Network Bulletin: December 2015 network bulletin - …€¢ UnitedHealthcare Nursing Home Plan Transitioning ... In the November 2015 Network Bulletin, ... Abnormal Uterine Bleeding

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: December 2015

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Network Bulletin: November 2013 - Volume 582

Table of Contents

For more information, call 877.842.3210 or visit UnitedHealthcareOnline.com

2 Network Bulletin: December 2015

Front & Center

• Refer a Child to the UnitedHealthcare Children’s Foundation

• UnitedHealthcareOnline.com Claim Reconsideration to be Retired

• New Coding for Intra-Uterine Devices Effective Jan. 1, 2016; HCPCS Code J7302 Deleted

UnitedHealthcare Commercial

• Medical Policy, Drug Policy, Coverage Determination Guideline, Utilization Review Guideline, and Quality of Care Guideline Updates

• Reminder: Genetic Counseling Requirement Effective Jan. 1, 2016

UnitedHealthcare Commercial Reimbursement Policies

• Revision to Place of Service 22 and New POS 19

• Multiple Procedure Payment Reduction Reimbursement Policies for Endoscopy and the Technical Component of Diagnostic Cardiovascular and Ophthalmology Procedures Delayed

• Replacement Codes Policy Implementation

• Changes to Telemedicine and Procedure to Modifier Policies

• Procedure to Modifier Policy Revised

UnitedHealthcare Community Plan

• Medical Policy & Coverage Determination Guideline Updates

• UnitedHealthcare Community Plan Added to Electronic Payments & Statements in 17 States

UnitedHealthcare Medicare Solutions

• UnitedHealthcare Medicare Advantage Coverage Summary Updates

• New Medicare Advantage Referral Required Plans

• UnitedHealthcare Nursing Home Plan Transitioning to UnitedHealthcare Administrative System

UnitedHealthcare Military & Veterans

• Referrals and Notifications

Doing Business Better

• Important Change to Our Network of DME Providers

UnitedHealthcare Affiliates

• UnitedHealthcare Oxford Medical and Administrative Policy Updates

• UnitedHealthcare of the River Valley Preauthorization List and Coverage Policy Updates

• SignatureValue Medical Management Guideline Updates

• SignatureValue Benefit Interpretation Policy Updates

• Reminder: Chemotherapy Prior Authorization Requirement Effective for UnitedHealthcare Oxford

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

or visit UnitedHealthcareOnline.comNetwork Bulletin: December 2015

Do you have a pediatric patient who would benefit from a grant to help pay medical expenses? The UnitedHealthcare Children’s Foundation (UHCCF) awards medical grants to help children gain access to health-related services not covered, or not fully covered, by their family’s commercial health insurance plan.

Applicants do not need to be UnitedHealthcare members, but must have coverage through a commercial health plan.

Grants are available throughout the year to children ages 16 and younger who are facing health-related challenges and whose families meet certain financial criteria. Qualifying families can receive up to $5,000 annually per child and up to a $10,000 lifetime maximum, to help cover the cost of medical treatments, equipment and services.

You can direct a family who may qualify for a grant to uhccf.org/apply. If you would like to receive UHCCF brochures for your practice, please call 855-MY-UHCCF or email [email protected].

Since 2007, UHCCF has awarded more than $29 million to children and their families across the United States. Funding is provided by contributions from individuals, corporations and UnitedHealth Group employees. The foundation awarded its 10,000th medical grant this past September, and aims to award more than 2,000 grants in 2016. Learn more about grant application criteria and how you can help the UHCCF change lives at UHCCF.org.

The UnitedHealthcare Children’s Foundation is a non-profit Section 501(c)(3) public charity and operates independently from UnitedHealthcare with its own Board of Directors.

Refer a Child to the UnitedHealthcare Children’s Foundation

Front & Center

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The Claim Status and Claim Reconsideration functions on UnitedHealthcareOnline.com have been enhanced in the applications on Link.

In the Claims Management application on Link, you can:• View claims for more UnitedHealthcare plans

• Flag claims you wish to follow up on

• Easily view remark codes and their descriptions

• Seamlessly initiate a claim reconsideration request

In the Claim Reconsideration application on Link, you can:• Search for denied claims

• Submit corrected claims

• Upload documents

• View the status and history of your requests

• Exchange comments with a claim adjustor

• Update your requests and resubmit them with additional information

Early in 2016 we are going to retire the Claim Reconsideration transaction from UnitedHealthcareOnline.com since the functionality on Link provides enhanced capabilities.

If you need access to the applications on Link, your Password Owner can update your account in User ID and Password Management. You can view your Password Owner’s name by logging in and going to “My Profile.”

For help using the apps on Link, please refer to our Quick Reference Guides. We also offer one-hour webinars on the second Thursday of each month. Please register for the session of your choice in advance.

We hope that moving to the Link applications will provide you with an even better web experience. If you have questions, please contact the Optum Support enter at 855-819-5909.

UnitedHealthcareOnline.com Claim Reconsideration to be Retired

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In the November 2015 Network Bulletin, we published an advanced notice of a potential price decrease effective Jan. 1, 2016 for HCPCS code J7302. The price decrease would have taken effect if the Centers for Medicare and Medicaid Services (CMS) added the lower-priced Liletta to HCPCS code J7302 for Mirena. However, since the article was published, the following separate HCPCS codes were created for Liletta and Mirena intra-uterine devices effective Jan. 1, 2016.

• HCPCS code J7302 will no longer be valid effective Dec. 31, 2015

• HCPCS code J7302 has been replaced with the following two new HCPCS codes, specific to Liletta and Mirena, effective Jan. 1, 2016.

– J7297 Levonorgestrel-releasing intrauterine contraceptive system, 52mg, 3 year duration (Liletta)

– J7298 Levonorgestrel-releasing intrauterine contraceptive system, 52 mg, 5 year duration (Mirena)

Because Liletta and Mirena will each have their own unique codes and pricing, there will not be a price decrease for Mirena currently billed under J7302. This applies to participating care providers who have drug reimbursements contracted at the CMS Drug Pricing or Red Book Average Wholesale Price.

If you have questions, please contact your local Network Management representative. Thank you.

New Coding for Intra-Uterine Devices Effective Jan. 1, 2016; HCPCS Code J7302 Deleted



Medical Policy, Drug Policy, Coverage Determination Guideline, Utilization Review Guideline, and Quality of Care Guideline Updates


For complete details on the policy updates listed in the table on the following pages, please refer to the November 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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https://www.unitedhealthcareonline.com/b2c/CmaAction.do?channelId=9b4f0ae1346e8410VgnVCM100000294ab10a____




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Policy Title Policy Type Effective Date

UPDATED/REVISED

Abnormal Uterine Bleeding and Uterine Fibroids Medical Jan. 1, 2016

Autologous Chondrocyte Transplantation in the Knee Medical Dec. 1, 2015

Breast Imaging for Screening and Diagnosing Cancer Medical Jan. 1, 2016

Breast Reconstruction Post Mastectomy CDG Jan. 1, 2016

Breast Repair/Reconstruction Not Following Mastectomy CDG Jan. 1, 2016

Computed Tomographic Colonography Medical Nov. 1, 2015

Cosmetic and Reconstructive Procedures CDG Dec. 1, 2015

Deep Brain Stimulation Medical Dec. 1, 2015

Electrical Stimulation for Treatment of Pain and Muscle Rehabilitation Medical Dec. 1, 2015

Genetic Testing for Hereditary Breast and/or Ovarian Cancer Syndrome (HBOC) Medical Jan. 1, 2016

Hospital Readmissions QOCG Nov. 1, 2015

Immune Globulin Site of Care Review Guidelines For Medical Necessity of Hospital Outpatient Facility Infusion URG Nov. 1, 2015

Implanted Electrical Stimulator for Spinal Cord Medical Dec. 1, 2015

Intensive Behavioral Therapy for Autism Spectrum Disorder Medical Nov. 1, 2015

Lupron® Depot/Lupron® Depot-Ped (Leuprolide Acetate) Drug Dec. 1, 2015

Obstructive Sleep Apnea Treatment Medical Dec. 1, 2015

Omnibus Codes Medical Jan. 1, 2016

Osteochondral Grafting of Knee Medical Dec. 1, 2015





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UPDATED/REVISED

Proton Beam Radiation Therapy Medical Dec. 1, 2015

Sandostatin®/Sandostatin LAR® Depot (Octreotide Acetate) Drug Dec. 1, 2015

Speech Language Pathology Services CDG Dec. 1, 2015

Standing Systems and Gait Trainers Medical Dec. 1, 2015

Vagus Nerve Stimulation Medical Dec. 1, 2015

Virtual Upper Gastrointestinal Endoscopy Medical Nov. 1, 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 in this Bulletin and the posted policy, the posted policy will prevail.





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Reminder: Genetic Counseling Requirement Effective Jan. 1, 2016

As communicated in the October Network Bulletin, effective Jan. 1, 2016, UnitedHealthcare commercial members with benefit plans that include medical necessity provisions will be required to receive genetic counseling before UnitedHealthcare approves prior authorization requests for testing for Breast Cancer (BRCA) mutations for hereditary breast and ovarian cancer.

A genetic counseling visit will help UnitedHealthcare members understand the advantages and limitations of BRCA mutation analysis so they can make informed health care decisions. Genetic counseling, which is recommended by the United States Preventive Services Tasks Force as well as the National Comprehensive Cancer Network (NCCN), will help our members understand if the test is right for them as well as help them interpret the results after testing. CPT codes impacted by this requirement include the following: 81211-81217, 81162, 81432 and 81433.

The counseling can be done over the phone or in an office setting. All care providers administering the BRCA laboratory test will be required to show evidence that the requirement has been fulfilled in order to receive prior authorization for the test.

The genetic counseling must be administered by an independent genetics care provider who is not employed by a genetic testing lab. Genetics care providers employed or contracted with a laboratory who are part of an integrated health system that routinely delivers health care services beyond laboratory testing are considered independent. Genetic testing for BRCA mutations requires documentation of medical necessity by one of the following

who has evaluated the individual and intends to engage in post-test follow-up counseling:• Board-eligible or board-certified genetics counselor

• Advanced genetics nurse

• Genetics clinical nurse

• Advanced practice nurse in genetics

• A board-eligible or board-certified clinical geneticist

• A board-certified care provider with experience incancer genetics who provides cancer risk assessmenton a regular basis and has received specializedongoing training in cancer genetics.

You can use one of the following methods to locate an independent genetics counselor:• Visit informedDNA.com or call InformedDNA at

800-975-4819 to access nationwide in-networktelephone genetic counseling.

• Visit the National Society of Genetic Counselors atNSGC.org. Check the “Genetic Counselor Certified”box at the bottom of the page. This list may howeverinclude genetic counselors that are non-participatingor employed by the lab.

For more information about this requirement, please go to UnitedHealthcareOnline.com > Clinician Resources > Oncology > Programs, Tools & Resources > BRCATesting > Tools & Resources > BRCA GeneticCounseling Requirement Frequently Asked Questions.If you have additional questions or need more information,please email us at [email protected]. Thank you.




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Unless otherwise noted, the following reimbursement policies apply to services reported using the 1500 Health Insurance Claim Form (CMS-1500) or its electronic equivalent or its successor form. UnitedHealthcare reimbursement policies do not address all factors that affect reimbursement for services rendered to UnitedHealthcare members, including legislative mandates, 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 between the information provided in the Network Bulletin and the posted policy, the posted policy prevails.

http://UnitedHealthcareOnline.com

https://www.unitedhealthcareonline.com/b2c/CmaAction.do?channelId=0e22f2ccadd1c010VgnVCM100000c520720a____




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Revision to Place of Service 22 and New Place of Service 19

To facilitate data collection when services are provided off-campus, the Centers for Medicare and Medicaid Services (CMS) has developed a new place of service (POS) 19 as well as revising the description of POS 22. These changes to the CMS POS Code Set will be effective for dates of service on and after Jan. 1, 2016.

POS 19: Off-Campus Outpatient HospitalDescriptor: A portion of an off-campus hospital provider-based department which provides diagnostic, therapeutic (both surgical and nonsurgical), and rehabilitation services to sick or injured persons who do not require hospitalization or institutionalization.

POS 22: On-Campus Outpatient Hospital Descriptor: A portion of a hospital’s main campus which provides diagnostic, therapeutic (both surgical and nonsurgical), and rehabilitation services to sick or injured persons who do not require hospitalization or institutionalization

For UnitedHealthcare Commercial and UnitedHealthcare Community Plan reimbursement policies that address POS 22, the new POS 19 will be added as part of our annual maintenance updates.

For more information, please refer to the MLN Matters article MM9231 at: https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM9231.pdf.

Multiple Procedure Payment Reduction Reimbursement Policies for Endoscopy and the Technical Component of Diagnostic Cardiovascular and Ophthalmology Procedures Delayed

The UnitedHealthcare reimbursement policy updates for Commercial plans for the technical component of diagnostic cardiology and ophthalmology services and for multiple procedures from the same endoscopy family have been delayed until March 1, 2016. These policy enhancements were previously communicated as being effective for claims with dates of service on or after Nov. 15, 2015 on pages 23 and 25 in the August Network Bulletin.

As part of UnitedHealthcare’s ongoing commitment to responsibly and effectively administer health insurance to customers and members, the company is enhancing the claims processing logic to align with industry standards. We are delaying implementation to the first quarter of 2016 in order to complete the programming within our claim adjudication platforms. Beginning with March 1, 2016 dates of service, UnitedHealthcare is reducing payment on specific “secondary services” rendered in a single course of care to account for duplicative components. Secondary services are related to the following procedures:

• Multiple endoscopic procedures in the same family; and

• Technical portion of certain diagnostic cardiology and ophthalmology services, including operating room access, payments made for the paper covering a patient lies on in the operating room, the syringe used to inject anesthesia and the insertion of a scope when the instrument is used to examine multiple internal areas.

For a more detailed description on these changes, please refer to pages 23 and 25 of the August 2015 Network Bulletin.




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Replacement Codes Policy Implementation

Effective for claims with dates of service on or after March 1, 2016, UnitedHealthcare will implement the Replacement Codes Policy. Consistent with the Centers for Medicare and Medicaid Services (CMS), UnitedHealthcare will deny reimbursement of specific codes assigned an “I” status according to the National Physician Fee Schedule (NPFS) where CMS has created replacement healthcare common procedure coding system (HCPCS) codes for physicians and/or healthcare professionals to report in lieu of the codes assigned an “I” status. According to CMS, codes assigned a status of I are not valid for Medicare purposes and CMS recognizes another code for reporting of and payment for the service provided. Please reference the following table for a comprehensive list of codes applicable according to the 2015 CMS NPFS. UnitedHealthcare will publish any necessary revisions based on the 2016 CMS NPFS within the February Network Bulletin.

Code Description

44705 Preparation of fecal microbiota for instillation, including assessment of donor specimen

95941 Continuous intraoperative neurophysiology monitoring, from outside the operating room (remote or nearby) or for monitoring of more than one case while in the operating room, per hour (List separately in addition to code for primary procedure)

H0001 Alcohol and/or drug assessment

H0002 Behavioral health screening to determine eligibility for admission to treatment program

H0003 Alcohol and/or drug screening; laboratory analysis of specimens for presence of alcohol and/or drugs

H0004 Behavioral health counseling and therapy, per 15 minutes

H0005 Alcohol and/or drug services; group counseling by a clinician

H0006 Alcohol and/or drug services; case management

H0007 Alcohol and/or drug services; crisis intervention (outpatient)

H0008 Alcohol and/or drug services; subacute detoxification (hospital inpatient)

H0009 Alcohol and/or drug services; acute detoxification (hospital inpatient)

H0010 Alcohol and/or drug services; subacute detoxification (residential addiction program inpatient)

UnitedHealthcare Commercial ReimbursementPolicies


or visit UnitedHealthcareOnline.com

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Network Bulletin: December 2015


Code Description

H0011 Alcohol and/or drug services; acute detoxification (residential addiction program inpatient)

H0012 Alcohol and/or drug services; subacute detoxification (residential addiction program outpatient)

H0013 Alcohol and/or drug services; acute detoxification (residential addiction program outpatient)

H0014 Alcohol and/or drug services; ambulatory detoxification

H0015Alcohol and/or drug services; intensive outpatient (treatment program that operates at least 3 hours/day and at least 3 days/week and is based on an individualized treatment plan), including assessment, counseling; crisis intervention, and activity therapies or education

H0016 Alcohol and/or drug services; medical/somatic (medical intervention in ambulatory setting)

H0017 Behavioral health; residential (hospital residential treatment program), without room and board, per diem

H0018 Behavioral health; short-term residential (nonhospital residential treatment program), without room and board, per diem

H0019 Behavioral health; long-term residential (nonmedical, nonacute care in a residential treatment program where stay is typically longer than 30 days), without room and board, per diem

H0020 Alcohol and/or drug services; methadone administration and/or service (provision of the drug by a licensed program)

H0021 Alcohol and/or drug training service (for staff and personnel not employed by providers)

H0022 Alcohol and/or drug intervention service (planned facilitation)

H0023 Behavioral health outreach service (planned approach to reach a targeted population)

H0024 Behavioral health prevention information dissemination service (one-way direct or nondirect contact with service audiences to affect knowledge and attitude)

H0025 Behavioral health prevention education service (delivery of services with target population to affect knowledge, attitude and/or behavior)

H0026 Alcohol and/or drug prevention process service, community-based (delivery of services to develop skills of impactors)

H0027 Alcohol and/or drug prevention environmental service (broad range of external activities geared toward modifying systems in order to mainstream prevention through policy and law)

H0028 Alcohol and/or drug prevention problem identification and referral service (e.g., student assistance and employee assistance programs), does not include assessment

UnitedHealthcare Commercial ReimbursementPolicies



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Code Description

H0029 Alcohol and/or drug prevention alternatives service (services for populations that exclude alcohol and other drug use e.g., alcohol free social events)

H0030 Behavioral health hotline service

H0031 Mental health assessment, by nonphysician

H0032 Mental health service plan development by nonphysician

H0033 Oral medication administration, direct observation

H0034 Medication training and support, per 15 minutes

H0035 Mental health partial hospitalization, treatment, less than 24 hours

H0036 Community psychiatric supportive treatment, face-to-face, per 15 minutes

H0037 Community psychiatric supportive treatment program, per diem




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Changes to Telemedicine and Procedure to Modifier Policies

UnitedHealthcare will reimburse telehealth services submitted with modifier GQ (via asynchronous telecommunications system) when the procedure/modifier combination is considered appropriate by third-party authorities, as determined by the Procedure to Modifier Policy. This change will become effective in the first quarter of 2016.

Procedure to Modifier Policy Revised – Modifiers Being Added

The following modifiers will be added to the Procedure to Modifier List and addressed through this policy:

• EC• SK

In accordance with correct coding, UnitedHealthcare will consider reimbursement for a procedure code/modifier combination only when the modifier has been used appropriately. The changes will occur in the first quarter of 2016.



Medical Policy & Coverage Determination Guideline Updates


For complete details on the policy updates in the following table, please refer to the November 2015 Medical Policy Update Bulletin at UHCCommunityPlan.com > Provider Information > UnitedHealthcare Community Plan Medical Policies and Coverage Determination Guidelines.

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NEW

Hospice (Applies to the State of Louisiana Only) CDG Dec. 1, 2015

UPDATED/REVISED

Abnormal Uterine Bleeding and Uterine Fibroids Medical Jan. 1, 2016

Autologous Chondrocyte Transplantation In The Knee Medical Dec. 1, 2015

Breast Imaging for Screening and Diagnosing Cancer Medical Jan. 1, 2016

Breast Reconstruction Post Mastectomy CDG Jan. 1, 2016

Breast Repair/Reconstruction Not Following Mastectomy CDG Jan. 1, 2016

Computed Tomographic Colonography Medical Nov. 1, 2015

Cosmetic and Reconstructive Procedures CDG Dec. 1, 2015

Deep Brain Stimulation Medical Dec. 1, 2015

Discogenic Pain Treatment Medical Dec. 1, 2015

Electrical Stimulation for the Treatment of Pain and Muscle Rehabilitation Medical Dec. 1, 2015

Genetic Testing for Hereditary Breast and/or Ovarian Cancer Syndrome (HBOC) Medical Jan. 1, 2016

High Frequency Chest Wall Compression Devices Medical Dec. 1, 2015

Implanted Electrical Stimulator for Spinal Cord Medical Dec. 1, 2015

Intensive Behavioral Therapy for Autism Spectrum Disorder Medical Jan. 1, 2016

Minimally Invasive Procedures for Gastroesophageal Reflux Disease (GERD) Medical Dec. 1, 2015

Neurophysiologic Testing Medical Dec. 1, 2015

Obstructive Sleep Apnea Treatment Medical Dec. 1, 2015

Omnibus Codes Medical Jan. 1, 2016

Osteochondral Grafting of Knee Medical Dec. 1, 2015




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Proton Beam Radiation Therapy Medical Dec. 1, 2015

Speech Language Pathology Services CDG Dec. 1, 2015

Standing Systems and Gait Trainers Medical Dec. 1, 2015

Vagus Nerve Stimulation Medical Dec. 1, 2015

Virtual Upper Gastrointestinal Endoscopy Medical Nov. 1, 2015






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UnitedHealthcare Community Plan Added to Electronic Payments & Statements in 17 States

Now you can use a single tool to access and manage payment information for most UnitedHealthcare benefit plans! UnitedHealthcare Community Plan has recently been added to Electronic Payments & Statements (EPS) in 17 states.*

EPS is UnitedHealthcare’s solution for electronic remittance advice (ERA) and electronic funds transfer (EFT). It allows you to receive direct deposit of claim payments to your designated bank accounts and access explanation of benefits/provider remittance advice online or via 835 ERA files.

You can learn more by:• Visiting WelcometoEPS.com,

• Watching a short video demo, or

• Attending a live 30-minute webinar for an overviewand answers to your questions.

You can enroll in EPS online or send us a completed enrollment form. If you have questions, please call 866-842-3278, option 5.

*Enrollment in EPS currently applies to payments from UnitedHealthcare Commercial; UnitedHealthcare Medicare Solutions;UnitedHealthcare Oxford; and UnitedHealthcare Community Plan of Arizona, Delaware, Florida, Hawaii, Iowa, Kansas,Louisiana, Maryland, Massachusetts, Michigan, Mississippi, Nebraska, New Jersey, New Mexico, New York, Ohio, Pennsylvania,Rhode Island, Tennessee, Texas, Washington and Wisconsin. UnitedHealthcare Community Plan of California will be effectiveon Jan. 1, 2016.



UnitedHealthcare Medicare SolutionsUnitedHealthcare Medicare Advantage Coverage Summary Updates

TABLE OF CONTENTS

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




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Policy Title

TAKE NOTE

ICD-10 Transition: Medicare Administrative Contractor (MAC) Local Coverage Determination (LCD) Updates

UPDATED/REVISED (Approved on Oct. 20, 2015)

Genetic Testing

Laboratory Tests and Services

Medications/Drugs (Outpatient/Part B)

Pain Management and Pain Rehabilitation

Renal Services and Procedures

Shoes and Foot Orthotics

Sleep Apnea – Diagnosis and Treatment

Stimulators – Electrical and Spinal Cord Stimulators

Stimulators – Osteogenic Stimulators

Transplants – Organ and Tissue Transplants

Transvenous (Catheter) for Pulmonary Embolectomy

Uterine Services and Procedures

Ventricular Assist Devices (VAD) and Artificial Heart


UnitedHealthcare Medicare Advantage Coverage Summary Updates




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New Medicare Advantage Referral Required Plans

UnitedHealthcare is pleased to introduce new referral required Medicare Advantage benefit plans for individual members effective Jan. 1, 2016. This affects participating providers for Medicare plans in the following states: Alabama, Arizona, Connecticut, Florida, Georgia, Illinois, Kentucky, Massachusetts, New Hampshire, New Jersey, New York, Ohio, Pennsylvania, Rhode Island, South Carolina, Tennessee, Texas, Vermont, Virginia, and Washington.

Key Plan Features: • PCP selection: Members are required to choose

a primary care physician (PCP) to manage theirhealthcare needs.

• PCP referrals to network specialists: Themember’s PCP must submit electronic referrals onUnitedHealthcareOnline.com prior to the memberseeking care from a network specialist or other healthcare professionals.

• Prior authorization and notification: Membersmust comply with the Notification Requirementssection outlined in the Administrative Guide.

Specialist liability for lack of referralsSpecialists are required to confirm an active referral is recorded on UnitedHealthcareOnline.com before services are rendered. If patients are seen without a referral, then services are not eligible for payment and the claim will deny as provider liability. The member cannot be balanced billed for such services as outlined in the Administrative Guide, section titled Medicare Advantage referral required plans.

How to identify Medicare Advantage Referral-Required Plans:

• Member ID card display: The front of the ID cardwill include the member’s plan name, contract number,PCP information and a referral-required identifier.

• Patient Eligibility: When checking patient eligibility,you can view the member’s plan, contract number anda message indicating that referrals are required forspecialists and other care providers. Please note thatEDI 271 response transactions do not indicate referralrequirements at this time.




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UnitedHealthcare Nursing Home Plan Transitioning to UnitedHealthcare Administrative System

As part of our continued efforts to consolidate and simplify our administrative and claims operations, we will migrate the UnitedHealthcare Nursing Home Plan from the UnitedHealthcare West claims system to the UnitedHealthcare claim system, effective Jan. 1, 2016.

To prepare for this migration, we are providing you advance notice of how these changes may affect your practice. These changes apply only to UnitedHealthcare Nursing Home Plan members and include:

• More consistent use of medical and reimbursement policies and claims operations. Please refer to the current UnitedHealthcare Administrative Guide posted on UnitedHealthcareOnline.com > Quick Links > Policies, Protocols and Administrative Guides. The UnitedHealthcare West supplement in this guide will no longer apply to plan members.

• A different provider website accessible through UnitedHealthcareOnline.com. UnitedHealthcareOnline.com can be used to submit claim reconsideration requests, inpatient notification and prior authorization, check eligibility and benefits, and access copies of member’s identification cards, among other features. Plan members will no longer use UHCWest.com.

• A new provider service phone number: 877-842-3210. Select option 3 to access telephonic inpatient notification and prior authorization. Provider service phone number 877-847-2862 will no longer be used for plan members.

• New health care ID cards with a new member ID number and claim mailing address. Please bill plan member claims with the new ID number beginning with date of service on or after Jan. 1, 2016.

• Access to Electronic Payments and Statements (EPS): UnitedHealthcare’s solution for electronic funds transfers (EFT) and electronic remittance advice (ERA). By enrolling in EPS, you can receive claims payments by direct deposit and access your explanations of benefits (EOBs) online or by 835 ERA files. Go to UnitedHealthcareOnline.com > Quick Links > Electronic Payments and Statements to get started.

• Cardiology and radiology prior authorization will no longer be required for plan members who are not part of a medical group delegated for utilization management beginning Jan. 1, 2016.

These changes will not impact any UnitedHealthcare product other than the UnitedHealthcare Nursing Home plan. Please continue to follow UnitedHealthcare West processes and protocols for other UnitedHealthcare plans as you do currently.

While this migration will involve some initial changes in your office procedures, the end result will be a more consistent and streamlined administrative experience. Thank you for your continued participation in our network. If you have questions, please contact your Network Management representative.





Referrals and Notifications

Knowing the difference between a referral and a notification and when a provider change is required is important to ensure accurate claim payment for the provider as well as increased patient satisfaction.

The most apparent and noticeable difference between a referral and a notification is that a referral number begins with a 7, while a notification number begins with a 4. A referral is the process of sending a TRICARE Prime patient to another professional provider for a consultation or health care service when the requested service is outside the scope of practice for the referring provider. A referral is required for most services for TRICARE Prime beneficiaries if the service is provided by a civilian provider other than the primary care manager (PCM). Referrals are not the same as authorizations.

A notification/authorization is most common with a request for services, a procedure, or admission to a hospital or facility that must be obtained before any service is given (or within 24 hours after an emergency admission unless otherwise specified in the provider’s contract). Authorizations must be obtained prior to services being delivered for those services on the prior authorization list, which can be found at uhcmilitarywest.com.

There are times when after a referral or authorization is approved, that the patient or provider might find the need for the patient to see a different servicing provider than that named on the approval letter. There are times when this requires a change to the named provider and times when it does not. Please review the following to better understand when a change is required.


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Referrals and Notifications

Referrals:If you have a Referral Number (starts with 7) the claim will pay as long as the following two conditions are met. No change is required:

1. You are contracted and have a matching specialty to that approved by the referral; and2. The referral has not been used

Changes or special authorization would be required in the following situations (the patient should contact their PCM to request a new referral):

1. The provider is non-contracted, then a special authorization would be needed, and only approved if there is no other medical resource available to perform the care within 100 miles of the beneficiary’s PCM;2. The provider’s specialty is different from that on the approved referral. A new care request will need to be generated from the beneficiary’s PCM to cover this new specialty; or3. The referral has already been used

Notifications:Unlike referrals, notifications require that the servicing provider on the approval letter must match the rendering provider on the claim. A notification number starts with a 4, and the claim will not pay unless the tax identification number (TIN) for the approved servicing provider in the approval letter matches the TIN for the rendering provider on the submitted claim. In addition, all of the procedures on submitted claims must be included on the approved authorization.

In the event that a change is necessary for a notification and the notification has not been used, please have the patient contact the UnitedHealthcare Military & Veterans Call Center at 877-988-9378.

We are dedicated and committed to payment of appropriate services rendered to eligible beneficiaries, and strive to provide the highest level of customer service to our providers. We look forward to our continued partnership in the delivery of healthcare services to members of the Armed Forces, Retirees, their families, and other TRICARE eligible beneficiaries.





Genadyne will no longer be a participating supplier/provider for negative pressure wound vac therapy (NPWT), support surfaces and breast pumps in the UnitedHealthcare durable medical equipment (DME) network for UnitedHealthcare Commercial, UnitedHealthcare Medicare Solutions, and UnitedHealthcare Community Plan, effective Dec. 31, 2015.

In addition, Target will no longer be a participating supplier for breast pumps in the UnitedHealthcare DME network for UnitedHealthcare Commercial, UnitedHealthcare Medicare Solutions, and UnitedHealthcare Community Plan, effective Dec. 31, 2015.

Please visit myuhc.com for a complete list of UnitedHealthcare local or national DME providers for negative pressure wound vac therapy, support surfaces or breast pumps.

Members who use out-of-network DME providers may incur increased financial liability and higher out-of-pocket expenses. Please refer your patients to in-network physicians and facilities, including DME providers, as outlined in your network participation agreement.

Important Change to Our Network of DME Providers

Doing Business Better

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For complete details on the policy updates listed in the following table, please refer to the November 2015 Policy Update Bulletin at OxfordHealth.com > Providers > Tools & Resources > Medical Information > Medical and Administrative Policies > Policy Update Bulletin.

UnitedHealthcare AffiliatesUnitedHealthcare Oxford Medical and Administrative Policy Updates

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UnitedHealthcare Oxford Medical and Administrative Policy Updates


NEW

Infertility Diagnosis and Treatment Reimbursement Dec. 1, 2015

UPDATED/REVISED

Assistant Surgeon Reimbursement Nov. 1, 2015

Autologous Chondrocyte Transplantation in the Knee Clinical Dec. 1, 2015

B Bundle Codes Reimbursement Dec. 1, 2015

Bilateral Procedures Reimbursement Dec. 1, 2015

Cosmetic and Reconstructive Procedures Reimbursement Dec. 1, 2015

Co-Surgeons; Team Surgeon Clinical Dec. 1, 2015

Deep Brain Stimulation Clinical Dec. 1, 2015

Diabetic Insulins Clinical Dec. 1, 2015

Discogenic Pain Treatment Clinical Dec. 1, 2015

Discontinued Procedures Reimbursement Dec. 1, 2015

Drug Coverage Criteria - New and Therapeutic Equivalent Medications Clinical Dec. 1, 2015

Drug Coverage Guidelines ClinicalNov. 1, 2015

Dec. 1, 2015

Durable Medical Equipment, Orthotics and Prosthetics Multiple Frequency Reimbursement Dec. 1, 2015

Electrical Stimulation for the Treatment of Pain and Muscle Rehabilitation Clinical Dec. 1, 2015

Implanted Electrical Stimulator for Spinal Cord Clinical Dec. 1, 2015

Injectable Chemotherapy Drugs: Application Of NCCN Clinical Practice Guidelines Clinical Dec. 1, 2015

Increased Procedural Services Reimbursement Dec. 1, 2015

Injectable Chemotherapy Drugs: Application Of NCCN Clinical Practice Guidelines Clinical Feb. 1, 2016




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Injection and Infusion Services Reimbursement Dec. 1, 2015

Lyme Disease Clinical Nov. 1, 2015

Maximum Dosage Policy Clinical Nov. 1, 2015

Maximum Frequency Per Day Reimbursement Dec. 1, 2015

Microsurgery Reimbursement Dec. 1, 2015

Minimally Invasive Procedures for Gastroesophageal Reflux Disease (GERD) Clinical Nov. 1, 2015

Moderate Sedation Reimbursement Dec. 1, 2015

Modifier Reference Reimbursement Dec. 1, 2015

Neurophysiologic Testing Clinical Dec. 1, 2015

Obstructive Sleep Apnea Treatment Clinical Dec. 1, 2015

One or More Sessions Reimbursement Dec. 1, 2015

Osteochondral Grafting of Knee Clinical Dec. 1, 2015

Par Gastroenterologists Using Non-Par Anesthesiologists in Office Settings Administrative Dec. 1, 2015

Preventive Medicine and Screening Reimbursement Dec. 1, 2015

Prolonged Services Reimbursement Dec. 1, 2015

Reduced Services Reimbursement Dec. 1, 2015

Robotic-Assisted Surgery Reimbursement Dec. 1, 2015

Same Day/Same Service Reimbursement Dec. 1, 2015

Select Brand Medications Clinical Nov. 1, 2015

Sensory Integration Therapy and Auditory Integration Training Clinical Nov. 1, 2015

Speech Therapy and Early Intervention Programs/Birth to Three Administrative Nov. 1, 2015

Split Surgical Package Reimbursement Dec. 1, 2015




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Standby Services Reimbursement Dec. 1, 2015

Standing Systems and Gait Trainers Clinical Dec. 1, 2015

Supply Policy Reimbursement Dec. 1, 2015

T Status Codes Reimbursement Dec. 1, 2015

Telemedicine Reimbursement Dec. 1, 2015

Urgent Care Reimbursement Dec. 1, 2015

Vagus Nerve Stimulation Clinical Dec. 1, 2015

Visual Information Processing Evaluation and Orthoptic and Vision Therapy Clinical Nov. 1, 2015

Warming Therapy and Ultrasound Therapy for Wounds Clinical Nov. 1, 2015

REPLACED/RETIRED

Diagnostic (Basic) Procedures for Infertility Clinical Dec. 1, 2015

Entresto (Valsartan-Sacubitril) Clinical Nov. 1, 2015

Infertility Procedures Requiring Notification and/or Precertification Clinical Dec. 1, 2015

Treatment of Infertility Clinical Dec. 1, 2015

Treatment of Infertility for Connecticut Groups Clinical Dec. 1, 2015

Treatment of Infertility for New Jersey Large Groups Clinical Dec. 1, 2015

Treatment of Infertility for New Jersey Small Groups and New Jersey Individual Plans Clinical Dec. 1, 2015

Treatment of Infertility for New York Large and Small Groups Clinical Dec. 1, 2015

Note: The inclusion of a service or procedure on this list does not imply that UnitedHealthcare Oxford provides coverage for the service or procedure. In the event of an inconsistency between the information 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.




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For complete details on the policy updates listed in the following table, please refer to the November 2015 Policy Update Bulletin at UHCRiverValley.com > Providers > Coverage Policy Library > Policy Update Bulletin.

Policy Title Policy Type

TAKE NOTE

Updated Prior Authorization List and Coverage Policies for UnitedHealthcare of the River Valley Feb. 1, 2016

UPDATED/REVISED

Abnormal Uterine Bleeding and Uterine Fibroids Jan. 1, 2016

Autologous Chondrocyte Transplantation in the Knee Dec. 1, 2015

Breast Imaging for Screening and Diagnosing Cancer Jan. 1, 2016

Breast Reconstruction Post-Mastectomy Jan. 1, 2016

Breast Repair/Reconstruction (Not Following Mastectomy) Jan. 1, 2016

Clinical Trials Dec. 1, 2015

Computed Tomographic Colonography Nov. 1, 2015

Cosmetic and Reconstructive Procedures Dec. 1, 2015

Deep Brain Stimulation Dec. 1, 2015

Electrical Stimulation for the Treatment of Pain and Muscle Rehabilitation Dec. 1, 2015

Genetic Testing for Hereditary Breast and/or Ovarian Cancer Syndrome (HBOC) Jan. 1, 2016

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

Implanted Electrical Stimulator for Spinal Cord Dec. 1, 2015

Infertility Diagnosis and Treatment Dec. 1, 2015

UnitedHealthcare of the River Valley Preauthorization List and Coverage Policy Updates




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UnitedHealthcare of the River Valley Preauthorization List and Coverage Policy Updates

Policy Title Policy Type

Intensive Behavioral Therapy for Autism Spectrum Disorder Nov. 1, 2015

Neurophysiologic Testing Dec. 1, 2015

Obstructive Sleep Apnea Treatment Dec. 1, 2015

Omnibus Codes Jan. 1, 2016

Osteochondral Grafting of Knee Dec. 1, 2015

Proton Beam Radiation Therapy Dec. 1, 2015

Standing Systems and Gait Trainers Dec. 1, 2015

Vagus Nerve Stimulation Dec. 1, 2015

Virtual Upper Gastrointestinal Endoscopy Nov. 1, 2015





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SignatureValue Medical Management Guideline Updates

For complete details on the policy updates listed in the following table, please refer to the November 2015 SignatureValue™ Medical Management Guidelines Update Bulletin at UHCWest.com > Provider Log In > Library > Resource Center > Guidelines & Interpretation Manuals.

Policy Title Effective Date

NEW

Molecular Profiling to Guide Cancer Treatment Dec. 1, 2015

UPDATED/REVISED

Abnormal Uterine Bleeding and Uterine Fibroids Jan. 1, 2016

Autologous Chondrocyte Transplantation in the Knee Dec. 1,2015

Breast Imaging for Screening and Diagnosing Cancer Jan. 1, 2016

Computed Tomographic Colonography Nov. 1, 2015

Cosmetic and Reconstructive Procedures Dec. 1,2015

Deep Brain Stimulation Dec. 1,2015

Electrical Stimulation for the Treatment of Pain and Muscle Rehabilitation Dec. 1,2015

Genetic Testing for Hereditary Breast and/or Ovarian Cancer Syndrome (HBOC) Jan. 1, 2016

Hospital Readmissions Nov. 1, 2015

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

Implanted Electrical Stimulator for Spinal Cord Dec. 1,2015

Intensive Behavioral Therapy for Autism Spectrum Disorder Nov. 1, 2015

Obstructive Sleep Apnea Treatment Dec. 1,2015




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SignatureValue Medical Management Guideline Updates

Policy Title Effective Date

UPDATED/REVISED

Omnibus Codes Jan. 1, 2016

Osteochondral Grafting of Knee Dec. 1,2015

Panniculectomy and Body Contouring Procedures Dec. 1,2015

Proton Beam Radiation Therapy Dec. 1,2015

Standing Systems and Gait Trainers Dec. 1,2015

Vagus Nerve Stimulation Dec. 1,2015

Virtual Upper Gastrointestinal Endoscopy Nov. 1, 2015





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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 November 2015 SignatureValue™ Benefit Interpretation Policy Update Bulletin at UHCWest.com > Provider Log In > Library > Resource Center > Guidelines & Interpretation Manuals.

Policy Title Applicable State(s)

UPDATED/REVISED (Effective Dec. 1, 2015)

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

Chemotherapy All

Clinical Trials All

Continuity of Care All

Developmental Delay and Learning Disabilities All

Pain Management All

Preventive Care Services Texas

Respite Care Washington





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Reminder: Chemotherapy Prior Authorization Requirement Effective for UnitedHealthcare Oxford

In an effort to improve cancer care and reduce service denials for UnitedHealthcare Oxford members undergoing cancer treatment, UnitedHealthcare Oxford will require prior authorization for injectable outpatient chemotherapy drugs given for a cancer diagnosis, effective Feb. 1, 2016.

UnitedHealthcare Oxford uses the National Comprehensive Cancer Network (NCCN) Compendium to review requests and claims for coverage for chemotherapy drugs administered in an outpatient setting. This source provides independent, respected recommendations and it is available at nccn.org. The new prior authorization review process continues to use the NCCN Guidelines and Compendium as the basis for coverage.

To support the injectable outpatient chemotherapy prior authorization process, we have contracted with eviCore National. The new program will review specific regimens and lines of therapy.

The following injectable chemotherapy drugs will require prior authorization:

• Chemotherapy injectable drugs (J9000 - J9999), Leucovorin (J0640), Levoleucovorin (J0641)

• Chemotherapy injectable drugs that have a Q code

• Chemotherapy injectable drugs that have not yet received an assigned code and will be billed under a miscellaneous healthcare common procedure coding system (HCPCS) code will require prior authorization

• All outpatient injectable chemotherapy drugs started after the chemotherapy prior authorization effective date require authorization

• Adding a new injectable chemotherapy drug to a regimen will require a new authorization

Additional details about the prior authorization requirement and how to obtain an authorization will be available in the provider section of https://www.oxhp.com/ and on UnitedHealthcareOnline.com in mid-January.

Network Bulletin: November 2013 - Volume 583636 Network Bulletin: December 2015

Doc#: 1-000065_11092015_11202015

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

Network Bulletin: December 2015 network bulletin - …€¢ UnitedHealthcare Nursing Home Plan Transitioning ... In the November 2015 Network Bulletin, ... Abnormal Uterine Bleeding

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