enter - unitedhealthcare online network bulletin was developed to share important updates regarding...

Important updates 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: September 2017

enter

Network Bulletin: November 2013 - Volume 582

Table of Contents

For more information, call 877.842.3210 or visit UnitedHealthcareOnline.com

2 Network Bulletin: September 2017

Front and Center• Introducing UHCprovider.com – Our

New Care Provider Website

• Sign Up for Our Complimentary Online Course for Improving Patient Engagement

• PreCheck MyScript App Provides Real-Time Prescription Costs and Coverage Detail

• Tell Us What You Think of Our Communications

• Request More Service Codes and Get Physical Therapy/Specialist Benefits with Eligibility and Benefit EDI Transactions (270/271)

• Pharmacy Update – Notice of Changes to Prior Authorization Requirements and Coverage Criteria for UnitedHealthcare Commercial and Oxford

• Prolonged Services Policy Change for UnitedHealthcare Commercial Plan and UnitedHealthare Community Plan

• Reminder on Overpayments Mailing Address

• Expansion of Notification/Prior Authorization Requirement for Certain Office-Based Procedures Performed in Other Sites of Service – Effective Oct. 1, 2017

• Reminder: Colony-Stimulating Factors Will Require Prior Authorization

UnitedHealthcare Commercial• Update to Truvada® Announcement Requiring

Notification/Prior Authorization

• Optum Neonatal Resource Services Guidelines

• Changes in Advance Notification and Prior Authorization Requirements

• On-Line Chemotherapy Prior Authorization System to Display Outcome Findings

• Reminder: Neighborhood Health Partnership and UnitedHealthcare of the River Valley Commercial Plan Changes in Advance Notification and Prior Authorization Requirements

• UnitedHealth Premium® Designation Program – September 2017 Updates

• UnitedHealthcare Medical Policy, Medical Benefit Drug Policy and Coverage Determination Guideline Updates

• UnitedHealthcare Genetic and Molecular Lab Testing Notification/Prior Authorization Requirement

UnitedHealthcare Commercial Reimbursement Policies

• Scheduled Revision to Consultation Services Policy

• Update to the Laboratory Services Policy

• Implementation Delay for UnitedHealthcare/Oxford’s Multiple Procedure Payment Reduction Reimbursement Policy for the Technical Component of Diagnostic Cardiovascular & Ophthalmology Procedures

• New Acupuncture Reimbursement Policy

• Revision to the Replacement Codes Policy

• Revision to the Supply Policy

UnitedHealthcare Community Plan• UnitedHealthcare Community Plan Launches

a Dual Special Needs Program – Dual Complete Medicare Advantage

• UnitedHealthcare Community Plan Medical Policy, Medical Benefit Drug Policy and Coverage Determination Guideline Updates

• UnitedHealthcare Community Plan Preferred Drug List Updates for Fourth Quarter 2017

UnitedHealthcare Medicare Solutions• Coverage of Annual Wellness Visits

and Routine Physicals

• UnitedHealthcare Medicare Advantage Coverage Summary Updates

• 2018 Medicare Advantage Service Area Reductions

• UnitedHealthcare Medicare Advantage Policy Guideline Updates

Doing Business Better • Closing Diabetic Gaps in Care

• Online Prevention Program Available for Information on Depression, Substance-Use Disorders and ADHD

• Evidenced-Based Clinical Practice Guideline

• Reminder on Case and Disease Management Programs

UnitedHealthcare Affiliates • SignatureValue/UnitedHealthcare Benefits Plan of

California Benefit Interpretation Policy Updates

• Oxford® Medical and Administrative Policy Updates

• SignatureValue/UnitedHealthcare Benefits Plan of California Medical Management Guideline Updates

Network Bulletin: November 2013 - Volume 5833 For more information, call 877.842.3210

or visit UnitedHealthcareOnline.comNetwork Bulletin: September 2017

Front & Center

Introducing UHCprovider.com – Our New Care Provider WebsiteYou asked for digital tools and content designed with you in mind, and we heard you. We will retire UnitedHealthcareOnline.com and UHCwest.com in favor of a new and improved website. The replacement site, UHCprovider.com, is available now and includes these new features:

• A predictive search function with filtering and sorting capabilities to help you find what you need faster

• A personalized view for signed-in users

• An easy-to-read design that looks great whether you’re on a desktop computer, tablet or smart phone

Your peers helped name and shape this new “front door” website, and we want your feedback to help us prioritize future enhancements. After you’ve visited the site, click the Feedback tab on the right side of every page to send us your thoughts and suggestions. You also may be randomly selected to take a short survey.

If you have questions, call the UnitedHealthcare Connectivity Help Desk at 866-842-3278, option 1.

TABLE OF CONTENTS

Next Article >

https://www.uhcprovider.com/?cid=NB_SiteLaunch_0917

Front & Center



TABLE OF CONTENTS

As care providers, your connections with your patients are essential to helping keep them engaged in their care. We want to remind you about an exciting new resource that can help you and your staff learn more about improving patient engagement.

Connecting with the Health Care Consumer is a complimentary, self-paced online course made available to you and your staff through a collaboration between UnitedHealthcare and Procter & Gamble (P&G). The course is based on a large consumer research project Procter & Gamble Personal Health Care recently conducted to understand what factors most influence patient satisfaction.

Care providers can access the course to:

• Learn more about what patients say are the drivers of satisfaction

• Discover ways to engage with patients in a meaningful way to increase the odds they will follow advice, recommendations and instructions

The course is specifically designed to account for busy schedules with short videos and brief learning segments that allow you and your office staff to come and go as needed. You’ll learn from fellow health care professional and former Chief of Medical Affairs for UnitedHealth Group, Dr. Reed Tuckson, and P&G consumer behavior expert, Phil McWaters.

To register for the course or to learn more, go to phc.thebigknow.com.

Sign Up for Our Complimentary Online Course for Improving Patient Engagement

Next Article >

https://phc.thebigknow.com/course/connecting-with-the-healthcare-consumer-part-1/session/connecting-with-the-healthcare-consumer/?utm_source=uhg&utm_medium=network_bulletin&utm_content=i2_sept&utm_campaign=providers

Front & Center



TABLE OF CONTENTS

PreCheck MyScript is a new app on Link that helps make it easy to run a pharmacy trial claim to get real-time prescription coverage details for your patients who are UnitedHealthcare benefit plan members.

PreCheck MyScript gives you:

• Current out-of-pocket prescription costs for patients at their selected pharmacy

• Information on lower-cost prescription alternatives, when available, to help save patients money

• Immediate alerts when a proposed prescription currently requires prior authorization, or is non-covered or non-preferred

• A quick online way to request prior authorization — without the need for a phone call or fax

The app is designed to integrate with your current office workflow, and it can save you time by reducing the need to fax or call for prescription coverage information. By alerting you when a medication requires prior authorization or isn’t covered, it may also reduce frustration and delays for members at the pharmacy.

PreCheck MyScript is available in the Link marketplace. To learn more about PreCheck MyScript please visit UHCprovider.com/PreCheckMyScript.

Not Receiving Our Emails? To make sure that you receive important notices from us, please update the email address in your profile:

1. Sign in to UnitedHealthcareOnline.com. 2. Select the UnitedHealthcare Online tile from your Link dashboard. 3. Click My Profile on the upper right corner of the screen. 4. Update your Business Email on the Manage My Account page. 5. Click Save.

PreCheck MyScript App Provides Real-Time Prescription Costs and Coverage Detail

Next Article >

Tell Us What You Think of Our Communications

As a regular reader of The Network Bulletin, your opinion is important to us. We’d like to get your thoughts about The Bulletin and UnitedHealthcare communications related to network changes, quality initiatives and other issues. Please take a few minutes today to complete the survey online at uhcresearch.az1.qualtrics.com/jfe/form/ SV_08sAsRnUY2Kb153. Thank you for your time.

http://UHCprovider.com/PreCheckMyScript

http://UnitedHealthcareOnline.com

https://uhcresearch.az1.qualtrics.com/jfe/form/SV_08sAsRnUY2Kb153

https://uhcresearch.az1.qualtrics.com/jfe/form/SV_08sAsRnUY2Kb153

Front & Center



TABLE OF CONTENTS

Starting Sept. 8, 2017, you will be able to request up to 10 service type codes (STC) for 270/271 EDI transactions with UnitedHealthcare. You’ll have access to more eligibility and benefit information for members and can request the specific information you need in one 270 transaction, such as:

STC Description5 Diagnostic lab30 Health plan benefit coverage47 Hospital96 SpecialistPT Physical therapy

Physical therapy and specialist benefits will be available in September, both as a generic response and an explicit response. Generic responses are obtained by requesting STC 30 and will automatically include physical therapy and specialist benefits. Explicit responses are obtained by requesting the specific STC only, such as PT or 96. In most cases, a message segment will be returned when benefits are for a specialist. This information has been communicated to our trading partners; we also encourage you to share it with your software vendor or clearinghouse.

If you have questions, please contact UnitedHealthcare EDI Support at 800-842-1109 or go online to our EDI Transaction Support Form.

Request More Service Codes and Get Physical Therapy/Specialist Benefits with Eligibility and Benefit EDI Transactions (270/271)

Next Article >

Pharmacy Update – Notice of Changes to Prior Authorization Requirements and Coverage Criteria for UnitedHealthcare Commercial and Oxford

A Pharmacy Bulletin outlining upcoming new or revised clinical programs and implementation dates is now available online for UnitedHealthcare Commercial. Go to UnitedHealthcareOnline.com > Tools & Resources > Pharmacy Resources. Then select Clinical Programs and scroll down to the Resources box to access the updates.

https://www.unitedhealthcareonline.com/b2c/CmaAction.do?txnType=ProblemReport&forwardToken=ProblemReport

https://www.unitedhealthcareonline.com/b2c/index.do

Front & Center



TABLE OF CONTENTS

Effective for claims processed on or after Sept. 3, 2017, UnitedHealthcare’s Prolonged Services Policy will be changed to allow reimbursement for two prolonged services CPT codes except when reported during the same service period as complex chronic care management services (CPT codes 99487 and 99489) or transitional care management services (CPT codes 99495 and 99496). The two prolonged services CPT codes are:

• 99358 – Prolonged evaluation and management service before and/or after direct patient care; first hour

• 99359 – Prolonged evaluation and management service before and/or after direct patient care; each additional 30 minutes (List separately in addition to code for prolonged service)

The revised Prolonged Services Policy reflecting this change will be published and effective on September 3, 2017. The revised policy will be accessible at UnitedHealthcareOnline.com under Tools & Resources > Policies, Protocols and Guides in September 2017.

Prolonged Services Policy Change for UnitedHealthcare Commercial Plan and UnitedHealthare Community Plan

Next Article >

Reminder on Overpayments Mailing Address

Please mail refunds for overpayments to the name and address indicated on the refund request form.

Regular mail: UnitedHealthcare Insurance Company PO Box 101760 Atlanta, GA 30392-1760

Overnight mail: UnitedHealthcare Insurance Company – Overnight Delivery Lockbox 101760 3585 Atlanta Ave Hapeville, GA 30354

The Overpayment Refund/Notification Form for care providers is located on UHCprovider.com > Menu > Claims, Billing and Payments > Overpayment Refund/Notification Form.

https://www.uhcprovider.com/content/dam/provider/docs/public/claims/Overpayment-Refund-Form.pdf

Front & Center



TABLE OF CONTENTS

As a reminder, for dates of service on or after Oct. 1, 2017, we’ll require notification/prior authorization for the following procedures when they’ll be performed in any setting other than a physician’s office. We previously announced this change on page 10 of the July Network Bulletin. Please note that notification/prior authorization is required when the following procedures are performed in a physician’s office, place of service code 11, with an accompanying facility charge.

Category CPT Code

Dermatologic10120 10140 11400 11401

11404 11420 11421 11423

11424 11426 11442 11606

Gastroenterology 45300 45330 46922

General Surgery 19000

Muscular/Skeletal 64520

Obstetrics/Gynecology 57460

Urology 55250

Vascular 36473 36475 36478

The requirement applies to the following UnitedHealthcare Commercial plans, including Exchange plans, in states where we already conduct site of service medical necessity reviews.

• Golden Rule Insurance Company (group 902667)

• Mid-AtlanticMD Healthplan Individual Practice Association, Inc. (M.D. IPA) or Optimum Choice, Inc. plans

• UnitedHealthcare of the River Valley*

• UnitedHealthcare Oxford*

• UnitedHealthcare

• UnitedHealthcare Life Insurance Company (group 755870)

* UnitedHealthcare Oxford and UnitedHealthcare of the River Valley plans already require prior authorization requests to evaluate whether it’s medically necessary for these procedures to be provided in any setting other than a physician’s office. Site of service will now be reviewed as part the existing prior authorization review process for these procedures.

If you have questions, please contact your local Network Management representative or call the Provider Services number on the back of the member’s ID card.

Expansion of Notification/Prior Authorization Requirement for Certain Office-Based Procedures Performed in Other Sites of Service – Effective Oct. 1, 2017

Next Article >

https://www.unitedhealthcareonline.com/ccmcontent/ProviderII/UHC/en-US/Assets/ProviderStaticFiles/ProviderStaticFilesPdf/News/July-Interactive-Network-Bulletin-2017.pdf

Front & Center



TABLE OF CONTENTS

Beginning Oct. 1, 2017, colony-stimulating factors administered to patients with a cancer diagnosis in the outpatient setting will require prior authorization. This requirement is for members of UnitedHealthcare Commercial, UnitedHealthcare Oxford and UnitedHealthcare Community Plans that currently require prior authorization for outpatient injectable chemotherapy.*

Care providers will use the online chemotherapy prior authorization tool to obtain the prior authorization for colony-stimulating factors. This system will identify the high and intermediate febrile neutropenia chemotherapy risk regimens. During the chemotherapy authorization process, regimens classified as a high or intermediate risk will include an authorization for a colony stimulating factor.

This prior authorization requirement includes these drugs:

• J1442 filgrastim (Neupogen)

• J1447 tbo-filgrastim (Granix)

• J2505 pegfilgrastim (Neulasta)

• J2820 sargramostim (Leukine)

• Q5101 filgrastim, bio similar (Zarxio)

For more information, go to the July and August Network Bulletins online at UHCprovider.com > News and Network Bulletin.

*Members insured under the UnitedHealthcare Community Plan in Tennessee are included in this requirement.

Reminder: Colony-Stimulating Factors Will Require Prior Authorization

Next Article >

https://www.uhcprovider.com/en/resource-library/news.html?NB_Sept2017_0917



UnitedHealthcare CommercialUpdate to Truvada® Announcement Requiring Notification/Prior Authorization

Earlier this year, UnitedHealthcare announced that effective July 1 there would be changes to the pharmacy benefit coverage of Truvada for UnitedHealthcare Commercial plan members, including a new notification/prior authorization requirement. This applied when Truvada was prescribed for pre-exposure prophylaxis (PrEP) to prevent HIV infection in patients who are determined to be at high risk for acquiring HIV.

What’s Happening Now

• Effective immediately, we are removing the prior authorization requirement for Truvada.

• UnitedHealthcare Commercial plan members who take Truvada aren’t required to use BriovaRx to fill their prescriptions. They can use a network pharmacy of their choice.

• To get their medication from the network pharmacy of their choice, they will need to call the BriovaRx Customer Service at 866-803-8570 to “opt out” of using BriovaRx.

If you have questions, please email us at [email protected].

TABLE OF CONTENTS

Next Article >



TABLE OF CONTENTS

Effective Nov. 30, 2017, the Neonatal Resource Services (NRS) Clinical Guidelines will be revised based on current clinical evidence and expert panel input. The revisions are:

• Apnea and Bradycardia: The apnea/bradycardia countdown for preterm infants and observation period following discontinuation of caffeine are being revised. Information on caffeine use and caffeine levels is being added.

• Discharge Planning: The 72-hour glucose level and information on powdered formula are being revised. Discharge readiness metrics, outpatient weight monitoring, speech-language interventions for infants with feeding difficulties, referral for outpatient hearing and retinopathy of prematurity (ROP) follow-up, information on self-resolution of brief bradycardic events and link to car seats for smaller infants are being added.

• Early-Onset Neonatal Sepsis (EONS): The incidence of neonatal Group B Strep (GBS) sepsis and timeframe of lab work for asymptomatic infants <37 weeks is being revised. Newer techniques for EONS assessment, emphasis on infant observation and incubation period for blood cultures will be added.

• Feeding the Neonate: The adequate weight gain amount will be revised. The use of TPN and electrolyte monitoring for extremely low birth weight (ELBW) infants, probiotic utilization, online tool for weight gain/loss and outpatient follow-up will be added.

• Inhaled Nitric Oxide (iNO): Utilization of hospital protocols for iNO use and timeframe for discontinuation when there is lack of infant response are being added.

• Neonatal Abstinence Syndrome: Utilization of the lowest effective medication dose, sum of last three Finnegan scores to initiate pharmacologic management and emphasis on non-pharmacologic measures will be added.

A new NRS medical necessity clinical guideline on Neonatal Hyperbilirubinemia will also take effect on Nov. 30, 2017. This guideline will address the optimal management of term and preterm infants in the NICU who have an elevated serum bilirubin concentration.

The new and revised clinical guidelines can be accessed at UnitedHealthCareOnline.com > Tools &Resources > Policies, Protocols and Guides > Medical & Drug Policies and Coverage Determination Guidelines – Commercial > Clinical Guidelines.

Next Article >

UnitedHealthcare Commercial

Optum Neonatal Resource Services Guidelines

https://www.unitedhealthcareonline.com/b2c/CmaAction.do?channelId=accaca74f198e110VgnVCM2000002cc0dc0a____



TABLE OF CONTENTS

Code E0652 was previously announced in the July Network Bulletin as requiring prior authorization for dates of service on or after Oct. 1, 2017 for UnitedHealthcare Commercial Plans (UnitedHealthcare Mid Atlantic Health Plan, Navigate, UnitedHealthOne, UnitedHealthcare Commercial, UnitedHealthcare West, UnitedHealthcare of the River Valley, and Neighborhood Health Partnership). Prior authorization will NOT be required for dates of service on or after Oct. 1, 2017 for E0652.

Category Code

Durable Medical Equipment – greater than $1,000 E0652

The UnitedHealthcare Community Plan of Nebraska (Medicaid Plan) requires prior authorization today for specific Durable Medical Equipment, orthotics and prosthetics procedure codes with a retail purchase or cumulative rental cost of more than $500. Effective for dates of service on or after Sept. 1, 2017, the Durable Medical Equipment, orthotics and prosthetics prior authorization requirement will apply with a retail purchase or cumulative rental cost of more than $750.

Beginning Oct. 1, 2017, the following codes will no longer require prior authorization for the following UnitedHealthcare Commercial Plans: UnitedHealthcare Mid Atlantic Health Plan, Navigate, UnitedHealthOne, UnitedHealthcare Commercial, and UnitedHealthcare West. The prior authorization reduction does not apply to Neighborhood Health Partnership, UnitedHealthcare of the River Valley and Oxford health plans.

Category Code

Home Health Care B4159 S9123 S9124 S9208 S9433

Potentially Unproven Services54240 65765 65767 86849 91299 95966 95967

0269T 0270T 0271T S3652

This change is part of UnitedHealthcare’s ongoing responsibility to evaluate our medical policies, clinical programs and health benefits compared to the latest scientific evidence and specialty society guidance. Using evidence-based medicine to guide coverage decisions supports quality patient care and reflects our shared commitment to the Triple Aim of better care, better health outcomes and lower costs.

Although prior authorization requirements are being removed for certain codes, post-service determinations may still be applicable based on criteria published in medical policies and/or local and national coverage determination criteria.

The most up-to-date Advance Notification lists are available online:

• UnitedHealthcare Medicare Solutions and UnitedHealthcare Commercial Plans – UnitedHealthcareOnline.com > Clinician Resources > Advance & Admission Notification

• UnitedHealthcare Community Plan – UHCCommunityPlan.com > For Health Care Professionals > Select your state.

Next Article >


Changes in Advance Notification and Prior Authorization Requirements

https://www.uhcprovider.com/content/dam/provider/docs/public/resources/news/2017/network-bulletin/July-2017-Network-Bulletin.pdf

https://www.unitedhealthcareonline.com/b2c/CmaAction.do?viewKey=PreLoginMain&forwardToken=PreLoginMain

http://www.uhccommunityplan.com/



TABLE OF CONTENTS

UnitedHealthcare is adding a new feature to our on-line chemotherapy prior authorization tool. In 2018, the

following outcome data will be provided to practices that request prior authorization for cancer treatment regimens:

• Median duration of treatment

• Relapse rate for adjuvant therapy

• Hospitalization rate

• Average monthly cost of care (while on treatment)

• Selection frequency for treatment regimen (by cancer and line of therapy)

This information on outcomes of cancer treatment regimens in our members is intended to supplement data obtained from clinical trials, which include selected patients and may not reflect the patients in your practice. We hope you find the additional information useful as you select the best treatment options for your patients who are our members and that you share this data and its impact on your decision-making process with your patients.

If you have any questions, send an email to [email protected].

Next Article >


On-Line Chemotherapy Prior Authorization System to Display Outcome Findings

mailto:unitedoncology%40uhc.com?subject=



TABLE OF CONTENTS

Effective for dates of service on or after Oct. 1, 2017, the Neighborhood Health Partnership and UnitedHealthcare of the River Valley Commercial plan will experience changes in their advance notification and prior authorization requirements. Elective inpatient admission notification requirements will continue as defined and are not impacted by these changes. The advance notification and prior authorization requirements have been reduced since the announcement in the July Network Bulletin. Please utilize the web paths below for the prior authorization requirements effective Oct. 1, 2017.

Please review the following information specific to Neighborhood Health Partnership and UnitedHealthcare of the River Valley Commercial plan:

Neighborhood Health Partnership

• Advance notification and prior authorization requirements will be defined by category and codes

• Referral requirements will continue as defined and are not impacted by these changes.

• A complete prior authorization list including service categories and procedure codes is available at UnitedHealthcareOnline. com > Clinician Resources > Advance & Admission Notification > Advance Notification Lists > Neighborhood Health Partnership Advance Notification Guide effective Oct. 1 2017

UnitedHealthcare of the River Valley Commercial

• Advance notification and prior authorization requirement changes will include procedure code removal and additions.

• A complete prior authorization list including service categories and procedure codes is available at UnitedHealthcareOnline. com > Clinician Resources > Advance & Admission Notification > Advance Notification Lists > UnitedHealthcare of the River Valley Advance Notification Procedure Codes effective Oct. 1 2017.

Next Article >


Reminder: Neighborhood Health Partnership and UnitedHealthcare of the River Valley Commercial Plan Changes in Advance Notification and Prior Authorization Requirements

https://www.uhcprovider.com/content/dam/provider/docs/public/resources/news/2017/network-bulletin/July-2017-Network-Bulletin.pdf

https://www.unitedhealthcareonline.com/b2c/CmaAction.do?channelId=9e2c3cd5d2da4110VgnVCM1000007740dc0a____






TABLE OF CONTENTS

Key Dates:

• Assessment letters mailed to Premium-eligible physicians: July 6, 2017

• Display date: Sept. 6, 2017

• Reconsideration end date: Nov. 13, 2017

The UnitedHealth Premium® designation program provides physician designations based on quality and cost efficiency criteria to help members make more informed choices about their medical care. Physicians also can use these designations when referring patients to other physicians.

New designations will display on our public websites on Sept. 6, 2017. We’ll continue to accept and review requests after this date. We’ll make any applicable change to your publicly-displayed designation. The last date to submit a reconsideration request is Nov. 13, 2017.

UnitedHealth Premium Designation Training Course

Our updated online course explains the methodology used to assess quality and cost efficiency, which determines Premium designations. UnitedHealthcare Link users can access UHC On Air by selecting the UHC On Air app on their Link dashboard. From there, go to UHC News Now, and click on UHC Commercial. You’ll find UnitedHealth Premium Designation Program listed alphabetically among courses. To access Link, sign in to UHCprovider.com or UnitedHealthcareOnline.com using your Optum ID. If you aren’t registered for UnitedHealthcareOnline.com and Link, visit UnitedHealthcareOnline.com and select New User in the top right corner.

For more information about UnitedHealth Premium and the methodology, go to UnitedHealthcareOnline.com > Quick Links > UnitedHealth Premium or call 866-270-5588.

Next Article >


UnitedHealth Premium® Designation Program – September 2017 Updates

https://www.uhcprovider.com/?NB_Sept2017_0917


https://www.unitedhealthcareonline.com/b2c/CmaAction.do?channelId=a7b0465138a17210VgnVCM1000002f10b10a____



TABLE OF CONTENTS

For complete details on the policy updates listed in the following table, please refer to the August 2017 Medical Policy Update Bulletin at UHCprovider.com > Menu > Policies and Protocols > Commercial Policies > Commercial Medical & Drug Policies and Coverage Determination Guidelines > Medical Policy Update Bulletins.

Policy Title Policy Type Effective Date

NEW

Brineura™ (Cerliponase Alfa) Drug Sept. 1, 2017

Laser Interstitial Thermal Therapy Medical Oct. 1, 2017

Radicava™ (Edaravone) Drug Sept. 1, 2017

White Blood Cell Colony Stimulating Factors Drug Sept. 1, 2017

UPDATED/REVISED

Apheresis Medical Oct. 1, 2017

Chemosensitivity and Chemoresistance Assays in Cancer Medical Sept. 1, 2017

Clotting Factors and Coagulant Blood Products Drug Sept. 1, 2017

Continuous Glucose Monitoring and Insulin Delivery for Managing Diabetes Medical Sept. 1, 2017

Cytological Examination of Breast Fluids for Cancer Screening Medical Aug. 1, 2017

Discogenic Pain Treatment Medical Aug. 1, 2017

Durable Medical Equipment, Orthotics, Ostomy Supplies, Medical Supplies and Repairs/Replacements CDG Oct. 1, 2017

Electrical Bioimpedance for Cardiac Output Measurement Medical Aug. 1, 2017

Functional Endoscopic Sinus Surgery (FESS) Medical Oct. 1, 2017

Home Health Care CDG Sept. 1, 2017

Infliximab (Remicade®, Inflectra™, Renflexis™) Drug Sept. 1, 2017

Magnetic Resonance Spectroscopy (MRS) Medical Aug. 1, 2017

Neuropsychological Testing Under the Medical Benefit Medical Sept. 1, 2017

Occipital Neuralgia and Headache Treatment Medical Aug. 1, 2017

Office Based Program URG Oct. 1, 2017

Omnibus Codes Medical Oct. 1, 2017

Osteochondral Grafting Medical Sept. 1, 2017

Preventive Care Services CDG Oct. 1, 2017

Prosthetic Devices, Wigs, Specialized, Microprocessor or Myoelectric Limbs CDG Oct. 1, 2017

Next Article >


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

https://www.uhcprovider.com/content/dam/provider/docs/public/resources/news/2017/mpub/medical-policy-update-bulletin-August-2017.pdf

https://www.uhcprovider.com/content/dam/provider/docs/public/resources/news/2017/mpub/medical-policy-update-bulletin-August-2017.pdf

https://www.uhcprovider.com/en/policies-protocols/commercial-policies/commercial-medical-drug-policies.html?NB_Sept2017_0917

https://www.uhcprovider.com/en/policies-protocols/commercial-policies/commercial-medical-drug-policies.html?NB_Sept2017_0917




TABLE OF CONTENTS


Proton Beam Radiation Therapy Medical Sept. 1, 2017

Repository Corticotropin Injection (H.P. Acthar Gel®) Drug Sept. 1, 2017

Skilled Care and Custodial Care Services CDG Sept. 1, 2017

Specialty Medication Administration – Site of Care Review Guidelines URG Sept. 1, 2017

Spinal Ultrasonography Medical Aug. 1, 2017

Total Artificial Heart Medical Aug. 1, 2017

Note: The inclusion of a health service (e.g., test, drug, device or procedure) on this list does not imply that UnitedHealthcare provides coverage for the health service. In the event of an inconsistency or conflict between the information in this bulletin and the posted policy, the provisions of the posted policy prevail.

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

Next Article >

UnitedHealthcare Genetic and Molecular Lab Testing Notification/Prior Authorization Requirement

As a reminder, effective Nov. 1, 2017, UnitedHealthcare will start using a new online notification/prior authorization process to help manage the appropriate use of certain genetic and molecular lab tests as utilization of these outpatient laboratory services grows. This requirement will be for certain genetic and molecular testing performed in an outpatient setting for our fully insured UnitedHealthcare Commercial Plan members.*

Beacon Laboratory Benefit Solutions, Inc. (BeaconLBS), a lab services management company working on behalf of UnitedHealthcare, will register labs participating in the program and manage the online notification/prior authorization request system. We’ll be providing labs with directions on how to register for the program. BeaconLBS created a streamlined notification/prior authorization process for care providers that will leverage UnitedHealthcare’s clinical policy requirements for all coverage determinations.

We previously announced this program in the August Network Bulletin. Please watch for updated program and training information for labs and ordering care providers at UHCprovider.com > Prior Authorization and Notification Resources about 30 days before the program’s start date. If you have any questions, please email us at [email protected].

* While this program will be national, laboratory services ordered by Florida networkproviders for fully insured UnitedHealthcare Commercial members in Florida are not included in this requirement due to their participation in the UnitedHealthcare Laboratory Benefit Management Program.

https://www.unitedhealthcareonline.com/ccmcontent/ProviderII/UHC/en-US/Assets/ProviderStaticFiles/ProviderStaticFilesPdf/News/August-Interactive-Network-Bulletin-2017.pdf

http://UHCprovider.com

http://[email protected]




Unless otherwise noted, the following reimbursement policies apply to services reported using the 1500 Health Insurance Claim Form (CMS-1500) or its electronic equivalent or its successor form. UnitedHealthcare reimbursement policies do not address all factors that affect reimbursement for services rendered to UnitedHealthcare members, including legislative mandates, member benefit coverage documents, UnitedHealthcare medical or drug policies, and the UnitedHealthcare Care Provider Administrative Guide. Meeting the terms of a particular reimbursement policy is not a guarantee of payment. Once implemented, the policies may be viewed in their entirety at UnitedHealthcareOnline.com > Tools & Resources > Policies, Protocols and Guides > Reimbursement Policies – Commercial. In the event of an inconsistency between the information provided in the Network Bulletin and the posted policy, the posted policy prevails.

TABLE OF CONTENTS

Next Article >





TABLE OF CONTENTS

Scheduled Revision to Consultation Services Policy

UnitedHealthcare will no longer reimburse consultation services represented by CPT codes 99241-99245 and 99251-99255 beginning with Oct. 1, 2017 dates of service. Care providers should report the appropriate evaluation and management (E/M) procedure code, which describes the office visit, hospital care, nursing facility care, home service or domiciliary/rest home care instead of a consultation services code.

Consultation services codes, including those reported with telehealth modifiers, will be denied, but they can be resubmitted with an appropriate E/M code that accurately describes the place and level of service provided. UnitedHealthcare Commercial Plan products will continue to consider reimbursement for initial inpatient, follow-up inpatient, critical care and emergency department consultations performed via telehealth services. These services are represented by HCPCS codes G0406-G0408, G0425-G0427 and G0508-G0509. Telehealth consultation services must also be billed with the modifier GT or GQ to identify the telehealth technology used to provide the service.

Details about this policy change were provided in the June and July 2017 Network Bulletins.

Next Article >

Update to the Laboratory Services Policy

Effective for dates of processing Oct. 1, 2017, CPT code 83992 (Phencyclidine [PCP]) will be denied. In the CPT Book, code 83992 has been placed between codes 80365 and 80366, which fall into the Drug Assay Testing code range. According to the Laboratory Services Policy, drug assay codes are considered non-reimbursable. These services may be reported under an appropriate Healthcare Common Procedure Coding System (HCPCS) code.

https://www.uhcprovider.com/en/resource-library/news.html?NB_Sept2017_0917




TABLE OF CONTENTS

Implementation Delay for UnitedHealthcare/Oxford’s Multiple Procedure Payment Reduction Reimbursement Policy for the Technical Component of Diagnostic Cardiovascular & Ophthalmology Procedures

The UnitedHealthcare/Oxford reimbursement policy update for the technical component (TC) of diagnostic cardiovascular and ophthalmology services procedures has been delayed until Nov. 1, 2017. This policy enhancement was intended to be implemented Sept. 1, 2017 as indicated on page 44 in the June 2017 Network Bulletin.

As previously communicated, UnitedHealthcare/Oxford is implementing a reimbursement policy to apply the Multiple Procedure Payment Reduction (MPPR) for diagnostic cardiovascular and ophthalmology services for commercial products. This will allow us to better align with Centers for Medicare & Medicaid Service (CMS) and UnitedHealthcare Commercial business.

Effective for claims with dates of service on or after Nov. 1, 2017, UnitedHealthcare/Oxford will apply a multiple procedure payment reduction (MPPR) when multiple services assigned MPI of 6 or 7 are furnished to the same patient on the same day by the same care provider or multiple care providers in the same group practice reporting under the same federal tax identification number (TIN). Services will be ranked by the CMS Total Non-Facility Relative Value Unit (RVU). The services with the highest RVU will be considered primary, and services with the lower RVU will be considered second and subsequent. The MPPR will apply independently to cardiovascular and ophthalmology services:

• For the TC of cardiovascular services (MPI 6), services ranked as primary will be allowed at 100% of the allowableamount. Second and subsequent services will be reduced by 25% of the allowable amount.

• For the TC of ophthalmology services (MPI 7), services ranked as primary will be allowed at 100% of the allowableamount. Second and subsequent services will be reduced by 20% of the allowable amount.

The new commercial reimbursement policy, titled Multiple Procedure Payment Reduction for Diagnostic Cardiovascular and Ophthalmology Procedures and published in June 2017, will indicate that the reductions will be effective for dates of service on or after Nov. 1, 2017.

Next Article >

https://www.uhcprovider.com/content/dam/provider/docs/public/resources/news/2017/network-bulletin/June-Interactive-Network-Bulletin-2017.pdf




TABLE OF CONTENTS

Next Article >

UnitedHealthcare will implement a new Acupuncture Reimbursement Policy for claims with a date of service on or after Dec. 1, 2017. This policy for UnitedHealthcare Commercial Plan members will apply to paper form CMS-1500 and Electronic Data Interface (EDI) transaction 837P claim file. The policy will establish a maximum unit of service (UOS) per patient per date of service for acupuncture services with one-on-one patient contact to align with the Centers for Medicare & Medicaid Services Medicaid National Correct Coding Initiative (NCCI) Medically Unlikely Edits (MUE). The maximum units of service are:

• 97810 1

• 97811 3

• 97813 1

• 97814 2

• S8930 3

The policy will also align with CMS NCCI Procedure to Procedure Coding Edits (PTP) by not separately reimbursing for needles, which are considered included in the acupuncture services.

The policy will not allow separate reimbursement for electrical stimulation (codes 97014 and 97032) when submitted with acupuncture codes that include the electrical stimulation. It also will address additional NCCI Procedure to Procedure editing involving electrical stimulation and acupuncture services.

Acupuncture services may be subject to additional UnitedHealthcare reimbursement policies including, but not limited to, UnitedHealthcare’s CCI Editing Policy.

New Acupuncture Reimbursement Policy

Revision to the Supply PolicyEffective on or after Aug. 21, 2017, intrauterine device (IUD) and contraceptive implant HCPCS codes J7297, J7298, J7300, J7301, J7306 and J7307 have been removed from Supply Policy edits. They will now be considered eligible for reimbursement when submitted on the CMS-1500 claim form or its electronic equivalent for services provided in the following facility places of service (POS): 19, 21, 22, 23 and 24. Removal of these codes from the Supply Policy edits will allow reimbursement for the IUD or contraceptive implant in those instances when the care provider supplies and inserts the IUD or contraceptive implant in a facility POS.

Revision to the Replacement Codes PolicyFor claims processed on or after Aug. 21, 2017, Intensity Modulated Radiation Treatment Delivery (IMRT) CPT codes 77385 and 77386 have been removed from Replacement Codes policy edits and are now considered valid codes for reimbursement purposes. This revision was necessary to support the prior authorization process for IMRT services, as the inclusion of CPT codes 77385 and 77386 in Replacement Codes policy edits has resulted in denials of authorized services. Care providers are encouraged to continue to obtain authorization for, and submit codes G6015 or G6016 instead of codes 77385 and 77386 when applicable. Please note, CPT and CMS have designated these IMRT codes 77385, 77386, G6015, and G6016 as technical only services (facility/equipment/technician) for IMRT treatment delivery and the codes are not reimbursable when reported in a facility place of service (POS). For additional information regarding POS and technical only services, please refer to the Professional Technical Component Policy.



UnitedHealthcare Community Plan

UnitedHealthcare Community Plan Launches a Dual Special Needs Program — Dual Complete Medicare Advantage

Effective Jan. 1, 2018, UnitedHealthcare Community Plan will begin to serve eligible members in a new Dual Special Needs Plan (DSNP) — “UnitedHealthcare Dual Complete Medicare Advantage” — in the following seven states and counties:

• Iowa – Dallas, Jasper, Madison, Marshall, Polk, Story, Warren

• Michigan – Berrien, Branch, Gratiot, Hillsdale, Tuscola, Washtenaw

• Missouri – Boone, Buchanan, Callaway, Cass, Christian, Clay, Crawford, Dade, Dallas, DeKalb, Franklin, Gasconade, Greene, Jackson, Jasper, Jefferson, Johnson, Laclede, Lafayette, Lawrence, Lincoln, Miller, Newton, Osage, Platte, Polk, Ray, St. Charles, St. Francois, St. Louis, St. Louis City, Ste. Genevieve, Stone, Taney, Warren, Washington, Webster, Wright.

• Nebraska – Cass, Douglas, Lancaster, Sarpy

• Oklahoma – Canadian, Cleveland, Kingfisher, Lincoln, Logan, McClain, Oklahoma, Pottawatomie

• Virginia – statewide

• North Carolina – statewide

This is a Medicare Advantage plan for members who qualify for both Medicare and Medicaid. DSNPs are a specialized type of Medicare Advantage Prescription Drug Plan (MAPD) and must follow existing Centers for Medicare & Medicaid Services (CMS) rules. DSNPs must:

• Adhere to required MAPD benefits

• Limit enrollment to Medicaid recipients (dually eligible – Medicare and Medicaid),

• Provide Part D benefits, and

• Offer targeted clinical programs, benefits, and services.

TABLE OF CONTENTS

Next Article >




TABLE OF CONTENTS

UnitedHealthcare Community Plan Launches a Dual Special Needs Program — Dual Complete Medicare Advantage

UnitedHealthcare Community Plan will be communicating more details about the program in the coming weeks. Please visit Link > UnitedHealthcare Community Plan application > For Health Care Providers > select your state > Dual Complete Medicare Advantage Program.

If you don’t have an Optum ID, go to UnitedHealthcareOnline.com or UHCProvider.com and select “New User” to begin registration.

• To learn more about using Link, please visit UHCprovider.com.

For more information about this program, please contact your network account manager or advocate.

Next Article >

https://healthid.optum.com/tb/app/index.html?relyingAppId=PRD23484&TARGET=https://linksession.optum.com/proxy?redirect%3Dhttps://provider.linkhealth.com/apps/secure/dashboards/provider-dashboard/#/login

https://www.uhcprovider.com/?NB_Sept2017_0917




TABLE OF CONTENTS

For complete details on the policy updates listed in the following table, please refer to the August 2017 Medical Policy Update Bulletin at UHCprovider.com > Menu > Policies and Protocols > Community Plan Policies > Medical & Drug Policies and Coverage Determination Guidelines > Medical Policy Update Bulletins.


NEW

Brineura™ (Cerliponase Alfa) Drug Nov. 1, 2017

Laser Interstitial Thermal Therapy Medical Oct. 1, 2017

Lemtrada (Alemtuzumab) Drug Oct. 1, 2017

Radicava™ (Edaravone) Drug Sept. 1, 2017

Soliris® (Eculizumab) Drug Oct. 1, 2017

Spinraza™ (Nusinersen) (for Pennsylvania Only) Drug Oct. 1, 2017

White Blood Cell Colony Stimulating Factors Drug Sept. 1, 2017

UPDATED/REVISED

Apheresis Medical Oct. 1, 2017

Attended Polysomnography for Evaluation of Sleep Disorders Medical Sept. 1, 2017

Chemosensitivity and Chemoresistance Assays in Cancer Medical Oct. 1, 2017

Chromosome Microarray Testing Medical Sept. 1, 2017

Continuous Glucose Monitoring and Insulin Delivery for Managing Diabetes Medical Sept. 1, 2017

Cytological Examination of Breast Fluids for Cancer Screening Medical Aug. 1, 2017

Discogenic Pain Treatment Medical Aug. 1, 2017

Durable Medical Equipment, Orthotics, Ostomy Supplies, Medical Supplies and Repairs/Replacements CDG Oct. 1, 2017

Electrical Bioimpedance for Cardiac Output Measurement Medical Aug. 1, 2017

Functional Endoscopic Sinus Surgery (FESS) Medical Oct. 1, 2017

Gender Dysphoria Treatment Medical Oct. 1, 2017

Home Health Care CDG Oct. 1, 2017

Infliximab (Remicade®, Inflectra™, Renflexis™) Drug Oct. 1, 2017

Intensity-Modulated Radiation Therapy Medical Sept. 1, 2017

Magnetic Resonance Spectroscopy (MRS) Medical Aug. 1, 2017

UnitedHealthcare Community Plan Medical Policy, Medical Benefit Drug Policy and Coverage Determination Guideline Updates

Next Article >

https://www.uhcprovider.com/content/dam/provider/docs/public/policies/medicaid-comm-plan/community-plan-medical-policy-update-bulletin-august-2017.pdf

https://www.uhcprovider.com/content/dam/provider/docs/public/policies/medicaid-comm-plan/community-plan-medical-policy-update-bulletin-august-2017.pdf

https://www.uhcprovider.com/en/policies-protocols/comm-plan-medicaid-policies/medicaid-community-state-policies.html?NB_Sept2017_0917

https://www.uhcprovider.com/en/policies-protocols/comm-plan-medicaid-policies/medicaid-community-state-policies.html?NB_Sept2017_0917




TABLE OF CONTENTS

UnitedHealthcare Community Plan Medical Policy, Medical Benefit Drug Policy and Coverage Determination Guideline Updates


Neuropsychological Testing Under the Medical Benefit Medical Oct. 1, 2017

Obstructive Sleep Apnea Treatment Medical Sept. 1, 2017

Occipital Neuralgia and Headache Treatment Medical Aug. 1, 2017

Off-Label/Unproven Specialty Drug Treatment Drug Sept. 1, 2017

Omnibus Codes Medical Oct. 1, 2017

Osteochondral Grafting Medical Oct. 1, 2017

Private Duty Nursing Services (PDN) CDG Sept. 1, 2017

Prosthetic Devices, Specialized, Microprocessor or Myoelectric Limbs CDG Oct. 1, 2017

Proton Beam Radiation Therapy Medical Sept. 1, 2017

Repository Corticotropin Injection (H.P. Acthar Gel®) Drug Oct. 1, 2017

Skilled Care and Custodial Care Services CDG Oct. 1, 2017

Spinal Ultrasonography Medical Aug. 1, 2017

Total Artificial Heart Medical Aug. 1, 2017


Next Article >




TABLE OF CONTENTS

UnitedHealthcare Community Plan’s Preferred Drug List (PDL) is updated quarterly by our Pharmacy and Therapeutics Committee. Please review the changes and update your references as necessary.

You may also view the changes at: UHCCommunityPlan.com > For Health Care Professionals > Select your state > Pharmacy Program.

We provided a list of available alternatives to UnitedHealthcare Community Plan members whose current treatment includes a medication removed from the PDL. Please provide affected members a prescription for a preferred alternative in one of the following ways:

• Call or fax the pharmacy.

• Use e-Script.

• Write a new prescription and give it directly to the member.

If a preferred alternative is not appropriate, please call 800-310-6826 for prior authorization for the UnitedHealthcare Community Plan member to remain on their current medication.

Changes will be effective Oct. 1, 2017: Arizona, Florida for Florida Healthy Kids, Hawaii, Louisiana, Maryland, Nevada, New Jersey, New Mexico, New York, Ohio, Pennsylvania, and Rhode Island.

The PDL changes in Washington will be effective upon state approval. Additional communication with the effective date will be sent at that time.

PDL Additions

Brand Name Generic Name Comments Notes

Vyvanse Chewable Lisdexamfetamine chewable tablet

Indicated for treating attention deficit

hyperactivity disorder and binge eating disorder. Diagnosis required.

Does not apply to Arizona, Louisiana, Maryland and Rhode Island plans. Prior Authorization required in Nevada for patients aged

18 and older.

AirDuo* RespiClick Fluticasone/Salmeterol inhalation

Indicated for treating asthma. Step therapy

applies.

Does not apply to Arizona plan.

Nuvigil* Armodanfinil tablet

Indicated for treating narcolepsy, obstructive

sleep apnea, and shift work sleep disorder. Diagnosis

required.

Does not apply to Louisiana and Maryland plans.

Prior Authorization required in Arizona.

UnitedHealthcare Community Plan Preferred Drug List Updates for Fourth Quarter 2017

Next Article >

http://www.uhccommunityplan.com/




TABLE OF CONTENTS

UnitedHealthcare Community PlanPreferred Drug List Updates for Fourth Quarter 2017

PDL Additions


Tymlos Abaloparatide injection

Indicated for treating postmenopausal women with osteoporosis at high risk for fracture. Prior authorization required. Available through

specialty pharmacy.

Does not apply to

Rhode Island plan.

Voltaren* Diclofenac DR tablet

Indicated for treating osteoarthritis and rheumatoid arthritis.

Voltaren-XR* Diclofenac ER tablet


Cataflam* Diclofenac potassium tablet


*Only Generics are covered

PDL Modifications


Provigil Modafinil tablet

Therapeutic alternative required. A history of failure, contraindication, or intolerance to armodafinil is required.

Does not apply to Louisiana or Maryland

plans.

Removed From PDL


DuleraMometasone/

formoterol inhalation

Alternative agents are available including Fluticasone/Salmeterol (generic AirDuo RespiClick) and

Breo Ellipta. Current users will not be grandfathered.

Does not apply to

Arizona plan and Ohio

plans.

Forteo Teriparatide injection

Alternative agent is available including Tymlos. Postmenopausal women with osteoporosis will be

required to switch to Tymlos. Forteo will continue to be available for

men with primary or hypogonadal osteoporosis and for patients with

osteoporosis associated with glucocorticoid therapy.

Does not apply to

Rhode Island plan.

Tamiflu Suspension

Oseltamivir suspension

Patients aged 12 and older will be required to use Oseltamivir

capsule. Tamiflu Suspension will continue to be available for any

patient less than 12 years of age.

Does not apply to

Arizona plan.

These changes don’t apply to UnitedHealthcare Community Plan in Delaware, Florida Medicaid, Iowa, Kansas, Michigan, Mississippi, Nebraska, Texas, and Virginia.

If you have any questions, please call UnitedHealthcare Community Plan’s Pharmacy Department at 800-310-6826.

Next Article >



UnitedHealthcare Medicare Solutions

Coverage of Annual Wellness Visits and Routine PhysicalsThe Annual Wellness Visit (or Personalized Prevention Plan Services (PPPS) is a yearly visit covered by Original Medicare to develop or update the member’s personalized prevention plan. UnitedHealthcare offers the Medicare-covered Annual Wellness Visit to all Medicare Advantage Plan members and an additional Annual Routine Physical Exam to many plan members.

Because Medicare Advantage plan enrollment is based on a calendar year, UnitedHealthcare covers both the Annual Wellness Visit and the Routine Physical (when covered) once every calendar year and the visits do not need to be 12 months apart. For example, if a member gets their Annual Wellness Visit and/or Routine Physical in June 2017, they do not need to wait until June 2018 for their next visit but can get one again anytime in 2018.

For more information on determining the appropriate submission codes for these wellness visits and other preventive services, go to UnitedHealthcareOnline.com > Tools & Resources > Medicare > Reference Materials > 2017 Medicare Advantage Preventive Services Coding Guidelines.

TABLE OF CONTENTS

Next Article >

https://www.unitedhealthcareonline.com/ccmcontent/ProviderII/UHC/en-US/Main Menu/Tools & Resources/Medicare/PATH/2017_Medicare_Advantage_Preventive_Screening_Guidelines.pdf

https://www.unitedhealthcareonline.com/ccmcontent/ProviderII/UHC/en-US/Main Menu/Tools & Resources/Medicare/PATH/2017_Medicare_Advantage_Preventive_Screening_Guidelines.pdf




TABLE OF CONTENTS

For complete details on the policy updates listed in the following table, please refer to the August 2017 Medicare Advantage Coverage Summary Update Bulletin at UHCprovider.com > Menu > Policies and Protocols > Medicare Advantage Policies > Coverage Summaries > Coverage Summary Update Bulletins.

Policy Title

UPDATED/REVISED (Approved on July 17, 2017)

Complementary and Alternative Medicine

Cryosurgery for Prostate Cancer

Durable Medical Equipment (DME), Prosthetics, Corrective Appliances/Orthotics (Non-Foot Orthotics) and Medical Supplies Grid

Extracranial-Intracranial (EC-IC) Arterial Bypass Surgery

Fabric Wrapping of Abdominal Aneurysms

Genetic Testing

Glaucoma Surgical Treatments

Hearing Screening and Audiologist Services

Joints and Joint Procedures

Mental Health Services and Procedures

Physician Services

Thermogenic Therapy

Transvenous (Catheter) for Pulmonary Embolectomy

UnitedHealthcare Medicare Advantage Coverage Summary Updates

2018 Medicare Advantage Service Area Reductions

We’ll be sending official non-renewal notices by Oct. 2, 2017 to UnitedHealthcare Medicare Advantage members who will be impacted by service area reductions effective Jan. 1, 2018. The non-renewal notice will give these members information about their special election period eligibility for 2018 coverage. The majority of care providers and facilities contracted for UnitedHealthcare Medicare Advantage products will not be affected by these changes.

To learn more and access frequently asked questions, please visit UnitedHealthcareOnline.com > Tools & Resources > Medicare, or contact your local Network Account Manager or Provider Advocate.

Next Article >

https://www.uhcprovider.com/content/dam/provider/docs/public/policies/medadv-coverage-sum/medicare-advantage-coverage-summary-update-bulletin-august-2017.pdf

https://www.uhcprovider.com/content/dam/provider/docs/public/policies/medadv-coverage-sum/medicare-advantage-coverage-summary-update-bulletin-august-2017.pdf

https://www.uhcprovider.com/en/policies-protocols/medicare-advantage-policies/medicare-advantage-coverage-sum.html?NB_Sept2017_0917

https://www.uhcprovider.com/en/policies-protocols/medicare-advantage-policies/medicare-advantage-coverage-sum.html?NB_Sept2017_0917




TABLE OF CONTENTS

The following UnitedHealthcare Medicare Advantage Policy Guidelines have been updated to reflect the most current clinical coverage rules and guidelines developed by the Centers for Medicare & Medicaid Services (CMS). The updated policies are available for your reference at UHCprovider.com > Menu > Policies and Protocols > Medicare Advantage Policies > UnitedHealthcare Medicare Advantage Policy Guidelines.

Policy Title

UPDATED/REVISED (Approved on July 12, 2017)

Adult Liver Transplantation (NCD 260.1)

Assessing Patient’s Suitability for Electrical Nerve Stimulation Therapy (NCD 160.7.1)

Avastin® (Bevacizumab)

Cavernous Nerves by Electrical Stimulation with Penile Plethysmography (NCD 160.26)

Cochlear Implantation (NCD 50.3)

Consultations with a Beneficiary’s Family and Associates (NCD 70.1)

Cryosurgery of Prostate (NCD 230.9)

Dental Examination Prior to Kidney Transplantation (NCD 260.6)

Diagnosis and Treatment of Impotence (NCD 230.4)

Esophageal Manometry (NCD 100.4)

High Resolution Anoscopy

Intestinal and Multi-Visceral Transplantation (NCD 260.5)

Manipulation (NCD 150.1)

Molecular Pathology/Molecular Diagnostics/Genetic Testing

Nebulizers

Ocular Telescope

Prostate Cancer Screening Tests (NCD 210.1)

Refractive Keratoplasty (NCD 80.7)

Screening and Behavioral Counseling Interventions in Primary Care to Reduce Alcohol Misuse (NCD 210.8)

Sleep Testing for Obstructive Sleep Apnea (OSA) (NCD 240.4.1)

Stem Cell Transplantation (NCD 110.23) (Formerly NCD 110.8.1)

Stereotactic Computer Assisted Volumetric and/or Navigational Procedures

UnitedHealthcare Medicare Advantage Policy Guideline Updates

Next Article >

https://www.uhcprovider.com/en/policies-protocols/medicare-advantage-policies/medicare-advantage-guidelines.html?NB_Sept2017_0917

https://www.uhcprovider.com/en/policies-protocols/medicare-advantage-policies/medicare-advantage-guidelines.html?NB_Sept2017_0917




TABLE OF CONTENTS

UnitedHealthcare Medicare Advantage Policy Guideline Updates

Policy Title

Thermogenic Therapy (NCD 30.2)

Thoracic Duct Drainage (TDD) in Renal Transplants (NCD 20.3)

Thrombolytic Agents

Transcendental Meditation (NCD 30.5)

Ultrasonic Surgery (NCD 50.8)

Urinary Drainage Bags (NCD 230.17)

Vertebral Artery Surgery (NCD 20.1)

Vitrectomy (NCD 80.11)


Next Article >



Doing Business Better

Closing Diabetic Gaps in Care

Regular screening of diabetic patients is key to determining disease status, and we have two options for your patients who are UnitedHealthcare Plan members to get screened at home for hemoglobin A1c and microalbumin: the Lab-in-a-Box (LIAB) and Lab-in-an-Envelope (LIAE) tests. The LIAB provides the microalbumin urine screening kit processed through Laboratory Corporation of America (LabCorp). The LIAE provides an easy kit for collecting a sample for testing hemoglobin A1c and is processed through LabCorp.

Our Clinical Quality Program team has a list of members who are eligible to have this type of testing and have no record of being tested this year. These members will have no copay for this testing as it will be covered at 100%. UnitedHealthcare will be mailing these kits directly to members to encourage them to be tested. While these kits will not be made available to your practice, the test results will be available on the LabCorp provider portal at – labcorp.com. A result report will be sent to care providers by mail for these members.

TABLE OF CONTENTS

Next Article >

Online Prevention Program Available for Information on Depression, Substance-Use Disorders and ADHD

United Behavioral Health has developed an online prevention program that offers information and practice tools to support your treatment of patients with depression, substance-use disorders and attention-deficit/hyperactivity disorder (ADHD). A convenient, reliable and free source of relevant health information, the prevention center for each condition includes a library of articles designed to support prevention and recovery; information about co-morbid conditions; links to nationally recognized practice guidelines; a printable self-appraisal to use or refer your patients to; and a listing of support resources for you, your patients and their families. Care providers may access the program at prevention.liveandworkwell.com.

http://labcorp.com

https://liveandworkwell.com/content/en/prevention.html




TABLE OF CONTENTS

Evidenced-Based Clinical Practice Guidelines

UnitedHealthcare uses evidenced-based clinical guidelines from nationally recognized sources to guide our quality and health management programs. The following clinical practice guidelines are available at UnitedHealthcareOnline.com > Tools & Resources > Policies, Protocols and Guides > Medical & Drug Policies and Coverage Determination Guidelines > Clinical Guidelines. There have been significant changes to the guidelines marked with an asterisk in the chart.

Topic Organization

Acute Myocardial Infarction with ST Elevation American College of Cardiology/American Heart Association

Acute Myocardial Infarction without ST Elevation American College of Cardiology/American Heart Association

Asthma National Heart, Lung and Blood Institute

Attention Deficit Hyperactivity Disorder (ADHD) American Academy of Child and Adolescent Psychiatry

Bipolar Disorder: Adults American Psychiatric Association

Bipolar Disorder: Children & Adolescents American Academy of Child and Adolescent Psychiatry

Cardiovascular Disease: Prevention in Women American Heart Association

Cardiovascular Disease: Secondary Prevention and Risk Reduction Therapy for Patients with Coronary and Other Atherosclerotic Vascular Disease

American College of Cardiology/American Heart Association

Cholesterol Management American College of Cardiology/American Heart Association

Chronic Obstructive Lung Disease* Global Initiative for Chronic Obstructive Lung Disease (GOLD)

Depression/Major Depressive Disorder American Psychiatric Association

Diabetes* American Diabetes Association

Dietary Guidelines U.S. Department of Health and Human Services

Heart Failure* American College of Cardiology/American Heart Association/Heart Failure Society of America

Hemophilia and von Willebrand Disease World Federation of Hemophilia and National Heart, Lung & Blood Institute

Human Immuno-deficiency Virus (HIV) HIV Medicine Association of the Infectious Diseases Society of America

Hyperbilirubinemia in Newborns American Academy of Pediatrics

HypertensionPanel Members Appointed to the Eighth Joint National Committee (JNC 8). Note: Guideline is freely available, but registration may be required.

Lifestyle Management to Reduce Cardiovascular Risk American College of Cardiology/American Heart Association

Next Article >





TABLE OF CONTENTS

Evidenced-Based Clinical Practice Guidelines

Topic Organization

Obesity American Heart Association/American College of Cardiology/The Obesity Society

Physical activity U.S. Department of Health and Human Services

Preventive Services Agency for Healthcare Research and Quality

Schizophrenia American Psychiatric Association

Sickle Cell Disease National Heart, Lung and Blood Institute

Spinal Stenosis North American Spine Society

Stable Ischemic Heart Disease American College of Cardiology/American Heart Association et al.

Substance Use Disorders American Psychiatric Association

Tobacco Use U.S. Department of Health and Human Services

Next Article >




TABLE OF CONTENTS

Reminder on Case and Disease Management Programs

UnitedHealthcare offers case and disease management programs to support care providers’ treatment plans and assist members in managing their conditions. Using medical, pharmacy and behavioral health claims data, our predictive model systems help us identify members who are at high risk and directs them to our programs.

Members can also be identified at time of hospital discharge via a Health Risk Assessment, Nurseline referral or member or caregiver referral. If you have UnitedHealthcare members who would benefit from case or disease management, you can refer them to the appropriate program by calling the number on the back of the member’s health insurance ID card.

Participation in these programs is voluntary. Upon referral, each member is assessed for the appropriate level of care for his or her individual needs. Programs vary depending on the member’s benefit plan.

Case Management

At the core of case management is identifying high-cost, complex, at-risk members who can benefit from these services. We collaborate with members and their care providers to facilitate health care access and decisions that can have a dramatic impact on the quality and affordability of their health care.

Our programs are designed to help ensure individuals:

• Receive evidenced-based care

• Have necessary self-care skills and/or caregiver resources

• Have the right equipment and supplies to perform self-care

• Have requisite access to the health care delivery system

• Are compliant with medications and the care provider’s treatment plan

UnitedHealthcare case managers are registered nurses who engage the appropriate internal, external or community-based resources needed to address members’ health care needs. When appropriate, we provide referrals to other internal programs such as disease management, complex condition management, behavioral health, employee assistance and disability. Case management services are voluntary and a member can opt out at any time.

Disease Management Programs

We offer disease management programs designed to provide members with specific conditions the appropriate level of intervention.

Depending on the member’s health plan and benefit plan design, disease management programs vary and may include:

• Coronary artery disease

• Diabetes

• Heart failure

Next Article >




TABLE OF CONTENTS

Reminder on Case and Disease Management Programs

• Asthma

• Chronic obstructive pulmonary disease

• Cancer

• High risk pregnancy

• Kidney disease

• Acute MI

• Hemophilia

Our programs include:

• Screening for depression and helping members access the appropriate resources.

• Addressing lifestyle-related health issues and referring to programs for weight management, nutrition, smoking cessation, exercise, diabetes care and stress management.

• Helping members understand and manage their condition and its implications.

• Education on how to reduce risk factors, maintain a healthy lifestyle, and adhere to treatment plans and medication regimens.

For some programs, members may receive:

• A comprehensive assessment by specialty-trained registered nurses to determine the appropriate level and frequency of interventions.

• Educational mailings, newsletters and tools such as a HealthLog to assist them in tracking their physician visits, health status and recommended targets or other screenings.

• Information on gaps in care and encouragement to discuss treatment plans, goals and results with the physician.

• Physicians with patients in moderate intensity programs may receive information on their patient’s care opportunities.

• Transitional case management when high risk patients are discharged from a hospital

• Outbound calls for the highest risk individuals to address particular gaps in care. You will be notified when patients are identified for the high-risk program.

These programs complement the physician’s treatment plan, reinforce instructions you may have provided, and offer support for healthy lifestyle choices.

*Limited to eligible UnitedHealthcare River Valley and Neighborhood Health Program members.

Next Article >



TABLE OF CONTENTS

UnitedHealthcare Affiliates

SignatureValue/UnitedHealthcare Benefits Plan of California Benefit Interpretation Policy Updates

For complete details on the policy updates listed in the following table, please refer to the August 2017 SignatureValue/UnitedHealthcare Benefits Plan of California Benefit Interpretation Policy Update Bulletin at UHCprovider.com > Menu > Policies and Protocols > Commercial Policies > UnitedHealthcare SignatureValue/UnitedHealthcare Benefits Plan of California Benefit Interpretation Policies > Benefit Interpretation Policy Update Bulletins.

Policy Title Applicable State(s)

Effective Date

UPDATED/REVISED

Blood and Blood Products

All (California, Oklahoma, Oregon, Texas, &

Washington)

Sept. 1, 2017

Durable Medical Equipment (DME), Prosthetics, Corrective Appliances/Orthotics (Non-Foot Orthotics) and Medical Supplies Grid

All Sept. 1, 2017

Emergency and Urgent Services All Sept. 1, 2017

Experimental and Investigational Services All Sept. 1, 2017

Gender Dysphoria (Gender Identity Disorder) Treatment

California, Oregon, &

WashingtonSept. 1, 2017

Hearing Services All Sept. 1, 2017

Inpatient Hospital Services All Sept. 1, 2017

Outpatient Hospital Services All Sept. 1, 2017

Preventive Care Services All Oct. 1, 2017

Sexual Dysfunction All Aug. 1, 2017


Next Article >

https://www.uhcprovider.com/content/dam/provider/docs/public/policies/signaturevalue-bip/sv-bip-update-bulletin-august-2017.pdf




https://www.uhcprovider.com/en/policies-protocols/commercial-policies/sv-benefit-interpretation-policies.html?NB_Sept2017_0917








TABLE OF CONTENTS

April

For complete details on the policy updates listed in the following table, please refer to the August 2017 Policy Update Bulletin at OxfordHealth.com > Providers > Tools & Resources > Medical Information > Medical and Administrative Policies > Policy Update Bulletin.


NEW

Brineura™ (Cerliponase Alfa) Clinical Sept. 1, 2017

Drug Testing Reimbursement Oct. 1, 2017

Follow-Up Care Rendered in an Emergency Room Site of Service Administrative Nov. 1, 2017

Laser Interstitial Thermal Therapy Clinical Oct. 1, 2017

Multiple Procedure Payment Reduction (MPPR) for Diagnostic Cardiovascular and Ophthalmology Procedures Reimbursement Nov. 1, 2017

Radicava™ (Edaravone) Clinical Sept. 1, 2017

White Blood Cell Colony Stimulating Factors Clinical Sept. 1, 2017

UPDATED/REVISED

Ambulance Reimbursement July 17, 2017

Attended Polysomnography for Evaluation of Sleep Disorders Clinical Sept. 1, 2017

Behavioral Health Services Administrative Oct. 1, 2017

Bronchial Thermoplasty Clinical Aug. 1, 2017

Chromosome Microarray Testing Clinical Sept. 1, 2017

Clinical Review Policy Administrative Sept. 1, 2017

Clotting Factors and Coagulant Blood Products Clinical Sept. 1, 2017

Consultation Services Reimbursement Oct. 1, 2017

Continuous Glucose Monitoring and Insulin Delivery for Managing Diabetes Clinical Sept. 1, 2017

Disclosure Policy Administrative Aug. 1, 2017

Drug Coverage Criteria - New and Therapeutic Equivalent Medications Clinical Sept. 1, 2017

Drug Coverage Guidelines Clinical Sept. 1, 2017

Global Days Reimbursement Oct. 1, 2017

Home Traction Therapy Clinical Aug. 1, 2017

Oxford® Medical and Administrative Policy Updates

Next Article >

https://www.oxhp.com/secure/policy/post_pin_comm_aug17.pdf

https://www.oxhp.com/secure/policy/post_pin_comm_aug17.pdf

https://www.oxhp.com/secure/policy/postpin_intro.html

https://www.oxhp.com/secure/policy/postpin_intro.html




TABLE OF CONTENTS

Oxford® Medical and Administrative Policy Updates


Infliximab (Remicade®, Inflectra™, Renflexis™) Clinical Sept. 1, 2017

Injection and Infusion Services Reimbursement Oct. 1, 2017

Light and Laser Therapy for Cutaneous Lesions and Pilonidal Disease Clinical Aug. 1, 2017

Maximum Frequency Per Day ReimbursementAug. 7, 2017

Oct. 1, 2017

Meniscus Implant and Allograft Clinical Aug. 1, 2017

Motorized Spinal Traction Clinical Aug. 1, 2017

Obstetrical Policy Reimbursement Oct. 1, 2017

Obstructive Sleep Apnea Treatment Clinical Sept. 1, 2017

Office Based Program Clinical Oct. 1, 2017

Pectus Deformity Repair Clinical Aug. 1, 2017

Precertification Exemptions for Outpatient Services Administrative Sept. 1, 2017

Preventive Care Services Clinical Oct. 1, 2017

Preventive Medicine and Screening Reimbursement Oct. 1, 2017

Private Duty Nursing Services (PDN) Clinical Sept. 1, 2017

Procedure and Place of Service Reimbursement July 17, 2017

Referrals Administrative Sept. 1, 2017

Repository Corticotropin Injection (H.P. Acthar Gel®) Clinical Sept. 1, 2017

Rhinoplasty and Other Nasal Surgeries Clinical Aug. 1, 2017

Specialty Medication Administration - Site of Care Review Guidelines Clinical Sept. 1, 2017

Umbilical Cord Blood Harvesting and Storage for Future Use Clinical Aug. 1, 2017

Note: The inclusion of a health service (e.g., test, drug, device or procedure) on this list does not imply that Oxford provides coverage for the health service. In the event of an inconsistency or conflict between the information in this bulletin and the posted policy, the provisions of the posted policy prevail.

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

Next Article >




TABLE OF CONTENTS

April

For complete details on the policy updates listed in the following table, please refer to the August 2017 SignatureValue/UnitedHealthcare Benefits Plan of California Medical Management Guidelines Update Bulletin at UHCprovider.com > Menu > Policies and Protocols > Commercial Policies > UnitedHealthcare SignatureValue/ UnitedHealthcare Benefits Plan of California Medical Management Guidelines > Medical Management Guideline Update Bulletins.

Policy Title Effective Date

NEW

Laser Interstitial Thermal Therapy Oct. 1, 2017

UPDATED/REVISED

Apheresis Oct. 1, 2017

Chemosensitivity and Chemoresistance Assays in Cancer Sept. 1, 2017

Continuous Glucose Monitoring and Insulin Delivery for Managing Diabetes Sept. 1, 2017

Cytological Examination of Breast Fluids for Cancer Screening Aug. 1, 2017

Discogenic Pain Treatment Aug. 1, 2017

Electrical Bioimpedance for Cardiac Output Measurement Aug. 1, 2017

Functional Endoscopic Sinus Surgery (FESS) Oct. 1, 2017

Gender Dysphoria Treatment Excluding California Oct. 1, 2017

Intensity-Modulated Radiation Therapy Sept. 1, 2017

Magnetic Resonance Spectroscopy (MRS) Aug. 1, 2017

Neuropsychological Testing Under the Medical Benefit Sept. 1, 2017

Occipital Neuralgia and Headache Treatment Aug. 1, 2017

Omnibus Codes Oct. 1, 2017

Osteochondral Grafting Sept. 1, 2017

Preventive Care Services Oct. 1, 2017

Proton Beam Radiation Therapy Sept. 1, 2017

Skilled Care and Custodial Care Services Sept. 1, 2017

Specialty Medication Administration – Site of Care Review Guidelines Sept. 1, 2017

Spinal Ultrasonography Aug. 1, 2017

Total Artificial Heart Aug. 1, 2017


SignatureValue/UnitedHealthcare Benefits Plan of California Medical Management Guideline Updates

Network Bulletin: November 2013 - Volume 584040 Network Bulletin: September 2017

Doc#: PCA-1-007550-08092017_08172017

Insurance coverage provided by or through UnitedHealthcare Insurance Company, All Savers Insurance Company or its affiliates. Health plan coverage provided by UnitedHealthcare of Arizona, Inc., UHC of California DBA UnitedHealthcare of California, UnitedHealthcare of Colorado, Inc., UnitedHealthcare of Oklahoma, Inc., UnitedHealthcare of Oregon, Inc., UnitedHealthcare of Texas, Inc., UnitedHealthcare Benefits of Texas, Inc., UnitedHealthcare of Utah, Inc. and UnitedHealthcare of Washington, Inc. or other affiliates. Administrative services provided by United HealthCare Services, Inc. OptumRx, OptumHealth Care Solutions, Inc. or its affiliates. Behavioral health products are provided by U.S. Behavioral Health Plan, California (USBHPC), United Behavioral Health (UBH) or its affiliates.

https://www.uhcprovider.com/content/dam/provider/docs/public/policies/signaturevalue-mmg/sv-mmg-update-bulletin-august-2017.pdf



https://www.uhcprovider.com/en/policies-protocols/commercial-policies/sv-medical-mgmt-guidelines.html?NB_Sept2017_0917



enter - unitedhealthcare online network bulletin was developed to share important updates regarding...

Documents