network bulletin: april 2015 network bulletin3 network bulletin: november 2013 - volume 58 3 for...

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: April 2015

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Network Bulletin: November 2013 - Volume 582

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For more information, call 877.842.3210 or visit UnitedHealthcareOnline.com

2 Network Bulletin: April 2015

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• Clinical Data to be Requested as part of State, Federal Requirements

• Inactive Termination: Please Review and Update your Records

• 2015 UnitedHealthcare Administrative Guide Available – Effective April 1, 2015*

• New State Disclosure Regulations Affect Physicians and Hospitals Providing Care on Out-of-Network Basis – Effective April 1

• Introducing the UnitedHealthcare Hospital Quality Program

• Training now Available for UnitedHealth Premium Designation Program

• Making Simple Adjustments When Filing Claims for Certain Preventive Care Services Performed at Office Visits Can Benefit Your Practice

UnitedHealthcare Commercial

• UnitedHealthcare Medical Policy, Drug Policy, Coverage Determination Guideline and Utilization Review Guideline Updates

UnitedHealthcare Commercial Reimbursement Policy

• Revision to Maximum Frequency per Day for Per Diem Codes

UnitedHealthcare Medicare Solutions

• Two Midnight Rule for Critical Access Hospitals

• UnitedHealthcare Medicare Advantage Coverage Summary Updates

• Scheduling of Annual Care Visit to Qualify for Member Rewards Program

• PECOS Ordering/Referring for Provider Claims Update

UnitedHealthcare Community Plan

• Medical Policy & Coverage Determination Guideline Updates

• New Prior Authorization Requirement for Enzyme Replacement Medications for Gaucher Disease – Cerezyme and Elelyso – Effective April 1

• Important changes in Advance Notification and Prior Authorization Requirements

• Provider’s Role in Coordination of Care for UnitedHealthcare Community Plan Members

• New Institutional Claim Edit

• Announcing the New Maryland Pharmacy Network for Medicaid Members

UnitedHealthcare Military & Veterans

• 2015 TRICARE Provider Handbook – Revised April 1, 2015

Doing Business Better

• Rights and Responsibilities for Medicare Members

• Optum Cloud Dashboard Enhancements to Notifications/Prior Authorizations

• New Optum Cloud Dashboard Feature Helps with Pended Claims

• Collaboration between Primary Care Physicians and Behavioral Health Clinicians Can Make a Difference

UnitedHealthcare Affiliates

• 2015 UnitedHealthcare West Capitated Administrative Guide Available April 1, 2015

• Provider Training Opportunity for UnitedHealthcare of the River Valley: Preauthorization List Additions for Radiology Services

• SignatureValue™ Benefit Interpretation Policy Updates

• SignatureValue™ Medical Management Guideline Updates

• UnitedHealthcare of the River Valley Preauthorization List and Policy Updates

• Oxford® Medical and Administrative Policy Updates

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

or visit UnitedHealthcareOnline.comNetwork Bulletin: April 2015

Effective July 1, 2015, care providers must submit to UnitedHealthcare all clinical data, including laboratory testing results, to support federal and state data collection and reporting requirements.

UnitedHealthcare will be requesting clinical data from you in order to comply with state and federal data collection and reporting requirements. The clinical data you provide will be used by UnitedHealthcare to assist in measuring quality for your patients who are our members and collaborating with you to address gaps in care. As such, care providers must submit to UnitedHealthcare all clinical data — including, but not limited to, laboratory testing results — by any available means including electronic data interchange, fax, telephone and/or physical data collection methods. All clinical data must be made available to UnitedHealthcare within 30 days of the date of service or within the time specified by applicable law.

For more information about the requirement, refer to UnitedHealthcareOnline.com >Tools & Resources > Polices, Protocols, and Guides > Protocols > UnitedHealthcare Clinical Information Submission.

Clinical Data to be Requested as part of State, Federal Requirements

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UnitedHealthcare is committed to working with physicians and other health care providers to keep our network information and directories up to date.

Up-to-date directories are a critical element of providing our members with the information they need to manage their health. In an effort to accurately reflect providers who are actively treating UnitedHealthcare members, effective Aug. 1, 2015, UnitedHealthcare will perform the following work on its provider directories:

1. Initiate a voluntary termination protocol in which we will terminate agreements for providers who have not submitted claims for a period of one (1) year on the basis that they are not actively treating UnitedHealthcare members, and have voluntarily ceased participation in our Network. UnitedHealthcare will initiate these administrative terminations beginning with providers who have not submitted any claims since 2013. We ask that providers review their current information in our online directory and provide any updates using UnitedHealthcareOnline.com. We are making efforts to contact providers regarding this voluntary cease in participation using the contact information we have on file. If providers do not respond, we will enact the termination.

2. Inactivate any tax identification numbers (TINs) under which there have been no claims submitted for a period of one (1) year or longer on the basis that they are not in active use. This is not a termination of the provider agreement because other TINs associated with their agreement are still active, and therefore no notice of termination will be provided. However, providers may contact UnitedHealthcare to reactivate an inactivated TIN.

Inactive Termination: Please Review and Update your Records


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The 2015 UnitedHealthcare Administrative Guide contains some important changes that will affect how we work together. The following list is a summary of selected updates to the Guide.

It does not include every update or the details of any update. Please refer to the Guide for the complete text and detailed updates.

Except as otherwise noted, the new Guide is effective on April 1, 2015 for currently participating providers, and effective immediately for new participating providers on or after Jan. 1, 2015.

This essential resource for physicians, hospitals, facilities and other health care providers is available at UnitedHealthcareOnline.com > Policies, Protocols and Guides.

New in the 2015 Guide:• Electronic Payments and Statements (EPS) with new

Virtual Card Payment Options (VCPs) – process for electronic funds transfer/remittance advice. If you currently receive paper checks and remittances, you will have a choice of direct deposit or VCP sometime in 2015. Stay tuned for more information later this year.

• Medicare Advantage Referral Required Plan – new benefit guidelines added for Medicare Advantage members.

• Therapeutic radiation (IMRT, SRS, SBRT) Prior Authorization Program – new outpatient prior authorization requirement for Medicare Advantage members.

Revised in the 2015 Guide:• Optum Cloud Dashboard – Our cloud-based

website offers three primary applications: Claim Reconsideration with or without attachments, Benefits and Eligibility and Claims Management

• Expansion of Commercial and Health Insurance Exchange Plans – new plan offerings

• Specialty Drug Prior Authorization for Medical Benefits for Commercial Members – now available at UnitedHealthcareOnline.com > Clinician Resources > Specialty Drug > Commercial Specialty Drug Prior Authorization Program

• Discontinued Part B Specialty Drug Prior Authorization Program – requirement for Medicare Advantage members

• Neighborhood Health Partnership Precertification List — now available at myNHP.com > Providers > References > Utilization Management Protocols > Prior Authorization Process (protocol III)

• Charging Members for Non-Covered Services – changes to this protocol only apply to Medicare Advantage members

• Providing advance notice to Commercial members for non-participating providers

Please contact your Network Management representative, Physician Advocate, or Hospital and Facility Advocate if you need a printed copy of the UnitedHealthcare Administrative Guide.

2015 UnitedHealthcare Administrative Guide Available – Effective April 1, 2015




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In 2014, the New York Legislature passed Senate Bill 6914 which enacts into law major components of legislation necessary to implement the State Health and Mental Hygiene budget for this fiscal year. There are a number of new disclosure requirements that affect physicians and hospitals who provide care to UnitedHealthcare members or members of any other health plan on an out-of-network basis. The changes take effect April 1 and apply to Commercial plans, and to some extent, Medicaid plans. The changes do not affect Medicare plans.

The disclosure requirements mean that physicians and hospitals must provide more detailed information to patients directly and via their website and other registration and admission materials regarding which health plan networks they participate in.

To help you navigate these new requirements, please see the following overview of those and what they mean to you:

New State Disclosure Regulations Affect Physicians and Hospitals Providing Care on Out-of-Network Basis – Effective April 1

New Physician Disclosure RequirementsPhysicians are required to:

• Notify patients which health plans they participate with and with which hospitals they are affiliated;

• If not participating in a patient’s health plan, give the patient an estimate of the bill for services; and

• Give patients the names and contact information for any ancillary providers to be used in an in-office procedure; and any physician whose services will be used for hospital procedures.

New Hospital Disclosure RequirementsHospitals are required to:

• Publish the following information on their websites:

– A current list – to the extent required by federal guidelines – of standard charges for the hospital’s items and services;

– The health plans in which the hospital participates;

– Notice that physician services provided in the hospital are not included in the hospital charges;

– Notice that physicians may or may not participate in the same health plans and the hospital;

– Warning that prospective patients should confirm the participation status of their physician;

– A list of physician groups contracted by the hospital to provide anesthesiology, pathology and radiology and how the patient can contact them;

– The names and contact information for physicians employed by the hospital and the health plans in which they participate.

• Include the following information in registration or admission materials:

– Advise patients to confirm with the physician arranging the hospital service the names of any other physicians whose services will be arranged by that physician, or if the services of any physician employed by the hospital are anticipated;

– Provide information about how patients can determine the health plan participation of physicians anticipated to service the patient in the hospital as determined by the admitting physician and employees of the hospital or contracted by the hospital to provide services including anesthesiology, radiology and/or pathology.


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Introducing the UnitedHealthcare Hospital Quality Program

The new UnitedHealthcare Hospital Quality Program provides comparative quality information to help members make informed health care choices about hospitals. The program results are based on key measures for acute care hospitals that include common inpatient conditions and procedures.

Consumers are increasingly engaged in seeking high-value health care. As a result, there is increased demand among our members for information to support them in making personal health care decisions. This hospital information will be provided to members to facilitate their clinical care choices in partnership with their physicians.

In February, we sent eligible hospitals their Hospital Quality Program Quality Rating Report, which shows their comparative quality results and the methodology used for the program. Your hospital quality information will be available to members this spring through myHealthcare Cost Estimator. myHealthcare Cost Estimator is an online and mobile application that gives members the transparency they want to understand health care costs and quality for specific physicians and hospitals. The tool provides a five-star relative quality rating along with comparative cost information for hospitals.

For more information on the UnitedHealthcare Hospital Quality Program, please go to UnitedHealthcareOnline.com > Clinician Resources > Performance Measurement & Reporting > Hospital Quality Program, or call 866-270-5588.

Training now Available for UnitedHealth Premium Designation® Program

We are pleased to announce the availability of the UnitedHealth Premium Overview training course. This online course will help you understand the Premium program’s key features and explain the resources available on UnitedHealthcareOnline.com. It also includes an introduction to the methodology used to determine quality and cost efficiency.

The self-paced course is available to you on-demand at UnitedHealthcareOnline.com > UnitedHealth Premium > Premium Helpful Resources.


http://www.UnitedHealthcareOnline.com

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Making Simple Adjustments When Filing Claims for Certain Preventive Care Services Performed at Office Visits Can Benefit Your Practice

When it comes to reporting BMI, Blood Pressure, HBA1C and Care for Older Adult screenings performed during an adult care office visit, did you know that simply including procedure and diagnosis codes when filing your claim saves you administrative time AND can improve patient care coordination?

Sound too good to be true? Consider this:• When procedure and diagnosis codes are used for

these specific services performed at an office visit, it decreases the need to request a member’s charts for this same information;

• Capturing this data helps to drive HEDIS performance improvements. When these codes are used, gaps in care are more quickly identified as closed which drives direct Star Ratings improvements and can increase performance in any incentives in which you participate;

• Coding for these services provides access to more accurate medical data which can help our efforts to support your care plan through more targeted case management services; and

• Patients are not unnecessarily contacted with reminders to get screenings they may have already received.

We’re all about improving quality care scores for Star Ratings and to support our Medicare and Retirement PATH program– and this is one more way to move the needle in a positive direction with only minor updates to coding!

For more information on the benefits of using these procedure and diagnosis codes, please contact your UnitedHealthcare Network contact or Practice Performance Manager.

How to Report CodesSo how do you report these codes and what are the codes for these screenings? Here’s the information you need to get you started!

Blood Pressure for Hypertensive Members (This code is not going to meet the intent for the CBP measure, but will for the CDC BP measure).Additionally, a BP reading code should be reported for each office visit. To capture the BP reading, please include a line for the BP Systolic and one for BP Diastolic procedure codes. Each need to be included and should be billed with a zero charge.

BP Systolic

Less than 130 3074F

130-139 3075F

140+ 3077F

BP Diastolic

Less than 80 3078F

80-89 3079F

90+ 3080F

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BMI at Office VisitsA BMI diagnosis code should be included on all office visit claims. The following diagnosis codes should be used to report a patient’s BMI to us. You do not need to link the BMI diagnosis code to a line item of a claim but it should be included in the diagnosis list transmitted on the claim.

BMI Diagnosis Codes

BMI less than 19 v85.0

19-24 v85.1

25-25.9 v85.21

26-26.9 v85.22

27-27.9 v85.23

28-28.9 v85.24

29-29.9 v85.25

30-30.9 v85.30

31-31.9 v85.31

32-32.0 v85.32

33-33.9 v85.33

34-34.9 v85.34

35-35.9 v85.35

36-36.9 v85.36

37-37.9 v85.37

38-38.9 v85.38

39-39.9 v85.39

40-44.9 v85.41

45-49.9 v85.42

50-59.9 v85.43

60-69.9 v85.44

70+ v85.45

Diabetes Hemoglobin A1c TestingClaims including procedure code 83036 or 83037 should include a line item with the resulting CPT procedure code below and be billed with a zero charge.

HbA1c

Below 7 3044F

7 - 9 3045F

Above 9 3046F

For more information on how to report CPT II codes, please contact your UnitedHealthcare Network contact or Practice Performance Manager.

Care for Older AdultsThe following codes assist in the assessment of older adult’s coordination of care. If you are performing standard functional assessments or pain screening using a standardized tool, you can include these quality HCPCS or CPT II codes with your office visit code to help meet the HEDIS Care for Older Adult Measures.

Assessment or Screening Type Applicable Code

Advance Care Planning 1157F

Advance Care Planning 1158F

Advance Care Planning S0257

Functional Status Assessment 1170F

Medication List 1159F

Medication List G8427

Medication Review 1160F

Medication Review 90863



Pain Assessment 1125F

Pain Assessment 1126F

TCM 7 Day 99496

Making Simple Adjustments When Filing Claims for Certain Preventive Care Services Performed at Office Visits Can Benefit Your Practice

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UnitedHealthcare Medical Policy, Drug Policy, Coverage Determination Guideline and Utilization Review Guideline Updates


For complete details on the policy updates listed in the following table, please refer to the March 2015 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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Policy Title Policy Type Effective Date

Balloon Sinus Ostial Dilation Medical Policy April 1, 2015

Hysterectomy for Benign Conditions Medical Policy April 1, 2015

Attended Polysomnography for Evaluation of Sleep Disorders Medical Policy April 1, 2015

Blepharoplasty, Blepharoptosis and Brow Ptosis RepairCoverage Determination Guideline

April 1, 2015

Breast Reduction SurgeryCoverage Determination Guideline

April 1, 2015

Chelation Therapy for Non-Overload Conditions Medical Policy March 1, 2015

Chemotherapy Observation or Inpatient Hospitalization Utilization Review Guideline April 1, 2015

Clotting Factors and Coagulant Blood Products Drug Policy April 1, 2015

Collagen Crosslinks and Biochemical Markers for Bone Turnover Medical Policy March 1, 2015

Continuous Glucose Monitoring and Insulin Delivery for Managing Diabetes Medical Policy April 1, 2015

Elbow Replacement Surgery (Arthroplasty) Medical Policy April 1, 2015

Electrical and Ultrasound Bone Growth Stimulators Medical Policy April 1, 2015

Fecal Calprotectin Testing Medical Policy April 1, 2015

Fecal DNA Testing Medical Policy April 1, 2015

Fetal Aneuploidy Testing Using Cell-Free Fetal Nucleic Acids in Maternal Blood Medical Policy April 1, 2015

Hip Replacement Surgery (Arthroplasty) Medical Policy April 1, 2015

Hospital Readmissions Quality of Care Guideline April 1, 2015

Immune Globulin (IVIG and SCIG) Drug Policy March 1, 2015

Immune Globulin Site of Care Review Guidelines for Medical Necessity of Hospital Outpatient Facility Infusion

Utilization Review Guideline April 1, 2015


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Implanted Electrical Stimulator for Spinal Cords Medical Policy April 1, 2015

Inpatient Pediatric Feeding Programs Utilization Review Guideline April 1, 2015

Knee Replacement Surgery (Arthroplasty) Medical Policy April 1, 2015

Manipulation Under Anesthesia Medical Policy April 1, 2015

Obstructive Sleep Apnea Treatment Medical Policy April 1, 2015

Orthognathic (Jaw) SurgeryCoverage Determination Guideline

April 1, 2015

Oscillatory Positive Expiratory Pressure Devices Medical Policy April 1, 2015

Outpatient Cardiovascular Telemetry Medical Policy March 1, 2015

Panniculectomy and Body Contouring ProceduresCoverage Determination Guideline

April 1, 2015

Platelet Derived Growth Factors for Treatment of Wounds Medical Policy April 1, 2015

Pneumatic Compression Devices Medical Policy April 1, 2015

Preventive Care ServicesCoverage Determination Guideline

April 1, 2015

Remicade® (Infliximab) Drug Policy April 1, 2015

Rhinoplasty and Repair of Vestibular Stenosis Coverage Determination Guideline

April 1, 2015

Shoulder Replacement Surgery (Arthroplasty) Medical Policy April 1, 2015

Site of Care Review Guidelines for Medical Necessity of Hospital Outpatient Facility Specialty Medication Infusion: Utilization Review Guideline

Utilization Review Guideline April 1, 2015

Skilled Care and Custodial Care ServicesCoverage Determination Guideline

April 1, 2015


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Speech Language Pathology ServicesCoverage Determination Guideline

April 1, 2015

Surgical Treatment for Spine Pain Medical Policy April 1, 2015

Temporomandibular Joint Disorders Medical Policy April 1, 2015

Thermal Capsulorrhaphy/ Thermal Shrinkage Therapy Medical Policy March 1, 2015

Wearable Cardioverter – Defibrillators Medical Policy April 1, 2015

Note: The inclusion of a service or procedure on this list does not imply that UnitedHealthcareprovides coverage for the service or procedure. In the event of an inconsistency between theinformation in this Network Bulletin and the posted policy, the posted policy prevails.


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Unless otherwise noted, these 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, enrollee benefit coverage documents, UnitedHealthcare medical or drug policies, and the UnitedHealthcare Physician, Health Care Professional, Facility and Ancillary 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 and Protocols > Reimbursement Policies-Commercial. In the event of an inconsistency or conflict between the information provided in the Network Bulletin and the posted policy, the provisions of the posted policy prevail.

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UnitedHealthcare has established maximum frequency per day (MFD) values, which are the highest number of units eligible for reimbursement of services on a single date of service.

As announced in the November 2014 Network Bulletin, UnitedHealthcare no longer permits reimbursement of multiple units submitted for a single date of service for procedure codes which state “per diem” or “per day” within the code description, effective first quarter 2015. This change was also intended to apply to those procedure codes where the code description for the service or supply indicates it should be reported only once daily.

Clarification on Revision to Maximum Frequency per Day Policy for Per Diem Codes




UnitedHealthcare Medicare SolutionsTwo Midnight Rule for Critical Access Hospitals

The Centers for Medicare & Medicaid Services (CMS) 2014 Fiscal Year Inpatient Prospective Payment System Final Rule includes a provision that clarifies Medicare admission and medical review criteria for hospital inpatient services, known as the Two Midnight Rule.

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The Two Midnight Rule is intended to help care providers determine whether a Medicare claim should be billed under Part A (hospital insurance – inpatient) or Part B (medical insurance – outpatient).

UnitedHealthcare has fully integrated the Two Midnight Rule into our Medicare Advantage inpatient management medical necessity review process. Integration of the Two Midnight Rule allows UnitedHealthcare to work with our care providers to meet CMS medical necessity requirements related to inpatient admissions. Integration for the Two Midnight Rule for Critical Access Hospitals will occur on July 1, 2015.

Based on the Two Midnight Rule, if the care provider expects the Medicare Advantage member’s medically necessary treatment will span less than two midnights, outpatient/observation status is appropriate. If a Medicare Advantage member requires medically necessary hospital care that is expected to span two or more midnights, inpatient admission is appropriate. The Two Midnight Rule does not apply to services CMS designates as inpatient only.

To facilitate integration of the Two Midnight Rule, facilities must provide to UnitedHealthcare, the physician’s inpatient admission order, in addition to any other clinical information needed to support hospital stays that span two or more midnights. Please note that facilities that have granted UnitedHealthcare inpatient care managers onsite or remote electronic medical record (EMR) access do not need to

submit clinical information to UnitedHealthcare because our care managers will access this information in the facility’s EMR system. Facilities that have fax or telephonic review processes will be required to fax a copy of the care provider’s inpatient admission order, when clinical information is requested by the UnitedHealthcare inpatient care manager.

UnitedHealthcare will continue to use evidence-based guidelines to support consistent and clinically valid decision-making for medically necessary hospital stays, in conjunction with the Two Midnight Rule. Facilities and admitting physicians will be expected to use the Medicare inpatient admission criteria as clarified in the Two Midnight Rule when admitting a Medicare Advantage member as an inpatient for medically necessary acute care services.

Care providers are encouraged to work with UnitedHealthcare medical directors to support the provision of evidence-based and medically necessary care for our members. We will continue to work collaboratively with you as we implement the Two Midnight Rule.

If you have questions, please contact your local market medical director.

Two Midnight Rule for Critical Access Hospitals

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Policy Title

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

Gastroesophageal and Gastrointestinal (GI) Services and Procedures

Incontinence – Urinary and Fecal Incontinence, Diagnosis and Treatments

Medications/Drugs (Outpatient/Part B)

Neurophysiological Studies

Non-Covered Services (including Services/Complications Related to Non-Covered Services)

Preventive Health Services and Procedures

Speech Generating Devices

Spine Procedures

Telemedicine/Telehealth Services

Ventriculectomy, Partial

Vision Services, Therapy and Rehabilitation

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

The following policies were approved on Feb. 17, 2015. For complete details on the policy updates listed in the following table, please refer to the March 2015 Medicare Advantage Coverage Summary Update Bulletin at UnitedHealthcareOnline.com > Tools & Resources > Policies, Protocols and Guides > UnitedHealthcare Medicare Advantage Coverage Summaries > Update Bulletin.

UnitedHealthcare Medicare Advantage Coverage Summary Updates


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Scheduling of Annual Care Visit to Qualify for Member Rewards Program

The Centers for Medicare & Medicaid Services (CMS) 2014 Fiscal Year Inpatient Prospective Payment System Final Rule includes a provision that clarifies Medicare admission and medical review criteria for hospital inpatient services, known as the Two Midnight Rule.

You may be receiving phone calls from Medicare Advantage members asking to schedule an annual visit with you. That’s because we are offering all Medicare Advantage members a $15 gift card to various restaurants or retailers for completing an annual visit. Either the annual wellness visit or annual routine physical qualifies for the $15 gift card, but not both. Please be sure to schedule them together as one annual care visit.

Each member is eligible for one reward per calendar year even if it has not been a full 12 months since their last annual care visit. These visits are covered benefits once per calendar year. Members must complete their annual care visit between Jan. 1, 2015 and Dec. 31, 2015.

After completion of the visit members, call 855-501-1011 to self-report their completed visit and redeem their reward.

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

PECOS Ordering/Referring for Provider Claims Update

On Jan. 6, 2014, the Centers for Medicare & Medicaid Services (CMS) instructed Medicare plan contractors to implement denial edits. To read more about the edits, please click here.


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UnitedHealthcare Community PlanMedical Policy & Coverage Determination Guideline Updates

For complete details on the policy updates listed in the following table, please refer to the monthly Medical Policy Update Bulletin at UHCCommunityPlan.com > Provider Information > Medical Policies and Coverage Determination Guidelines for Community Plan.

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Medical Policy Update Bulletin

NEW

Balloon Sinus Ostial Dilation Medical Policy June 1, 2015March 2015April 2015

UPDATED/REVISED

Abnormal Uterine Bleeding and Uterine Fibroids Medical Policy April 1, 2015 March 2015

Attended Polysomnography for Evaluation of Sleep Disorders Medical Policy April 1, 2015 March 2015

Blepharoplasty, Blepharoptosis and Brow Ptosis Repair

Coverage Determination Guideline

April 1, 2015 March 2015

Breast Reduction SurgeryCoverage Determination Guideline


Chelation Therapy for Non-Overload Conditions Medical Policy May 1, 2015March 2015April 2015

Collagen Crosslinks and Biochemical Markers of Bone Turnover Medical Policy May 1, 2015

March 2015April 2015

Continuous Glucose Monitoring and Insulin Delivery for Managing Diabetes Medical Policy April 1, 2015 March 2015

Elbow Replacement Surgery (Arthroplasty) Medical Policy May 1, 2015March 2015April 2015

Electrical and Ultrasound Bone Growth Stimulators Medical Policy May 1, 2015March 2015April 2015

Fecal Calprotectin Testing Medical Policy May 1, 2015March 2015April 2015

Fecal DNA Testing Medical Policy March 1, 2015March 2015April 2015

Fetal Aneuploidy Testing Using Cell-Free Fetal Nucleic Acids in Maternal Blood Medical Policy May 1, 2015


Hip Replacement Surgery (Arthroplasty) Medical Policy May 1, 2015March 2015April 2015

Implanted Electrical Stimulator for Spinal Cord Medical Policy May 1, 2015March 2015 April 2015

Medical Policy & Coverage Determination Guideline Updates

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Medical Policy Update Bulletin

Knee Replacement Surgery (Arthroplasty) Medical Policy May 1, 2015March 2015April 2015

Manipulation Under Anesthesia Medical Policy May 1, 2015March 2015April 2015

Obstructive Sleep Apnea Treatment Medical Policy April 1, 2015 March 2015

Orthognathic (Jaw) SurgeryCoverage Determination Guideline

May 1, 2015March 2015April 2015

Oscillatory Positive Expiratory Pressure Devices Medical Policy May 1, 2015March 2015April 2015

Outpatient Cardiovascular Telemetry Medical Policy May 1, 2015March 2015April 2015

Panniculectomy & Body Contouring ProceduresCoverage Determination Guideline


Platelet Derived Growth Factors for Treatment of Wounds Medical Policy May 1, 2015


Pneumatic Compression Devices Medical Policy May 1, 2015March 2015April 2015

Rhinoplasty and Repair of Vestibular StenosisCoverage Determination Guideline


Shoulder Replacement Surgery (Arthroplasty) Medical Policy May 1, 2015March 2015April 2015

Skilled Care and Custodial Care ServicesCoverage Determination Guideline


Speech Language Pathology ServicesCoverage Determination Guideline


Surgical Treatment for Spine Pain Medical Policy April 1, 2015 March 2015

Thermal Capsulorrhaphy/Thermal Shrinkage Therapy Medical Policy May 1, 2015March 2015April 2015

Wearable Cardioverter-Defibrillators Medical Policy May 1, 2015March 2015April 2015

Note: The inclusion of a service or procedure on this list does not imply that UnitedHealthcare provides coverage for the service or procedure. In the event of an inconsistency between the information provided in this Network Bulletin and the posted policy, the posted policy prevails.

Medical Policy & Coverage Determination Guideline Updates

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In an effort to support evidence-based use of specialty medications, UnitedHealthcare Community Plan* will require all physicians and other health care professionals billing under the medical benefit to obtain prior authorization before administering enzyme replacement therapy medications Cerezyme and Elelyso to treat Gaucher disease for members. This requirement, which is effective April 1, 2015, will affect both new and existing members on therapy.

Requests for coverage of Cerezyme and Elelyso will be subject to medical necessity review. Prior authorization will not be required for Velaglucerase alfa (VPRIV).

New Prior Authorization Requirement for Enzyme Replacement Medications for Gaucher Disease – Cerezyme and Elelyso – Effective April 1

Code(s) Generic Name Brand Name Preferred Product

272.7, E75.22, J1786 Imiglucerase Cerezyme No

272.7, E75.22, J3060 Taliglucerase alfa Elelyso No

272.7, E75.22, J3385 Velaglucerase alfa VPRIV Yes

Effective for dates of service on or after April 1, 2015, please request prior authorization for the non-preferred products of Cerezyme and Elelyso. Complete a prior authorization form and fax it along with the necessary medical records.

You may access and review UnitedHealthcare’s drug policies and prescription enrollment forms on UnitedHealthcareOnline.com > Tools & Resources > Pharmacy Resources > Specialty Pharmacy Program > Policies, Protocols, and Guides.

If a provider does not obtain prior authorization approval before administration of the product, the claim will be denied and the member cannot be billed for the service. UnitedHealthcare Community Plan’s standard appeal process will apply to any denied administrative claims.

Letters were mailed to our members using Cerezyme or Elelyso to advise them of this prior authorization requirement.

If you have questions, please contact your local Network Management representative or call the phone number on the back of the member’s health plan identification card.

* These requirements apply to the following UnitedHealthcare Community Plans: Arizona, Delaware, Florida Healthy Kids, Iowa, Louisiana, Maryland, Mississippi, Nebraska, New Jersey, New York, Ohio, Pennsylvania, Rhode Island, Tennessee, Washington.






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Effective for dates of service on or after March 1, 2015, codes T1002 and T1003 for Home Health Care have been added to the advance notification or prior authorization requirements for the following UnitedHealthcare Community Plans: Florida, Hawaii, Iowa, Louisiana, Massachusetts, Mississippi, New Mexico, Rhode Island and Tennessee.

As a reminder, some members have benefit plans that cover pre-service clinical coverage reviews, while others do not. The process to initiate an advance notification or a prior authorization request is the same, regardless of the type of benefit plan.

The current processes for submitting an advance notification or a prior authorization request will not change. If you are planning to perform a service on the standardized list, please notify us in advance. We will let you know if a clinical coverage review is required for that service and ask you to submit the necessary information to complete the review. Once a coverage determination is made, we will share that decision with you so that you and your patient can make informed decisions before services are performed. We determine coverage consistent with the member’s benefit plan.

Please keep in mind that while receipt of an approved advance notification or prior authorization for services confirms coverage, it does not guarantee or authorize payment. Payment of covered services is subject to the terms and conditions of your contract with UnitedHealthcare and the member’s health benefit plan in effect at the time services are rendered, including but not limited to exclusions, limitations, conditions, patient eligibility, medical policies and claim processing requirements.

The most up-to-date list of procedures that will continue to require Advance Notification or Prior Authorization as well as the effective date for each health plan can be found at UHCCommunityPlan.com > Bulletins.

Important changes in Advance Notification and Prior Authorization Requirements


http://UHCCommunityPlan.com




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Providers have a very important role in the coordination of care for our UnitedHealthcare Community Plan members. In our new Model of Care, each member will have access to an interdisciplinary care team.

The care team includes the member and the provider, as well as the member’s designated caregivers, case managers, behavioral health advocates, community health workers and other supporting individuals as identified by the member.

The care team will collaborate to develop an individualized care plan to meet the member’s unique care needs and remove barriers to accessing care as well as assist with finding community resources. When the care plan has been developed, it will be shared with the care team, that will work together to coordinate care and services to meet the member’s needs. The initial care plan, and updates to the care plan, will be shared between the team by fax, email, mail and UHCCommunityPlan.com.

As an essential care team member, your responsibilities as a care provider are to:

• Review the member’s care plan

• Comment and/or provide feedback to the care plan

• Interact with the care team to ensure coordination of care and specialized benefits to meet members’ needs

• Participate in care team meetings when requested

For our highest risk members, we will share member care plans with providers and other care team members using Community Care, a web-based health care management system designed to improve collaboration among the interdisciplinary care team.

The care plans will be used by the care team to help ensure coordination of care to meet the complex needs of these especially vulnerable members. Real-time access to member care plans is expected to enhance your ability to coordinate care with the entire care team.

Provider’s Role in Coordination of Care for UnitedHealthcare Community Plan Members

New Institutional Claim Edit

UnitedHealthcare Community Plan has implemented a new edit requiring the individual attending physician first and last name with a valid NPI on all institutional claims (UB billers) submitted via paper or electronic transactions. We strive to provide our State Medicaid agencies with all the needed information for Medicaid encounters, as contractually required. This edit ensures that we maintain compliance. Please also continue to include the appropriate taxonomy code for billing and attending provider.





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As of April 1, 2015 UnitedHealthcare Community Plan in Maryland will be introducing a New Pharmacy Network, and our members will be required to access this new network for their pharmacy benefits. The network provides access to hundreds of leading retail drug stores across Maryland that provide them with convenience and access to getting prescriptions.

The new Maryland Pharmacy Network was created to include pharmacies that provide high quality at a great value.

After April 1, 2015 we ask that you help our UnitedHealthcare Community Plan in Maryland Medicaid members transition to the new Maryland Pharmacy Network for any refills or new prescriptions that they previously received from pharmacies that are no longer in-network. To assist you and your staff with this transition, a complete list of participating pharmacies in the Maryland Pharmacy Network is available at UHCCommunityPlan.com.

We are sending members a letter that will include the steps they need to take to transfer their prescriptions to a pharmacy in the new network, and the names and addresses of up to three drug stores located in their neighborhood.

This pharmacy network change will not affect members in either UnitedHealthcare Commercial and Medicare plans. These members can continue using their current pharmacy.

If you have any questions, please call your Provider Services at 800-445-1638.

Announcing the New Maryland Pharmacy Network for Medicaid Members




2015 TRICARE Provider Handbook – Revised April 1, 2015

An updated version of the UnitedHealthcare Military & Veterans’ TRICARE Provider Handbook has been posted. Except as otherwise noted, the new Handbook is effective July 1, 2015 for currently contracted providers and will be effective immediately for providers newly contracted on or after April 1, 2015.

The Handbook can be viewed at UHCMilitaryWest.com > Providers, or at UnitedHealthcareOnline.com > Tools & Resources > Policies, Protocols & Guides.


Next Article >

TABLE OF CONTENTS


https://www.uhcmilitarywest.com




TABLE OF CONTENTS

The following is a summary of important changes you will find in the April 2015 publication. This summary of selected updates to the Handbook does not include every update or the details of any update. Please refer to the Handbook for the complete text and detailed updates.

• Online Referral and Authorization Process – UHCMilitaryWest.com has been updated to allow online submissions and approvals of referrals and authorizations. More attention has been drawn to this faster process in several references in the Handbook.

• Referral and Appointment Process –

A) Clarified requirements that must be met to change a provider on an existing authorization

B) Authorization expiration date: changed reference from “180 days” to “Date span as stated on the authorization.” The default date span is 180 days, but can vary based on the service or specialty provided.

• TRICARE ECHO and Autism Programs – this information has also been updated on UHCMilitaryWest.com. Several key updates that reflect the government’s efforts to simplify the autism benefit, including:

A) TRICARE Autism Programs are now referred to as the TRICARE Comprehensive Autism Care Demonstration Program (ACD) to align with government verbiage.

B) Hippotherapy has been added as a covered treatment under ECHO.

C) ECHO Home Health Care Benefit (EHHC) expenses are now included in the government’s maximum cost-share accrual of $36,000.

D) Costs related to Autism Care Demonstration (ACD) do not apply to the government’s maximum cost-share accrual of $36,000.

E) ECHO phone and fax numbers are updated: Information and Referrals: 855-874-6800Case Management Center: 866-480-0070Fax: 877-890-8156

F) ABA Therapy clarifications regarding the Sole Provider Model vs. the Tiered Delivery Model

G) BCBAs, BCBA-Ds, BCaBA and Behavior Technicians’ roles and responsibilities clarified per government guidelines. References to the role of tutors deleted.

H) ECHO Authorization codes have been updated. Codes listed in previous versions of the Handbook are no longer applicable.

2015 TRICARE Provider Handbook – Revised April 1, 2015

Next Article >




Our members have certain rights and responsibilities, all of which are intended to help uphold the quality of care and services they receive from you. These rights and responsibilities may be found at https://www.uhcmedicaresolutions.com/health-plans medicare-advantage-plans/resources-plan-material/ma-medicare-forms/medicare-rights-center.html

Please feel free to distribute this statement to your patients.

If your patient has questions or concerns about their rights as Medicare customer, or need help with communication, such as assistance from a language interpreter, please refer them to the Customer Service phone number listed on the back of their health plan member ID card. Members receive information about their Rights and Responsibilities upon enrollment and annually thereafter.

Rights and Responsibilities for Medicare Members


TABLE OF CONTENTS


https://www.uhcmedicaresolutions.com/health-plans/medicare-advantage-plans/resources-plan-material/ma-medicare-forms/medicare-rights-center.html








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Optum Cloud Dashboard Enhancements to Notifications/Prior Authorizations

Optum Cloud Dashboard’s Eligibility & Benefits Center can now be used to check if a Notification/Prior Authorization is required, to submit the Notification/Prior Authorization via single sign-on to UnitedHealthcareOnline.com and to upload supporting documentation (if prompted to do so). This functionality is available for UnitedHealthcare Commercial, UnitedHealthcare Medicare Solutions and UnitedHealthcare Community Plan membership. It is also available for UnitedHealthcare One, however, no benefit information is provided.

Checking if Notification/Prior Authorization is Required When checking eligibility and benefits for a patient on Optum Cloud Dashboard, a field called “Able to Submit Prior Authorization/Notification Request” will be displayed. If the field contains “Yes,” the “My Actions” dropdown will include a link to “Submit Prior Auth Request”. You can link to the page and fill in the required fields to determine if a Notification/ Prior Authorization is required for the planned procedure(s). If one is required, an “Initiate Now” button will be available to begin the submission. Clicking the button will bring you to the Case Information screen on UnitedHealthcareOnline.com (pre-populated with the data entered into Optum Cloud Dashboard) to complete the Notification/Prior Authorization Submission.

Adding Attachments and Clinical Notes After a Notification/Prior Authorization has been submitted, you may be prompted to supply additional information either by fax or attachment. If prompted to upload an attachment, you can upload as many as needed, one at a time. The system will accept bmp, doc, docx, gif, jpg, jpeg, pdf, png, tiff, and tx files up to 3.5 MB in size. Note: once a file is uploaded it cannot be removed. Whether or not an attachment is uploaded, you can type in the Clinical Notes section.

For information regarding the clinical documentation that may be required for the service, refer to UnitedHealthcareOnline.com > Tools & Resources > Policies, Protocols & Guides > Protocols > Medical Records Requirement for Pre-Service.

Next Article >



https://www.unitedhealthcareonline.com/ccmcontent/ProviderII/UHC/en-US/Assets/ProviderStaticFiles/ProviderStaticFilesPdf/Tools%20and%20Resources/Policies%20and%20Protocols/Pre-Service_Required_Medical_Records_Guide_PCA11558.pdf

https://www.unitedhealthcareonline.com/ccmcontent/ProviderII/UHC/en-US/Assets/ProviderStaticFiles/ProviderStaticFilesPdf/Tools%20and%20Resources/Policies%20and%20Protocols/Pre-Service_Required_Medical_Records_Guide_PCA11558.pdf




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Checking Notification/Prior Authorization StatusIf you initiated your submission on Optum Cloud Dashboard, you will see the Notification/Prior Authorization status at the bottom of the home screen in the Eligibility & Benefits application. Clicking “View Details” allows you to:

• View the status of each procedure code

• Check if additional documentation is required

• View a list of your attachments and upload more

• View and update the Clinical Notes

If you initiated your submission on UnitedHealthcareOnline.com, you must first locate the Notification/Prior Authorization by Service Reference Number (SRN) in the “Search Cases by Case Number” tool in the middle of the Eligibility & Benefits home screen. You will then be able to see the same details listed above and the Notification/Prior Authorization will automatically display on the bottom of the home screen on subsequent visits.

Updating Notifications/Prior Authorizations At this time, all updates must be made in the Notification/Prior Authorization Status transaction on UnitedHealthcareOnline.com, regardless of where the submission was initiated. If an update results in a request for additional information, either the Fax or Attachment window will open.

For additional information, please refer to the quick reference guide on UnitedHealthcareOnline.com > Help > Optum Cloud Dashboard > Optum Cloud Dashboard.

Optum Cloud Dashboard Enhancements to Notifications/Prior Authorizations

Next Article >




https://www.unitedhealthcareonline.com/b2c/CmaAction.do?channelId=c7eddcbe73e8e310VgnVCM2000002a4ab10a____




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New Optum Cloud Dashboard Feature Helps with Pended Claims

The Claims Management application has been updated so you can submit attachments for pended claims requiring additional information.

When a claim is placed into pending status because additional information is required, you receive a letter in the mail requesting specific information. In the past you had to submit this information by mail or fax – now you can speed up the process by submitting attachments online via Optum Cloud Dashboard.

When you check claims status in Claims Management, the search results screen shows claims in pended status. Selecting a pended claim will allow you to review the Remark Code and its description. Then you can select

“Submit Attachment” from the “My Actions” menu. After submission, please allow 30 days for claim processing before checking the status using the “First and Last Date of Service” option on the Claim Search screen.

For more information, go to UnitedHealthcareOnline.com > Help > Optum Cloud Dashboard and refer to the Optum Cloud – Claims Management Quick Reference Guide.

Note: We frequently make enhancements to Optum Cloud Dashboard. To make sure you don’t miss important information, please keep an eye on the News section of the UnitedHealthcareOnline.com home page.

Collaboration between Primary Care Physicians and Behavioral Health Clinicians Can Make a Difference

A substantial number of patients with serious medical illnesses also have behavioral health conditions. Continuity and coordination of care take on greater importance for patients with severe and persistent mental health and/or substance abuse problems. This is especially true when medications are prescribed, when there are co-existing medical/psychiatric symptoms and when patients have been hospitalized for a medical or psychiatric condition.

Please discuss with your patients the benefits of sharing essential clinical information. When applicable, we encourage you to obtain a signed release from each UnitedHealthcare patient that allows you to share appropriate treatment information with the patient’s behavioral health clinician.



https://www.unitedhealthcareonline.com/ccmcontent/ProviderII/UHC/en-US/Assets/ProviderStaticFiles/ProviderStaticFilesPdf/Help/Optum_Cloud_Dashboard_Eligibility_and_Benefits_Center.pdf



The 2015 UnitedHealthcare West Provider Capitated Administrative Guide will be available on April 1, 2015 at UHCWest.com > Provider > Library > Provider Administrative Guides.

If you need a paper copy, please contact your local UnitedHealthcare Network Management Representative, Physician Advocate, or Hospital and Facility Advocate. Your contract requires compliance with the Guide and non-compliance can affect reimbursement.

Except as otherwise noted, the new Guide is effective on July 1, 2015 for currently contracted providers, and effective immediately for providers newly contracted on or after April 1, 2015.

UnitedHealthcare Affiliates2015 UnitedHealthcare West Capitated Administrative Guide Available April 1, 2015

Next Article >

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http://UHCWest.com




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Important Updates in the 2015 Guide

The following list is a summary of selected updates, and does not represent every detail of changes made. For complete details of all updates, please refer to the 2015 UnitedHealthcare West Provider Capitated Guide at UHCWest.com.

• Co-insurance Calculation (Medicare Advantage only) – New instructions have been added to assist care providers in calculating co-insurance for all Medicare Advantage plans.

• Compliance Audits – Established new policies and procedures to monitor delegated entities’ compliance with state and federal claims processing requirements.

• Medical Observation for Medicare Advantage Members – Clarifications added regarding review criteria for observation and inpatient admissions.

• CMS Audit Results – Based on CMS 2013 audit findings, UnitedHealthcare may escalate its usual oversight and corrective action process to require an immediate corrective action, for the top five common areas for improvement.

• Medicare Advantage Part C Reopening of Organization Determinations – A new section has been added defining a Part C Reopening, and clarifying reason categories and other instructions related to the reopening of organization determinations.

• Preventive Health and Clinical Practice Guidelines – This section has been updated based on information from nationally recognized sources. Guidelines with significant changes have been marked with an asterisk in the guideline table. Clinical and preventive evidence-based guidelines include: Diabetes, Heart Failure, Cardiovascular Disease, ADHD, Major Depressive Disorders, Perinatal Care and Preventive Services.

• Facility Denial Process – The Facility Denial Process has been revised.

To distinguish between administrative rules applicable to UnitedHealthcare plans, we use a reference to “UnitedHealthcare West.” The following legal entities are included in the reference to “UnitedHealthcare West:” UHC of California doing business as UnitedHealthcare of California, UnitedHealthcare of Oklahoma, Inc., UnitedHealthcare of Oregon, Inc., UnitedHealthcare Benefits of Texas, Inc., UnitedHealthcare of Washington, Inc., PacifiCare of Arizona, Inc., PacifiCare of Colorado, Inc., PacifiCare of Nevada, Inc., and UnitedHealthcare Services, Inc. The products offered by these legal entities have been rebranded. PacifiCare Health Systems, LLC remains as a stand-alone legal entity today. Behavioral health products are provided by U.S. Behavioral Health Plan, California (USBHPC) or United Behavioral Health (UBH).

2015 UnitedHealthcare West Capitated Administrative Guide Available April 1, 2015

Next Article >


http://UHCWest.com




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Per the November 2014 Network Bulletin, UnitedHealthcare of the River Valley will introduce new preauthorization requirements for certain radiology services for our Commercial members. The effective date for these requirements has been changed from Feb. 16, 2015 to May 18, 2015.

For care providers subject to the UnitedHealthcare of the River Valley Entities Supplement, certain advanced imaging procedures provided to UnitedHealthcare of the River Valley Commercial members, including: computerized tomography (CT), magnetic resonance imaging (MRI), magnetic resonance angiography (MRA), positron-emission tomography (PET), nuclear medicine and nuclear cardiology, will require preauthorization.

The new requirement is in accordance with the Outpatient Radiology/ Notification/Prior Authorization Protocol for Commercial Customers set forth in the Physician, Health Care Professional, Facility and Ancillary Provider Administrative Guide for Commercial and Medicare Advantage Products. Preauthorization requirements for certain cardiology procedures provided to UnitedHealthcare of the River Valley commercial members, including: outpatient diagnostic catheterizations, inpatient and outpatient electrophysiology implants, outpatient echocardiograms and outpatient stress echocardiograms, remain in effect for participating providers who are subject to the River Valley Entities Supplement of the Administrative Guide.

The Administrative Guide, including the River Valley Entities Supplement, is available at UnitedHealthcareOnline.com > Tools & Resources > Policies, Protocols & Guides > Administrative Guides, or at UHCRiverValley.com > Providers > Provider Manuals. Additional information regarding these protocols for UnitedHealthcare of the River Valley Commercial members is available beginning on page 15 of the November 2014 Network Bulletin.

For more information, you can also go to UHCRiverValley.com > Preauthorization > Procedures, Durable Medical Equipment, and Other Services > Radiology/Advanced Outpatient Imaging Procedures (effective 5/18/15); or go to UHCRiverValley.com > Preauthorization > Procedures, Durable Medical Equipment, and Other Services > Cardiology – Diagnostic Catheterizations, Electrophysiology (EP) Implant Echocardiogram and Stress Echocardiograms.

We will also host live question and answer conference calls on April 28, 2015 and April 30, 2015. You can register to attend a conference call at: UHCRiverValley.com > Providers.

Provider Training Opportunity for UnitedHealthcare of the River Valley: Preauthorization List Additions for Radiology Services





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SignatureValue™ Benefit Interpretation Policy Updates

For complete details on the policy updates listed in the following table, please refer to the monthly SignatureValue™ Benefit Interpretation Policy Update Bulletin at UHCWest.com > Provider Log In > Library > Resource Center > Guidelines & Interpretation Manuals.

Policy Title Applicable State(s)

Effective Date

Update Bulletin

UPDATED/REVISED

Court, Attorney or Agency Requested Services

All (California, Oklahoma, Oregon, Texas, & Washington)


Detoxification: Chemical Dependency/Substance Abuse Detoxification

Diabetes: Diabetic Management, Services and Supplies

Dialysis Services

Rehabilitation: Chemical Dependency/Substance Abuse Rehabilitation

Rehabilitation: Medical Rehabilitation (Physical, Occupational, and Speech Therapy)

Services While Confined/Incarcerated

REPLACED

Dialysis: Continuous Ambulatory Peritoneal Dialysis (CAPD)All April 1, 2015 March 2015

Dialysis: End Stage Renal Disease (ESRD)

Note: The inclusion of a service or procedure on this list does not imply that UnitedHealthcare provides coverage for the service or procedure. In the event of an inconsistency between the information in this Network Bulletin and the posted policy, the posted policy prevails.


https://www.uhcwest.com/

https://www.uhcrivervalley.com/downloads/CPL/Policy_Update_Bulletin_Mar_2015.pdf





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Please review the March 2015 Update Bulletin for more information on each of the following policies:

Title Effective Date

Abnormal Uterine Bleeding and Uterine Fibroids April 1, 2015

Attended Polysomnography for Evaluation of Sleep Disorders April 1, 2015

Blepharoplasty, Blepharoptosis, and Brow Ptosis Repair April 1, 2015

Breast Reduction Surgery April 1, 2015

Chelation Therapy for Non-Overload Conditions March 2015

Chemotherapy Observation or Inpatient Hospitalization April 1, 2015

Clinical Practice Guidelines April 1, 2015

Collagen Crosslinks and Biochemical Markers of Bone Turnover March 1, 2015

Continuous Glucose Monitoring and Insulin Delivery for Managing Diabetes April 1, 2015

Elbow Replacement Surgery (Arthroplasty) April 1, 2015

Electrical Ultrasound Bone Growth Stimulator April 1, 2015

Fecal Calprotectin Testing April 1, 2015

Fecal DNA Testing April 1, 2015

Fetal Aneuploidy Testing Using Cell-Free Fetal Nucleic Acids in Maternal Blood April 1, 2015

Hip Replacement Surgery (Arthroplasty) April 1, 2015

Hospital Readmissions April 1, 2015

Immune Globulin Site of Care Review Guidelines for Medical Necessity of Hospital Outpatient Facility Infusion April 1, 2015

For complete details on the

policy updates listed in the

following table, please refer to

the monthly SignatureValue™

Medical Management

Guidelines Update Bulletin at

UHCWest.com > Provider

Log In > Library > Resource

Center > Guidelines &

Interpretation Manuals.

SignatureValue™ Medical Management Guideline Updates

Next Article >



http://www.UHCWest.com




TABLE OF CONTENTS

Title Effective Date

Implanted Electrical Stimulator for Spinal Cords April 1, 2015

Inpatient Pediatric Feeding Programs April 1, 2015

Knee Replacement Surgery (Arthroplasty) April 1, 2015

Manipulation Under Anesthesia April 1, 2015

Obstructive Sleep Apnea Treatment April 1, 2015

Orthognathic (Jaw) Surgery April 1, 2015

Oscillatory Positive Expiratory Pressure Devices April 1, 2015

Outpatient Cardiovascular Telemetry March 1, 2015

Panniculectomy and Body Contouring Procedures April 1, 2015

Platelet Derived Growth Factors for Treatment of Wounds April 1, 2015

Pneumatic Compression Devices April 1, 2015

Preventive Care Services April 1, 2015

Rhinoplasty and Repair of Vestibular Stenosis April 1, 2015

Shoulder Replacement Surgery (Arthroplasty) April 1, 2015

Site of Care Review Guidelines for Medical Necessity of Hospital Outpatient Facility Specialty Medication Infusion April 1, 2015

Surgical Treatment for Spine Pain April 1, 2015

Temporomandibular Joint Disorders April 1, 2015

Thermal Capsulorrhaphy/Thermal Shrinkage Therapy March 1, 2015

Wearable Cardioverter-Defibrillators April 1, 2015

SignatureValue™ Medical Management Guideline Updates


Next Article >





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These updates apply to UnitedHealthcare of the River Valley Commercial and hawk-i plan members only.

Policy Title Effective Date Policy Update Bulletin

TAKE NOTE

Reimbursement Policies that Apply to Commercial Claims that are Subject to the River Valley Entities Supplement

June 1, 2015 March 2015April 2015

NEW

Clotting Factors and Coagulant Blood ProductsImplementation cancelled; previously announced with an effective date of April 1, 2015

Implementation cancelled April 2015

Entyvio™ (Vedolizumab)Implementation cancelled; previously announced with an effective date of April 1, 2015


Off-Label /Unproven Specialty Drug Treatment June 1, 2015 March 2015April 2015

Simponi® Aria™ (Golimumab)Implementation cancelled; previously announced with an effective date of April 1, 2015


UPDATED/REVISED

Abnormal Uterine Bleeding and Uterine Fibroids April 1, 2015 March 2015

Attended Polysomnography for Evaluation of Sleep Disorders April 1, 2015 March 2015

Blepharoplasty, Blepharoptosis and Brow Ptosis Repair April 1, 2015 March 2015

Breast Reduction Surgery April 1, 2015 March 2015

Chelation Therapy for Non-Overload Conditions March 1, 2015 March 2015

Collagen Crosslinks and Biochemical Markers of Bone Turnover March 1, 2015 March 2015


new and/or revised policies and

guidelines listed in the following

table, please refer to the

monthly Policy Update Bulletin

at UHCRiverValley.com >

Providers > Coverage Policy

Library > Policy Update Bulletin.

UnitedHealthcare of the River Valley Preauthorization List and Policy Updates

Next Article >



https://www.uhcrivervalley.com/downloads/CPL/Policy_Update_Bulletin_Apr_2015.pdf












http://wwwdev.uhcrivervalley.com/Providers/Coverage_Policy_Library/Policy_Update_Bulletin.html






TABLE OF CONTENTS


Continuous Glucose Monitoring and Insulin Delivery for Managing Diabetes April 1, 2015 March 2015

DME, Orthotics, Ostomy Supplies, Medical Supplies and Repairs/Replacements April 1, 2015 March 2015

Elbow Replacement Surgery (Arthroplasty) April 1, 2015 March 2015

Electrical & Ultrasound Bone Growth Stimulators April 1, 2015 March 2015

Fecal Calprotectin Testing April 1, 2015 March 2015

Fecal DNA Testing April 1, 2015 April 2015

Hip Replacement Surgery (Arthroplasty) April 1, 2015 March 2015

Immune Globulin Site of Care Review Guidelines for Medical Necessity of Hospital Outpatient Facility Infusion April 1, 2015 March 2015

Implanted Electrical Stimulator for Spinal Cord April 1, 2015 March 2015

Inpatient Pediatric Feeding Programs April 1, 2015 March 2015

Manipulation Under Anesthesia April 1, 2015 March 2015

Fetal Aneuploidy Testing Using Cell-Free Fetal Nucleic Acids in Maternal Blood April 1, 2015 March 2015

Obstructive Sleep Apnea Treatment April 1, 2015 March 2015

Orthognathic (Jaw) Surgery April 1, 2015 March 2015

Oscillatory Positive Expiratory Pressure Devices April 1, 2015 March 2015

Outpatient Cardiovascular Telemetry March 1, 2015 March 2015

Panniculectomy and Body Contouring Procedures April 1, 2015 March 2015

Platelet Derived Growth Factors for Treatment of Wounds April 1, 2015 March 2015

Pneumatic Compression Devices April 1, 2015 March 2015

Preventive Care Services April 1, 2015 March 2015

Prosthetic Devices, Wigs, Specialized, Microprocessor or Myoelectric Limbs April 1, 2015 March 2015


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TABLE OF CONTENTS


Rhinoplasty and Repair of Vestibular Stenosis April 1, 2015 March 2015

Shoulder Replacement Surgery (Arthroplasty) April 1, 2015 March 2015

Site of Care Review Guidelines for Medical Necessity of Hospital Outpatient Facility Specialty Medication Infusion April 1, 2015 March 2015

Skilled Care and Custodial Care Services April 1, 2015 March 2015

Sodium Hyaluronate April 1, 2015 March 2015

Surgical Treatment for Spine Pain April 1, 2015 March 2015

Temporomandibular Joint Disorders April 1, 2015 March 2015

Thermal Capsulorrhaphy/ Thermal Shrinkage Therapy April 1, 2015 March 2015

Wearable Cardioverter Defibrillators April 1, 2015 March 2015

REPLACED/RETIRED

Assistant Surgeon Policy June 1, 2015 March 2015April 2015

Transthoracic Echocardiography (for hawk-i only) April 1, 2015 April 2015

Wrong Surgical or Other Invasive Procedures Policy June 1, 2015 March 2015April 2015



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TABLE OF CONTENTS


new and/or revised policies

listed in the following table,

please refer to the monthly

Policy Update Bulletin at

OxfordHealth.com

> Providers > Tools &

Resources > Medical

Information > Medical and

Administrative Policies >

Policy Update Bulletin.


Policy Update Bulletin

NEW

Balloon Sinus Ostial Dilation Clinical Policy April 1, 2015 March 2015

Hysterectomy for Benign Conditions Clinical Policy April 1, 2015 March 2015

Off-Label/Unproven Specialty Drug Treatment Clinical Policy March 1, 2015 March 2015

UPDATED/REVISED

Abnormal Uterine Bleeding and Uterine Fibroids Clinical Policy April 1, 2015 March 2015

Abortions (Therapeutic and Elective) Administrative Policy March 1, 2015 March 2015

Assisted Administration of Clotting Factors and Coagulant Blood Products Clinical Policy March 1, 2015 March 2015

Attended Polysomnography for Evaluation of Sleep Disorders Clinical Policy April 1, 2015 March 2015

Blepharoplasty, Blepharoptosis and Brow Ptosis Repair Clinical Policy April 1, 2015 March 2015

Bone or Soft Tissues Healing and Fusion Enhancement Products Clinical Policy April 1, 2015 March 2015

Breast Imaging for Screening and Diagnosing Cancer Clinical Policy April 1, 2015 March 2015

Breast Reduction Surgery Clinical Policy April 1, 2015 March 2015

Complementary and Alternative Medicine (CAM) Contracted Rate Program

Administrative Policy April 1, 2015 March 2015

Continuous Glucose Monitoring and Insulin Delivery for Managing Diabetes Clinical Policy April 1, 2015 March 2015

DME, Orthotics, Ostomy Supplies, Medical Supplies, and Repairs/Replacements

Administrative Policy April 1, 2015 March 2015

Drug Coverage Criteria - New and Therapeutic Equivalent Medications Clinical Policy April 1, 2015 March 2015

Oxford® Medical and Administrative Policy Updates


https://www.oxhp.com/secure/policy/post_pin_comm_mar15.pdf


















TABLE OF CONTENTS



Drug Coverage Guidelines Clinical Policy April 1, 2015 March 2015

Elbow Replacement Surgery (Arthroplasty) Clinical Policy April 1, 2015 March 2015

Electrical and Ultrasound Bone Growth Stimulators Clinical Policy April 1, 2015 March 2015

Hip Replacement Surgery (Arthroplasty) Clinical Policy April 1, 2015 March 2015

Home Hemodialysis Clinical Policy April 1, 2015 March 2015

Immune Globulin Site of Care Review Guidelines for Medical Necessity of Hospital Outpatient Facility Infusion

Clinical Policy April 1, 2015 March 2015

Implanted Electrical Stimulator for Spinal Cord Clinical Policy April 1, 2015 March 2015

In-Network Exceptions for Breast Reconstruction Surgery Following Mastectomy

Administrative Policy May 1, 2015 March 2015

April 2015

Knee Replacement Surgery (Arthroplasty) Clinical Policy April 1, 2015 March 2015

Maximum Frequency Per Day Policy Reimbursement Policy April 1, 2015 March 2015

Observation Care Clinical Policy April 1, 2015 March 2015

Obstructive Sleep Apnea Treatment Clinical Policy April 1, 2015 March 2015

Omnibus Codes Clinical Policy April 1, 2015 March 2015

Orthognathic (Jaw) Surgery Clinical Policy April 1, 2015 March 2015

Orthopedic Services Clinical Policy April 1, 2015 March 2015

Oscillatory Positive Expiratory Pressure Devices Clinical Policy April 1, 2015 March 2015

Panniculectomy and Body Contouring Procedures Clinical Policy April 1, 2015 March 2015

Pneumatic Compression Devices Clinical Policy April 1, 2015 March 2015

Preventive Care Services Clinical Policy April 1, 2015 March 2015

Requests for In-Network Exceptions Administrative Policy May 1, 2015 March 2015

Rhinoplasty, Septoplasty and Repair of Vestibular Stenosis Clinical Policy April 1, 2015 March 2015

Rituxan (Rituximab) Clinical Policy April 1, 2015 March 2015

Shoulder Replacement Surgery (Arthroplasty) Clinical Policy April 1, 2015 March 2015

Site of Care Review Guidelines for Medical Necessity of Hospital Outpatient Facility Specialty Medication Infusion: Utilization Review Guideline

Clinical Policy April 1, 2015 March 2015











https://www.oxhp.com/secure/policy/post_pin_comm_apr15.pdf

















TABLE OF CONTENTS


TABLE OF CONTENTS

Network Bulletin: November 2013 - Volume 58 For more information call 877.842.3210, or visit UnitedHealthcareOnline.com4444 Network Bulletin: April 2015

Doc#: PCA16301_20150326



Skilled Care and Custodial Care Services Administrative Policy April 1, 2015 March 2015

Speech Therapy and Early Intervention Programs/Birth to Three

Administrative Policy March 1, 2015 March 2015

Surgical and Ablative Procedures for Venous Insufficiency and Varicose Veins Clinical Policy April 1, 2015 March 2015

Surgical Treatment For Spine Pain Clinical Policy April 1, 2015 March 2015

Temporomandibular Joint Disorders Clinical Policy April 1, 2015 March 2015

Transportation Services Administrative Policy March 1, 2015 March 2015

Vision Services Administrative Policy April 1, 2015 March 2015

Wearable Cardioverter-Defibrillators Clinical Policy April 1, 2015 March 2015

RETIRED

Interim New Product Coverage Criteria Clinical Policy March 1, 2015 March 2015


Note: The appearance of a service or procedure on this list does not imply that Oxford provides coverage for the service or procedure. In the event of an inconsistency between the information provided in this bulletin and the posted policy, the posted policy will 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.

Insurance coverage provided by UnitedHealthcare Insurance Company or its affiliates. Health plan coverage provided by UnitedHealthcare of Arizona, Inc., UnitedHealthcare of California, UnitedHealthcare of Colorado, Inc., UnitedHealthcare of Oregon, Inc., UnitedHealthcare of Utah, Inc. and UnitedHealthcare of Washington, Inc. or other affiliates. Administrative services provided by UnitedHealthcare Services, Inc. or its affiliates.











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