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 net work bulletin Network Bulletin: February 2015 enter
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Transcript
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 suchapplicable federal and/or state law
network bulletinNetwork Bulletin: February 2015
enter
Network Bulletin: November 2013 - Volume 58 For more information call 877.842.3210, or visit UnitedHealthcareOnline.com2
Table of Contents
For more information call 877.842.3210, or visit UnitedHealthcareOnline.com2 Network Bulletin: February 2015
In order to save you time as you go about your busy day, you can click on any of the articles below and be taken directly to that article. You can also return to the Table of Contents from any page in the Network Bulletin by simply clicking “Table of Contents” in the top right-hand corner of any page.
Front & Center
• Update to Global Surgery Reimbursement Policy
• Injectable Chemotherapy Prior Authorization Program
• Credentialing Plan Changes Effective April 1, 2015
• IMRT Prior Authorization Requirementfor Commercially Insured Members
• Preauthorization List Additions for UnitedHealthcareof the River Valley Commercial Members Delayed
• Enhanced HIPAA Claim Edits Planned for March 2015
UnitedHealthcare Commercial
• UnitedHealthcare Medical Policy, Drug Policy,Coverage Determination Guideline andUtilization Review Guideline Updates
• SignatureValue™ Medical ManagementGuideline Updates
• UnitedHealthcare Oxford® Medical andAdministrative Policy Updates
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Network Bulletin: November 2013 - Volume 58 For more information call 877.842.3210, or visit UnitedHealthcareOnline.com33 For more information call 877.842.3210,
or visit UnitedHealthcareOnline.comNetwork Bulletin: February 2015
To further align with the Centers for Medicare and Medicaid Services (CMS), UnitedHealthcare will adopttheCMSprocessformodifier78forMedicareAdvantage plans effective April 1, 2015.
Whenmodifier78isreportedforaprocedurehavingaGlobalDaysValue of 010 or 090, UnitedHealthcare will reimburse only for the intraoperativepercentageofthemodifiedprocedure,determinedby the intraoperative percentage listed on the CMS Medicare Physician Fee Schedule (MPFS). This will result in payment reductions accordingly.
According to the CMS Medicare Claims Processing Manual, Chapter 12, Section 40.4C: “When a CPT code billed with modifier‘-78’describestheservicesinvolvingareturntriptotheoperating room to deal with complications, pay the value of the intra-operative services of the code that describes the treatment of the complications. Refer to Field 18 of the MPFS to determine the percentage of the global package for the intra-operative services.”
Policy updates to include this information will be published to UnitedHealthcareOnline.com, and the reductions noted above will become effective beginning April 1, 2015.
To view the policy, please go to:
UnitedHealthcareOnline.com > Tools & Resources > Policies, Protocols and Guides > Medicare Advantage Reimbursement Policies > Global Surgery.
Update to Global Surgery Reimbursement Policy
Front & Center
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Front & Center
TABLE OF CONTENTS
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Network Bulletin: November 2013 - Volume 58 For more information call 877.842.3210, or visit UnitedHealthcareOnline.com44 For more information call 877.842.3210,
or visit UnitedHealthcareOnline.comNetwork Bulletin: February 2015
Effective June 1, 2015, providers billing for outpatient injectable chemotherapy for UnitedHealthcare Commercial members* being treated for a cancer diagnosis are required to obtain prior authorization for services.
UnitedHealthcare’sInjectableChemotherapyPriorAuthorization Program will be managed by CareCore National’sOncologyDivisiononourbehalfandproviders will be able to obtain injectable chemotherapy authorizationsonCareCore’swebsite.
Authorizations that follow the National Comprehensive Cancer Network (NCCN) regimens will be approved at the time of the request online. Requests for pediatric chemotherapy regimens, rare cancers, or chemotherapy regimens that are not NCCN-recommended, can also receive a timely response if necessary supporting documentation is provided at the time of the prior authorization request.
UnitedHealthcare Injectable Chemotherapy Prior Authorization training and live question and answer sessions will be held by WebEx.
Registration details will be posted on our website in April at: UnitedHealthcareOnline.com > Clinician Resources > Cancer – Oncology > Chemotherapy Prior Authorization Program.
*UnitedHealthcare Fully Insured and select ASO membership will require chemotherapy prior authorization. The CareCore National website will assist providers in identifying members that require prior authorization for chemotherapy.
Injectable Chemotherapy Prior Authorization Program
Front & Center
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Network Bulletin: November 2013 - Volume 58 For more information call 877.842.3210, or visit UnitedHealthcareOnline.com55 For more information call 877.842.3210,
or visit UnitedHealthcareOnline.comNetwork Bulletin: February 2015
UnitedHealthcare reviews and updates our Credentialing Plan at least every two years to ensure continued compliance with all State and Federal regulatory requirements and National Committee for Quality Assurance (NCQA) accreditation requirements.
The 2015-2016 Credentialing Plan and State and Federal Regulatory Addendum will become effective April 1, 2015. The following are some of the key changes:
or prohibition from performing a service or proceduretypically provided by other practitioners in the sameor a similar specialty is a material restriction that willresult in termination of participation.
Section 4.0 Initial Credentialing of Licensed Independent Practitioner Applicants• Clarifieslanguageregardingtheimpactofalicense
sanction from a state where the practitioner islicensed but is no longer in active practice. Licenseactions from non-practice states may result in denial/termination unless the license action is based onadministrative issues or as a result of action taken byanother state licensing board.
Management. UnitedHealthcare has committed to ourmembers and care providers to support the Triple Aimof improving the patient care experience, improvinghealth outcomes, and reducing the cost of health care.
To drive continuous improvement in quality through Healthcare Effectiveness Data and Information Set (HEDIS) and Centers for Medicare and Medicaid Services’StarRatingsmeasuresandefficiencyofhealth care models, the credentialing entity may, from time to time, send reports to participating licensed independent physicians (LIPs) regarding their performance as compared to peers. To support physicians in their efforts, when practice patterns areidentifiedthatmayrepresentopportunitiestoimprove quality and reduce unwarranted variation, UnitedHealthcare will identify those practice patterns andprovideidentifiedphysicianswiththetoolsandinformation to improve resource utilization in a way consistent with evidence-based medicine guidelines. In the event that unwarranted variation does not improve, UnitedHealthcare may take actions up to and including termination of participation status
The Credentialing Plan will be posted to UnitedHealthcareOnline.com by April 1, 2015.
Credentialing Plan Changes Effective April 1, 2015
Front & Center
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Network Bulletin: November 2013 - Volume 58 For more information call 877.842.3210, or visit UnitedHealthcareOnline.com66 For more information call 877.842.3210,
or visit UnitedHealthcareOnline.comNetwork Bulletin: February 2015
For several years, prior authorization for Intensity Modulated Radiation Therapy (IMRT) CPT codes 77418 and 0073T has been required. On Jan. 1, 2015, the American Medical Association (AMA) released CPT code changes affecting the billing for IMRT services and codes 77418 and 0073T were deleted. Prior authorization will, as a result, be required for the following codes, effective Jan. 1, 2015:
• G6016: Compensator-based beam modulationtreatment delivery of inverse planned treatmentusing 3 or more high resolution (milled or cast)compensator,convergentbeammodulatedfields,per treatment session
• 77385: Intensity modulated radiation treatmentdelivery, includes guidance and tracking, whenperformed; simple
• 77386: Intensity modulated radiation treatmentdelivery, includes guidance and tracking, whenperformed; complex
These codes impact Commercial members of the following health plans:• UnitedHealthcare
• UnitedHealthcare West
• UnitedHealthcare of the Mid-Atlantic
• UnitedHealthcare Plan of the River Valley
• Neighborhood Health Partnership
Please use the G6015 and G6016 codes when billing for IMRT services in 2015.
Prior authorization requests approved in 2014 with an authorized date range, including services in 2015, are not affected. A claims crosswalk table will be used to process claims for CPT codes G6015, G6016, 77385 and 77386, when an authorization is in place for 77418 and/or 0073T for authorized dates of service in 2015. Services that are billed that do not fall within the authorized date range will require prior authorization.
Revised IMRT fax cover sheets that include the new CPT codes for IMRT services (G6015, G6016, 77385 and 77386) are available on at UnitedHealthcareOnline.com > Clinician Resources > Oncology > Intensity Modulated Radiation Therapy > Related Links.
The clinical questions and list of diagnosis codes that do not require additional clinical information have been updatedtoreflectourrevisedIMRTclinicalpolicy. Prior authorization requests submitted after Jan. 1, 2015 will not be accepted if submitted on the 2014 IMRT fax cover sheets.
ThemostefficientwaytorequestpriorauthorizationforIMRT is to complete the appropriate IMRT clinical form and fax cover sheet and fax your request.
You may also request prior authorization for IMRT at UnitedHealthcareOnline.com.
IMRT Prior Authorization Requirement for Commercially Insured Members
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Network Bulletin: November 2013 - Volume 58 For more information call 877.842.3210, or visit UnitedHealthcareOnline.com77 For more information call 877.842.3210,
or visit UnitedHealthcareOnline.comNetwork Bulletin: February 2015
Previously announced changes have been delayed until further notice for UnitedHealthcare of the River Valley commercial members and participating providers that are subject to the River Valley Entities Supplement. Updates regarding the changes will be included in a future issue of the Network Bulletin.
In the November 2014 Network Bulletin, we announced a new requirement with respect to certain radiology services that would become effective Feb. 16, 2015 for River Valley commercial members and participating providers that are subject to the River Valley Entities Supplement.
Given the delay and until further notice, providers will not be required to obtain preauthorization prior to rendering certain advanced imaging procedures provided to River Valley Commercial members, including: Computerized Tomography (CT), Magnetic Resonance Imaging (MRI), Magnetic Resonance Angiography (MRA), Positron-Emission Tomography (PET), Nuclear Medicine and Nuclear Cardiology.
Youcanfindinformationaboutthe preauthorization requirements at UHCRiverValley.com > Preauthorizations > Procedures, DME, and Other Services
Preauthorization List Additions for UnitedHealthcare of the River Valley Commercial Members Delayed
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Network Bulletin: November 2013 - Volume 58 For more information call 877.842.3210, or visit UnitedHealthcareOnline.com88 For more information call 877.842.3210,
or visit UnitedHealthcareOnline.comNetwork Bulletin: February 2015
Enhanced HIPAA Claim Edits Planned for March 2015
Effective March 25, 2015, UnitedHealthcare will apply additional WEDI Strategic National Implementation Process (SNIP) HIPAA edits to professional (837p) and institutional (837i) claimssubmittedelectronicallytomostUnitedHealthcareandaffiliatepayer IDs.* These are new edits that were not applied with the edit enhancements released in 2014. For more information on current and previous edit releases, visit the Enhanced Claim Edits section of UnitedHealthcareOnline.
Because the new edits will be applied on a pre-adjudication basis, an increase in the number of claim rejections may occur. This will enable you to identifyandcorrectrejectedinformationpriortotheclaim’sacceptance into our adjudication system for processing. Thebenefitwillbefewerdeniedclaimsandlessinterruptionto revenue streams.
The primary impact to you will come from edits that will validate code sets (such as diagnosis, procedure andmodifiercodes)atapre-adjudicationlevel.The new edits have been distributed to clearinghouses and software vendors.
It’simportanttocheckallofyourclaimsubmissionreportsregularly. Claims may be rejected by your clearinghouse or UnitedHealthcare; therefore, you may receive multiple reports per submission. View tracking your electronicclaims to learn more about reports and rejections.
Rejections that may occur from the enhanced edits will appear at a clearinghouse level. Your Electronic Data Interchange (EDI) vendor or clearinghouse should be your firstpointofcontactforassistanceregardingtheseeditsorto resolve rejections. For assistance from UnitedHealthcare, please contact EDI Support:
* Excluded: Harvard Pilgrim (04271), Medica HealthCare Plans (78857), Preferred Care Partners (65088), the Alliance (88461) and TRICARE West (99726)
UnitedHealthcare Commercial, UnitedHealthcare Medicare Solutions and UnitedHealthcare West
Network Bulletin: November 2013 - Volume 58 For more information call 877.842.3210, or visit UnitedHealthcareOnline.com99 For more information call 877.842.3210,
or visit UnitedHealthcareOnline.comNetwork Bulletin: February 2015
UnitedHealthcare Medical Policy, Drug Policy, Coverage Determination Guideline and Utilization Review Guideline Updates
UnitedHealthcare Commercial
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For complete details on the policy updates listed in the table on the following page, please refer to the monthly Medical Policy Update Bulletin at UnitedHealthcareOnline.com > Tools & Resources > Policies, Protocols and Guides > Medical & Drug Policies and Coverage Determination Guidelines > Medical Policy Update Bulletin.
UnitedHealthcare Commercial
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Network Bulletin: November 2013 - Volume 58 For more information call 877.842.3210, or visit UnitedHealthcareOnline.com1010 For more information call 877.842.3210,
or visit UnitedHealthcareOnline.comNetwork Bulletin: February 2015
UnitedHealthcare Medical Policy, Drug Policy, Coverage Determination Guideline and Utilization Review Guideline Updates
Policy Title Policy Type Effective Date
Medical Policy Update Bulletin
NEW
Balloon Sinus Ostial Dilation Medical Policy April 1, 2015 Jan. 2015Feb. 2015
Entyvio (Vedolizumab) Drug Policy March 1, 2015 Dec. 2014Jan. 2015Feb. 2015
Hysterectomy for Benign Conditions Medical Policy April 1, 2015 Jan. 2015Feb. 2015
Simponi Aria (Golimumab) Drug Policy March 1, 2015 Dec. 2014Jan. 2015Feb. 2015
UPDATED/REVISED
Deep Brain Stimulation Medical Policy Feb. 1, 2015 Jan. 2015
Electrical Stimulation and Electromagnetic Therapy for Wounds
Medical Policy Feb. 1, 2015 Jan. 2015
Epiduroscopy, Epidural Lysis of Adhesions and Functional Anesthetic Discography
Medical Policy Feb. 1, 2015 Jan. 2015
Hip Resurfacing Arthroplasty Medical Policy Feb. 1, 2015 Jan. 2015
Implantable Beta-Emitting Microspheres for Treatment of Malignant Tumors
Medical Policy Feb. 1, 2015 Jan. 2015
Infertility Diagnosis and Treatment Medical Policy Feb. 1, 2015 Jan. 2015
Mechanical Stretching and Continuous Passive Motion Devices
Medical Policy Feb. 1, 2015 Jan. 2015
Nerve Graft to Restore Erectile Function Medical Policy Feb. 1, 2015 Jan. 2015
Omnibus Codes Medical Policy Feb. 1, 2015 Jan. 2015
Preventive Care Services Coverage Determination Guideline
Feb. 15, 2015 Jan. 2015
Prosthetic Devices, Wigs, Specialized, Microprocessor or Myoelectric Limbs
Coverage Determination Guideline
Feb. 1, 2015 Jan. 2015
UnitedHealthcare Commercial
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Network Bulletin: November 2013 - Volume 58 For more information call 877.842.3210, or visit UnitedHealthcareOnline.com1111 For more information call 877.842.3210,
or visit UnitedHealthcareOnline.comNetwork Bulletin: February 2015
Policy Title Policy Type Effective Date
Medical Policy Update Bulletin
Radiofrequency Therapy and Tibial Nerve Stimulation for Urinary Disorders
Medical Policy Feb. 1, 2015 Jan. 2015
Sensory Integration Therapy and Auditory Integration Training
Medical Policy Feb. 1, 2015 Jan. 2015
Surgical Treatment for Spine Pain Medical Policy Feb. 1, 2015 Jan. 2015
Temporomandibular Joint Disorders Medical Policy Jan. 1, 2015 Jan. 2015
Transcranial Magnetic Stimulation Medical Policy Feb. 1, 2015 Jan. 2015
Intrastromal Corneal Ring Segments Medical Policy Jan. 1, 2015 Jan. 2015
UnitedHealthcare Medical Policy, Drug Policy, Coverage Determination Guideline and Utilization Review Guideline Updates
Note: The inclusion of a service or procedure on this list does not imply that UnitedHealthcare provides coverage for the service or procedure. In the event
of an inconsistency between the information provided in this Network Bulletin and the posted policy, the posted policy prevails.
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Network Bulletin: November 2013 - Volume 58 For more information call 877.842.3210, or visit UnitedHealthcareOnline.com1212 For more information call 877.842.3210,
or visit UnitedHealthcareOnline.comNetwork Bulletin: February 2015
For complete details on the updated/revised policies listed in the table on the following page, please refer to the Medicare Advantage Coverage Summary Update Bulletin at UnitedHealthcareOnline.com> Tools & Resources > Policies, Protocols and Guides > UnitedHealthcare Medicare Advantage Coverage Summaries > Update Bulletin.
UnitedHealthcare Medicare Solutions
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Network Bulletin: November 2013 - Volume 58 For more information call 877.842.3210, or visit UnitedHealthcareOnline.com1313 For more information call 877.842.3210,
or visit UnitedHealthcareOnline.comNetwork Bulletin: February 2015
Policy Title Approval Date Update Bulletin
UPDATED/REVISED
Chemotherapy, and Associated Drugs and Treatments Dec. 16, 2014 Jan. 2015
Family Planning (Birth Control) Dec. 16, 2014 Jan. 2015
Foot Care Services Dec. 16, 2014 Jan. 2015
Hearing Aids, Auditory Implants and Related Procedures Dec. 16, 2014 Jan. 2015
Hyperbaric Oxygen Therapy Dec. 16, 2014 Jan. 2015
Nasal and Sinus Procedures Dec. 16, 2014 Jan. 2015
Orthopedic Procedures, Devices and Products Dec. 16, 2014 Jan. 2015
Note: The inclusion of a service or procedure on this list does not imply that UnitedHealthcare provides coverage for the service or procedure. In the event
of an inconsistency between the information provided in this Network Bulletin and the posted policy, the posted policy prevails.
UnitedHealthcare Medicare Solutions
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Network Bulletin: November 2013 - Volume 58 For more information call 877.842.3210, or visit UnitedHealthcareOnline.com1414 For more information call 877.842.3210,
or visit UnitedHealthcareOnline.comNetwork Bulletin: February 2015
Medical Policy & Coverage Determination Guideline Updates
For complete details on the policy updates listed in the table on the following page, please refer to the monthly Medical Policy Update Bulletin at UHCCommunityPlan.com > Provider Information > Medical Policies and Coverage Determination Guidelines for Community Plan.
UnitedHealthcare Community Plan
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Network Bulletin: November 2013 - Volume 58 For more information call 877.842.3210, or visit UnitedHealthcareOnline.com1515 For more information call 877.842.3210,
or visit UnitedHealthcareOnline.comNetwork Bulletin: February 2015
Policy Title Policy Type Effective Date
Medical Policy Update Bulletin
UPDATED/REVISED
Deep Brain Stimulation Medical Policy March 1, 2015 Jan. 2015Feb. 2015
Electrical Stimulation and Electromagnetic Therapy for Wounds
Medical Policy March 1, 2015 Jan. 2015Feb. 2015
Epiduroscopy, Epidural Lysis of Adhesions and Functional Anesthetic Discography
Medical Policy March 1, 2015 Jan. 2015Feb. 2015
Hip Resurfacing Arthroplasty Medical Policy March 1, 2015 Jan. 2015Feb. 2015
Implantable Beta-Emitting Microspheres for Treatment of Malignant Tumors
Medical Policy March 1, 2015 Jan. 2015Feb. 2015
Mechanical Stretching and Continuous Passive Motion Devices
Medical Policy March 1, 2015 Jan. 2015Feb. 2015
Nerve Graft to Restore Erectile Function During Radical Prostatectomy
Medical Policy March 1, 2015 Jan. 2015Feb. 2015
Obstructive Sleep Apnea Treatment Medical Policy March 1, 2015 Jan. 2015Feb. 2015
Omnibus Codes Medical Policy March 1, 2015 Jan. 2015Feb. 2015
Radiofrequency Therapy and Tibial Nerve Stimulation for Urinary Disorders
Medical Policy March 1, 2015 Jan. 2015Feb. 2015
Sensory Integration Therapy and Auditory Integration Training
Medical Policy March 1, 2015 Jan. 2015Feb. 2015
Surgical Treatment for Spine Pain Medical Policy March 1, 2015 Jan. 2015Feb. 2015
Medical Policy & Coverage Determination Guideline Updates
UnitedHealthcare Community Plan
UnitedHealthcare Community Plan
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Network Bulletin: November 2013 - Volume 58 For more information call 877.842.3210, or visit UnitedHealthcareOnline.com1616 For more information call 877.842.3210,
or visit UnitedHealthcareOnline.comNetwork Bulletin: February 2015
Medical Policy & Coverage Determination Guideline Updates
Policy Title Policy Type Effective Date
Medical Policy Update Bulletin
Transcranial Magnetic Stimulation Medical Policy March 1, 2015 Jan. 2015Feb. 2015
RETIRED
Intrastromal Corneal Ring Segments Medical Policy Jan. 1, 2015 Jan. 2015
Temporomandibular Joint Disorders Medical Policy Jan. 1, 2015 Jan. 2015
Note: The inclusion of a service or procedure on this list does not imply that UnitedHealthcare provides coverage for the service or procedure. In the event
of an inconsistency between the information provided in this Network Bulletin and the posted policy, the posted policy prevails.
Next Article >
Network Bulletin: November 2013 - Volume 58 For more information call 877.842.3210, or visit UnitedHealthcareOnline.com1717 For more information call 877.842.3210,
or visit UnitedHealthcareOnline.comNetwork Bulletin: February 2015
E-Prescribing – Now Available at Military Pharmacies
On Dec. 31, 2014, the Military Health System (MHS) deployed electronic prescribing capability. TRICARE providers can now send prescriptions electronically to military pharmacies, offering a new option for their patients.
To send a prescription electronically to a military pharmacy, providersonlyneedtofindthelocalmilitarypharmacynameintheir existing e-prescribing software application. Military pharmacy namesusuallystartwiththeprefix“DOD”.TRICAREpatientswhofillmedicationsatamilitarypharmacycangetuptoa90-daysupply for most medications, compared to a 30-day supply through a retail network pharmacy. They also have no copay or cost share for medications from military pharmacies.
One thing to keep in mind is that military pharmacies may have more limited formularies than some retail pharmacies. All pharmaciesintheMHSstockmedicationsthatareonTRICARE’s
“basic core formulary” can also carry additional medications based on the needs of the military population they serve. Military pharmacies will not be able to accept electronic prescriptions for controlled substances. You will still need a hand written prescription for these medications.
For the latest information on electronic prescribing at military pharmacies, you can visit the Defense Health Agency Pharmacoeconomic Branch website. For more information ontheTRICAREmembersfillingprescriptionsatmilitarypharmacies,ortofindamilitarypharmacynearyouthatyourTRICARE patients might want to use, please visit the TRICARE Pharmacy page.
UnitedHealthcare Military & Veterans
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Network Bulletin: November 2013 - Volume 58 For more information call 877.842.3210, or visit UnitedHealthcareOnline.com1818 For more information call 877.842.3210,
or visit UnitedHealthcareOnline.comNetwork Bulletin: February 2015
Unless otherwise noted, these reimbursement policies apply to services reported using the 1500 Health Insurance Claim Form (CMS-1500) or its electronic equivalent or its successor form. UnitedHealthcare reimbursement policies do not address all factors that affect reimbursement for services rendered to UnitedHealthcare members,includinglegislativemandates,enrolleebenefitcoveragedocuments, 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 ofaninconsistencyorconflictbetweentheinformationprovidedin the Network Bulletin and the posted policy, the provisions of the posted policy prevail.
UnitedHealthcare Commercial Reimbursement Policy
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UnitedHealthcare Commercial Reimbursement Policy
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Network Bulletin: November 2013 - Volume 58 For more information call 877.842.3210, or visit UnitedHealthcareOnline.com1919 For more information call 877.842.3210,
or visit UnitedHealthcareOnline.comNetwork Bulletin: February 2015
UnitedHealthcare does not currently reimburse Evaluation and Management (E/M) CPT codes 99201-99499whensubmittedbyspecificnonphysicianhealthcareprofessionals.Accordingtothe Centers for Medicare and Medicaid Services (CMS), E/M services are reimbursable to certain nonphysicianpractitioners,limitedtonursepractitioners,clinicalnursespecialists,certifiednursemidwives, and physician assistants.
Effective in the second quarter of 2015, UnitedHealthcare will expand the scope of this policy to not reimburse E/M CPT 99201-99499 when reported by the following nonphysician health care professionals:
• Licensed practical nurse
• Licensed vocational nurse
• Home health/private duty nurse
• Visiting nurse
• Behavioral analyst
• Genetic counselor
• Alcohol and drug counselor
• Crisis diversion
• Employee assistance program (EAP) counselor
• Empowerment coach
• Marriage & family therapy/licensed marriageand family therapy
• Licensed professional counselor
• Substance abuse services, alcohol & drug
• Other mental health counselor
• Christian science practitioner
• Registered social worker
• Marriage and family social worker
• Pharmacist
These professionals should review the CPT and healthcare common procedure coding system (HCPCS) national code sets to select a more accurate code that describes the services they are providing.
Revision to the Nonphysician Health Care Professionals Billing Evaluation and Management Codes Policy
UnitedHealthcare Commercial Reimbursement Policy
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Network Bulletin: November 2013 - Volume 58 For more information call 877.842.3210, or visit UnitedHealthcareOnline.com2020 For more information call 877.842.3210,
or visit UnitedHealthcareOnline.comNetwork Bulletin: February 2015
UnitedHealthcarewillnotreimbursemodifiersH9,HU-HZ, QJ or TR, effective in the second quarter of2015.Theuseofthefollowingmodifiersindicates that a service has been funded by a county, state or federal agency; therefore, no cost has been incurred requiring reimbursement:
ModifiersBeingAddedtoServicesandModifiersNot Reimbursable to Health Care Professionals Policy
Modifier Description
H9 Court-ordered
HU Funded by child welfare agency
HV Funded state addictions agency
HW Funded by state mental health agency
HX Funded by county/local agency
HY Funded by juvenile justice agency
HZ Funded by criminal justice agency
QJ Services/items provided to a prisoner or patient in state or local custody, however the state or local government, as applicable, meets the requirements in 42 CFR 411.4 (B)
TR School-based individualized education program services provided outside the public school district responsible for the student
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Network Bulletin: November 2013 - Volume 58 For more information call 877.842.3210, or visit UnitedHealthcareOnline.com2121 For more information call 877.842.3210,
or visit UnitedHealthcareOnline.comNetwork Bulletin: February 2015
We continue to monitor and review our processes to provide the best service to our constituents. We completed our annual review of the claim reconsideration and appeal process for our Provider Administrative Guide for 2015 and wanted to take this opportunity to highlight the following summary*:
The Two-Step Process Step one is the reconsideration level: Requests for reconsideration must be submitted within 12 months of the date ontheinitialExplanationofBenefits(EOB).Itisimportanttosubmit the reconsideration level early in the process since the reconsideration level and the appeal level share one 12-month timeframe. The request must include the Claim Reconsideration Form located online and all supporting documentation.
For more information on how to obtain the form, please see the Provider Administrative Guide located at UnitedHealthcareOnline.com > Policies, Protocols and Administrative Guides > UnitedHealthcare Administrative Guide for 2015.
If the reconsideration does not result in an overturned decision, the EOB or response letter will include next level rights and where to submit a request for further review.
Step two is the appeal level: Appeals must be submitted within the same 12-month time period as stated above. Please submit all supporting materials that you wish to have reviewed in the
Claim Reconsideration and Appeal Process Summary
Doing Business Better
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Doing Business Better
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or visit UnitedHealthcareOnline.comNetwork Bulletin: February 2015
appeal including a letter requesting a formal appeal. Please submit to the appropriate address located in the Provider Administrative Guide. Appeals must be submitted in writing. If the appeal does not result in an overturned decision, the provider must review their contract for further dispute resolution steps.
If you have additional questions on the claim reconsideration or appeal process, please reference the Provider Administrative Guide under the applicable section.
* Claim reconsideration does not apply to California or ColoradoCommercial, or as required by state law, refer to ProviderDispute Resolution (PDR).
Claim Reconsideration and Appeal Process Summary
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Network Bulletin: November 2013 - Volume 58 For more information call 877.842.3210, or visit UnitedHealthcareOnline.com2323 For more information call 877.842.3210,
or visit UnitedHealthcareOnline.comNetwork Bulletin: February 2015
For complete details on the policy updates listed in the table on the following page, please refer to the monthly Policy Update Bulletin at UHCRiverValley.com > Providers > Coverage Policy Library > Policy Update Bulletin.
UnitedHealthcare AffiliatesUnitedHealthcare of the River Valley Preauthorization List and Policy Updates
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UnitedHealthcare Affiliates
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Network Bulletin: November 2013 - Volume 58 For more information call 877.842.3210, or visit UnitedHealthcareOnline.com2424 For more information call 877.842.3210,
or visit UnitedHealthcareOnline.comNetwork Bulletin: February 2015
UnitedHealthcare of the River Valley Preauthorization List and Policy Updates
These updates apply to UnitedHealthcare of the River Valley commercial and hawk-i plan members only.
Policy Title Effective Date Coverage Policy Update Bulletin
TAKE NOTE
New Preauthorization Requirements for Radiology/Advanced Outpatient Imaging Procedures *Implementation delayed
To be decided Feb. 2015
NEW
Balloon Sinus Ostial Dilation April 1, 2015 Jan. 2015Feb. 2015
Clotting Factors and Coagulant Blood Products April 1, 2015 Jan. 2015Feb. 2015
Entyvio™ (vedolizumab) April 1, 2015 Jan. 2015Feb. 2015
Hysterectomy for Benign Conditions April 1, 2015 Jan. 2015Feb. 2015
Radiology/Advanced Outpatient Imaging Procedures
*Implementation delayed; previously announced with an effective date of Feb. 16, 2015
To be decided Feb. 2015
Simponi® Aria™ (golimumab) April 1, 2015 Jan. 2015Feb. 2015
DME, Orthotics, Ostomy Supplies, Medical Supplies and Repairs/Replacements
Feb. 1, 2015 Jan. 2015
Electrical Stimulation and Electromagnetic Therapy for Wounds Feb. 1, 2015 Jan. 2015
Epiduroscopy, Epidural Lysis of Adhesions and Functional Anesthetic Discography
Feb. 1, 2015 Jan. 2015
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UnitedHealthcare Affiliates
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Network Bulletin: November 2013 - Volume 58 For more information call 877.842.3210, or visit UnitedHealthcareOnline.com2525 For more information call 877.842.3210,
or visit UnitedHealthcareOnline.comNetwork Bulletin: February 2015
UnitedHealthcare of the River Valley Prior Authorization List and Policy Updates
Policy Title Effective Date Coverage Policy Update Bulletin
Hip Resurfacing Arthroplasty Feb. 1, 2015 Jan. 2015
Immune Globulin (IVIG and SCIG) Feb. 1, 2015 Jan. 2015
Implantable Beta-Emitting Microspheres for Treatment of Malignant Tumors
Feb. 1, 2015 Jan. 2015
Infertility Diagnosis and Treatment Feb. 1, 2015 Jan. 2015
Transcranial Magnetic Stimulation Feb. 1, 2015 Jan. 2015
RETIRED
Intrastromal Corneal Ring Segments Feb. 1, 2015 Feb. 2015
Note: The inclusion of a service or procedure on this list does not imply that UnitedHealthcare provides coverage for the service or procedure. In the event
of an inconsistency between the information provided in this Network Bulletin and the posted policy, the posted policy prevails.
UnitedHealthcare Affiliates
TABLE OF CONTENTS
Network Bulletin: November 2013 - Volume 58 For more information call 877.842.3210, or visit UnitedHealthcareOnline.com2626 For more information call 877.842.3210,
or visit UnitedHealthcareOnline.comNetwork Bulletin: February 2015
Policy Title Applicable State(s) Effective Date
Update Bulletin
UPDATED/REVISED
Complementary and Alternative Medicine All (California, Oklahoma, Oregon, Texas, & Washington)
Feb. 1, 2015 Jan. 2015
Medical Necessity All Jan. 1, 2015 Jan. 2015
Nutritional Therapy: Enteral and Oral Nutritional Therapy
All Feb. 1, 2015 Jan. 2015
Member Initiated Second and Third Opinion All Feb. 1, 2015 Jan. 2015
Post Mastectomy Surgery All Feb. 1, 2015 Jan. 2015
Telemedicine/Telehealth Services All Feb. 1, 2015 Jan. 2015
SignatureValue™BenefitInterpretationPolicyUpdates
For complete details on the policy updates listed in the following table, please refer to the monthly SignatureValue™ Benefit Interpretation Policy Update Bulletin at UHCWest.com > Provider Log In > Library > Resource Center > Guidelines & Interpretation Manuals.
Note: The inclusion of a service or procedure on this list does not imply that coverage is provided for the service or procedure. In the event of an
inconsistency between the information provided in this Network Bulletin and the posted policy, the posted policy prevails.
Next Article >
UnitedHealthcare Affiliates
TABLE OF CONTENTS
Network Bulletin: November 2013 - Volume 58 For more information call 877.842.3210, or visit UnitedHealthcareOnline.com2727 For more information call 877.842.3210,
or visit UnitedHealthcareOnline.comNetwork Bulletin: February 2015
Policy Title Effective Date Update Bulletin
NEW
Balloon Sinus Ostial Dilation April 1, 2015 Jan. 2015
Hysterectomy for Benign Conditions April 1, 2015 Jan. 2015
UPDATED/REVISED
Deep Brain Stimulation Feb. 1, 2015 Jan. 2015
Electrical Stimulation and Electromagnetic Therapy for Wounds
Feb. 1, 2015 Jan. 2015
Epiduroscopy, Epidural Lysis of Adhesions and Functional Anesthetic Discography
Feb. 1, 2015 Jan. 2015
Hip Resurfacing Arthroplasty Feb. 1, 2015 Jan. 2015
Implantable Beta-Emitting Microspheres for Treatment of Malignant Tumors
Feb. 1, 2015 Jan. 2015
Mechanical Circulatory Support Device (MCSD) Jan. 1, 2015 Jan. 2015
Mechanical Stretching and Continuous Passive Motion Devices
Feb. 1, 2015 Jan. 2015
Nerve Graft to Restore Erectile Function During Radical Prostatectomy
Radiofrequency Therapy and Tibial Nerve Stimulation for Urinary Disorders
Feb. 1, 2015 Jan. 2015
SignatureValue™ Medical Management Guideline Updates
For complete details on the policy updates listed in the following table, please refer to the monthly SignatureValue™ Medical Management Guidelines Update Bulletin at UHCWest.com > Provider Log In > Library > Resource Center > Guidelines & Interpretation Manuals.
Next Article >
UnitedHealthcare Affiliates
TABLE OF CONTENTS
Next Article >
Network Bulletin: November 2013 - Volume 58 For more information call 877.842.3210, or visit UnitedHealthcareOnline.com2828 For more information call 877.842.3210,
or visit UnitedHealthcareOnline.comNetwork Bulletin: February 2015
SignatureValue™ Medical Management Guideline Updates
Policy Title Effective Date Update Bulletin
Sensory Integration Therapy and Auditory Integration Training
Feb. 1, 2015 Jan. 2015
Surgical Treatment for Spine Pain Feb. 1, 2015 Jan. 2015
Transcranial Magnetic Stimulation Feb. 1, 2015 Jan. 2015
RETIRED
Intrastromal Corneal Ring Segments Jan. 1, 2015 Jan. 2015
Note: The inclusion of a service or procedure on this list does not imply that coverage is provided for the service or procedure. In the event of an
inconsistency between the information provided in this Network Bulletin and the posted policy, the posted policy prevails.
UnitedHealthcare Affiliates
TABLE OF CONTENTS
Network Bulletin: November 2013 - Volume 58 For more information call 877.842.3210, or visit UnitedHealthcareOnline.com2929 For more information call 877.842.3210,
or visit UnitedHealthcareOnline.comNetwork Bulletin: February 2015
Co-Surgeons; Team Surgeon Policy Reimbursement Policy
Jan. 1, 2015 Jan. 2015
Drug Coverage Criteria - New and Therapeutic Equivalent Medications
Clinical Policy Feb. 1, 2015 Jan. 2015
Drug Coverage Guidelines Clinical Policy Feb. 1, 2015 Jan. 2015
Femoroacetabular Impingement Syndrome Treatment
Clinical Policy Feb. 1, 2015 Jan. 2015
Global Days Policy Reimbursement Policy
Jan. 1, 2015 Jan. 2015
For complete details on the new and/or revised policies listed in the following table, refer to the monthly Policy Update Bulletin at OxfordHealth.com > Providers > Tools & Resources > Medical Information > Medical and Administrative Policies > Policy Update Bulletin.
TAKE NOTE
- Oxford®
UnitedHealthcare Affiliates
TABLE OF CONTENTS
Network Bulletin: November 2013 - Volume 58 For more information call 877.842.3210, or visit UnitedHealthcareOnline.com3030 Insurance coverage provided by UnitedHealthcare Insurance Company or its affiliates. Health plan coverage provided by UnitedHealthcare of
Arizona, Inc., UnitedHealthcare of California, UnitedHealthcare of Colorado, Inc., UnitedHealthcare of Oregon, Inc., UnitedHealthcare of Utah, Inc. and UnitedHealthcare of Washington, Inc. or other affiliates. Administrative services provided by UnitedHealthcare Services, Inc. or its affiliates.
Network Bulletin: February 2015Doc#: PCA15610_20150120
Oxford Medical and Administrative Policy Updates
Policy Title Policy Type Effective Date
Policy Update Bulletin
UPDATED/REVISED
Hearing Aids And Devices Including Wearable, Bone-Anchored and Semi-Implantable