Ancillary Services - Oxford Health Plans · 2007. 4. 24. · 100 Section 6 — Ancillary Services Hospital Laboratories Barnert Hospital Laboratory services 973-977-6647 Connecticut

6Ancillary Services

Laboratory . . . . . . . . . . . . . . . . . . . . . . . . . . . .99

Radiology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .103

Physical and Occupational Therapy . . . . . . .122

Acupuncture Guidelines . . . . . . . . . . . . . . . .125

Pharmacy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .125

98 www.oxfordhealth.com

Section 6 — Ancillary Services

www.oxfordhealth.com 99

Ancillary Services — Section 6

Laboratory

Through Oxford’s laboratory network, we intend to provide you access to the tests you need to treatyour patients, to reasonably control the increasingcost of medical care, and to limit your patients’unnecessary out-of-pocket costs. Oxford’s outpatientlaboratory network is comprised of:

• Full-service labs

• Niche labs (i.e., esoteric/specialty labs)

• Hospital labs (not all participating hospitals have participating outpatient laboratories)

Outpatient Laboratory Policies and Procedures• Effective January 1, 2007, all outpatient laboratory

specimens must be sent to one of the contractedlaboratories through Laboratory Corporation ofAmerica and listed below. A complete listing isalso on our web site at www.oxfordhealth.com

• A referral is not required for lab specimens sent to participating laboratories (only a physician’sprescription or lab order form is required)

• Oxford reviews laboratory ordering information on a periodic basis in an effort to support full useof Oxford’s contracted laboratory network; if ourdata shows a pattern of out-of-network utilizationfor your practice, we will contact you to share this information and engage you to utilize thecontracted network

Full Service Laboratories

American Clinical Services 1-800-910-5227

Bayside Diagnostics Laboratory 718-886-8500

BioReference Laboratories, Inc. 201-421-2300

Clinical Laboratory Management 908-810-1113

Clinical Laboratory Partners 1-800-286-9800

Collaborative Laboratory Services 860-714-6103

Enzo Clinical Labs 631-755-5500 or 1-800-522-5052

GJL Medical Labs 516-326-0700 or 1-800-924-1650

Laboratory Corporation of America Patient service center locator number for Members 1-888-Lab-Corp

North New Jersey 1-800-223-0631

South New Jersey 1-800-633-5221

New York 1-800-223-0631

Connecticut 1-800-631-5250

Quentin Medical Laboratory, Inc. 718-492-2600

Sunrise Medical Laboratories 1-800-782-0282

Shiel Medical Laboratory, Inc. 718-552-1000 or 1-800-553-0873

Specialty Laboratories

Ackerman Academy of Dermatopathology* 212-889-6225 or 1-800-553-6621

Acu-Path Laboratories, Inc. 1-888-228-7284

AmeriPath Esoteric Institute 866-436-9631

Ameripath 1-800-388-3995

DermPath 1-800-942-3376

Dianon 1-800-328-2666

Dermatology/Urology/Gastroenterology

Genzyme Genetics 1-800-848-4436

GI Diagnostics 203-447-8605

Home Healthcare Laboratory of America 1-888-522-4452/1-888-LAB-HHLA

Horizon Molecular Medicine 1-888-448-1495

Esoterix, Inc. 1-800-444-9111

Endocrinology

Institute for Dermatopathology, PC. 610-260-0555

Medical Diagnostics Laboratories, LLC 1-877-269-0090

Infectious Disease

Myriad Genetics, Inc. 1-800-469-7423

Genetic Testing, BRACA

Pathology Associates 1-800-388-3995

US Labs 1-888-450-0145

* Provides anatomic pathology services



Hospital Laboratories

Barnert HospitalLaboratory services 973-977-6647

Connecticut Hospital Laboratory Network, LLC 860-423-1584

Continuum Health Partners, Inc.Beth Israel Medical Center Pathology and Laboratory Medicine 1-800-420-LABS

Long Island Medical College Pathology and Laboratory Medicine 1-800-420-LABS

St. Luke’s-Roosevelt Hospital Pathology and Laboratory Medicine 1-800-420-LABS

Hackensack University Medical CenterTotalab 1-877-868-2522

Client services 201-996-4881

Mount Sinai Medical Center Mount Sinai Hospital of New York 212-241-4675

Mount Sinai Hospital of Queens 212-241-4675

Mount Sinai Hospital Clinic 212-241-4675

Mount Sinai Center for Clinical Laboratories 212-241-4675

Mount Sinai Pathology Associates 212-241-3985

Mount Sinai Pathology Consultants 212-241-8014

Mount Sinai Medical Center, Department of Dermatopathology 212-241-6064

New York University Medical Center NYU Medical Center Laboratories 212-263-7313

NYU Pathology Associates 212-263-5475

NYU Dermatopathology Associates 212-263-7250

New York Presbyterian Healthcare System New York Presbyterian Hospital:

New York Weill Center/New York Hospital Laboratories 212-746-0670

Columbia Presbyterian Center/Clinical Lab Services 212-305-2155

Columbia Presbyterian Pathologists 1-800-653-8200/

212-305-4840

The Brooklyn Hospital Center, Department of Pathology 718-250-8000

Laboratory of Dermatopathology, Department of DermatopathologyCollege of Physicians and Surgeons of Columbia University 212-305-2155

New York Community Hospital of Brooklyn, Department of Pathology and Lab Medicine 718-692-5371

New York Methodist Hospital — Outpatient Laboratory 718-780-3645

New York Westchester Square Medical Center Laboratory 718-430-7345

NYHQ/Charter Diagnostics Laboratory 718-670-2575

New York Presbyterian Hospital —Payne 914-682-9100Whitney Westchester

North Shore-Long Island Jewish (LIJ)Health System Client Services:

Nassau and Suffolk counties 516-719-1000

Brooklyn and Richmond counties 718-226-5227

Participating hospitals in the North Shore System-LIJ include:

North Shore University Hospital Manhasset

North Shore Hospital System Central Laboratories

Long Island Jewish Medical Center

Schneider Children’s Hospital Laboratory

Staten Island University Hospital



In-office Laboratory Testing ListThe In-office Laboratory Testing List includes codesfor laboratory procedures reimbursed to physicianswhen performed in their offices. All other laboratoryprocedures must be performed by one of theparticipating laboratories in Oxford’s network.

Please note: This list is subject to change, for an up-to-date list log on to our website at www.oxfordhealth.com.

Primary Care Physicians and Specialists

*81000 Urinalysis with microscopy

*81002 Urinalysis non-automated, without microscopy

*81003 Urinalysis automated, without microscopy

81025 Urine pregnancy test by visual color comparison methods

****82270 Blood, occult by peroxidase activity (e.g., guaiac), qualitative;other sources

****82272 Blood, occult by peroxidase activity(e.g., guaiac), qualitative, feces, single specimen (e.g., from digitalrectal exam)

82948 Glucose blood, reagent strip

82962 Glucose blood sugar by glucometer

83014 Helicobacter pylori, breath testanalysis; drug administration andsample collection (Note: Dianonprovides test kit free of charge —call 1-800-328-2666.)

83026 Hemoglobin by copper sulfatemethod, non-automated

***85013 Spun microhematocrit

***85018 Blood count hemoglobin

85651 Sedimentation rate erythrocyte; non-automated

****86403 Particle agglutination screen, each antibody

86485-86586 Skin tests; various

**87070 Culture, bacterial; any other sourcebut urine, blood or stool, withisolation and presumptiveidentification of isolates

**87081 Culture, bacterial; screening only for single organisms

87177 Ova and parasites, direct smears,concentration and identification

87210 Smear wet mount with simple stain, for bacteria, fungi, ova, and/or parasites

87220 Tissue examination for fungi (e.g., KOH slide)

****87880 Infectious agent detection byimmunoassay — streptococcusgroup A

89100 Duodenal intubation and aspirationsingle specimen plus appropriate test

89105 Duodenal intubation and aspiration;collection of multiple fractionalspecimens with pancreatic orgallbladder stimulation, single or double lumen tube

89130-89141 Gastric intubation and aspiration; various

89350 Sputum, obtaining specimen,aerosol-induced technique

99195 Phlebotomy, therapeutic (separate procedure)



For STAT Purposes Only, claim must be marked STAT

***85025 Hemogram and platelet count,automated and automated completedifferential WBC count (CBC)

*,**,***,**** Reimbursement is limited to one procedure (within the relatedfamily of codes) per visit.

Pediatricians Only

82247 Bilirubin, Total

Pulmonologist Only

82803 Gases, blood, any combination ofpH, pCO2, pO2, CO2, HCO3(including calculated O2 saturation)

Obstetricians, Gynecologists, ReproductiveEndocrinologists, and Infertility Specialists Only

82670 Estradiol

83001 Gonadotropin follicle stimulatinghormone (FSH)

83002 Gonadotropin luteinizing hormone (LH)

84144 Progesterone

84702 Gonadotropin chorionic (hCG);quantitative

+89250 Culture and fertilization of oocyte(s)

+89251 Culture and fertilization of oocyte(s)with co-culture of embryos

+89253 Assisted embryo hatching,microtechniques (any method)

+89254 Oocyte identification from follicular fluid

+89255 Preparation of embryo for transfer(any method)

+89257 Sperm identification from aspiration(other than seminal fluid)

+89260 Sperm isolation; simple prep (e.g., sperm wash, swim-up) for insemination or diagnosisw/semen analysis

+89261 Sperm isolation complex prep (e.g., Percoll gradient, albumingradient) for insemination ordiagnosis with semen analysis

+89300 Semen analysis presence and/ormotility of sperm including Huhner test (post coital)

89310 Semen analysis motility and count

89320 Semen analysis complete (volume,count, motility, and differential)

89321 Semen analysis presence and/ormotility of sperm

+89325 Sperm antibodies

+89329 Sperm evaluation hamsterpenetration test

+89330 Sperm evaluation cervical mucuspenetration test, with or withoutspinnbarkeit test

+ Member must have the infertility benefit.

Rheumatologists

89060 Crystal identification by lightmicroscopy with or withoutpolarizing lens analysis, and body fluid (except urine)

Reproductive Endocrinologists and InfertilitySpecialists Only

89268 Insemination of oocytes

89272 Extended culture of oocyte(s)/embryo(s), 4-7 days

89280 Assisted oocyte fertilization,microtechnique; less than or equal to 10 oocytes

89281 Assisted oocyte fertilization,microtechnique; greater than 10 oocytes

89290 Biopsy oocyte polar body or embryo blastomere, microtechnique(for pre-implantation geneticdiagnosis); less than or equal to 5 embryos



89291 Biopsy oocyte polar body or embryo blastomere, microtechnique(for pre-implantation geneticdiagnosis); greater than 5 embryos

89352 Thawing of cryopreserved; embryo(s)

Hematologists, Oncologists and Pediatric Hematologists

85007 BL Smear w/diff WBC count

***85025 Hemogram and platelet count,automated and automated completedifferential WBC count (CBC)

***85027 Complete WBC, automated

85097 Bone marrow smear interpretationonly, with or without differentialcell count

86077 Blood bank physician services;difficult cross-match and/orevaluation of irregular antibody(s),interpretation and written report

86078 Blood bank physician services;investigation of transfusion reaction, including suspicion oftransmissible disease, interpretationand written report

86079 Blood bank physician services;authorization for deviation fromstandard blood-banking procedures,with written report

86927-86999 Transfusion medicine

*** Reimbursement is limited to one procedure (within the related family of codes) per visit.

Urologists Only

89300 Semen analysis presence and/ormotility of sperm including Huhner test (post coital)

89310 Semen analysis motility and count

89320 Semen analysis complete (volume,count, motility and differential)

89321 Semen analysis presence and/ormotility of sperm

Radiology

CareCore National Management Services, LLC, a physician-owned radiology network comprised of leading board certified radiologists, is Oxford’snetwork manager for all outpatient commercial and Medicare imaging services. Please be aware that inpatient, ambulatory surgery, emergency room radiology services, radiation therapy,radionuclide therapy, ophthalmic ultrasound, and any delegated physician arrangement are not included in this arrangement. Oxford haseliminated the need to submit referrals foroutpatient radiology procedures performed byparticipating radiologists or radiology facilities.



Privileging by SpecialtyOxford’s privileging program is designed to improve the quality of imaging services by limiting coverage to services provided in the most appropriate setting. Below is a list of imaging CPT codes for services that physicians, other than radiologists, can perform in their office.

Please note: The privileging program applies to office and outpatient (non-ambulatory surgery) procedures.

Privileging List* These following procedures require precertification; call 1-877-PREAUTH.

*** Any studies beyond three (3) require precertification; call 1-877-PREAUTH.

Physician Type CPT Codes Description

Primary Care Physicians: 71010-71030 Chest imagingInternal Med., Family Practice 76075, 76076, 0028T DEXA studies, bone densitometry

General Surgeons: 76942 Ultrasonic guidance for needle biopsyAIUM-accredited

Cardiologists 71010-71030 Chest imaging

78464*, 78465*, 78469* Tomographic SPECT studies

78472*, 78473*, 78494* Cardiac blood pool imaging

78478 Wall motion study

78480 Ejection fraction study

Cardiologists: CBNC, ABNM or ABR 78464*, 78465*, 78469* Tomographic SPECT studiescertified cardiologists and ICANL or

78472*, 78473*, 78494* Cardiac blood pool imagingACR accredited cardiology labs only

78478 Wall motion study

78480 Ejection fraction study

Cardiologists — Pediatric only 76825, 76826, 76827, 76828 Echocardiography, fetal

76376*, 76377* 3D interpretation/reporting

Chiropractors 72010, 72040, 72069, 72070, Spine imaging72080, 72100

Endocrinologists 76075, 76076 DEXA studies, bone densitometry

76942, 0028T Ultrasonic guidance for needle biopsy

76536 (AACE Accredited Thyroid ultrasoundEndocrinologists only)

Gastroenterologists 76975* Endoscopic ultrasound



Privileging List (continued)


General Surgeons, Vascular Surgeons, 75940 Percutaneous placement of Cardiovascular Surgeons IVC filter, radiological supervision

and interpretation

75952 Endovascular repair of infrarenalabdominal aortic aneurysm

75953 Placement of proximal or distalextensionprosthesis for endovascular repair

93303-93308, 93320-93325 Transthoracic echocardiography(performed every 12 months)

Hand Surgeons 76000, 73000-73140 Fluoroscopy

Maternal Fetal Medicine/Neonatal 76083 Digitization of radiographic imagesPerinatal Medicine

76092 Screening mammography

76801***-76828*** Ultrasounds — pelvis

76830-76857 Ultrasounds — pelvis

76930, 76941, 76942 Ultrasounds — pelvis, non-obstetrical76945, 76946, 76948

76075, 76076, 0028T DEXA studies, bone densitometry

OB/GYNS 76083 Digitization of radiographic images


76815***, 76816***, Ultrasounds — pelvis

76817*** Ultrasounds — pelvis

76830, 76831, 76856, 76857, Ultrasonic guidance

76930, 76941, 76945, 76946 Ultrasonic guidance


OB/GYNS (AIUM/ACR Accredited) 76801***, 76802***, Ultrasounds — pelvis




76820*** Doppler velocimetry

Oral Surgeons 70100, 70110, 70140, 70150 Mandible and facial bone imaging

70300, 70310, 70320 Teeth imaging

70328, 70330 TMJ imaging

70350 Cephalogram, orthodontic

70355 Orthopantogram





Orthopedists/Orthopedic Surgeons 71100-71111 Radiologic examination, ribs

71120-71130 Radiologic examination, sternum

72010-72120, 72170, 72190, Spine and pelvis imaging

72200-72220 Spine and pelvis imaging

73000-73140, 73500-73660 Imaging — upper and lower extremities

76000, 76003, 76005 Fluoroscopies

76006 Radiologic examination, any joint

76040 Bone length studies

76066 Joint survey

Pain Management Specialists: 76000, 76003, 76005, 72275 FluoroscopyPhysical Rehabilitation Medicine,Anesthesiologists, Neurologists, and Neurosurgeons

Pediatricians 71010-71030 Chest imaging


Perinatologists-Neonatologists 76092 Screening mammography








76830-76857 Ultrasounds — pelvis

76930, 76945, 76946, 76941 Ultrasonic guidance

76942 Ultrasound — pelvis, non-obstetrical

76948 Ultrasonic guidance for aspiration of ova

76075, 76076 DEXA studies, bone densitometry





Podiatrists 73620, 73630, 73650, 73660 Lower extremity imaging

Pulmonologists 71010-71030 Chest imaging

Radiation Oncologists 76950 Ultrasonic guidance for placement of radiation therapy fields

76965 Ultrasonic guidance for interstitialradioelement application

76360, 76370* Computerized tomography guidance

76873 Determinate of prostate volume for brachytherapy

Reproductive Endocrinologists 76083 Digitization of radiographic images


76801, 76802, G0202 Ultrasound, pelvis

76815-76819 Ultrasound, pelvis

76830, 76856, 76857 Ultrasound, non-obstetrical

76930, 76941 Ultrasonic guidance76945, 76946

76948 Ultrasonic guidance for aspiration of ova, imaging supervision and interpretation

76075, 76076, 0028T Bone densitometry

Rheumatologists 72010-72120, 72170, 72190, Spine and pelvis imaging

72200-72220 Spine and pelvis imaging

73000-73140, 73500-73660 Imaging — upper and lower extremities

76000, 76003 Fluoroscopies

76040, 76066 Bone length studies, joint survey


Urologists 76870, 76872, 76873 Ultrasounds — echography, genitalia, bladder

76942 Ultrasonic guidance for needle biopsy



Imaging RequiringPrecertificationIt is the responsibility of the referring physician,who has access to the patient’s complete medicalhistory, to contact CareCore National ManagementServices, LLC to request precertification and toprovide sufficient history to demonstrate theappropriateness of the requested.

Radiology Precertification Policy for Urgent Cases

It is the imaging facility’s responsibility to confirmthat an authorization number has been issued prior to providing a service. In the case of urgentexaminations, in which there is no time to obtainan authorization number and in cases in which, inthe opinion of the attending physician, a change isrequired from the precertified examination, and the CareCore offices are unavailable, the servicesmay be performed, and you may request a new ormodified authorization number. Requests must bemade within two (2) business days of the date ofservice through the Imaging Care ManagementDepartment in the usual manner by calling or faxingyour request. If the CareCore offices are available,the request should be made immediately. Clinicaljustification for the request will be reviewed usingthe same criteria as a routine request.

Radiology Precertification Online

CareCore now provides a secure web-based process to initiate clinical certification for diagnostic imagingrequests. Log on to www.carecorenational.comand the automated system will guide you through aseries of computer screen prompts to collect routinedemographic data. Each web-initiated request isevaluated promptly by CareCore clinical review staff.A short return call to you from CareCore completesthe certification process.

This eliminates the need for a call to CareCore andallows you to enter multiple clinical certificationrequests at your convenience.

Radiology Utilization Review Process

The utilization review process involves matchingthe patient clinical history and diagnosticinformation with the approved criteria for eachimaging procedure requested. Utilization reviewdecisions are made by qualified health professionalsincluding board certified radiologists. Datacollection for clinical certification of imagingservices may be assigned to non-medical personnelworking under the direction of qualified healthprofessionals. You will receive notification of review determinations for non-urgent care bytelephone within two (2) working days of receivingall the necessary information. Notification for a determination involving an urgent request is given within three (3) hours.

For non-urgent care requests for Medicare Members,a determination must be issued within 14 calendardays of the request for service. For commercialMembers, requests for retrospective clinicalcertification review of medically urgent care areaccepted up to two (2) business days after the care has been given, if the services are performedoutside CareCore’s hours of operation. Retrospectivereview decisions are made within 30 businessdays of receiving all of the necessary information. If your request is not authorized, the reviewdetermination will be sent in writing to the Member and the requesting physician within five (5) business days of the decision.



Below is a list of imaging CPT codes that require authorization for commercial and Medicare Members.

Please note: Oxford will inform you of any new procedures or other changes to this list on the Oxford web page and in our quarterlyProvider Program and Policy Update.

To precertify a procedure, you can call CareCore National Management Services, LLC at 1-877-PREAUTH (1-877-773-2884), fax to 845-298-1490 or log on towww.carecorenational.com.

When you call or fax a request to the RadiologyPrecertification unit, please provide the following information:

Patient Identifiers:

• Health plan name

• Last six (6) characters of the patient Oxford ID number

• Patient date of birth

• 10-digit patient phone number

• Patient name

Medical Identifiers:

• Last four (4) characters of the ordering provider’s Oxford ID

• First three letters of the ordering provider’s last name

• Ordering provider’s office number

• Ordering provider’s fax number

Clinical Information:

• Examination(s) being requested, with CPT codes if available

• Presumptive diagnosis or “rule out,” with ICD-9 codes if available

• Patient’s signs and symptoms, listed in somedetail, with severity and duration

• Any treatments that have been tried, includingdosage and duration for drugs and dates for other therapies

• Any other information that you believe will help in evaluating the request, including priordiagnostic tests, consultation reports, etc.

All authorization reference numbers are issued at the time of approval. CareCore National uses the reference CPT code as the last five (5) digits of the authorization number.

Oxford requires the submission of clinical officenotes for specific procedures. Clinical notes includethe patient’s medical record and/or letters receivedfrom specialists that indicate:

• Patient symptoms, with duration and severity

• Patient medical history

• Previous imaging studies and findings

• Prior treatment and/or therapy, including surgery,with history

• Drug dosage prescribed and duration

Please note: Radiopharmaceuticals in excess of $50.00 will be reimbursed. Submission of an invoice detailing the cost and name of the administered material is still required.

If you choose to fax your authorization request,please include all of the information mentionedabove, including the request form, to CareCore at 845-298-1490.



CT Scans

All CT units must be ACR accredited.

** Study requires the submission of clinical notes to CareCore.

Please note: The information below is not to supersede any exceptions set forth by Oxford Health Plans.

CPT Code Clinical Notes Required Description

70450 CT Head/Brain w/o Contrast

70460 CT Head/Brain w/Contrast

70470 CT Head/Brain w/o and w/Contrast

70480 CT Orbit w/o Contrast

70481 CT Orbit w/Contrast

70482 CT Orbit w/o and w/Contrast

70486 CT Maxllfcl w/o Contrast

70487 CT Maxllfcl w/Contrast

70488 CT Maxllfcl w/o and w/Contrast

70490 CT Soft Tissue w/o Contrast

70491 CT Soft Tissue w/Contrast

70492 CT Soft Tissue w/o and w/Contrast

70496 CT Angiography, Head

70498 CT Angiography, Neck

71250 CT Thorax w/o Contrast

71260 CT Thorax w/Contrast

71270 CT Thorax w/o and w/Contrast

71275 CT Angiography Chest

72125 CT C Spine w/o Contrast

72126 CT C Spine w/Contrast

72127 CT C Spine w/o and w/Contrast

72128 CT T Spine w/o Contrast

72129 CT T Spine w/Contrast



CT Scans (continued)


72130 CT T Spine w/o and w/Contrast

**72131 Yes CT L Spine w/o Contrast

**72132 Yes CT L Spine w/Contrast

**72133 Yes CT L Spine w/o and w/Contrast

72191 CT Angiography Pelvis

72192 CT Pelvis w/o Contrast

72193 CT Pelvis w/Contrast

72194 CT Pelvis w/o and w/Contrast

73200 CT Upper Extremity w/o Contrast

73201 CT Upper Extremity w/Contrast

73202 CT Upper Extremity w/o and w/Contrast

73206 CT Angiography Upper Extremity

73700 CT Lower Extremity w/o Contrast

73701 CT Lower Extremity w/Contrast

73702 CT Lower Extremity w/o and w/Contrast

73706 CT Angiography Lower Extremity

74150 CT Abdomen w/o Contrast

74160 CT Abdomen w/Contrast

74170 CT Abdomen w/o and w/Contrast

74175 CT Angiography Abdomen

75635 CT Angiography Abdominal Aorta

76013 X-ray Supervision and Interpretation, PercutaneousVertebralplasty Per Vertebral Body under CT Guidance

76362 CT Guidance for and Monitoring of Tissue Ablation

76380 CT Limited or Localized Follow-up Study

76497 Unlisted CT Procedure

0150T Cardiac Structure and Morphology in Congenital Heart Disease



MRI Procedures

All MRI units must be ACR accredited.

Please note: The information below is not to supersede any exceptions set forth by Oxford Health Plans.


70336 MRI TMJ

70540 MRI Face, Orbit, Neck w/o Contrast

70542 MRI Face, Orbit, Neck w/Contrast

70543 MRI Face, Orbit, Neck w/and w/o Contrast

70551 MRI Head w/o Contrast

**70552 Yes MRI Head w/Contrast

**70553 Yes MRI Head w/and w/o Contrast

71550 MRI Chest w/o Contrast

71551 MRI Chest w/Contrast

71552 MRI Chest w/and w/o Contrast

**72141 Yes MRI Cervical Spine w/o Contrast

**72142 Yes MRI Cervical Spine w/Contrast

**72146 Yes MRI Thoracic Spine w/o Contrast

**72147 Yes MRI Thoracic Spine w/Contrast

**72148 Yes MRI Lumbar Spine w/o Contrast

**72149 Yes MRI Lumbar Spine w/Contrast

**72156 Yes MRI C Spine w/and w/o Contrast

**72157 Yes MRI T Spine w/and w/o Contrast

**72158 Yes MRI L Spine w/and w/o Contrast

72195 MRI Pelvis w/o Contrast

72196 MRI Pelvis w/Contrast

72197 MRI Pelvis w/and w/o Contrast

**73218 Yes MRI Upper Extremity other than Joint w/o Contrast

**73219 Yes MRI Upper Extremity other than Joint w/Contrast

**73220 Yes MRI Upper Extremity other than Joint w/and w/o Contrast

**73221 Yes MRI Upper Extremity Joint w/o Contrast

**73222 Yes MRI Upper Extremity Joint w/Contrast



MRI Procedures (continued)


**73223 Yes MRI Upper Extremity Joint w/ and w/o Contrast

**73718 Yes MRI Lower Extremity other than Joint w/o Contrast

**73719 Yes MRI Lower Extremity other than Joint w/Contrast

**73720 Yes MRI Lower Extremity other than Joint w/and w/o Contrast

**73721 Yes MRI Lower Extremity Joint w/o Contrast

**73722 Yes MRI Lower Extremity Joint w/Contrast

**73723 Yes MRI Lower Extremity Joint w/and w/o Contrast

74181 MRI Abdomen w/o Contrast

74182 MRI Abdomen w/Contrast

74183 MRI Abdomen w/and w/o Contrast

75552 Cardiac MRI for Morphology w/o Contrast (Gated Heart)

75553 Cardiac MRI Morphology w/Contrast

75554 Cardiac MRI Complete w/or w/o Morphology

75555 Cardiac MRI Limited

75556 Cardiac MRI Velocity Flow

**76093 MRI Breast w/and/or w/o Contrast

**76094 MRI Breast Bilateral

76376 3D Rendering with Interpretation and Reporting of Computed Tomography, Magnetic Resonance Imaging, Ultrasound, or Other Tomographic Modality; Not Requiring Image Postprocessing on an Independent Workstation

76377 3D Rendering with Interpretation and Reporting ofComputed Tomography, Magnetic Resonance Imaging,Ultrasound, or Other Tomographic Modality; RequiringImage Postprocessing on an Independent Workstation

76390 MRI Spectroscopy

76393 MRI Guidance for Placement Radiological Supervisionand Interpretation

76394 MRI Guidance for and Monitoring of Tissue Ablation

76400 MRI Bone Marrow Blood Supply

76499 Unlisted Procedure



MRA Procedures

CPT Code Description

70544 MRA Head w/o Contrast

70545 MRA Head w/Contrast

70546 MRA Head w/and w/o Contrast

70547 MRA Neck w/o Contrast

70548 MRA Neck w/Contrast

70549 MRA Neck w/and w/o Contrast

71555 MRA Chest (Exc. Myocardium) w/or w/o Contrast

72159 MRA Spinal Canal w/or w/o Contrast

72198 MRA Pelvis w/or w/o Contrast

73225 MRA Upper Extremity w/or w/o Contrast

73725 MRA Lower Extremity w/or w/o Contrast

74185 MRA Abdomen w/or w/o Contrast

PET Scans

All PET units must be ACR accredited.

** Study requires the submission of clinical notes to CareCore.

Please note: Clinical notes are required for all PET scans.


**78459 Yes Myocardial Imaging, Positron Emission Tomography(PET) Metabolic Evaluation

**78491 Yes Myocardial Imaging, Positron Emission Tomography(PET), Perfusion; Single Study at Rest or Stress

**78492 Yes Myocardial Imaging, Positron Emission Tomography(PET), Perfusion; Multiple Studies at Rest or Stress

**78608 Yes Brain Imaging, Positron Emission Tomography (PET)Metabolic Evaluation

**78609 Yes Brain Imaging, Positron Emission Tomography (PET)Metabolic Evaluation, Perfusion Evaluation

**78811 Yes Tumor Imaging, Positron Emission Tomography (PET);Limited Area (e.g., Chest, Head/Neck)

**78812 Yes Tumor Imaging, Positron Emission Tomography (PET);Skull Base to Mid-thigh



PET Scans (continued)


**78813 Yes Tumor Imaging, Positron Emission Tomography (PET);Whole Body

**78814 Yes Tumor Imaging, Positron Emission Tomography (PET)with Concurrently Acquired Computer Tomography (CT)for Attenuation Correction and Anatomical Localization;Limited Area (e.g., Chest, Head/Neck)

**78815 Yes Tumor Imaging, Positron Emission Tomography (PET)with Concurrently Acquired Computer Tomography (CT)for Attenuation Correction and Anatomical Localization;Skull Base to Mid-thigh

**78816 Yes Tumor Imaging, Positron Emission Tomography (PET)with Concurrently Acquired Computer Tomography (CT)for Attenuation Correction and Anatomical Localization;Whole Body

**G0252 Yes PET, Full and Partial Ring PET Scanners Only for InitialDiagnosis of Breast Cancer and/or Surgical Planning forBreast Cancer

Nuclear Medicine

Please note: All nuclear cardiology providers interpreting nuclear cardiology examinations arerequired to meet one of the following standards in order to receive reimbursement for nuclearcardiology claims:

• Certification by the Certification Board for Nuclear Cardiology (CBNC)1

• Board certification in nuclear medicine by the American Board of Nuclear Medicine (ABNM)

• Board certification in radiology by the American Board of Radiology (ABR)

1 Nuclear cardiology facilities must be accredited by either the Intersocietal Commission for the Accreditation of Nuclear Laboratories (ICANL) or the American College of Radiology (ACR) in order to receive reimbursement for nuclear cardiology claims.


78000 Thyroid RAI Uptake

78001 Thyroid, Multiple Uptakes

78003 Thyroid Suppress or Stimulation

78006 Thyroid Uptake and Scan

78007 Thyroid, Image, Multiple Uptakes

78010 Thyroid Scan Only

78011 Thyroid Imaging with Flow

78015 Thyroid Met Imaging

78016 Thyroid Met Imaging with Additional Studies



Nuclear Medicine (continued)


78018 Thyroid Scan Whole Body

78020 Thyroid Carcinoma Metastases Uptake

78070 Parathyroid Nuclear Imaging

78075 Adrenal Nuclear Imaging

78099 Unlisted Endocrine Procedure, Diagnostic Nuclear Medicine

78102 Bone Marrow Imaging, Limited

78103 Bone Marrow Imaging, Multiple

78104 Bone Marrow Imaging, Whole Body

78110 Plasma Volume, Single

78111 Plasma Volume, Multiple Sampling

78120 Red Cell Volume Determination, Single Sampling

78121 Red Cell Volume Determination, Multiple Sampling

78122 Whole Blood Volume Determination, SEP Plasma and Red Cell

78130 Red Cell Survival Study

78135 Differential Organ/Tissues Kinetic

78140 Labeled Red Cell Sequestration

78185 Spleen Imaging w and w/o VAS Flow

78190 Platelet Survival, Kinetics

78191 Platelet Survival

78195 Lymph System Imaging

78199 Unlisted Hematopoietic Diagnostic Nuclear Med

78201 Liver Imaging

78202 Liver Imaging with Flow

78205 Liver Imaging SPECT (3-D)

78206 Liver Imaging SPECT w/Vascular Flow

78215 Liver and Spleen Imaging

78216 Liver and Spleen Imaging with Flow

78220 Liver Function Study





78223 HIDA Scan

78230 Salivary Gland Imaging

78231 Serial Salivary Gland

78232 Salivary Gland Function Exam

78258 Esophageal Motility Study

78261 Gastric Mucosa Imaging

78262 Gastroesophageal Reflux Exam

78264 Gastric Emptying Study

78270 VIT-B12 Absorption Exam

78271 VIT-B12 Absorption Exam, lF

78272 VIT-B12 Absorption Exam Combined

78278 GI Bleeder Scan

78282 GI Protein Loss Exam

78290 Meckel’s Diverticulum Imaging

78291 Leveen Shunt Patency Exam

78299 Unlisted Gastrointestinal Procedure

78399 Unlisted Musculoskeletal Procedure

78300 Bone or Joint Imaging LTD

78305 Bone or Joint Imaging Multiple

78306 Bone Scan Whole Body

78315 Bone Scan 3-phase Study

78320 Bone Joint Imaging Tomo Test

78414 Non-imaging Heart Function

78428 Cardiac Shunt Imaging

78445 Radionuclide Venogram Non-cardiac

78455 Venous Thrombosis Study

78456 Acute Venous Thrombosis Imaging

78457 Venous Thrombosis Imaging Unilateral

78458 Venous Thrombosis Images, Bilateral





78460 Thallium Scan Rest Only

78461 Myocardial Perf Stress or Rest Multiple Study

78464 Heart Image (3-D) Single

78465 Myocardial Perf w/SPECT Multiple

78466 Myocardial Infarction Scan

78468 Heart Infarct Image EF

78469 Heart Infarct Image 3-D

78472 Gated Heart, Resting

78473 Cardiac Blood Pool Muga Scan

78481 Heart First Pass Single

78483 Cardiac Blood Pool Imaging — Multiple

78494 Cardiac Blood Pool Imaging, SPECT

78496 Cardiac Blood Pool Imaging — Single Study at Rest (Use with 78472)

78499 Unlisted Cardiovascular Nuclear Exam

78580 Pulmonary Perfusion Imaging

78584 Pulmonary Perfusion with Vent Single Breath

78585 Pulmonary Perfusion w/Washout, w/or w/o Single Breath

78586 Pulmonary Ventilation Imaging

78587 Pulmonary Ventilation Multi

78588 Pulmonary Perfusion w/Ventilation

78591 Vent Image 1 Breath, 1 Projection

78593 Vent Image 1 Projection, Gas

78594 Vent Image Multi Projection, Gas

78596 Lung Differential Function

78599 Unlisted Respiratory Nuclear Exam

78600 Brain Imaging LTD Static

78601 Brain LTD Imaging and Flow

78605 Brain Imaging Complete





78606 Brain Imaging Complete with Flow

78607 Brain Imaging 3-D

78610 Brain Flow Imaging Only

78615 Cerebral Blood Flow Imaging

78630 Cisternogram (Cerebrospinal Fluid Flow)

78635 Cerebrospinal Ventriculography

78645 CSF Shunt Evaluation

78647 Cerebrospinal Fluid Scan

78650 CSF Leakage Detection and Localization

78660 Radiopharmaceutical Dacryocystography

78699 Unlisted Diagnostic Nuclear Med Procedure

78700 Kidney Imaging (Static)

78701 Kidney Imaging w/Vascular Flow

78704 Kidney Imaging w/Function Study

78707 Kidney Imaging w/Vascular Flow and Functional Single Study

78708 Kidney Imaging Single Study w/Pharm. Intervention

78709 Kidney Imaging — Multiple Studies w/ and w/o Pharm. Intervention

78710 Kidney Imaging — Tomographic (SPECT)

78715 Kidney Vascular Flow Only

78725 Kidney Function Study — Non-imaging Radioisotopic

78730 Urinary Bladder Residual Study

78740 Ureteral Reflux Study

78760 Testicular Imaging

78761 Testicular Imaging w/Vascular Flow

78799 Unlisted Genitourinary Procedure

78800 Radiopharm Localization of Tumor, Limited Area

78801 Radiopharm Localization of Tumor, Multiple Areas

78802 Radiopharm Localization of Tumor, Whole Body





78803 Radiopharm Localization of Tumor Tomographic (SPECT)

78804 Radiopharm Localization of Tumor or Distribution of Radiopharm Agents’Whole Body

78805 Radiopharm Localization of Abscess, Limited Area

78806 Radiopharm Localization of Abscess, Whole Body

78807 Radiopharm Localization of Abscess, Tomographic SPECT

78999 Unlisted Misc. Procedure

79299 Unlisted Gastrointestinal Procedure

Obstetrical Ultrasounds

Authorization required for fourth and subsequent procedures.

Please note: OB/GYNs must have AIUM or ACR accreditation in order to be reimbursed for CPT codes 76801, 76802, 76805, 76810, 76811, 76812, 76818, 76819, 76820, 76821, 76825, 76826,76827, and 76828.


76801 Ultrasound, Pregnant Uterus, Real Time with Image Documentation, Fetal and Maternal Evaluation, First Trimester (<14 Weeks 0 Days),Transabdominal Approach; Single or First Gestation

76802 Ultrasound, Pregnant Uterus, Real Time with Image Documentation, Fetal and Maternal Evaluation, First Trimester (<14 Weeks 0 Days),Transabdominal Approach; Each Additional Gestation (List separately in addition to Code for Primary Procedure Performed) [Use 76802 inconjunction with 76801]

76805 Echography, Pregnant Uterus, B-Scan and/or Real Time w/ImageDocumentation, Complete Fetal and Maternal Evaluation

76810 Complete — Fetal and Maternal Evaluation, Multiple Gestation, after First Trimester

76811 Ultrasound, Pregnant Uterus, Real Time with Image Documentation, Fetal and Maternal Evaluation Plus Detailed Fetal Anatomic Examination,Transabdominal Approach; Single or First Gestation



Obstetrical Ultrasounds (continued)


76812 Ultrasound, Pregnant Uterus, Real Time with Image Documentation, Fetal and Maternal Evaluation Plus Detailed Fetal Anatomic Examination,Transabdominal Approach; Each Additional Gestation (List separately inaddition to Code for Primary Procedure Performed) [Use 76812 in conjunctionwith Code 76811]

76815 Limited — Fetal Size, Heart Beat, Placental Location, Fetal Position orEmergency in the Delivery Room

76816 Follow-up or Repeat

76817 Ultrasound, Pregnant Uterus, Real Time with Image Documentation,Transvaginal [For Non-obstetrical Transvaginal Ultrasound, use 76830] [If Transvaginal Examination is done in addition to Transabdominal Obstetrical Ultrasound Exam, use 76817 in addition to appropriateTransabdominal Exam Code]

76818 Fetal Biophysical Profile

76819 Fetal Biophysical Profile; w/o Stress or Non-stress Testing

76820 Doppler Velocimetry, Fetal; Umbilical Artery

76821 Doppler Velocimetry, Fetal; Middle Cerebral Artery

76825 Echocardiography, Fetal, Cardiovascular System, Real Time w/ImageDocumentation (2d), w/or w/o M-Mode Recording

76826 Follow-up or Repeat Study

76827 Doppler Echocardiography, Fetal, Cardiovascular System, Pulsed Wave and/or Continuous Wave w/Spectral Display, Complete

76828 Follow-up or Repeat Study

76975 Endoscopic Ultrasound


Physical and Occupational Therapy

OrthoNet, a musculoskeletal disease managementcompany, is Oxford’s network manager for mostcommercial outpatient physical and occupationaltherapy services. OrthoNet is a local company with an office in White Plains, New York.

Most commercial physical and occupational therapy services following the initial evaluation(CPT codes 97001 and 97003) in the CPT code list below require an OrthoNet authorization.

A referral is required for the initial evaluation(excludes non-gatekeeper Members). Providers will receive a response by fax. The goal is to provide responses within two (2) business days of receipt of all required clinical documentation. The CPT codes listed on the following page require utilization review.

Authorization requests can be made by faxing the necessary documentation to OrthoNet at 1-800-216-0810.

For urgent requests or inquiries about clinical care, treatment plans, status, and outcomes, call the OrthoNet Medical ManagementDepartment at 1-800-201-4872.

For PCPs, there are no changes to the currentOxford referral process for the first therapy visit(CPT codes 97001 and 97003); simply refer theMember. Do not indicate the number of visits forwhich the Member is approved, since that will bedetermined as part of the utilization review process.

Please note: Electronic referral receipts, whichshow the number of visits, cannot be used inlieu of OrthoNet’s authorization. All visitsbeyond the initial evaluations must still beprecertified with OrthoNet regardless of thenumber of visits that may be listed on theelectronic referral receipt.

For providers of physical and occupational therapy, there are no changes to the existing claims submission process or the Oxford feeschedule. Remember that failure to comply with the new medical management policy fortherapy services after the initial evaluation may result in non-payment.

If you have any questions on how to obtain thenecessary forms, please call OrthoNet’s ProviderServices Department at 1-800-201-4891.




CPT Codes Requiring OrthoNet Precertification* Cannot be billed by an occupational therapist (also applies to CPT code 97001).


*97002 Physical therapy re-evaluation

97004 Occupational therapy re-evaluation

97010 Application of a modality — does not require direct patient-provider contact, hot or cold packs

*97012 Application of a modality — does not require direct patient-provider contact, traction — mechanical

97014 Application of a modality — does not require direct patient-provider contact, electrical stimulation (unattended)

97016 Application of a modality — does not require direct patient-provider contact,vasopneumatic devices

97018 Application of a modality — does not require direct patient-provider contact, paraffin bath

97022 Application of a modality — does not require direct patient-provider contact, whirlpool

*97024 Application of a modality — does not require direct patient-provider contact, diathermy

*97026 Application of a modality — does not require direct patient-provider contact, infrared

*97028 Application of a modality — does not require direct patient-provider contact, ultraviolet

*97032 Application of a modality — requires direct patient-provider contact, electricalstimulation (manual)

*97033 Application of a modality — requires direct patient-provider contact, iontophoresis

97034 Application of a modality — requires direct patient-provider contact, contrast baths

*97035 Application of a modality — requires direct patient-provider contact, ultrasound

*97036 Application of a modality — requires direct patient-provider contact, Hubbard tank

97039 Application of a modality — requires direct patient-provider contact, unlisted modality (specify)

97110 Therapeutic exercises to develop strength and endurance, range of motion and flexibility

97112 Neuromuscular re-education of movement

*97113 Aquatic therapy with therapeutic exercises

97116 Gait training (included stair climbing)

97124 Massage, including effleurage, petrissage and/or tapotement

97139 Unlisted therapeutic procedure (specify)



CPT Codes Requiring OrthoNet Precertification (continued)


97140 Manual therapy techniques, one or more regions

97150 Therapeutic procedures, group (2 or more individuals)

97530 Therapeutic activities — direct patient-provider contact, use of dynamic activities to improve functional performance

97532 Development of cognitive skills to improve attention, memory, problem solving

97533 Sensory integrative techniques to enhance sensory processing and promote adaptive responses to environmental demands

97535 Self-care/home management training — direct patient-provider contact

97537 Community/work re-integration training — direct patient-provider contact

97542 Wheelchair management/propulsion training

97545 Work hardening/conditioning, initial 2 hours

97546 Work hardening/conditioning, each additional hour

97750 Physical performance test or measurement

97799 Unlisted physical medicine/rehabilitation service or procedure

G0151 Services of physical therapist in home health setting, each 15 minutes

G0152 Services of occupational therapist in home health setting, each 15 minutes

G0283 Electrical stimulation (unattended), to one or more areas for indication(s) other than wound care, as part of a therapy plan of care

G9041 Sensory integrative techniques to enhance sensory processing and promote adaptiveresponses to environmental demands, self care/home management training,community/work reintegration training, direct one-on-one contact by the provider, each 15 minutes






Acupuncture Guidelines

Oxford covers acupuncture as a benefit only forthose Members who have the alternative medicinerider, and will deny all requests for acupuncture if the rider is not part of the Member’s benefitpackage, even if a letter of medical necessity has been submitted. Acupuncture is covered forcommercial Members only on an in-network basis and must be performed by one of followingprovider types:

• Participating licensed acupuncturist (LAC)

• Participating licensed naturopaths

• Participating physician (MD or DO) who has been credentialed as physician acupuncturist

Pharmacy

Pharmacy ManagementPrograms

Oxford’s pharmacy benefit plan is comprised of a comprehensive package of benefits that includes access to a drug formulary and pharmacymanagement programs. These programs are updated as new medications are approved by theFood and Drug Administration (FDA) and when new pharmaceutical information becomes available.

Along with benefit changes, Oxford will continue to implement clinical pharmacy managementprograms that are designed to improve quality ofcare access and to better manage costs by reducingmedication and hospital expenses incurred throughuse of unnecessary medications and waste, and bylimiting exposure to medical costs due to adversemedication reactions. Oxford has establishedprograms to encourage medication therapy that is medically appropriate and economical for ourMembers. These programs are largely based onguidelines established by the FDA.

Pharmacy and Therapeutics Committee

The Pharmacy and Therapeutics (P&T) Committeeis responsible for evaluating and providing clinicalevidence to the Prescription Drug List (PDL)Management Committee to assist them in assigning medications to tiers on the PDL.

The clinical evidence that the P&T Committeeprovides includes, but it is not limited, toevaluations of a prescription medication’s place in therapy and the relative safety or relative efficacy of the prescription medication. The P&T Committee also determines whether supplylimits or notification requirements should apply to the prescription medication.

The P&T Committee evaluates clinical evidencefor outpatient medications and specialtymedications, which require administration orsupervision by a qualified, licensed healthcareprofessional. The P&T Committee also reviewsclinical programs and clinical policies to assure that the clinical programs and related materials are consistent with published clinical evidence.



The P&T Committee includes medical directors,network physicians, consultant physicians, andpharmacy directors. The P&T Committee meets no less than quarterly.

Quality Management and Patient Safety Programs

Drug Utilization Review (DUR)

Pharmacists submit almost all prescriptionselectronically. Within seconds, the Member’s claim registers and the past prescription history is reviewed for potential medication-relatedproblems. DUR helps safeguard patients frompotentially harmful medication interactions,overutilization and other adverse medication eventsin an effort to maximize therapy effectiveness withthe appropriate medication and dosing parameters.

There are two types of DUR programs: concurrent and retrospective.

1) Concurrent DUR

The Concurrent Drug Utilization Review (C-DUR) program performs online, real-time DUR analysis at the point of prescriptiondispensing. This program screens everyprescription prior to dispensing for a broad range of safety and utilization considerations. C-DUR uses a clinical database to compare thecurrent prescription to the patient inferreddiagnosis, demographic data and past prescriptionhistory. Criteria are used to evaluate potentialinappropriate medication consumption, medicalconflicts or dangerous interactions that may result if the prescription is dispensed.

As the pharmacist enters the prescriptioninformation, the system performs a number ofchecks for safety and utilization criteria. When a potential problem is identified, the system either notifies the dispensing pharmacist bysending a soft alert (warning message) or a hardalert (a warning message that also requires thepharmacist to enter an override). The professionaljudgment of the dispensing pharmacist willdetermine appropriate interventions, such ascontacting the prescribing physician, discussingconcerns with the consumer and dispensing themedication. The consumer benefits of thisprogram include safeguards from medicationinteractions in a timely manner, improvement

in the quality of healthcare and reduction innumber of inappropriately prescribed medications.

In many cases, the pharmacist will quicklyaddress the potential issue and the programimpact will be minimal or unknown to theconsumer. The computer system will check forvarious edits and delay the claim adjudicationonly in cases where a potentially significantproblem exists. The pharmacist can simplyacknowledge the message and complete thedispensing, or can delay dispensing while anaction is completed that is necessary according to his/her professional judgment.

2) Retrospective DUR

The Retrospective Drug Utilization Review (R-DUR) program involves a quarterly review of prescription claims data to identify medicationprescribing and/or medication utilization patternsthat may indicate inappropriate or unnecessarymedication use. A clinical database is used to review profiles for medication quantityconsiderations, dose and duration considerations,therapeutic duplications, and potential misuse and abuse. Physicians receive a patient-specificinformation package that will identify potentiallyinappropriate patterns of medication utilizationand provide current treatment guidelines publishedin the medical literature.

A clinical database is used to track prescriptionactivity over a three-month period of time andprovide information for potential prescription issues. A quarterly mailing is sent to individualphysicians notifying them of any unusual prescribing patterns and asking them to respond to the issues and concerns raised. The physicianmailing includes the following: (1) a cover letterproviding an explanation of the purpose of themailing; (2) a patient-specific summary thatprovides the clinical guidelines that address thepatient’s utilization issue; and (3) a prescriptionclaims history that provides a comprehensive listof prescriptions that the patient has received forup to one year. This combination of clinicalguidelines and personalized patient claim historywill allow the physician to make an informeddecision. Changes in therapy and accompanyingsavings are identified and reported based onsubsequent claims information.



Because this is a retrospective program, there is no immediate effect on the Member obtaining aprescription. The intent is to notify physicians of potential issues and allow the physician to make changes if necessary. The program providesinformation that can be used to change therapy,potentially avoid medical misadventures and provide savings.

FDA Alerts and Product Recalls

Oxford’s pharmacy benefit manager (PBM) has aformal process to address FDA and manufacturermedication recall designed to ensure that the healthand safety of patients is considered with every event.Where possible, patients affected by FDA-required or voluntary medication withdrawals are identifiedand notified by mail. Patients are provided themedication product lot numbers affected by therecall and asked to share this information with theirphysician or other healthcare professional. Patientsare instructed on where to send the recalled productreceived from the PBM. Information on medicationrecalls is also posted on the PBM’s web site.

High Utilization Narcotic Program

The High Utilization Narcotic Program identifiesMembers who may be overutilizing narcoticanalgesics or potentially seeking narcoticsinappropriately from several physicians/prescribers.

Member Identification and Physician Outreach

This program utilizes standard criteria to identify Members that may be using narcoticsinappropriately. The three (3) criteria include:

• Nine (9) or more narcotic prescriptions during a quarter

• Three (3) or more physicians/prescribers

• Three (3) or more pharmacies

Patient-specific prescription information is provided to each physician/prescriber that will assist in the review of the pharmacy utilization.

Pharmacy Limitation

An enhancement to the program includes aPharmacy Limitation feature. Members who appearon more than two consecutive quarterly reports are reviewed by Medical Directors and may belimited to a single retail pharmacy. The Member

receives a registered letter notifying him or her ofthe limitation and is allowed 30 days to select fromone of his or her last three (3) pharmacies utilized. If the Member does not select a pharmacy, the last retail pharmacy of record will be assigned.

Utilization ManagementEnsuring that patients receive the appropriatemedication at the right dose for the length of timenecessary to treat a particular medical condition is key to providing appropriate pharmacy care.Guidelines for diagnosis and treatment for some of the most common chronic conditions have beenestablished by the FDA and other government andmedical subspecialty societies.

Medications Requiring Precertification

Based on plan designs, selected high-risk or high-cost medication may require notification (also known as prior authorization) by Oxford inorder to be eligible for coverage. Notification criteriahave been established by the P&T Committee withinput from plan physicians and considerations of thecurrent medical literature. For most Members withpharmacy benefit coverage through Oxford, themedications on the following list (including theirgeneric equivalent, if available) generally requirenotification through Oxford’s pharmacy benefitmanager (PBM) based on Oxford’s coverage criteria.Notification requires that you formally submit arequest and receive approval for coverage of certainprescription medications.

You may be asked to provide information explainingmedical necessity and past therapeutic failures. A representative will collect all pertinent clinicaldata for the service requested. For those requeststhat do not meet the criteria for approval, you will be informed that the coverage determinationrequires further review by an Oxford MedicalDirector. Decisions are communicated within one (1) business day of receipt of the request. If the necessary information required to render adecision is not received with your initial request, the information will be requested within 24 hours of receipt of the request.

If you have any questions regarding themedications on this list or any other medications,please call Pharmacy Customer Service at 1-800-905-0201.



Medications Requiring Precertification —Commercial Members only (subject to plan design)

Anti-infectives

• Copegus

• Rebetol

Dermatologicals/Topical Therapy

• Avita1

• Differin1

• Elidel

• Protopic

• Raptiva

• Regranex

• Retin A1

• Tazorac1

Endocrine/Diabetes

• Exubera

Gastroenterology

• Aciphex

• Lotronex

• Nexium

• Prevacid

• Prilosec

• Protonix

• Zegerid

• Zelnorm

Immunology, Vaccines and Biotechnology

• Genotropin

• Humatrope

• Infergen

• Intron A

• Norditropin

• Nutropin

• Nutropin AQ

• Nutropin Depot

• PEG-Intron

• Pegasys

• Protropin

• Rebetron

• Roferon-A

• Saizen

• Serostim

• Tev-Tropin

• Zorbtive

Miscellaneous Agents

• Increlex

• IPLEX

• Nutritional Therapy2

Musculoskeletal and Rheumatology

• Celebrex

• Enbrel

• Humira

• Kineret

Narcotics

• Actiq

Ophthalmology

• Restasis

Psychotherapeutic Agents

• Provigil

• Wellbutrin

• Wellbutrin SR

• Wellbutrin XL



Pulmonary Agents

• Revatio

• Tracleer

• Ventavis

Urologicals

• Avodart3

• Caverject

• Cialis

• Edex

• Levitra

• Muse

• Proscar3

• Viagra

1 Applies only to Members greater than 29 years old.

2 For coverage information, Members can call our Customer Service Department at the number on their Oxford ID card.

3 Applies only to Members 46 years of age or older.

Please note: Notification requirements may vary depending on the Member’s pharmacybenefit plan.

This list is subject to change without notice.

To obtain notification for the drug list above, please call Medco directly at 1-800-753-2851, Mon. - Fri. 8 AM to 9 PM (Eastern Standard Time).

For the most up-to-date information, please callPharmacy Customer Service at 1-800-905-0201.

Medications Requiring Precertification —MedicareComplete® Members

• Actiq

• Accuneb

• Acetylcysteine

• Actimmune

• Airet

• Albuterol Sulfate

• Alimta

• Androderm

• Androgel

• Android

• Anzemet

• Apokyn

• Aralast

• Avastin

• Aranesp

• Avonex

• Betaseron

• Baygam

• Byetta

• Carimune Nanofiltered (1gm Injection, 3gm Injection, 6gm Injection)



• Cellcept

• Cellcept Intravenous

• Cerezyme

• Copaxone

• Cromolyn Sodium

• Cyclophosphamide

• Cyclosporine (Capsule, Injection, Solution)

• Cyclosporine Modified

• Duoneb

• Elaprase

• Emend

• Enbrel

• Engerix-B

• Engerix-B SDV

• Erbitux

• Exubera

• Flebogamma

• Forteo

• Gamastan S/D

• Gammagard

• Gammagard S/D

• Gammar-P I.V.

• Gengraf

• Immune Globulin

• Iveegam EN

• Genotropin

• Humatrope

• Humira

• Intron A

• Intron A w/Diluent

• Ipratropium Bromide

• Kineret

• Kytril

• Marinol

• Metaproterenol Sulfate

• Miacalcin

• Myfortic

• Neupogen

• Norditropin

• Nutropin AQ

• Octreotide Acetate

• Pegasys

• PEG-Intron

• PEG-Intron Redipen

• Polygam S/D

• Procrit

• Provigil

• Prograf

• Proleukin

• Pulmicort

• Ranexa

• Raptiva

• Rapamune

• Rebetol (solution)

• Recombivax HB

• Regranex

• Revatio

• Rebif

• Rebif Titration Pack

• Revlimid



• Ribasphere

• Ribatab

• Ribavirin

• Rituxan

• Roferon-A

• Remicade

• Saizen

• Sandostatin LAR Depot

• Somavert

• Sporanox solution

• Striant

• Symlin

• Testim

• Thalomid

• Tracleer

• Vancocin HCI

• Venoglobulin-S

• Vfend

• Topamax

• Xolair

• Xopenex

• Zelnorm

• Zofran ODT

• Zofran tablet

• Zyvox

This list is subject to change without notice.

To obtain precertification for the drugs listedabove, please call Prescription Solutions directly at 1-800-711-4555.

Quantity Limits (subject to plan design)

Certain medications may be subject to quantity level limits (QLL) based upon the manufacturer’spackage size, FDA-approved dosing guidelines and/or the medical literature. The purpose of QLL is to ensure the proper billing of products and/orencourage the use of therapeutically indicatedmedication regimens. This program focuses on select medications or categories of medications that are high cost and/or are frequently used outside of generally accepted clinical standards.

The program establishes a maximum quantity level limit per prescription or co-payment. If the Member’s prescription exceeds the limit, the claim is rejected at the point-of-service. The Member can request a coverage review for those medications that have override criteria.

The QLL is based on FDA-approved dosingguidelines as defined in the product package insert and the medical literature or guidelines that support the use of higher dosages than the FDA-recommended dosage. When a pharmacistenters a prescription, the online claims processingsystem compares the quantity entered with theallowable limits. If the prescription exceeds theestablished QLL, the claim is rejected and thepharmacist receives a message. The messageindicates the QLL is exceeded and lists the allowable maximum quantity. A subset ofmedications has coverage criteria available, and for these medications, the pharmacist alsoreceives the message to call a toll-free number.

The Member will have the following options whenthe QLL is exceeded: (1) accept the establishedquantity limit and receive that quantity; (2) discussthe prescription with his or her physician; or (3)request coverage review for those medications that do have coverage criteria.

Medications affected by QLL are designated by an asterisk (*) in the PDL available online atwww.oxfordhealth.com.



Half-tab Program

Program Overview

The Half-tab Program is used when themanufacturer makes available two differentstrengths of a drug for approximately the same price. For example, Drug-X is available in 50 mg and 100 mg tablets for the same price. The 100 mgtablet is scored to allow the tablet to be easilybroken in half. For example, if a Member is taking a 50 mg tablet, the Member can use the 100 mgtablet and split it.The quantity of medicationdispensed is cut in half. The Member receives the prescribed dose, and pays half a copayment per prescription (Members with a coinsurance plan will save up to 50 percent). The plan sponsorscan also save up to 50 percent through reducedingredient costs. There are currently 16 medications(including their generic equivalent, if available)included in the Half-tab Program.

Class Brand Name

ACE Inhibitors Aceon

Mavik

Univasc

ARBs Atacand

Avapro

Benicar

Cozaar

Diovan

Antidepressants Lexapro

Pexeva

Zoloft

Lipid-lowering Crestor

Lipitor

Pravachol

Zocor

Antivirals Valtrex

Program Description

This is a voluntary program and Members willchoose whether to participate. The medicationsinvolved are in tablet form and are suitable for tablet splitting. One free tablet splitter will beprovided to assist Members. Members can obtain a tablet splitter by calling a toll-free number or going to the program web site.

Members who elect to participate in the Half-tab Program:

• Will receive 15 tablets for a 30-day supply at retail (Members may also receive 16 tablets for a 32-day supply or 17 tablets for a 34-daysupply, per their benefit plan)

• Will receive 45 tablets to meet a 90-day supplyat mail order (if available)

• Must obtain an appropriate prescription from their physician (half the days supply, double the strength)

Messaging will be provided to retail pharmacies at the point-of-service to inform the pharmacistsabout the Half-tab program.



Three-tier Pharmacy Benefit Plan — Commercial Members Oxford has a three-tier pharmacy benefit available for many commercial plans. The Prescription Drug List(PDL) for this benefit plan was carefully designed to promote medically appropriate, cost-effective healthcarewhile preserving your ability to prescribe specific medications of choice for your patients. The three tiersinclude Tier 1 (lowest cost option) medications, Tier 2 (midrange cost option) medications, and Tier 3(highest cost option) medications with an increase in copayment (out-of-pocket cost) to our Members witheach tier. Members covered by the three-tier pharmacy benefit may have one of the following plan designs,depending on the benefit chosen by their employer:

Plan Design* Tier 1: Tier 2: Tier 3: lowest cost option midrange cost option highest cost option

Rx Plan A copayments $5 $15 $35

Rx Plan B copayments $5 $15 $50

Rx Plan C copayments $7 $20 $50

Rx Plan D copayments $5 $10 $20

Rx Plan E copayments $7 $15 $35

Rx Plan F copayments $10 $20 $50

* Plan designs are not available in all states. Not all Members have a three-tier pharmacy benefit plan.

Please note: This is not a complete listing. This three-tier pharmacy benefit structure may beextended to other groups.

Please refer to our Provider Program and PolicyUpdate for any changes.

You may continue to choose from the many qualitymedications available, using your patient’s out-of-pocket cost as a consideration when prescribing.

Please note: For New York and Connecticutplans, if a prescription is written for amedication available as an over-the-counter(OTC) product in the identical dosage, form,strength, and active ingredient, the prescriptionmay not be covered. The pharmacist should refer the Member to the OTC product. If theMember or physician insists on the prescriptionequivalent product, the Member will beresponsible for the entire cost of the prescription.

Compounded medications, those medicationscontaining one or more ingredients that are prepared“on-site” by a pharmacist, are classified at the Tier 3 level, provided that the individual ingredientsused in the compounding are covered under thepharmacy benefit.

Please review the PDL and, where appropriate foryour patients, consider changing Tier 3 prescriptionsto Tier 1 or Tier 2 medications. The complete PDL is available online at www.oxfordhealth.com.

Please note: This three-tier pharmacy benefitplan structure may be extended to other groups.Please refer to our Provider Program and PolicyUpdates for any changes.



Four-tier Pharmacy Drug Plan — SecureHorizons® | Oxfordand Evercare Plan DH MembersThere is a four-tier prescription drug benefitavailable for all MedicareComplete® and EvercareDH plans, except MedicareComplete Essentialplans. As of January 1, 2007, we transitioned toPrescription (Rx) Solutions as our pharmacy benefit manager. The Prescription Drug List for this benefit was carefully designed to promotemedically appropriate, cost-effective healthcarewhile preserving your ability to prescribe specificdrugs of choice for your patients and to comply with the guidelines set forth by the Centers forMedicare & Medicaid Services (CMS) for the Part D benefit. Members covered by the four-tierprescription plan benefit have the following plan design:

For all MedicareComplete Plans

There is no deductible. Before the total yearly drug costs (paid by both the Member andSecureHorizons® | Oxford) reach $2,400, the Member must pay the following for prescription drugs:

• $4 for a one-month (30-day) supply of Tier 1



• 33 percent coinsurance for a one-month (30-day)supply of Tier 4

• $12 for a three-month (90-day) supply of Tier 1


• $174 for a for a three-month (90-day) supply of Tier 3

• 33 percent coinsurance for a three-month (90-day)supply of Tier 4

Mail Order — preferred




• 33 percent coinsurance for a three-month (90-day) supply of Tier 4

Mail Order — non-preferred





For Evercare Plan DH (formerly OxfordMedicare Advantage Select)




• 33 percent coinsurance for a one-month (30-day)supply of Tier 4







Mail Order — preferred





Mail Order — non-preferred





Members must use designated retail pharmacies ormail order to get their prescription drugs. After thetotal yearly drug costs (paid by both the Member andOxford) reach $2,400, the Member pays 100 percentof their prescription drug costs. After the Member’syearly out-of-pocket drug costs reach $3,850, theMember pays the greater of:

• $2.15 or 5 percent coinsurance for generic(including brand drugs treated as generic)

• $5.35 or 5 percent coinsurance for all other drugs

You may continue to choose from the many qualitydrugs available, using your patient’s out-of-pocketcost as a consideration when prescribing.

Please review the Prescription Drug List and, where appropriate for your patients, considerchanging Tier 3 prescriptions to Tier 1 or 2 drugs.Look for the Medicare complete drug formulary at www.securehorizons.com.

Mail Order for Commercial Members Oxford offers Members the ability to obtain up to a 90-day supply of certain medications withinseveral therapeutic categories of medications bymail. Maintenance medications are prescriptionmedications associated with the treatment of certainchronic conditions, such as diabetes, hypertensionand epilepsy. All Members whose plans include themail-order benefit are entitled to use this service.

Please note: Mail-order coverage may varydepending on the Member’s benefit. Please refer to the Member’s Certificate of Coverage or Prescription Drug Rider for specific coverageinformation. Not all Members have a plan thatincludes mail-order coverage.

For Commercial Members

Medco By Mail P.O. Box 747000Cincinnati, OH 45274-7000

For Medicare Members

Prescription SolutionsP.O. Box 2975Shawnee Mission, KS 66201-1375

OOX F O R D | IMPORTANT ADDRESSES



The Prescription Drug ListThe Prescription Drug List (PDL) is a dynamiclisting of medications that is reviewed at leastannually and updated at least quarterly to reflect advances in pharmaceutical care. Quarterly updates appear in the Provider Program and Policy Update (PPU). Also available at www.oxfordhealth.com, the PDL details inclusions, Tier 1, Tier 2 and Tier 3 medications, quantity limits, andprecertification requirements.

As of January 1, 2007, Medicare will have a separate Prescription Drug List than Oxfordcommercial plans. The Medicare Prescription Drug List will also be a dynamic listing ofmedications that is reviewed at least annually and updated quarterly to reflect advances in medicalcare and requirements by CMS. Also available atwww.securehorizons.com, the drug list detailsinclusions, generic and preferred brand drugs, drugquantity limits, and precertification requirements.

Please note: The listing of a medication producton a PDL does not guarantee coverage, ascertain products are excluded due to benefitplan design limitations that are specific toMember’s individual or group benefits. Inaddition, diabetic supplies that are availablethrough the Member’s base medical benefit aresubject to the applicable office visit copayment(out-of-pocket cost) noted on the Member’sSummary of Benefits.

The PDL includes Tier 1, Tier 2 and Tier 3medications. If a brand name medication is notlisted, it is a Tier 3 or a specialty drug (Tier 4),subject to the three or four-tier pharmacy benefit(depending on Member’s benefit). The list isalphabetized by the name of the medication. Tier 1 medications are listed in lower case lettersand Tier 2 medications are listed in bolded capitalletters. Medications affected by quantity limits arepreceded by an asterisk (*). Medications requiringnotification are designated as (PAR).

Please note: The PDL is subject to change. Whena medication changes tiers, the Member may berequired to pay more or less for that medication.These changes may occur without prior notice toyou or your patient. However, you may visit ourweb site for the most up-to-date information fora particular medication.

Ancillary Services - Oxford Health Plans · 2007. 4. 24. · 100 Section 6 — Ancillary Services Hospital Laboratories Barnert Hospital Laboratory services 973-977-6647 Connecticut

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