authorization Program > 2014 Cardiology Prior Authorization Table and CPT Code Crosswalk.

Onceapriorauthorizationrequestforaplannedcardiologyprocedure is received, UnitedHealthcare will conduct a clinical coverage review to determine whether the service is medically necessary. The provider will be informed of the decision.

• Rendering providers who are subject to the Administrative Guide and the UnitedHealthcare West Non-CapitatedSupplementandpracticeinArizona,Colorado,Oklahoma,Oregon,TexasandWashingtonmustconfirmthatthepriorauthorizationprocesshasbeencompletedand verify that a coverage decision has been issued before rendering any cardiology procedure.

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Priorauthorizationfordiagnosticcatheterizations,echocardiograms and stress echocardiograms is required for outpatientandoffice-basedservicesonly.Priorauthorizationforelectrophysiologyimplantsisrequiredforoutpatient,office-based and inpatient services.

Cardiology procedures rendered in and appropriately billed with any of the following places of service do not require prior authorization:emergencyroom,urgentcarecenterorinpatientsetting(exceptforelectrophysiologyimplants,whichrequirepriorauthorizationduringaninpatientstay).

Medicare Advantage Plans Subject to This Prior Authorization Process

As of the effective date of this communication, the prior authorizationrequirementssetforthabovewillapplytoUnitedHealthcare West’s Medicare Advantage plans that are subject to the Administrative Guide and UnitedHealthcare West Non-Capitated Supplement including but not limited to UnitedHealthcare® Medicare Complete®, UnitedHealthcare Dual Complete™, UnitedHealthcare® Chronic Complete and AARP® MedicareComplete® plans. Please note that excluded plans may have separate radiology or cardiology priorauthorizationrequirements.Pleaserefertotherespective

supplements in the Administrative Guide for details.For additional information, see the following Additional Resource Information section:

Additional Resource Information Prior Authorization Process

Providersmust(a)providenotificationandcompletethepriorauthorizationprocess,and(b)confirmthatacoveragedecision has been made as follows:

• Online at UnitedHealthcareOnline.com > Notifications/Prior Authorizations > Radiology Notification & Authorization – Submission & Status.

• Online at UnitedHealthcareOnline.com > Notifications/Prior Authorizations > Cardiology Notification & Authorization – Submission & Status.

• Call866-889-8054(7a.m.to7p.m.localtime, Monday – Friday).

Please note that payment for covered services is contingent uponcoverageunderthemember’sbenefitplan,the provider’s eligibility for payment, any claim processing requirements and the provider’s participation agreement with UnitedHealthcare West.


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Failure to Complete the Prior Authorization Process and Meet Medical Necessity Criteria

Failuretoprovidenotificationandcompletethepriorauthorizationprocess, or verify that a coverage determination has been issued, prior to rendering an advanced outpatient imaging procedure or cardiology procedure will result in an administrative claim reimbursement reduction, in part or in full. Members cannot be billed for claims that are administratively denied.

ForUnitedHealthcareWestMedicareAdvantagebenefitplans,anauthorizationnumberisissuedforbothapprovedandclinicallydeniedpriorauthorizations.Aclinicaldenialwillbeissuedifitisdetermined during the clinical coverage review process that the service does not meet medical necessity criteria. The clinical denial will be communicated via a letter faxed to the provider and a letter will be mailed to the Medicare Advantage member.

Members can be billed for requested services that are clinically denied, provided adequate written consent is obtained from the member prior to rendering the service.

Additional Information About Process

Additional information regarding the requirements you must follow, including requirements with respect to urgent requestsandtheretrospectivenotificationprocess,issetforthinthe(a)OutpatientRadiologyPriorAuthorizationProtocolforMedicareAdvantagemembers,and(b)CardiologyPriorAuthorizationProtocolfor Medicare Advantage members. These protocols are set forth in the Administrative Guide. We strongly encourage you to review the protocols.

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ContraceptiveServicesOnlyBenefit and Eligible Organizations

Under the Patient Protection and Affordable Care Act (PPACA),mosthealthinsuranceplansmustcovercertainbirthcontrolmethods(contraceptivesandsterilization)for women at no cost - when received from an in-network doctor, health care professional or pharmacy.

Somenonprofits,referredtoasEligibleOrganizations,don’t have to cover birth control as part of their group healthplanforreligiousreasons.EligibleOrganizationswill not contract, arrange, pay, or refer for contraceptive coverage, as part of their group health plan. Instead, UnitedHealthcare will pay for certain types of female birth control for members without cost-sharing through our“ContraceptiveServicesOnly”benefit,whichwearerequired by law to make available to members.

About the Contraceptive Services OnlyBenefit

Women who request the Contraceptive Services Only(CSO)benefitwillreceiveaCSOIDcard. This card is like a regular UnitedHealthcare member ID cardandmustbeusedatthedoctor’sofficeorpharmacyto ensure they don’t pay for the birth control drugs, products or services covered by the Contraceptive ServicesOnlybenefit.

Women’s Preventive Care Services Updates

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Health Plan (80840) 911-87726-04Member ID: Group Number:Member:

Payer ID 87726

Rx Bin: 610279Rx PCN: 9999Rx Grp: UHEALTH

DOI-0501UnitedHealthcare Choice

Underwritten by [Appropriate Legal Entity]

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EMPLOYEE SMITHContraceptive Services Only

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Health Plan (80840) 911-87726-04Member ID: Group Number:Member:

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Rx Bin: 610279Rx PCN: 9999Rx Grp: UHEALTH

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EMPLOYEE SMITHContraceptive Services Only

DependentsSPOUSE SMITHCHILD1 SMITHCHILD2 SMITHCHILD3 SMITH

030829275950

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RUN_DATE 20130917 09:08:54DATA_SEQ_NO 0000001CLIENT_NUMBER 003082UHG_TYPE DIG2CARDDOC_ID DOC_SEQ_ID 0000001NAME SMITH ,EMPLOYEEMAILSET_NUMBER 0000001CUSTCES_KEY1 0000010000100000100001_KEY0 CARD1CUSTCES_KEY1 0000010000100000100001_KEY0 CARD2CUSTCES_KEY2 0755733CUSTCES_KEY2 0755733CUSTCES_KEY3 EMPLOYEECUSTCES_KEY3 EMPLOYEECUSTCES_KEY4 HCAC/MedicalCUSTCES_KEY4 HCAC/MedicalCUSTCES_KEY5 00CUSTCES_KEY5 01CUSTCES_KEY5 02CUSTCES_KEY5 03CUSTCES_KEY5 04CUSTCES_KEY5 00CUSTCES_KEY5 01CUSTCES_KEY5 02CUSTCES_KEY5 03CUSTCES_KEY5 04CUSTCES_KEY6 20130917CUSTCES_KEY6 20130917CUSTCES_KEY7 00000100001~00CARD1CUSTCES_KEY7 00000100001~01CARD1CUSTCES_KEY7 00000100001~02CARD1CUSTCES_KEY7 00000100001~03CARD1CUSTCES_KEY7 00000100001~04CARD1CUSTCES_KEY7 00000100001~00CARD2CUSTCES_KEY7 00000100001~01CARD2CUSTCES_KEY7 00000100001~02CARD2CUSTCES_KEY7 00000100001~03CARD2CUSTCES_KEY7 00000100001~04CARD2CUSTCES_KEY8 123456789CUSTCES_KEY8 123456789CUSTCES_KEY9 123456789~00CARD1CUSTCES_KEY9 123456789~01CARD1CUSTCES_KEY9 123456789~02CARD1CUSTCES_KEY9 123456789~03CARD1CUSTCES_KEY9 123456789~04CARD1CUSTCES_KEY9 123456789~00CARD2CUSTCES_KEY9 123456789~01CARD2CUSTCES_KEY9 123456789~02CARD2CUSTCES_KEY9 123456789~03CARD2CUSTCES_KEY9 123456789~04CARD2

Thereview

andapprovalofhealthcareservices,basedonmedicalnecessity,doesnotguaranteecoverage

underyourpolicy.Also,verificationofeligibilityforbenefitsandcoveragedoesnotguaranteecoverage.Actual

benefitsandcoveragewillbedeterminedunderthetermsandconditionsofyourpolicywhenaclaimis

submitted.ThisMedicalIDCardistobeusedsolelyinconnectionwithandissubjecttothetermsand

conditionsofyourhealthormedicalcoverageissuedoradministeredbyUnitedHealthcareoritsaffiliates.

UnitedHealthcareanditsaffiliatesreserveallrightsintheeventofimproperuse.

WelcometoUnitedHealthcare

Thankyouforchoosingusasyourhealthcarebenefitplanprovider.

AttachedisyourUnitedHealthcarehealthplanIDcard.Beginusingiton

thedayyourcoveragestarts.

Manageyourhealthcareonlineatmyuhc.com.Youwillfind

personalizedtoolsandinformationtohelpyou:

•Manageyourclaimsandseehowmuchyouowe

•Findadoctororhospital

•Estimateyourhealthcarecosts

•Researchhealthtopics

•Findanswerstoyourhealthcarequestions

Formorehelp,pleasecallusatthenumberonthebackofyourcard.

Graciasporelegirnoscomoproveedordesuplandebeneficiosde

atencióndelasalud.Adjuntamossutarjetadeidentificacióndelplande

saluddeUnitedHealthcare.Empieceausarlaeldíaenquecomiencesu

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Printed: 09/17/13

This card does not guarantee coverage. To verify benefits, view claims, or finda provider, visit the websites or call.For Members: www.myuhc.com 123-456-7890

For Providers: www.unitedhealthcareonline.com 877-842-3210Medical Claims: PO Box 30555, Salt Lake City UT 84130-0555

Pharmacy Claims: OptumRx PO Box 29044 Hot Springs, AR 71903For Pharmacists: 888-290-5416

Printed: 09/17/13

This card does not guarantee coverage. To verify benefits, view claims, or finda provider, visit the websites or call.For Members: www.myuhc.com 123-456-7890

For Providers: www.unitedhealthcareonline.com 877-842-3210Medical Claims: PO Box 30555, Salt Lake City UT 84130-0555

Pharmacy Claims: OptumRx PO Box 29044 Hot Springs, AR 71903For Pharmacists: 888-290-5416

*117*

Shipper ID: 00000000 Insert #1 Insert #2Shipping Method: 2ND DAY Insert #3 Insert #4CARRIER: UPS Insert #5 Insert #6Address: Insert #7 Insert #8TO: Contraceptive Services Only Insert #9 Insert #10Contraceptive Services Only Insert #11 Insert #12ATTN: UHC123 Any Street Cycle Date: 20130917Hartford, CT 12345 PDF Date: Tue Sep 17, 2013 @ 09:08:54

MaxMover: NMailing/Meter Date: UHG JOB ID: 8782 GRP: 0755733 PV: 0001 RC: 0001 MKT: 77777

MT: 00 SA: 00 OI: 01 FORM: K20001 CPAY: BDALE BROWN: YESTEMPLATE: NEW FAMILY/IND : STD FAMILY : STANDARD : STANDARD

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Front & Center




Important Information About the CSOBenefit

• Only female birth control on the CSO list is availableat no cost. And includes many types of birth controlthat are covered, including: birth control pills, femalecondoms, and long-lasting birth control.

• Birth control services must be received at an in-networkpharmacyordoctor’soffice.

• Members must have a prescription for this birth controlto be covered at no cost - even for items that can bepurchased without a prescription.

For more information, please call your Provider Advocate or Provider Services.

Members Can Now Receive Breast Pumps Within 30 Days of Delivery

Under PPACA, breast-feeding services and equipment are covered without cost-sharing when received by a network provider, during pregnancy and/or in the postpartum period.

Members may purchase breast pumps without cost-share by contacting a network doctor or durable medicalequipment(DME)supplierwithin30daysoftheestimateddeliverydate.(Previously,mothershadtobelactating before receiving a breast pump.)

• For a list of breast pump suppliers, members maycall the number on the back of their ID card.

• If contacting the breast pump supplier directly, membersmay be asked for their doctor’s contact information, thebaby’s due date or the date the baby was delivered.The breast pump supplier may verify this and otherinformation with the member’s doctor before the breastpump is shipped.

• National breast pump suppliers ship the breastpump directly to the lactating mother.

• The doctor or DME supplier will bill UnitedHealthcaredirectly for reimbursement.

• Members do not need a prescription when contacting aDME breast pump supplier.

• Members will not be reimbursed for breast pumpspurchased at retail stores.

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Front & Center



Our Preventive Care Services Coverage Determination Guideline was updated Jan.1,2014toreflectthischange.

How Members Obtain a Breast Pump

For more information, contact your Physician Advocate or Provider Services; or visit the United for Reform Resource Center at uhc.com/reform and click the preventive services provision for the latest health reform news or review our Preventive Care Services Coverage Determination Guideline information about what preventive services must be covered under the health reform law is found at HealthCare.gov.


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UnitedHealthcare Medical Policy, Drug Policy, Coverage Determination Guideline and UtilizationReviewGuidelineUpdates

For complete details on the new and/or revised policies and guidelines listed in the table on the following page, refer to the monthly Medical Policy Update Bulletin at UnitedHealthcareOnline.com > Tools & Resources > Policies, Protocols and Guides > Medical & Drug Policies and Coverage Determination Guidelines > Medical Policy Update Bulletin.




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UnitedHealthcare Medical Policy, Drug Policy, Coverage Determination GuidelineandUtilizationReviewGuidelineUpdates

Policy Title Policy Type Effective Date Medical Policy Update Bulletin

TAKE NOTE

Annual CPT® and HCPCS Code Updates All Jan. 1, 2014 Jan. 2014

NEW

EnzymeReplacementTherapyfor Gaucher Disease

Drug Policy Feb. 1, 2014 Nov. 2013Dec. 2013Jan. 2014

MechanicalCirculatorySupportDevice(MCSD) Clinical Guideline Jan. 1, 2014 Nov. 2013 Dec. 2013

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Medical Policy Jan. 1, 2014 Dec. 2013

UPDATED/REVISED

Abnormal Uterine Bleeding and Uterine Fibroids





Apheresis Medical Policy Jan. 1, 2014 Dec. 2013

Bariatric Surgery Medical Policy Jan. 1, 2014 Dec. 2013

Blepharoplasty, Blepharoptosis, and Brow Ptosis Repair

Coverage Determination Guideline

Jan. 1, 2014 Dec. 2013

Campath(Alemtuzumab) Drug Policy Jan. 1, 2014 Dec. 2013

Cardiovascular Disease Risk Tests Medical Policy Jan. 1, 2014 Dec. 2013

Epidural Steroid and Facet Injections for Spinal Pain

Medical Policy Nov. 1, 2013 Nov. 2013

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

Medical Policy Dec. 1, 2013 Nov. 2013

Hip Resurfacing Arthroplasty Medical Policy Jan. 1, 2014 Dec. 2013

ImmuneGlobulin(IVIG) Drug Policy Dec. 1, 2013 Nov. 2013

Omnibus Codes Medical Policy Jan. 1, 2014 Dec. 2013

Oncology Medication Clinical Coverage Policy Drug Policy Jan. 1, 2014 Dec. 2013

Polysomnography and Portable Monitoring for Evaluation of Sleep Related Breathing Disorders

Medical Policy Dec. 1, 2013 Nov. 2013

Preventive Care Services Coverage Determination Guideline

Jan. 1, 2014 Dec. 2013

UnitedHealthcare Medical Policy, Drug Policy, Coverage Determination Guideline and UtilizationReviewGuideline Updates


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Proton Beam Radiation Therapy Medical Policy Jan. 1, 2014 Dec. 2013

Repository Corticotropin Injection (H.P.ActharGel)

Drug Policy Dec. 1, 2013 Nov. 2013

Transcatheter Heart Valve Procedures Medical Policy Jan. 1, 2014 Dec. 2013

RETIRED

Breast Pump UtilizationReviewGuideline Jan. 1, 2014 Dec. 2013

Cardiac Outpatient Rehabilitation (ExerciseTraining)


Nov. 1, 2013 Nov. 2013

Complementary and Alternative Medicine Coverage Determination Guideline

Nov. 1, 2013 Nov. 2013

DefinitionofMedicallyNecessary Coverage Determination Guideline

Nov. 1, 2013 Nov. 2013

Dental Exclusion and Accidental Dental Coverage Determination Guideline

Jan. 1, 2014 Jan. 2014

Hearing Aids Coverage Determination Guideline

Dec. 1, 2013 Nov. 2013

Hyperbaric Oxygen Therapy and Topical Oxygen Therapy

Medical Policy Jan. 1, 2014 Jan. 2014

Maternity Services and Complications Coverage Determination Guideline

Dec. 1, 2013 Dec. 2013


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Nutrition(Including:Counseling,Therapy,Enteral Nutrition, Infant Formula, Breast Milk, Supplements and Food)


Dec. 1, 2013 Dec. 2013

Physical Medicine and Rehabilitation Services-Inpatient and Outpatient


Nov. 1, 2013 Nov. 2013

Pulmonary Rehabilitation - Outpatient Coverage Determination Guideline

Nov. 1, 2013 Nov. 2013

Snoring Treatment Coverage Determination Guideline

Dec. 1, 2013 Nov. 2013

TotalAnkleReplacement(Arthroplasty) Medical Policy Jan. 1, 2014 Jan. 2014

Treatment of Complications Coverage Determination Guideline

Nov. 1, 2013 Nov. 2013

Wireless Capsule Endoscopy Medical Policy Jan. 1, 2014 Jan. 2014


Note: The appearance of a service or procedure on this list does not imply that UnitedHealthcare provides coverage for the service or procedure. In the eventofaninconsistencyorconflictbetweentheinformationprovidedinthisbulletinandthepostedpolicy,theprovisionsofthepostedpolicywillprevail.

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ThenewformsfortheUnitedHealthcareIntensityModulatedRadiationTherapy(IMRT)priorauthorizationprogramwillbepostedonourwebsiteinJanuary2014.Youcanfindtheformsat:UnitedHealthcareOnline > Clinician Resources > Cancer – Oncology > IMRT > Related Links.

We are changing the data collection form to enable therequestingphysiciantoprovidedisease-specificclinical details for the radiation oncologist reviewing the priorauthorizationrequest.Onourwebsite,underRelatedLinks,youwillfindthedisease-specificforms.Ifaformisnot available for the patient’s medical condition, a generic form will be available. Please note that incomplete forms may delay the review for IMRT services.

Questions can be forwarded to [email protected].


NewDisease-specificIMRTFormsforUnitedHealthcarePriorAuthorizationProcess

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mailto:unitedoncology%40uhc.com?subject=



The Preferred Payment Method for Your UnitedHealthcare Patients: Member Payments

Last summer, UnitedHealthcare implemented a new online payment capability for UnitedHealthcare members to make online payments directly to you and all their health care providers through myuhc.com. We are the firstnationalinsurancecarriertoofferourmembersonlinebillpaymentcapabilitiesthatarefullyintegratedwith online claim information.

Online Member Payments, designed in collaboration with InstaMed, a leading health care payments network, helps you get paid faster and easier than ever. Since the implementation, there has been a steady growth in patients using the service, averaging an additional 1,000 unique patients each day who are paying online at myuhc.com.

UnitedHealthcare members appreciate the capability because they can manage their claims and health care expenses all from one site.

How Online Member Payments Work:

Registered Providers:

• Providers register to receive patient payments electronically, which are then deposited directly into your designated bank accounts.

• Registered providers pay a low merchant transaction fee, similar to what you pay today when patients pay with credit/debit or bank withdrawals.

• Thefeeisaflatrateof2.99percentpertransaction when patients pay using credit/debit cards, and 1.5 percent when patients pay using their bank account.

• There are no sign-up fees, no monthly fees, and no minimum usage fees.

• InstaMed(thepaymentsprocessor)sendsemailnotificationstoproviderswhenpatientpaymentshavebeen made.

• Automatic posting of these payments can be made directly to your patient accounting system.

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Non-Registered Providers:

• If you haven’t registered, UnitedHealthcare members can still pay you online from their member portal.

• You will receive these patient payments by mail in the form of a one-time use MasterCard debit card.

• You incur normal costs to process these payments through your existing merchant account - no additional fee is charged.

• Payments are manually processed similar to a remittance and posted to your patients’ accounts.

Register to receive these payments directly deposited to your bank account by visiting www.uhcmemberpayments.com. If you have questions or want to learn more, sign up to attend a webinar training session. You can also contact [email protected], call 215-789-3682 or contact your UnitedHealthcare

Physician or Hospital Advocate.

The Preferred Payment Method for Your UnitedHealthcare Patients: Member Payments

Next Article >

mailto:info%40instamed.com?subject=

Unless otherwise noted, these reimbursement policies apply to servicesreportedusingthe1500HealthInsuranceClaimForm(CMS-1500)oritselectronic equivalent or its successor form. UnitedHealthcare reimbursementpolicies do not address all factors that affect reimbursement for servicesrenderedtoUnitedHealthcaremembers,includingmemberbenefitplandocuments, UnitedHealthcare medical policies and the UnitedHealthcarePhysician, Health Care Professional, Facility and Ancillary ProviderAdministrative Guide. Meeting the terms of a particular reimbursement policy isnot a guarantee of payment. Once implemented the policies may be viewed intheir entirety at UnitedHealthcareOnline.com > Tools & Resources > Policiesand Protocols > Reimbursement Policies-Commercial. In the event ofaninconsistencyorconflictbetweentheinformationprovidedintheNetworkBulletin and the posted policy, the provisions of the posted policy prevail.




Next Article >




Revision to CCI Editing Policy

PreviouslyannouncedasarevisiontotheRebundlingPolicyandeffectiveinthefirstquarter of 2014, UnitedHealthcare will deny Preventive Medicine Evaluation and Management(E/M)services(CPTcodes99381-99397)whenreportedonthesamedateofserviceasanimmunizationadministrationservice(CPTcodes90460-90461and 90471-90474) through the CCI Editing Policy. This change aligns with the CMS NationalCorrectCodingInitiative(NCCI)andtheAmericanMedicalAssociationCurrentProceduralTerminology(CPT®)

Ifmodifier25isreportedwiththePreventiveMedicineE/MserviceandthedocumentationsupportsthatasignificantandseparatelyidentifiableE/Mservicewasprovidedonthesamedateastheadministration service, both would be reimbursed. It would not be appropriate to additionally report the Preventive Medicine E/M code for the counseling provided when a vaccine is administered.

Next Article >




Revision to the Professional/Technical Component Policy- Denial of Drug Administration Codes and PC/TC Indicator 8

According to the CMS NCCI Policy Manual, drug administration codes (CPT96360-96379,96401-96425,and96521-96523) are considered included in the facility payment when reported in place ofservice(POS)24(ambulatorysurgicalcenter(ASC)).

Additionally, the CMS National Physician Fee Schedule guidelines advise that payment should not berecognizedforprofessional/technical(PC/TC)Indicator8codes,whicharedefinedasphysicianinterpretation codes, furnished to patients in the outpatient or non-hospital setting.

To better align with CMS, UnitedHealthcare will denydrugadministrationcodes(CPT96360-96379, 96401-96425, and 96521-96523) reported by a physician or other health care professional in a POS 24. We will also deny PCTC Indicator 8, CPT code 85060, when reported by a physician or other health care professional with a place of service code other than inpatient hospital (POS21).Thischangewilloccurinthesecondquarter of 2014.

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Multiple Procedure Policy Revisions to Apply to Same Group

The revision to the Multiple Procedure Policy, announced in the July 2013 Network Bulletin, was partially implemented for three weeks, from November 17, 2013 through December 7, 2013. The revision administered multiple procedure reductions to eligible surgical and medical procedures provided on the same day and reported by the same group practice, which included all physicians and other health care professionals with the same federaltaxidentificationnumber.

To allow for system enhancements, effective with dates of process beginning December 8, 2013, the Multiple Procedure Policy temporarily reverted to the previous method of applying multiple procedure reductions for secondary and subsequent eligible services only when provided on the same day to the same patient by the same individual physician or health care professional.

In February 2014, the Multiple Procedure Policy revision will be fully implemented to again apply multiple procedure reductions based on the same group practice. This revision will align the policy with CMS guidelines with application of multiple procedure reductions to all physicians and non-physicians in the same group practice, acting in the same capacity. Co-surgeon and team surgeon services will continue to be ranked separately from procedures reported by another physician.

Next Article >

2013 Member Rewards Program – Better Health has its Rewards

At UnitedHealthcare, preventive screenings are an important part of our health promotion efforts and the basis of our Member Rewards program.

The 2013 Member Rewards program has ended. As a result of us working together, we sent out the following numbers of pre-paid debit cards as of mid-December:

• 103,864 Annual Wellness Visit/BMI rewards

• 10,718 Colorectal Screening rewards

• 14,442 Glaucoma Screening rewards

• 3,502 Breast Cancer Screening rewards

Please continue talking to your patients about the importance of scheduling and completing a health assessment and other preventive health screenings and exams. Also, be on the look-out for communication about the 2014 Member Rewards program in the coming months.

For more information, please call Provider Services at 877-842-3210 or visit Member Rewards.




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UnitedHealthcare Wins Bid for State of Illinois

We will offer our UnitedHealthcare Group Medicare Advantage National PPO plan to the state’s 123,000 Medicare-eligible retirees. The plan is the only plan to be available across the entire service area including retirees who live outside of Illinois.

State retiree coverage is effective Feb. 1, 2014. The UnitedHealthcare Group Medicare Advantage National PPO Plan is open access with no referrals or gatekeeper. In addition, under this plan the member’s cost share is the same whether using an in-network or out-of-network provider.

• Providers who are in-network for UnitedHealthcare’s Medicare Advantage products will be paid according to their current agreement for these members.

• Out-of-network providers for UnitedHealthcare’s Medicare Advantage products will be paid according to Medicare’s allowable fee schedule.

The UnitedHealthcare Group Medicare Advantage NationalPPOplandoesnotrequirepriorauthorizations orpriornotificationsforout-of-networkphysicianswho see our members.

The State of Illinois Department of Central Management Services announced that UnitedHealthcare was one of three bidders awarded a competitive contract to offer a Medicare Advantage plan.

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UnitedHealthcare Medicare Advantage Coverage Summary Updates

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

Policy Title Approval Date Update Bulletin

REVISED

Bariatric Surgery Oct. 24, 2013 Nov. 2013

Blood, Blood Products and Related Procedures and Drugs Oct. 24, 2013 Nov. 2013

CardiacPacemakersandDefibrillators Oct. 24, 2013 Nov. 2013

Cosmetic and Reconstructive Procedures Oct. 24, 2013 Nov. 2013

Experimental Procedures and Items, Investigational Devices and Clinical Trials Oct. 24, 2013 Nov. 2013

GastroesophagealandGastrointestinal(GI)ServicesandProcedures Oct. 24, 2013 Nov. 2013

HospitalObservationCare(OutpatientHospital) Oct. 24, 2013 Nov. 2013

HospitalServices(InpatientandOutpatient) Oct. 24, 2013 Nov. 2013

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UnitedHealthcare Medicare Advantage Coverage Summary Updates

Policy Title Approval Date Update Bulletin

Laboratory Tests and Services Oct. 24, 2013 Nov. 2013

PositronEmissionTomography(PET)/CombinedPET-CT(ComputedTomography) Oct. 24, 2013 Nov. 2013

Rehabilitation-MedicalRehabilitation(PT,OT,andST,including Cognitive Rehabilitation)

Oct. 24, 2013 Nov. 2013

SkilledNursingFacility(SNF)CareandExhaustionofSNFBenefits Oct. 24, 2013 Nov. 2013

VentricularAssistDevice(VAD)andArtificialHeart Oct. 24, 2013 Nov. 2013

VeteranAdministration(VA)andIndianHealthServices(IHS) Oct. 24, 2013 Nov. 2013

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

Next Article >




ThisisareminderthatUnitedHealthcarerequiresadvancenotificationandprior authorizationforthestandardizedlistofinpatientandoutpatientproceduresacross Medicare plans for UB04 and HCFA billers.

Ifyoudonotobtainpriorauthorizationorverifytheauthorizationhasbeenobtainedbeforerenderingtheprocedure, it may result in an administrative claim denial. A clinical denial will be issued if it is determined during the priorauthorizationprocessthattherequestedservicedoesnot meet Medicare’s medical necessity criteria.

Follow this link for more information about the MedicareAdvantagepriorauthorizationprogramincluding medical, radiology, and cardiology: https://www.unitedhealthcareonline.com /b2c/CmaAction.do?channelId=12f8c79 58f5fa010VgnVCM100000c520720a____

ReminderforAdvanceNotificationandPriorAuthorization

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Important Reimbursement Policy Reminder

UnitedHealthcare Community Plan’s quality of care program factors readmission review to its reimbursements to participating and non-participating facilities based upon individual state and CMS published guidelines.*

Acute care admissions which occur within 30 days - or another time period depending on state guidelines or your provider agreement - of another acute care admission with the same or similar diagnosis will require a medical record review on a post service/prepayment basis. If a readmission undergoes clinical review because of a potential quality issue, the claim may be denied. Please note that if the claim is denied in full or part, providers cannot balance bill the member for a denied claim. Please note individual stateregulationsandcontractrequirementssupersedespecificpolicylanguage.

For more information, please refer to the UnitedHealthcare Community Plan ReadmissionPolicy(F7001).

Information That may be Requested for Medical Record Reviews

Patient medical records containing the admit through discharge information for thehospitalstaysbeginningonadmitdatesofservice(initialadmissiondateandsubsequent admission date) need to include:

• History and Physical

• Admission and Discharge Summary

• Physicians’ orders

• Emergency room records

• Progress notes

• Nurses’ notes

• Diagnostic and laboratory testing




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Important Reimbursement Policy Reminder

General Information Regarding Our Reimbursement Policies

Unless otherwise noted, our reimbursement policies apply to services reported using the CMS 1450 claim form (formerlyknownasUB-04),oritselectronicequivalent,orits successor form.

UnitedHealthcare Community Plan reimbursement policies do not address all issues related to reimbursement for services rendered to our members. Other resources that addressreimbursementincludethemember’sbenefitplandocuments, UnitedHealthcare Community Plan medical policies, and the UnitedHealthcare Community Plan Physician, Health Care Professional, Facility and Ancillary Provider Administrative Guide. Meeting the terms of a particular reimbursement policy is not a guarantee of payment. Likewise, retirement of a reimbursement policy affects only those system edits on claimsassociatedwiththespecificpolicybeingretired.

Retirement of a reimbursement policy is not a guarantee of payment. Other applicable reimbursement policies, medical policies and claims edits will continue to apply. Once implemented, the policies may be viewed in their entirety at UHCCommunityPlan.com > Find Plans By State (click on the appropriate state) > If you are a Health Professional > Reimbursement Policies.

Intheeventofaninconsistencyorconflictbetweentheinformationprovidedinthisnotificationandthepostedpolicy on UHCCommunityPlan.com, the provisions of the posted reimbursement policy will prevail.

If you have any questions please contact your Provider Advocate or call the number on your Provider Remittance Advice/ExplanationofBenefits.

* Note: This only applies to the states of TN, PA, DC, DE, OH, KS, MS, WA, IA, NJ, NY, WI, NM, and HI.

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Provider Disclosure of Ownership Form Now Online

UnitedHealthcareCommunityPlanisexcitedtorolloutanewonlineformforproviders(physician,facility and health care professionals) participating in UnitedHealthcare Community Medicaid plans. Providers can now complete the Disclosure of Ownership form securely online through a partnership with EchoSign.

The Disclosure of Ownership form is a federal regulation requirement applicable to all providers that contract with a State Medicaid agency. The launch of the new online form allows providers easy access to an electronic version of the requirement disclosure elements, needed to meet federal regulation.

The process is secure and complies with all federally requirement mandates to house personal information. EchoSignusesaKnowledgeBasedAuthentication(KBA)protection that allows a more advanced security around who is completing and signing the Disclosure of Ownership form. TheKBAisamethodthatisusedbyfinancialinstitutionsall over the world to ensure your personal information is transmitted securely.

Once the Disclosure of Ownership form has been successfully submitted you will receive an automated messageofconfirmation.

This form can be used in all UnitedHealthcare Community Plan markets. To complete the Disclosure of Ownership Form securely online, please visit UHCCommunityPlan.com and go to Health Care Professionals to select your state. The Disclosure of Ownership link is posted under Provider Forms at each state health plan site.

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Changes to the UnitedHealthcare Community Plan of Pennsylvania Claims Payer ID and Electronic Remittance Advice Payer ID

Enhancements to the enrollment and claims system for UnitedHealthcare Community Plan of Pennsylvania will become operational on or after March 1, 2014. Your claims payer ID will change to 87726 and your electronic remittance advice payer ID will change to 04567.

Readmission Policy Frequently Asked Questions

To learn more about UnitedHealthcare Community Plan’s Readmission Review policies, please go to UnitedHealthcare Community Plan Readmission Review Frequently Asked Questions *

* This only applies to the states of: TN, PA, DC, DE, NE, OH, WA, KS, MS, IA, NJ, NY, WI, HI, and NM.

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Important Change: Arriva Medical Has Acquired Diabetes Care Club

Diabetes Care Club, a national diabetic supply provider, has been acquired by Arriva Medical. Arriva Medical is now a nationally contracted provider for all lines of business. Arriva Medical provides diabetic test strips, lancets, testing monitors and supplies via mail order.

Nationally Contracted Diabetic Testing Supplies Providers Are:

Arriva Medical www.arrivamedical.com 800-580-1871 Byram www.byramhealthcare.com 877-902-9726 Edgepark www.edgepark.com 800-321-0591 Liberty www.libertymedical.com 800-695-2500




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Medline Industries Joins Network

Medline Industries has joined our network of medical supply providers effective Nov. 1, 2013 for all lines of business. Medline provides incontinence products such as diapers and urologicals, and woundcaresuppliessuchasgauze,tapes,andbandagestoourmembers.

Nationally Contracted Medical Supply Providers Are:

Byram www.byramhealthcare.com 877-902-9726 Edgepark www.edgepark.com 800-321-0591

Gordian www.amtwoundcare.com 800-568-5514 (Nursinghomeonly)

Medline www.medline.com 800-MEDLINE (800-633-5463)

Omnicare www.omnicare.com 800-990-6664 (Nursinghomeonly)

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UnitedHealthcare Preventive Plan Design

UnitedHealthcare has developed a limited plan design product called UnitedHealthcare Preventive. UnitedHealthcare Preventive will be indicated on the front of these members’ healthcareidentificationcards below where the patient’s employer/payer is located.

This limited plan design provides coverage for preventive care which includes all Patient Protection and Accountable CareAct(PPACA)-mandatedcoverage,includingwomen’spreventive health care. Other services covered include:

• One physical checkup every year

• OneOB/GYNcheckupeveryyear(Papsmear)

• One screening test for breast cancer every year

• Birth control pills or other forms of birth control

• Shots for measles or other childhood diseases

• Onecolonoscopyeveryfiveyears (colorectalcancerscreeningtest)

• Other preventive tests required by the Affordable Care Act

• Over-the-counter medications prescribed by physicians mandated by ACA including: Aspirin, Fluoride and Vitamin D supplements

UnitedHealthcare Preventive uses the UnitedHealthcare Options PPO network and services received outside of the network are not covered.

Costs for additional services, such as X-rays, blood tests, emergency department visits or other services to treat medical conditions, are not covered.

Some employers may choose to buy-up an additional optionandprovidetwosickofficevisitsandoneroutinevision exam.

• Thesickofficevisitscaneitherbeataspecialistorgeneralpractitionersofficebutthevisionexammust occur at a UnitedHealthcare vision provider location(Spectera).

• Thecoverageforsickofficevisitsincludesthechargefortheofficevisit.Relatedservicessuchasdiagnostic labs, x-rays, etc. are not covered.

To determine if your patient has preventive carewithsickofficevisitbenefits,contactCustomer Care at 877-842-3210 or go to UnitedHealthcareOnline.com and have the member’s information available to verify eligibility.

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Introducing COB Smart™: Receive Payments Accurately, Predictably and Reliably

Last fall, UnitedHealthcare, in collaboration with other payers and the Council for AffordableHealthcare(CAQH),anonprofitalliance of health plans and trade associations, introduced COB Smart. COB Smart helps improve the accuracy of Coordination of Benefits(COB)processesforproviders and members.

How Does COB Smart Work? COB Smart can assist providers in getting needed insurance information without the administrative hassle. UnitedHealthcare directly contributes to a registry of coverage information that can help providers and health planscorrectlyidentifywhichmembershavebenefitsthat should be coordinated in order for corresponding claimstobeprocessedcorrectlythefirsttime.Eachweek, UnitedHealthcare supplies coverage information to the registry, where it is compared with information

from other participating payers to identify individuals

with more than one form of coverage. Standard primacy

rules are then applied to determine the correct order

ofbenefits.

COB Smart can be integrated with most existing

health information tools and processes, such as

ElectronicHealthRecords,toconfirmapatient’s

eligibility, allowing providers to access complete

coordinationofbenefitsinformation,helpingincrease

payment accuracy and timeliness while reducing

paperworkandimprovingcashflow.

To learn more about COB Smart from CAQH,

click here.

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UnitedHealthcare’s Position on “Never Events”

In an ongoing effort to enhance the quality of care for its members, UnitedHealthcare continues to adopt the Never Event position of the Leapfrog Group. We ask physicians and other health care professionals to join us in the effort to eliminate preventable medical errors.

The Leapfrog Group’s Never Events position is based on the National Quality Forum’s list of serious reportable events. This list looks at medical errors that should never happen to a patient. The Leapfrog Group’s position in the case of a Never Event occurrence is for hospitals to:

• Apologizetothepatientandfamily

• Report the event to at least one reporting programsuch as the Joint Commission on Accreditation ofHealthcareOrganizations,astatereportingprogramorapatientsafetyorganization

• Perform root cause analysis

• Waive all costs directly related to the event and refrainfrom seeking reimbursement from the patient or athird-party payer

In the instance a Never Event has not been reported, we willattempttodetermineifanyclaimsfiledwithusmeetthe criteria, as outlined by the NQF and adopted by CMS and The Leapfrog Group, as a Serious Reportable Adverse Event. To the extent that a provider does not comply with these requirements, that provider’s claim will be denied and will be a provider’s liability. The provider may not bill the member for these charges.

For more information, tools, articles and resources

on patient safety and the Leapfrog Group, visit

UnitedHealthcareOnline.com >

Clinician Resources > Patient Safety

Resources. For coding guidance, also visit

UnitedHealthcareOnline.com > Tools &

Resources > Policies, Protocols and Guides >

Reimbursement Policies - Commercial > Wrong

Surgical or Other Invasive Procedures Policy.

If you have questions about UnitedHealthcare’s

Patient Safety Program, contact Rebecca Lankford

at [email protected].

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mailto:Rebecca_Lankford%40uhc.com?subject=




Navigate Products and Related Administrative Processes

UnitedHealthcare Navigate® is a gated product that meets member needs around access and cost with an emphasis on primary care and referrals to network specialists. Navigate enrollment continues to grow as more UnitedHealthcare members are seeking lower cost options.

As the Navigate product continues to expand, we will continuetosharestate/market-specificinformationand requirements.

For more information about Navigate, please go to UnitedHealthcareOnline.com > Tools & Resources > Products & Services > UnitedHealthcare Navigate.

Here is a Checklist of Reminders When Seeing UnitedHealthcare Navigate Members:

• Check the member’s ID card to identify theirspecificbenefitproduct.

• Verifythemember’sbenefitsandeligibilityonUnitedHealthcareOnline.com.

• Checkforpriornotification/authorizationrequirements on UnitedHealthcareOnline.com(e.g.radiology,cardiology).

• When making referrals, please ensure you’re referring to participating network specialists. Refer to the Referral Requirements Quick Reference Guide for more information on what requires a referral.

• Submit referrals using our secure physician websiteby logging in at UnitedHealthcareOnline.com >Notifications/Prior Authorizations > ReferralSubmission prior to the specialist servicebeing received. Referrals cannot be accepted byphone, fax or paper.

• Submit claims to the address on the back of themember ID card.

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Training Sessions for Electronic Solutions

We offer instructor-led webcast training sessions that can help automate and streamline administrative processes. Session topics include:

• UnitedHealthcareOnline.com

• UnitedHealthcareOnline.com Password Owner

• UnitedHealthcareOnline.comNotification/PriorAuthorizationFunctionOverview

• Electronic Payments and Statements

• Electronic Data Interchange 101

• OxfordHealth.com Overview

• Post-n-Track® Demonstration

• PNC Remittance Advantage for ElectronicOxford Payments and EOBs

Physician and Provider Demographic Changes

To ensure that we have the most current information for our participating physicians and health care providers, please update your practice information at UnitedHealthcareOnline.com > Contact us. Or call 877-842-3210. For any tax ID updates, please use the Provider Demographic Change Form and include a W-9. If you have questions, please call your local UnitedHealthcare Physician Advocate.

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Click to learn more about UnitedHealthcare and Oxford sessions and how to register.




Wellness Programs: Recommending Alternative Actions

One of the requirements of PPACA relates to wellness programs. PPACA regulations build on existing wellness program policies to help promote good health through wellness rewards.

The new regulations, which affect group health plans for plan years beginning on or after Jan. 1, 2014, increase the maximum reward allowed under certain wellness programsandprovideotherclarificationsregardingreasonable design of health-contingent wellness programs and the reasonable alternatives that must be offered to avoid prohibited discrimination.

Wellness programs should be reasonably designed to promote health or prevent disease. In the rare case when a health-contingent wellness program’s reasonable alternative is not medically appropriate for one of your patients, the regulations allow you to recommend an alternative action.

To learn more, please click here.

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Checking Status of Claim Reconsideration Requests With Attachments

Now you can check the status of your requests submitted via Optum Cloud Dashboard without making a phone call.

Simply log into Optum Cloud Dashboard to view information about your existing claim reconsideration requests with attachments. Statuses include In-Progress,Closed(completed)andRejected. You can read reviewer comments and update your request if needed. Reconsideration requests are reviewed within 30 days.

Please refer to the Claim Reconsideration with Attachment Quick Reference Guide for instructions.

Electronic Inpatient AdmissionNotifications

Please use the Electronic Data Interchange278Ntosubmitnotificationsfrom your practice management system for UnitedHealthcare, UnitedHealthcare Medicare Solutions and UnitedHealthcare Community Plan. For more information, go to AdmissionNotification(278N), contact your clearinghouse/vendor or UnitedHealthcare at 888-804-0663 or [email protected].

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mailto:278n%40uhc.com?subject=




CoverageDeterminationandUtilizationManagementDecisions

Other resources used during the coverage decision process include:

• Federal and state requirements as applicable to commercial, Medicare and Medicaid members.

• For commercial plan members we use the applicable definitionsinthemember-specificdocumenttodetermine coverage.

• ForMedicaremembers,weusetheCMSdefinitionof“reasonable and necessary” within Medicare coverage rules and regulations.

Please note that UnitedHealthcare does not offer incentives tophysicianstoencourageunder-utilizationofcareorservices, or to encourage barriers to care and service. The coverage determination process is focused on ensuring that UnitedHealthcare members receive the most appropriate care based on applicable law, evidence-based medicine and theirbenefitplandesign.

Our health care coverage decisions are based on applicable federal and state regulations, thepatient’sspecificbenefitplandesignand applicable clinical policies and/or guidelines.

All Savers Alternative Funding Product - New Portal

The All Savers Alternate Funding plan is an innovative product designed specificallyforsmallbusinesses. All Savers plans give members access to the UnitedHealthcare Choice Plus network, which today includes nearly 705,000 health care professionals and 56,000 hospitals across the nation.

Health care professions and hospitals can obtain eligibility, claim payment, EOB and additional information at www.myallsaversprovider.com

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UnitedHealth Premium® Results Available to Public Soon

NotificationsofnewUnitedHealthPremiumdesignationsforqualityandcostefficiencyweresent by mail to physicians in November 2013. The physicians’ letters included instructions on how to access their full suite of UnitedHealth Premium assessment reports online at UnitedHealthcareOnline.com. Physicians may also submit reconsideration requests online through this site.

Most physician designations will be published to our online websites such as myuhc.com on Jan. 8, 2014. The publication date for physicians in Connecticut, Delaware, New Jersey, New York, Pennsylvania and Rhode Island will be on April 2, 2014.

The public designation display date allowed time for physicians to submit reconsiderations before the results were available to the public. Of course, as is our practice, physicians may submit a reconsideration request at any time during the review cycle. All requests will be reviewed expeditiously.

Further Information: Go to UnitedHealthcareOnline.com and select “UnitedHealth Premium” on the top navigation bar tofindresourcesandtoolsthatexplaintheprogram. Send us an email though the Contact Premium Program link or call 866-270-5588.

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BMI Documentation in the Medical Record

Supporting members in their efforts to maintain a healthy body weight is crucial to our commitment to “helping people live healthier lives.”

The National Institutes of Health and the World Health Organizationhaveadoptedthemeasurementofabodymassindex(BMI)of30oraboveasamethodforidentifyingobesity in adults. BMI measurement is also a HEDIS measure that the National Committee for Quality Assurance is using in 2014 to evaluate health plan quality.

Patients with a high BMI have a higher risk for chronic health problems, which includes high blood pressure, type 2 diabetes, coronary heart disease, stroke, gallbladder disease, osteoarthritis, respiratory problems and endometrial, breast, prostate and colon cancer. Conditions caused or exacerbated by obesity are the second leading cause of preventable death in our country.

It is important to note that BMI measurement is calculated differently for children than it is for adults. BMI calculations for adults are based strictly on the patient’s height and weight information. BMI calculations for children also include gender, age and use of growth charts. The Centers for Disease Control and Prevention have BMI graphs and charts available for both adults and children at www.cdc.gov. Your EMR programs may already have BMI calculations available, making documentation easy in the medical record. Make sure your electronic medical record (EMR)BMIcalculationprogramisturnedon.

Further detail and information on how to incorporate BMI documentation into your medical records can be found at www.cdc.gov.

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Medicare Change to Physician-initiated Prescriptions at Mail Pharmacies

Starting in 2014, mail order pharmacies are required to get your patient’sconfirmationandapprovalforanyprescriptionordersthatyou send directly to the mail pharmacy.

Any new prescription or renewal that you send to a mail order pharmacy will require yourpatienttoconfirmtheirorderwiththe pharmacy. This includes both new andrefillmedicationsthatyoufax,phoneor e-prescribe for your patients and send to a mail order pharmacy.

Beginning Jan. 1, 2014, OptumRx and all other mail order pharmacies will contact your patients for any prescription you send to the mail order pharmacy.

UnitedHealthcare has informed your patients who are currently using mail order by providing a note in all existing prescriptions since October 1, 2013. Any help you can provide your patients by mentioning this change when you are discussing prescriptions you will send to a mail order pharmacy will help to ensure that there are no delays in any therapies you are prescribing.




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EffectiveFeb.1,2014:NewPriorAuthorizationRequirementsforEnzymeReplacementMedications(forUnitedHealthcareIntegratedCommercialFully Insured and Self-funded Plans Only)

Effective Feb. 1, 2014, UnitedHealthcare will require all participating network providersbillingunderthemedicalbenefittoobtain priorauthorizationbeforeadministeringenzymereplacementmedications,Cerezyme® and Elelyso®, to treat Gaucher disease for UnitedHealthcare commercial plan members. This requirement will affect both new and existing members.

RequestforcoverageofCerezymeandElelysomay be subject to medical necessity review. As a result, you may be required to switch patients to VPRIV®, a lower-cost clinically similar medication, in order to continuebenefitcoverage.Priorauthorizationwillnotbe required for VPRIV.

Please review the FAQ for information on the medical necessityreviewandhowtorequestpriorauthorizationfor your patient.

If you have questions, please contact your local network manager or call the provider services phone number on the back of the member’s health care ID card.

ThisprotocolappliesonlytoUnitedHealthcaremembersincommercialbenefitplans insured or administered by UnitedHealthcare, Mid-Atlantic Medical Services, Neighborhood Health Partnership, Oxford and River Valley. This protocol does not apply to the State of New York Empire Plan, UnitedHealthcare West or UnitedHealthcare Community Plan.

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New OptumRx Specialty Pharmacy Resource Guide

To give your patients the best experience and help make their transition to our specialty pharmacy as easy as possible, we encourage you to use our new OptumRx Specialty Pharmacy Resource Guide for access to:

• Direct phone numbers

• Howtosubmitpriorauthorizations–includingonline(theeasiestandfastestway)

• Howtogetyourpatient(s)set-upwiththeSpecialtyPharmacy Program

• Information on what we offer to your patients

To download and print the Resource Guide, go to UnitedHealthcareOnline.com > Tools and Resources > Pharmacy Resources > Specialty Pharmacy Program.

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Our coupon policy limits pharmacies participating in UnitedHealthcare’ s Designated Specialty Pharmacy Program from facilitating redemption of manufacturer-sponsored coupons or cards as payment of the member’s cost share in the following instances:

• ForTiers3or4(highestmembercost)medicationslisted in this comprehensive drug list.

• For any new specialty medications released to the market in a therapeutic class currently on the list.

Coupons can encourage use of higher-cost medications, despite availability of lower-cost, clinically similar options, resultinginsignificantcosttomembersandemployergroups. This policy change is meant to reinforce our PrescriptionDrugList(PDL)design,whichencouragesuse of lower tier, lower-cost options. Our effort follows the U.S. government’s long-time practice of not allowing coupons to be redeemed for patients covered by Medicare, Medicaid and other federal health care programs.

Physicianscanhelpminimizetheimpacttopatientsby: 1. PrescribingTiers1or2optionsfirst:Fora

comprehensive drug list with alternatives included, visit UnitedHealthcareOnline.com >Tools & Resources > Pharmacy Resources.

2. Working with pharmacies: Pharmacists from our Designated Specialty Pharmacies may contact your officeonbehalfofamemberinterestedinswitchingto a lower cost option. They will review with you the lower cost options available to your patient. If you agree to change the patient’s prescription to aTier2medication,pleaseauthorizethis change by speaking to a pharmacist directly or by faxing a new prescription or e-prescribing to the specialty pharmacy.

If you have questions about the policy for these specialty medications, please call the provider services phone number on your patient’s health plan ID card. This protocol applies only to UnitedHealthcare members in commercial benefitplansinsuredoradministeredbyUnitedHealthcare.ItalsoappliestoNeighborhood Health Partnership, Oxford, River Valley, and Sierra. This protocol does not apply to the State of New York Empire Plan, Mid-Atlantic Medical Services, UnitedHealthcare West or UnitedHealthcare Community Plan.

Reminder: 25 Specialty Medications Added to Coupon Policy for Jan. 1, 2014

Effective Jan. 1, 2014, UnitedHealthcare will add 25 new specialty medications to our coupon policy.

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UnitedHealthcareisconsolidatingandmanagingitspharmacybenefitprogramsinternallythroughOptumRx and in 2013 all services for our commercial members currently handled by Medco were transferred to OptumRx.

Thefinaltransition,includingmembersfromUnitedHealthcareEmployer & Individual, UnitedHealth One, Golden Rule, and All Savers, will occur on Jan. 1, 2014.

Bringing all our pharmacy services in-house will enhance our ability to partner with you and your patients to improve health outcomes and better manage total health care costs.

Itisimportanttonotethatprescriptiondruglists,benefitplan designs, specialty pharmacy and clinical programs will continue to be managed within UnitedHealthcare. Members will continue to have access to more than 64,000 retail network pharmacies. These essential elements will not require any action on your part or that of your patients. We will simply transition information to OptumRx.

You and Your Patients

Most existing mail service prescriptions will transfer to OptumRx. Prescriptions for certain medications, like painkillers, and expired prescriptions will not transfer, and your patient will receive a letter from UnitedHealthcare instructing them to contact your officeforanewprescription.

OnceyourpatientstransitiontoOptumRx,you’llfindthattheonlinepriorauthorizationtool(availablethroughUnitedHealthCareOnline.com) is easy to use. The majority of onlinepriorauthorizationsareapprovedinrealtime,andanauto-population feature provides 95 percent of a member’s information.(TheOptumRxPriorAuthorizationteamisalsoavailable by phone at 800-711-4555.)

UnitedHealthcareConsolidatedPharmacyBenefitProgram

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UnitedHealthcareConsolidatedPharmacyBenefitProgram

In addition to members of UnitedHealthcare Employer & Individual,thischangeappliestopriorauthorizationsfor Oxford, Medica, Harvard Pilgrim, River Valley and Neighborhood HealthPlan(OnlinePriorAuthorizationtoolavailablethroughOptumRx.com). For members of the Health Plan of Nevada and Sierra Health & Life, please continue to use the current prior authorizationprocess.IfyouE-prescribethroughSureScripts,the NCPDP ID for OptumRx is #0556540.

Timing Considerations

To ensure that members experience seamless service and access to the covered full range of pharmacy benefits,thetransitionoccurredonastagedbasisthroughout2013(seechart).ThefinalgroupsofmemberswilltransitiononJanuary 1, 2014. We’ve provided the adjacent schedule (seechart,subjecttochange),butyoumayalsowant to ask patients to present their new ID card, which will contain the updated information.

Date Region PlansJan. 1, 2013 UnitedHealthcare

Employees and select clients

UnitedHealthcare commercial, Harvard Pilgrim.

Apr. 1, 2013 West region and Northeast region

UnitedHealthcare commercial, Medica, Harvard Pilgrim.

June 1, 2013 Central region UnitedHealthcare commercial, Medica, Harvard Pilgrim.

July 1, 2013 National Account clients across all regions

UnitedHealthcare commercial, Medica, Harvard Pilgrim.

Sept. 1, 2013 Southeast region UnitedHealthcare commercial, Medica, Harvard Pilgrim.

Oct. 1, 2013 All regions Oxford, Sierra, River Valley, Neighborhood Health Plan.

Jan 1, 2014 All regions UnitedHealthcare commercial, UnitedHealth One, Golden Rule, All Savers.

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Inaccurate billing can lead to member dissatisfaction, confusion and frustration. Billing errors also generate workflowinefficienciesthatleadtounnecessaryadministrative costs for providers.

To help prevent billing errors, please ask members in the Dual SpecialNeedsPlan(D-SNP)residinginAZ,MI,NJ,NY,PA,TNand WI to show their state Medicaid card and UnitedHealthcare Community PlanIDcardateveryvisit.Verificationofdualcoveragewhenservices are rendered expedites claim payments and reduces patient calls to youroffice.

D-SNPmemberswillalsoreceiveeducationaboutthebenefitsofpresentingbothcardsateachofficevisit.


AccurateBillingImprovesOfficeEfficiency and Dual SNP Member Satisfaction



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AccessingExplanationsofBenefitsOnline

Plan Option 1 Option 2UnitedHealthcare Commercial, Medicare Solutions and UnitedHealthcare Community Plan in some states.

Single EOB Search

• Register or log on to UnitedHealthcareOnline.com

• Select Claims & Payments > Electronic Payments and Statements (EPS) > Single EOB Search

• You may locate EOBs by payment number or status and date.

A Quick Reference guide is available.

With additional enrollment in Electronic Payments & Statements (EPS) you can:

• Search for EOBs using additional options

• View, save or print EOBs and consolidated payment summaries

• Receive payments by direct deposit

Learn more on our website or call 866-842-3278, option 5, for more information.

Oxford Commercial Claim Status

• Register or log on to OxfordHealth.com

• Select Claims in the Check column on the Transaction tab

• You may locate claims and EOBs using several search options.

Provider and Facility Quick Reference guides are available.

With additional enrollment in PNC Remittance Advantage you can:

• Search for EOBs using additional options

• View, save or print EOBs

• Receive payments by direct deposit

Learn more on our website or call 877-597-5489, option 1, for more information or to request a demonstration.

YoucanreducethetimeyouspendrequestingcopiesofExplanationsofBenefits(EOBs)byusingourwebsitesrather than calling. Please see the following table for information about obtaining UnitedHealthcare and Oxford EOBs online:

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Coding Update to Facility OPG Mapping – Effective Jan. 1, 2014

Effective Jan. 1, 2014, the following code updates were made to the current UnitedHealthcare 2013 Outpatient Procedure Grouper (OPG)mapping:

• 77 codes that are new for Jan. 1, 2014 were added to the applicable 0-10 grouper levels.

• 40 codes that expired effective Dec. 31, 2013 were removed from the mapping.

There are no other grouper level assignment changes to existing codes. Please remember that for reimbursement under OPG, UnitedHealthcare requires the appropriate line level CPT/Healthcare Common Procedure Coding System (HCPCS)codeinadditiontotherevenuecodewhenbillingfor outpatient procedures.

A list of the new and deleted codes is below:

NEW CODES ADDED TO OPG

Description 1/1/2014 OPG Group

0335T Extraosseousjointstblztion 3

0336T Lapablatuterinefibroids 7

0338T Trnscth renal symp denrv unl 4

0339T Trnscth renal symp denrv bil 4

0340T Ablate pulm tumors + extnsn 6

0342T Thxp apheresis w/hdl delip 5

10030 Guidecathetfluiddrainage 0

19081 Bx breast 1st lesion strtctc 2

19082 Bx breast add lesion strtctc 0

19083 Bx breast 1st lesion us imag 2

19084 Bx breast add lesion us imag 0

19085 Bx breast 1st lesion mr imag 2

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19086 Bx breast add lesion mr imag 0

19281 Perq device breast 1st imag 0

19282 Perq device breast ea imag 0

19283 Perq dev breast 1st strtctc 0

19284 Perq dev breast add strtctc 0

19285 Perq dev breast 1st us imag 0

19286 Perq dev breast add us imag 0

19287 Perq dev breast 1st mr guide 0

19288 Perq dev breast add mr guide 0

23333 Remove shoulder fb deep 1

23334 Shoulder prosthesis removal 3

37236 Open/perq place stent 1st 7

37237 Open/perq place stent ea add 6


37238 Open/perq place stent same 7

37239 Open/perq place stent ea add 6

37241 Vascembolize/occludevenous 7

37242 Vascembolize/occludeartery 7

37243 Vascembolize/occludeorgan 7

37244 Vascembolize/occludebleed 7

43191 Esophagoscopy rigid trnso dx 1

43192 Esophagoscp rig trnso inject 2

43193 Esophagoscp rig trnso biopsy 2

43194 Esophagoscp rig trnso rem fb 2

43195 Esophagoscopy rigid balloon 2

43196 Esophagoscp guide wire dilat 2

43197 Esophagoscopyflexdxbrush 1

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43198 Esophagoscflextrnsnbiopy 1

43211 Esophagoscop mucosal resect 1

43212 Esophagoscop stent placement 4

43213 Esophagoscopy retro balloon 2

43214 Esophagosc dilate balloon 30 2

43229 Esophagoscopy lesion ablate 3

43233 Egd balloon dil esoph30 mm/> 2

43253 Egd us transmural injxn/mark 2

43254 Egd endo mucosal resection 1

43266 Egd endoscopic stent place 4

43270 Egd lesion ablation 2

43274 Ercp duct stent placement 3

43275 Ercp remove forgn body duct 3


43276 Ercp stent exchange w/dilate 3

43277 Ercp ea duct/ampulla dilate 3

43278 Ercp lesion ablate w/dilate 3

49405 Imagecathfluidcolxnvisc 2

49406 Imagecathfluidperi/retro 2

49407 Imagecathfluidtrns/vgnl 2

52356 Cysto/uretero w/lithotripsy 5

64616 Chemodenerv musc neck dyston 0

64617 Chemodener muscle larynx emg 1

64642 Chemodenerv 1 extremity 1-4 1

64643 Chemodenerv 1 extrem 1-4 ea 0

64644 Chemodenerv 1 extrem 5/> mus 1

64645 Chemodenerv 1 extrem 5/> ea 0


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64646 Chemodenerv trunk musc 1-5 1

64647 Chemodenerv trunk musc 6/> 1

66183 Insert ant drainage device 5

93582 Perq transcath closure pda 8

C5271 Low cost skin substitute app 1








C9737 Lap esoph augmentation 7

CODES DELETED FROM THE OPG

Code Description

0124T CONJUNCTIVAL DRUG PLACEMENT

0186T SUPRACHOROIDAL DRUG DELIVERY

0192T INSERT ANT SEGMENT DRAIN EXT

13150 REPAIR OF WOUND OR LESION

19102 BX BREAST PERCUT W/IMAGE

19103 BX BREAST PERCUT W/DEVICE

19290 PLACE NEEDLE WIRE BREAST

19291 PLACE NEEDLE WIRE BREAST

19295 PLACE BREAST CLIP PERCUT

23331 REMOVE SHOULDER FOREIGN BODY

32201 DRAIN PERCUT LUNG LESION

37204 TRANSCATHETER OCCLUSION

37205 TRANSCATH IV STENT PERCUT

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Code Description

37206 TRANSCATH IV STENT/PERC ADDL

37207 TRANSCATH IV STENT OPEN

37208 TRANSCATH IV STENT/OPEN ADDL

37210 EMBOLIZATIONUTERINEFIBROID

42802 BIOPSY OF THROAT

43219 ESOPHAGUS ENDOSCOPY

43228 ESOPH ENDOSCOPY ABLATION

43256 UPPR GI ENDOSCOPY W/STENT

43258 OPERATIVE UPPER GI ENDOSCOPY

43267 ENDO CHOLANGIOPANCREATOGRAPH




Code Description


43456 DILATE ESOPHAGUS

43458 DILATE ESOPHAGUS

44901 DRAIN APP ABSCESS PERCUT

47011 PERCUT DRAIN LIVER LESION

48511 DRAIN PANCREATIC PSEUDOCYST

49021 DRAIN ABDOMINAL ABSCESS

49041 DRAIN PERCUT ABDOM ABSCESS

49061 DRAIN PERCUT RETROPER ABSC

50021 RENAL ABSCESS PERCUT DRAIN

58823 DRAIN PELVIC ABSCESS PERCUT

64613 DESTROY NERVE NECK MUSCLE

64614 DESTROY NERVE EXTREM MUSC

C9736 LAP SURG RF ABLAT UT FIBROIDS IO GD MON WHEN PER

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Oxford® Medical and Administrative Policy Updates


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


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Oxford® Medical and Administrative Policy Updates

Policy Title Policy Type Effective Date

Policy Update Bulletin

UPDATED/REVISED

Annual CPT® and HCPCS Code Updates All Jan. 1, 2014 Jan. 2014

NEW

Brilinta(Ticagrelor) Clinical Policy Jan. 1, 2014 Dec. 2013

CystaranTM(Cysteamine)OphthalmicSolution Clinical Policy Jan. 1, 2014 Dec. 2013

EnzymeReplacementTherapyforGaucherDisease Clinical Policy Feb. 1, 2014 Nov. 2013Dec. 2013 Jan. 2014

GilotrifTM(Afatinib) Clinical Policy Jan. 1, 2014 Dec. 2013

Lotronex(Alosteron) Clinical Policy Jan. 1, 2014 Dec. 2013

MechanicalCirculatorySupportDevice(MCSD) Administrative Policy Jan. 1, 2014 Nov. 2013Dec. 2013

Mekinist(Trametinib) Clinical Policy Jan. 1, 2014 Dec. 2013

TAKE NOTE

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Oxford Medical and Administrative Policy Updates



UPDATED/REVISED

Pulmozyme®(DornaseAlfa Clinical Policy Jan. 1, 2014 Dec. 2013

StribildTM(Elvitegravir/Cobicistat/Emtricitabine/TenofovirDisoproxil Fumarate)

Clinical Policy Dec. 1, 2013 Nov. 2013

Tafinlar(Dabrafenib) Clinical Policy Jan. 1, 2014 Dec. 2013

TobiTMNebulizerSolution(TobramycinInhalationSolution)andTobi®Podhaler™(TobramycinInhalationPowder)

Clinical Policy Jan. 1, 2014 Dec. 2013

UPDATED/REVISED

Agents for Migraine-Triptans Clinical Policy Jan. 1, 2014 Dec. 2013

Anticonvulsants - Depakote ER®, Keppra®, Keppra XR®, Lamictal®, Lamictal XR®, Generic Levetiracetam XR, Lamictal ODT®, Lamotrigine Extended-Release, Oxtellar XR™, Topamax®, Stavzor®,Banzel®, Potiga™, Vimpat® , Trokendi XR and Lamotrigine Oral Disintegrating Tablets


Apheresis Clinical Policy Jan. 1, 2014 Dec. 2013

Autism Clinical Policy Dec. 1, 2013 Nov. 2013

Autologous Chondrocyte Transplantation in the Knee Clinical Policy Dec. 1, 2013 Nov. 2013

Bariatric Surgery Clinical Policy Jan. 1, 2014 Dec. 2013

Bosulif®(Bosutinib) Clinical Policy Jan. 1, 2014 Dec. 2013

NEW

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UPDATED/REVISED

Breast Reconstruction Post Mastectomy Clinical Policy Dec. 1, 2013 Nov. 2013

BreastRepair/Reconstruction(NotFollowingaMastectomy) Clinical Policy Dec. 1, 2013 Nov. 2013

Cardiovascular Disease Risk Tests Clinical Policy Jan. 1, 2014 Dec. 2013

Clinical Trials Clinical Policy Jan. 1, 2014 Dec. 2013

Compounds and Bulk Powders Clinical Policy Jan. 1, 2014 Dec. 2013

Connecticut Clinical Trials Clinical Policy Jan. 1, 2014 Dec. 2013

Core Decompression for Avascular Necrosis Clinical Policy Jan. 1, 2014 Dec. 2013

Daliresp®(Roflumilast) Clinical Policy Jan. 1, 2014 Dec. 2013

Discogenic Pain, Treatment Clinical Policy Jan. 1, 2014 Dec. 2013

DPP4Inhibitors(Janumet,Januvia,JanumetXR)CheckTitle Clinical Policy Jan. 1, 2014 Dec. 2013

Drug Coverage Criteria - New and Therapeutic Equivalent Medications

Clinical Policy Dec. 1, 2013 Jan. 1, 2014

Nov. 2013 Dec. 2013

Drug Coverage Guidelines Clinical Policy Jan. 1, 2014 Dec. 2013

Durable Medical Equipment, Orthotics and Prosthetics Multiple Frequency

Reimbursement Policy Dec. 1, 2013 Nov. 2013

Erivedge(Vismodegib) Clinical Policy Jan. 1, 2014 Dec. 2013

Genetic Testing for Hereditary Breast and/or Ovarian CancerSyndrome(HBOC)


Next Article >







UPDATED/REVISED

Home Health Care Clinical Policy Feb. 1, 2014 Jan. 2014

Iclusig(Ponatinib) Clinical Policy Dec. 1, 2013 Jan. 1, 2014

Dec. 2013

ImmuneGlobulin(IVIGandSCIG) Clinical Policy Dec. 1, 2013 Nov. 2013 Dec. 2013

In-OfficeLaboratoryTestingandProceduresList Reimbursement Policy Dec. 1, 2013 Jan. 1, 2014

Nov. 2013 Dec. 2013

Lyme Disease Clinical Policy Dec. 1, 2013 Nov. 2013

Isotretinoin Oral Products Clinical Policy Jan. 1, 2014 Dec. 2013

Kuvan(SapropterinDihydrochloride) Clinical Policy Jan. 1, 2014 Dec. 2013

Maximum Frequency Per Day Reimbursement Policy Dec. 1, 2013 Nov. 2013

Modafinil(Provigil)andArmodafinil(Nuvigil) Clinical Policy Jan. 1, 2014 Dec. 2013

ModifierSUPolicy Reimbursement Policy Dec. 1, 2013 Nov. 2013

MultipleSclerosis:InterferonB-1A(Avonex,Rebif),InterferonB-1BBetaseron,Extavia,Glatiramer(Copaxone),Fingolimod(Gilenya),andTeriflunomide(Aubagio)


MultipleSclerosis:InterferonB-1A(Avonex,Rebif), InterferonB-1BBetaseron,Extavia,Glatiramer(Copaxone),Fingolimod(Gilenya),Teriflunomide(Aubagio),andDimethylFumarate(Tecfidera)


Omnibus Codes Clinical Policy Jan. 1, 2014 Dec. 2013

Next Article >







UPDATED/REVISED

Opioid Dependence Agents: Buprenorphine HCL and Naloxone (Suboxone)andBuprenorphineHCL


Oral and Nasal Fentanyl Medications Clinical Policy Jan. 1, 2014 Dec. 2013

Oral Chemotherapy Drugs: Application of NCCN Clinical Practice Guidelines


Osteochondral Grafting of Knee Clinical Policy Jan. 1, 2014 Dec. 2013

Oxford’s Outpatient Imaging Self-Referral Policy Clinical Policy Dec. 1, 2013 Nov. 2013

Plagiocephaly and Craniosynostosis Treatment Clinical Policy Dec. 1, 2013 Nov. 2013



Presacral Neurectomy and Uterine Nerve Ablation for Pelvic Pain


Preventive Care Clinical Policy Jan. 1, 2014 Dec. 2013

ProgesteroneProducts:Crinone(ProgesteroneGel),Endometrin(ProgesteroneVaginalInsert)andFirstProgesteroneVGS(ProgesteroneVaginalSuppositoryUSPCompounding Kit) for Non-Fertility Use


PulmonaryArterialHypertension(PAH)DrugTherapy Clinical Policy Jan. 1, 2014 Dec. 2013

Radiopharmaceuticals and Contrast Media Clinical Policy Dec. 1, 2013 Nov. 2013

Rectiv(NitroglycerinOintment) Clinical Policy Jan. 1, 2014 Dec. 2013

Routine Foot Care Clinical Policy Jan. 1, 2014 Dec. 2013

Next Article >

https://www.oxhp.com/secure/policy/post_pin_comm_dec13.pdf















UPDATED/REVISED

Sedative Hypnotic Agents Clinical Policy Jan. 1, 2014 Dec. 2013

Speech Therapy and Early Intervention Programs/Birth to Three Clinical Policy Dec. 1, 2013 Nov. 2013

Sprycel®(Dasatinib) Clinical Policy Jan. 1, 2014 Dec. 2013

Subcutaneous Leuprolide Acetate Clinical Policy Jan. 1, 2014 Dec. 2013

TopicalRetinoids(PharmaceuticalTreatmentofAcne) Clinical Policy Jan. 1, 2014 Dec. 2013

Transcatheter Heart Valve Procedures Clinical Policy Jan. 1, 2014 Dec. 2013

Unicondylar Spacer Devices for Treatment of Pain or Disability Clinical Policy Dec. 1, 2013 Nov. 2013

Vaccines Clinical Policy Jan. 1, 2014 Dec. 2013

Vagus Nerve Stimulation Clinical Policy Jan. 1, 2014 Dec. 2013

Virtual Upper Gastrointestinal Endoscopy Clinical Policy Dec. 1, 2013 Nov. 2013

Visual Information Processing Evaluation and Orthoptic and Vision Therapy


Warming Therapy and Ultrasound Therapy for Wounds Clinical Policy Jan. 1, 2014 Dec. 2013

Xtandi®(Enzalutamide) Clinical Policy Jan. 1, 2014 Dec. 2013


Note: The appearance of a service or procedure on this list does not imply that Oxford provides coverage for the service or procedure. In the event ofaninconsistencyorconflictbetweentheinformationprovidedinthisbulletinandthepostedpolicy,theprovisionsofthepostedpolicywillprevail.

OxfordHMOproductsareunderwrittenbyOxfordHealthPlans(NY),Inc.,OxfordHealthPlans(NJ),Inc.andOxfordHealthPlans(CT),Inc. Oxford insurance products are underwritten by Oxford Health Insurance, Inc.

Next Article >












UnitedHealthcareoftheRiverValleyPreauthorizationList and Policy Updates

For complete details on the new and/or revised policies and guidelines listed in the table below, refer to the monthly Policy Update Bulletin at UHCRiverValley.com > Providers > Coverage Policy Library > Policy Update Bulletin. These updates apply to UnitedHealthcare of the River Valley commercial and hawk-i plan membership only; they do not apply to members enrolled in a River Valley Ohio product or South Carolina product.

Policy Title Effective Date Coverage Policy Update Bulletin

TAKE NOTE

Annual CPT® and HCPCS Code Updates Jan. 1, 2014 Jan. 2014

NEW

EnzymeReplacementTherapyforGaucherDisease Feb. 1, 2014 Nov. 2013 Dec. 2013Jan. 2014

MechanicalCirculatorySupportDevice(MCSD) Jan. 1, 2014 Nov. 2013 Dec. 2013

UPDATED/REVISED

Abnormal Uterine Bleeding and Uterine Fibroids Jan. 1, 2014 Dec. 2013

Apheresis Jan. 1, 2014 Dec. 2013

Bariatric Surgery Jan. 1, 2014 Dec. 2013

Blepharoplasty, Blepharoptosis and Brow Ptosis Repair Jan. 1, 2014 Dec. 2013

Breast Reconstruction Post Mastectomy Dec. 1, 2013 Nov. 2013

Next Article >




UnitedHealthcare of the River Valley Prior AuthorizationListandPolicy Updates


BreastRepair/Reconstruction(NotFollowingMastectomy) Dec. 1, 2013 Nov. 2013

Cardiovascular Disease Stress Tests Jan. 1, 2014 Dec. 2013

Cochlear Implants Dec. 1, 2013 Nov. 2013

Computed Tomographic Colonography Jan. 1, 2014 Nov. 2013 Dec. 2013

Core Decompression for Avascular Necrosis Dec. 1, 2013 Nov. 2013

Deep Brain Stimulation Jan. 1, 2014 Dec. 2013

Hip Resurfacing Arthroplasty Jan. 1, 2014 Dec. 2013

Hyperbaric Oxygen Therapy and Topical Oxygen Therapy Jan. 1, 2014 Dec. 2013

ImmuneGlobulin(IVIGandSCIG) Jan. 1, 2014 Dec. 2013

Implantable Beta-Emitting Microspheres for Treatment of Malignant Tumors Jan. 1, 2014 Dec. 2013

Intensity-Modulated Radiation Therapy Jan. 1, 2014 Dec. 2013

Nerve Graft to Restore Erectile Function During Radical Prostatectomy Jan. 1, 2014 Dec. 2013

Noninvasive Prenatal Diagnosis of Fetal Aneuploidy Using Cell-Free Fetal Nucleic Acids in Maternal Blood

Feb. 1, 2014 Dec. 2013 Jan. 2014

Omnibus Codes Jan. 1, 2014 Nov. 2013 Dec. 2013

Orencia®(Abatacept) Dec. 1, 2013 Nov. 2013

Polysomnography and Portable Monitoring For Evaluation of Sleep Related Breathing Disorders

Dec. 1, 2013 Nov. 2013

Preventive Care Services Jan. 1, 2014 Dec. 2013

Next Article >





Proton Beam Radiation Therapy Jan. 1, 2014 Dec. 2013

RepositoryCorticotropinInjection(HPActharGel) Jan. 1, 2014 Dec. 2013

Transcatheter Heart Valve Procedures Jan. 1, 2014 Dec. 2013

Vaccines Jan. 1, 2014 Dec. 2013

Vagus Nerve Stimulation Dec. 1, 2013 Nov. 2013

RETIRED

TotalAnkleReplacementSurgery(Arthroplasty) Jan. 1, 2014 Dec. 2013

Wireless Capsule Endoscopy Jan. 1, 2014 Dec. 2013

Xyntha-FactorVIII(AntihemophilicFactor,Recombinant) Jan. 1, 2014 Dec. 2013

UnitedHealthcare of the River Valley Prior AuthorizationListandPolicy Updates

Note: The appearance of a service or procedure on this list does not imply that UnitedHealthcare provides coverage for the service or procedure. In the eventofaninconsistencyorconflictbetweentheinformationprovidedinthisbulletinandthepostedpolicy,theprovisionsofthepostedpolicywillprevail.

Next Article >



For complete details on the revised policy listed below, refer to the monthly SignatureValue™BenefitInterpretation Policy Update Bulletin at UHCWest.com > Provider Log In > Library > Resource Center > Guidelines & Interpretation Manuals.

SignatureValue™BenefitInterpretation Policy Updates

Policy Title Applicable State(s) Effective Date


UPDATED/REVISED

Biofeedback All Jan. 1, 2014 Dec. 2013

Clinical Trials: Routine Costs in Clinical Trials All Dec. 1, 2013 Nov. 2013

Jan. 1, 2014 Dec. 2013

Complementary and Alternative Medicine All Jan. 1, 2014 Dec. 2013

Detoxification:ChemicalDependency/Substance AbuseDetoxification

Oregon Dec. 1, 2013 Nov. 2013

All Jan. 1, 2014 Dec. 2013

DurableMedicalEquipment(DME),Prosthetics,CorrectiveAppliances/Orthotics(Non-FootOrthotics)and Medical Supplies Grid

All Jan. 1, 2014 Dec. 2013

Next Article >




Policy Title Applicable State(s) Effective Date


Hearing: Hearing Screening, Hearing Examinations and Hearing Aids and Hearing Devices

All Jan. 1, 2014 Dec. 2013

Hospice Care and Services California Jan. 1, 2014 Dec. 2013

Maternity and Newborn Care Oregon Jan. 1, 2014 Dec. 2013

Nutritional Therapy: Enteral and Oral Nutritional Therapy All Jan. 1, 2014 Dec. 2013

Ostomy: Ostomy Supplies All Jan. 1, 2014 Dec. 2013

Ostomy: Ostomy Supplies Grid All Jan. 1, 2014 Dec. 2013

Physician Services: Primary Care and Specialist Visits California, Oregon & Washington

Jan. 1, 2014 Dec. 2013

Radiology: Diagnostic and Therapeutic Radiology Services

All Jan. 1, 2014 Dec. 2013

SignatureValue™ BenefitInterpretation Policy Updates

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

Next Article >



For complete details on the new and/or revised policies listed in the table below, refer to the monthly SignatureValue™ Medical Management Guidelines Update Bulletin at UHCWest.com > Provider Log In > Library > Resource Center > Guidelines & Interpretation Manuals.

SignatureValue™ Medical Management Guideline Updates

Title Effective Date Update Bulletin

TAKE NOTE

Annual CPT® and HCPCS Code Updates Jan. 1, 2014 Jan. 2014

NEW

Clinical Trials Jan. 1, 2014 Nov. 2013 Dec. 2013

Hospital Readmissions: Quality of Care Guideline Dec. 1, 2014 Nov. 2013

MechanicalCirculatorySupportDevice(MCSD) Jan. 1, 2014 Nov. 2013 Dec. 2013

UPDATED/REVISED

Abnormal Uterine Bleeding and Uterine Fibroids Jan. 1, 2014 Dec. 2013

Apheresis Jan. 1, 2014 Dec. 2013

Autism Spectrum Disorder Nov. 1, 2013 Nov. 2013

Bariatric Surgery Jan. 1, 2014 Dec. 2013

Cardiovascular Disease Risk Tests Jan. 1, 2014 Dec. 2013

Next Article >




Title Effective Date Update Bulletin

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

Jan. 1, 2014 Dec. 2013

Hip Resurfacing Arthroplasty Jan. 1, 2014 Dec. 2013

Omnibus Codes Jan. 1, 2014 Dec. 2013


Dec. 1, 2013 Nov. 2013

Preventive Care Services Jan. 1, 2014 Dec. 2013

Proton Beam Radiation Therapy Jan. 1, 2014 Dec. 2013

Transcatheter Heart Valve Procedures Jan. 1, 2014 Dec. 2013

RETIRED

Hyperbaric Oxygen Therapy and Topical Oxygen Therapy Jan. 1, 2014 Jan. 2014

TotalAnkleReplacement(Arthroplasty) Jan. 1, 2014 Jan. 2014

Wireless Capsule Endoscopy Jan. 1, 2014 Jan. 2014

SignatureValue™ Medical Management Guideline Updates

Note: The appearance of a service or procedure on this list does not imply that coverage is provided for the service or procedure. In the event of aninconsistencyorconflictbetweentheinformationprovidedinthisbulletinandthepostedpolicy,theprovisionsofthepostedpolicywillprevail.

Next Article >



UnitedHealthcareAffiliates

UnitedHealthcare of the River Valley and Neighborhood Health Partnership:Disease Management Programs

UnitedHealthcare of the River Valley (UnitedHealthcareRiverValley)diseasemanagement programs serve members in the UnitedHealthcare River Valley and Neighborhood Health Partnership (NHP)plans.Servicesavailablefor members include:

• Educational materials

• Periodicdisease-specificnewsletters

• Notificationofcareopportunitiessuchasmissedtests, medication compliance, and emergentorinpatient admissions for an exacerbation

• Case management interventions for membersidentifiedathighestrisk

Providers receive quarterly reports and notificationsregardingcareopportunitiesfor patients. The UnitedHealthcare River Valley website at UHCrv.com provides information about the programs and disease management member and provider rights and responsibilities. Providers may contact the disease management staff to request information about the programs, refer patients for services or communicate a complaint or offer feedback.

Normal business hours are from 8 a.m. to 4:30 p.m., Monday through Friday, with voicemail options after hours.To contact us, call 800-369-2704, Option 4; Fax: 866-950-7759; or send an email to [email protected].

Insurance coverage provided by UnitedHealthcare Insurance Company or its affiliates.HealthplancoverageprovidedbyUnitedHealthcareofCalifornia,UnitedHealthcare of Colorado, Inc., UnitedHealthcare of Oregon, Inc., and UnitedHealthcareofWashington,Inc.orotheraffiliates.AdministrativeservicesprovidedbyUnitedHealthCareServices,Inc.oritsaffiliates.

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