Network Bulletin: January 2015 network bulletinassets.fiercemarkets.net/public/unitedhealthbulletin.pdf · Net rticle 3 Network Bulletin: November 2013 - olume 58 For more information

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: January 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: January 2015

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

• UnitedHealthcare to Begin Publishing theNetwork Bulletin Monthly in 2015

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

• HysterectomyPriorNotificationRequirements, Effective April, 6, 2015

• New Requirement for Immunoglobulin Infusion Therapy

• Sinuplasty Procedures to be Added to PriorAuthorization List on April 6, 2015

• LaboratoryBenefitManagementProgramUpdate

• Elect Your Payment Method in 2015

• Prior Authorization and AdvanceNotificationRequirementReminders

• HEDIS® 2015 Data Collection for UnitedHealthcareCommercial, Medicare and Medicaid Plans

UnitedHealthcare Medicare Solutions

• UnitedHealthcare Medicare AdvantageCoverage Summary Updates

UnitedHealthcare Commercial

• UnitedHealthcare Medical Policy, Drug Policy,Coverage Determination Guideline andUtilization Review Guideline Updates

• RadiologyandCardiologyNotification/PriorAuthorization Protocols for the State of Rhode IslandEffective Feb 1, 2015 – Training Opportunity

UnitedHealthcare Community Plan

• ImportantChangesinAdvanceNotificationand Prior Authorization Requirements

• Medical Policy & CoverageDetermination Guideline Updates

• Changes to the Cardiology Prior AuthorizationProtocol for Rhode Island MedicaidMembers Effective Feb. 1, 2015

UnitedHealthcare Commercial Reimbursement Policy

• New“X”ModifiersandImpacttoUnitedHealthcare CommercialReimbursement Policies

UnitedHealthcare Military & Veterans

• Introducing a New Civilian Referral Request Form

Doing Business Better

• Enhanced HIPAA Claim EditsPlanned for February 2015

• UnitedHealthcare Medicare SolutionsCoinsurance Calculation Reminder for Providers

• Coverage Determinations andUtilization Management Decisions

UnitedHealthcare Affiliates

• UnitedHealthcare of the River ValleyPreauthorization List and Policy Updates

• SignatureValue™BenefitInterpretation Policy Updates

• SignatureValue™ Medical ManagementGuideline Updates

• Oxford® Medical and AdministrativePolicy Updates

• UnitedHealthcare Negotiates National Contractwith Medway Air Ambulance, Inc. for Fixed-Wing Air Ambulance Services

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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: January 2015

The Network Bulletin will move from a bimonthly to monthly publication beginning with this issue. The Bulletinwillnowbeavailableonthefirstbusinessdayof every month.

The transition to the monthly Bulletin means you will receive the information you need from us in a timelier manner. And you will seeasignificantreductionofcontentineachedition,makingitamore user-friendly resource as you go about your busy day.

The monthly Bulletin is a direct result of your input. We appreciate your suggestions and welcome any additional ideas on how we can best communicate with you.

Please email us at [email protected] with any questions or feedback.

UnitedHealthcare to Begin Publishing the Network Bulletin Monthly in 2015

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The Guide contains some important changes you will want to review. The following list is a high level summary of selected updates to the Guide; it is not intended nor should it be interpreted to represent every update or the details of any update. Please refer to the Guide for the complete text and detailed updates.

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

New in the 2015 Guide

• Electronic Payments and Statements (EPS) with new Virtual Card Payment Options (VCPs) – process for electronicfundstransfer/remittanceadvice.Ifyoucurrently receive paper checks and remittances, you will have a choice of direct deposit or VCP in 2015.

• Medicare Advantage Referral Required Product – newbenefitguidelinesaddedforMedicare Advantage members.

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

Revised in the 2015 Guide

• Optum Cloud Dashboard – Our cloud-based website offers three primary applications: Claim Reconsideration (with or without attachments), Benefits&Eligibility,andClaimsManagement.

• Expansion of Commercial and Health Insurance Marketplace Products – new product offerings to support the Commercial and Health Insurance Marketplacebenefitplans.

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

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

• NeighborhoodHealthPartnershipPrecertificationList – now online at myNHP.com > Providers > References > Utilization Management Protocols > Prior Authorization Process (protocol III).

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

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

Please contact your Network Management representative, Physician Advocate, or Hospital & Facility Advocate for a printed copy of the UnitedHealthcare Administrative Guide.

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

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

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TheAmericanCongressofObstetriciansandGynecologists(ACOG)hasidentifiedthepreferred method for hysterectomies to be vaginal. Per ACOG, “evidence demonstrates that, in general, vaginal hysterectomy is associated with better outcomes and fewer complications than laparoscopic or abdominal hysterectomies.”

To align with ACOG’s recommendation and provide better outcomes for our members, UnitedHealthcare and UnitedHealthcare West Commercia and Medicare Planswill require prior authorization for certain hysterectomy procedures starting April 6, 2015. The following table lists the impacted codes:

Vaginal hysterectomies done on an outpatient basis do not need prior authorization. Failure to complete the prior authorization process will result in an administrative claim denial. Members cannot be billed for claims that are administratively denied.

A clinical denial will be issued, and a prior authorization number will not be issued, if it is determined during the clinical coverage review process that the service does not meet medical necessity criteria. Upon issuance of a clinical denial, the member and provider will receive denial notices with the appeal process outlined. Appeals for clinical denials will be conducted by UnitedHealthcare.

The member cannot be billed for services we determined to be medically unnecessary unless the member, with the knowledge of our determination, agrees in writing to be responsible for the cost of the services.

If you have questions regarding these requirements, please contact your UnitedHealthcare market medical director or Physician Advocate.

HysterectomyPriorNotificationRequirements,Effective April, 6, 2015

Abdominal hysterectomy

Laparoscopic hysterectomy

Vaginal hysterectomy

Laparoscopic assisted vaginal hysterectomy

58150 58541 58260 58550

58152 58542 58262 58552

58180 58543 58263 58553

68.3 58544 58267 58554

68.39 58570 58270 68.51

68.4 58571 58275

68.49 58572 58280

58573 58290

68.31 58291

68.41 58292

58293

58294

68.5

68.59

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Effective Feb. 1, 2015, UnitedHealthcare will review the medical necessity of the site of service in additiontopriorauthorizationreviewforbenefitcoverageofimmunoglobulininfusiontherapy.

• For UnitedHealthcare Commercial plan and Mid-Atlantic members: Immunoglobulin prior authorization with medical necessity review will be required for your patients who receive outpatient facility infusion services. Based on the outcome of that review, you may need to switch patients to an alternative site of service for them to continue to receivebenefitcoverage.

• For UnitedHealthcare Oxford members: Members who use outpatient infusion services for immunoglobulin therapy are already subject to medical necessity review. Additionally, for those infusion services that are administered in a home care setting, these services will continue to require precertificationtoestablishthemedicalnecessity of the home care service.

• For UnitedHealthcare River Valley members: Members who use outpatient infusion services for immunoglobulin therapy are already subject to medical necessity review.

Failure to complete the new process prior to administering infusion services for immunoglobulin therapy will result in claims denial. Providers cannot bill members for services that are denied due to lack of prior authorization.

For more information about the requirement for immunoglobulin infusion therapy:

• UnitedHealthcare Commercial: Refer to the Physician, Health Care Professional, Facility and Ancillary Provider Administrative Guide for Commercial and Medicare Advantage Products under the Specialty Drug Prior Authorization process found on UnitedHealthcareOnline.com > Clinician Resources > Specialty Drugs> Commercial Specialty Drug Prior Authorization Program.

• UnitedHealthcare of the Mid-Atlantic: Information about our evidence-based medical polices is available at UnitedHealthcareOnline.com > Clinician Resources > Specialty Drugs> Commercial Specialty Drug Prior Authorization Program.

• UnitedHealthcare Oxford: Information is available at OxfordHealth.com > Providers > Tools & Resources > Medical and Administrative Policies > Medical & Administrative Policies.

• UnitedHealthcare of the River Valley: Information is available at UHCRiverValley.com > Providers > Coverage Policy Library > Services requiring preauthorization.

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Effective April 6, 2015, UnitedHealthcare Medicare Advantage and Commercial plans will require prior authorization for nasal sinus endoscopy procedures for patients 12 years and older who havefailedtohaveoneormoreofthefollowingmedicaltreatments:nasallavage,antibioticsand/or corticosteroids. The procedure is not proven for patients younger than 12.

The following is a list of impacted codes:

Failure to complete the prior authorization process will result in an administrative claim denial. Members cannot be billed for claims that are administratively denied.

A clinical denial will be issued, and a preauthorization number will not be issued, if it is determined during the clinical coverage review process that the service does not meet medical necessity criteria. Upon issuance of a clinical denial, the member and provider will receive a denial notice with the appeal process outlined. Appeals for clinical denials will be conducted by UnitedHealthcare.

The member cannot be billed for services we determined to be medically unnecessary unless the member, with the knowledge of our determination, agrees in writing to be responsible for the cost of the services.

If you have questions regarding these requirements, please contact your UnitedHealthcare market medical director or Physician Advocate.

Sinuplasty Procedures to be Added to the Prior Authorization List on April 6, 2015

CPT Code Procedure description

31295 Nasal/sinusendoscopy,surgical;withdilation of maxillary sinus ostium (eg, balloon dilation), transnasal

31296 Nasal/sinusendoscopy,surgical;withdilation of frontal sinus ostium (eg, balloon dilation) or via canine fossa

31297 Nasal/sinusendoscopy,surgical;withdilation of sphenoid sinus ostium (eg, balloon dilation)

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TheUnitedHealthcareLaboratoryBenefitManagement Program started Oct. 1, 2014. This new program is designed to help improve quality of care and support appropriate utilization for outpatient laboratory services. The pilot launch is for laboratory services for fully insured UnitedHealthcare Commercial members in Florida, excluding Neighborhood Health Partnership. UnitedHealthcare previously communicated that claims impact related to the program would go into effect on Jan. 1, 2015. We have been closely monitoring progress ofthispilotprogramandaremakingrefinementsbasedondata, experience and input. We appreciate the constructive feedback we have received regarding the Laboratory BenefitManagementProgram.Theprogramremainsineffect; however, as a result of this input, we will initiate claims impact on a delayed schedule to be effective in the near future. We will notify you 30 days prior to initiating claimsimpactassociatedwiththeLaboratoryBenefitManagement Program.

In addition, we will be implementing additional Medical Policies and a revised Administrative Protocol starting Apr.1,2015,aspartoftheLaboratoryBenefit Management Program.

The updated program requirements will be posted by Jan 1, 2015 at UnitedHealthcareOnline.com > Tools & Resources > Policies, Protocols and Guides > Protocols > UnitedHealthcare Laboratory Benefit Management Program.

Please contact your UnitedHealthcare Provider Advocate if you have questions or feedback as you begin implementing the program in your practice.

LaboratoryBenefitManagementProgramUpdate

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UnitedHealthcare continuously looks for ways to simplify administrative processes, reduce administrative costs and accelerate access to the information network providers need. Optum’s Electronic Payments and Statements (EPS) is a free electronic funds transfer (EFT) and electronic remittance advice (ERA) service brought to you by UnitedHealthcare. It is the standard forreceivingUnitedHealthcarepaymentsandexplanationofbenefits(EOBs).EPSdeliverselectronicpaymentsdirectlytoproviders’specifiedbankaccount(s)andprovidesonlineEOBsto physicians, hospitals, other health care professionals and billing companies. In 2015, a Virtual Card Payment option will be added.

Paper, mail and tracking fees are a major expense within the health care industry. If all payers and providers move to electronic payments and EOBs, the health care industry could save $860 million. Currently, the Centers for Medicare and Medicaid Services (CMS) requires new applicants to leverage electronic payments as part of their credentialing process.

In support of positive industry trends, all existing and new UnitedHealthcare-contracted providers, who have not yet enrolled in EPS, must elect their preferred electronic claim payment method in 2015. Contracted providers can opt to receive payments directly to their bank account or through Virtual Card Payments. Virtual Card Payments are a secure electronic payment method that does not require your bank account information. Providers will receive reminders regardingfinalpaymentmethodelectiondeadlinedates90days prior to those deadline dates. If your organization does not elect either direct deposit (ACH) or Virtual Card Payments by your payment election deadline, your election will default to Virtual Card Payments and your organization will begin receiving Virtual Card Payments.

If your business operations require continued paper payments, please contact UnitedHealthcare after April 1 and prior to your payment election deadline. Further information will be provided by email.

Features of EPS with direct deposit or Virtual Card Payments:• ReceivepaymentsandEOBsfivetosevendaysfaster

than with paper

• Multiple claim payments generated in one day for thesame payer are combined into one deposit or VCPand one electronic EOB for easy reconciliation

• Simplifiedprocessingandreconciliation–automatepaymentpostingusingthe835/ERAorcontinuewith your existing paper process using our EOBprinting options

• Printeitherasingleconsolidatedfile(lesspaper)containing all EOBs for a given deposit or printindividual EOBs to submit to other carriers for yoursecondary claim submissions

• EOBs are available for 13 months and can bedownloadedasPDFfilestostoreonyourownsystem

• Reduced risk of lost, misrouted and stolen checks

Elect Your Payment Method in 2015

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Elect Your Payment Method in 2015

• Potential elimination of bank lockbox fees

• Practice management software and technical expertiseare NOT required.

• You can post payments the same way you do today

EPS Registration

To learn more about EPS, visit UnitedHealthcareOnline.com and select Electronic Payments and Statements under Quick Links on the home page. You can register for EPS with direct deposit any time, online or send us a completed enrollment form.

Enrollment for Virtual Card Payments will be available beginning in April 2015.

If you have questions about EPS, direct deposit, Virtual Card Payments or enrollment, call us at 866-842-3278 and select option 5, to speak with an EPS representative.

1 You acknowledge that that by processing a Virtual Card payment, you are subject to the terms and conditions governing card processing between you and your card service processor and that you are responsible for any charges and related third party fees, including interchange, merchant discount, or other card processing fees that may be imposed as a result of processing a Virtual Card payment through a card processor.

EPS with direct deposit: • No credit card processing fees• While funds are deposited to your

account, UnitedHealthcare will not debit or deduct claim adjustments from your checking or savings account. You can also contact your bank to ensure that you have appropriately placed controls over the electronic funds transfers to and from your account.

EPS with Virtual Card Payments:• Virtual Card Payments can

be processed using the same method leveraged by your organization to process credit card transactions. Please note, your current credit card processing fees will apply. Please confirmthoserateswithyourbank of choice directly.[2]

• Banking information is not shared outside your organization.

Posting and balancing with direct deposit:

1. Receiveemailnotificationswhenpayments are deposited to your designated bank account(s).

2. View the amount of the deposit and all EOBs associated with that deposit by logging on to EPS.

3. View or print EOBs and post payments manually to your practice management system, or auto-post using the free electronic remittance advice835/ERA.

Posting and balancing with Virtual Card Payment:

1. Your practice will receive a virtual card number in the mail and this card number should be retained in a secure location as you will need it for future payments. You willbenotifiedviaemailofnewclaim payments.

2. Redeem payments using the “card not present” transaction on your credit card terminal.

3. View or print EOBs and post payments manually to your practice management system, or auto-post using the free electronic remittance advice 835/ERA.

1 CAQH“2013U.S.HealthcareEfficiencyIndexElectronicAdministrativeTransaction Adoption and Savings.” Caqh.org. Revised May 5, 2014. Web. 16July2014.<http://caqh.org/EfficiencyIndex.php>.

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Effective for dates of service on or after Jan. 1, 2015, certain services have changed from theadvancenotificationorpriorauthorizationrequirementsfortheUnitedHealthcareandUnitedHealthcare West Commercial and Medicare Advantage Plans.

Orthopedic Procedures is a new category that will be added effective April 6, 2015 for UnitedHealthcare and UnitedHealthcare West Commercial and Medicare Advantage Plans. This new category will encompass Spinal Surgeries, Joint Replacements, and Hip Surgery.

The most up-to-date list of procedures requiring Advance NotificationorPriorAuthorizationfor:

• UnitedHealthcare Commercial can be found at UnitedHealthcareOnline.com > Clinician Resources > Advance & Admission Notification.

• UnitedHealthcare and UnitedHealthcare West Medicare Advantage Plans can be found at UnitedHealthcareOnline.com > Clinician Resources > Advance & Admission Notification.

• UnitedHealthcare Community Plans can be found at UHCCommunityPlan.com > For Health Care Professionals > Select your State.

PriorAuthorizationandAdvanceNotification Requirement Reminders

Service Category(Effective Date)

Applies to Eliminated Codes

Added Codes

Orthopedic Procedures(April 6, 2015)

Commercial 29914

Medicare 29915

Community 29916

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HEDIS® 2015 Data Collection for UnitedHealthcare Commercial, Medicare and Medicaid Plans

UnitedHealthcare is required to collect Healthcare Effectiveness Data and Information Set (HEDIS) information annually from our participating care providers for our Commercial, Medicare and Medicaid members. Our network must, therefore, provide requested medical record information so we can comply with the Centers for Medicare & Medicaid Services (CMS), state and federal regulators and accreditation organization requirements. HEDIS data collection takes place from February to May. We are grateful for your collaboration in this effort.

The following are key facts about the HEDIS data collection process:• HEDIS results are used to evaluate clinical care

performance, help ensure health plan members receive their recommended services, and measure health outcomes. The results are also used to support quality improvement and chronic condition improvement programs required by CMS.

• TheindicatedHEDISyearreflectstheyearthedatais collected rather than the year the care was given. For example, for the HEDIS 2015 cycle, we collect data for services rendered in 2014 or earlier. Medical records for services rendered in 2015 are not included in that data collection cycle.

• Your patients who are our members are randomly selectedforeachdatacollectioncycle.Yourofficemayreceivethisnotificationletterbutnothaveanypatients included for the HEDIS 2015 cycle. You will not need to take action unless contacted directly by UnitedHealthcare or a vendor working on our behalf.

• Ifyourofficeiscontacted,pleaserespondwithinfivebusiness days. A timely response helps ensure the data we report to state and federal regulators and accreditationorganization,isaccurateandreflectsthehigh quality care that you strive to provide.

• The collection vendors that may contact you on our behalf include Enterprise Consulting Solutions, Inc.,

RecordFlow, HealthPort and Altegra Health. They will arrange with you a convenient medical record collection time, or let you know if the records can be faxed, mailed or sent electronically. UnitedHealthcare staff may also contact you directly to ask for certain medical record information to be faxed or mailed.

• Vendorsaresubjecttoprivacy,confidentialityandthe Health Insurance Portability and Accountability Act (HIPAA) business associate requirements. The HIPAAPrivacyRuleallowsforexchangeofconfidentialpatient information to conduct Treatment, Payment, or Healthcare Operations and may occur without any writtenconsentorauthorizationbythepatient/memberbetween covered entities and UnitedHealthcare.

• If a patient chart included on the list we provide to you is not available at your practice location, or a patient is listed that has not ever received services from your practice, please alert the contact person or entity on the list immediately.

We appreciate the time and attention you and your officearetakingtofulfilltheseannualrequirements.Please contact us at 877-211-6545 or [email protected] with any questions.

*Under the Health Insurance Portability and Accountability Act (HIPAA), health care operations include disclosure of Protected Health Information (PHI) for accreditation (e.g., Healthcare EffectivenessDataandInformationSet(HEDIS)reporting)andcertificationactivities.Thesedisclosures may be made to a business associate, acting on behalf of the covered entity. The American Recovery and Reinvestment Act of 2009 (ARRA) also permits release of records. Our vendors have executed HIPAA-compliant business associate agreements to perform the medical records reviews.

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UnitedHealthcare Medicare Advantage Coverage Summary Updates

Forcompletedetailsontheupdated/revisedpolicieslistedin the table on the following page 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.


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Policy Title Approval Date Update Bulletin

TAKE NOTE

Availability of the Medicare Advantage Coverage Summary Update Bulletin

N/A Jan. 2015

UPDATED/REVISED

Abortion Nov. 18, 2014 Dec. 2014

Age Related Macular Degeneration (AMD) Therapy (Macugen ®, Lucentis ®, Avastin®, EYLEA®)

Oct. 21, 2014 Nov. 2014

Alcohol,Chemicaland/orSubstanceAbuse- DetoxificationandRehabilitation

Nov. 18, 2014 Dec. 2014

Blood, Blood Products and Related Procedures and Drugs Nov. 18, 2014 Dec. 2014

Breast Reconstruction Following Mastectomy Oct. 21, 2014 Nov. 2014

CardiacPacemakersandDefibrillators Oct. 21, 2014 Nov. 2014

Change in Membership Status while Hospitalized (Acute, LTC and SNF) or Receiving Home Health

Nov. 18, 2014 Dec. 2014

Chemotherapy, and Associated Drugs and Treatments Oct. 21, 2014 Nov. 2014

Cochleostomy with Neurovascular Transplant for Meniere's Disease Oct. 21, 2014 Nov. 2014

Court, Attorney or Agency Requested Services Nov. 18, 2014 Dec. 2014

Dental Services, Oral Surgery and Treatment of Temporomandibular Joint (TMJ)

Oct. 21, 2014 Nov. 2014

Diabetes Management, Equipment and Supplies Oct. 21, 2014 Nov. 2014

Diagnostic Pap Smear Nov. 18, 2014 Dec. 2014

Durable Medical Equipment (DME), Prosthetics, CorrectiveAppliances/Orthotics(Non-FootOrthotics) and Medical Supplies Grid

Oct. 21, 2014 Nov. 2014

DurableMedicalEquipment,Prosthetics,CorrectiveAppliances/Orthotics and Medical Supplies

Oct. 21, 2014 Nov. 2014



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Educational Programs Oct. 21, 2014 Nov. 2014

Emergent/UrgentServices,Post-StabilizationCare and Out-of-Area Services

Nov. 18, 2014 Dec. 2014

Extracorporeal Photopheresis Oct. 21, 2014 Nov. 2014

Impotence Treatment Oct. 21, 2014 Nov. 2014

Incontinence - Urinary and Fecal Incontinence, Diagnosis and Treatments

Oct. 21, 2014 Nov. 2014

Infertility Services Oct. 21, 2014 Nov. 2014

Infusion Pump Therapy Oct. 21, 2014 Nov. 2014

Medications/Drugs(Outpatient/PartB) Oct. 21, 2014 Nov. 2014

Nov. 18, 2014 Dec. 2014

Mobility Assistive Equipment (MAE) Oct. 21, 2014 Nov. 2014

Oxygen for Home Use Oct. 21, 2014 Nov. 2014

Pain Management and Pain Rehabilitation Oct. 21, 2014 Nov. 2014

Preventive Health Services and Procedures Oct. 21, 2014 Nov. 2014

Rehabilitation - Cardiac Rehabilitation Services (Outpatient) Oct. 21, 2014 Nov. 2014

Nov. 18, 2014 Dec. 2014

Renal Services and Procedures Oct. 21, 2014 Nov. 2014

Respiratory Therapy, Pulmonary Rehabilitation and Pulmonary Services

Oct. 21, 2014 Nov. 2014

Shoes and Foot Orthotics Oct. 21, 2014 Nov. 2014

Skin Treatment, Services and Procedures Oct. 21, 2014 Nov. 2014



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Sleep Apnea - Diagnosis and Treatment Oct. 21, 2014 Nov. 2014

Nov. 18, 2014 Dec. 2014

Speech Generating Devices Oct. 21, 2014 Nov. 2014

Spine Procedures Oct. 21, 2014 Nov. 2014

Stimulators – Electrical and Spinal Cord Stimulators Oct. 21, 2014 Nov. 2014

Stimulators – Osteogenic Stimulators Oct. 21, 2014 Nov. 2014

Transcatheter Heart Valve Procedures Nov. 18, 2014 Dec. 2014

Uterine Services and Procedures Oct. 21, 2014 Nov. 2014

Varicose Veins Treatment Oct. 21, 2014 Nov. 2014

VentricularAssistDevice(VAD)andArtificialHeart Oct. 21, 2014 Nov. 2014

Vision Services, Therapy and Rehabilitation Oct. 21, 2014 Nov. 2014

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

of an inconsistency between the information in this Network Bulletin and the posted policy, the posted policy will prevail.

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


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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.


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Policy Title Policy Type Effective Date

Medical Policy Update Bulletin

TAKE NOTE

Annual CPT® and HCPCS Code Updates All Jan. 1, 2015 Jan. 2015

Availability of the Medical Policy Update Bulletin All N/A Jan. 2015

NEW

Entyvio (Vedolizumab) Drug Policy Mar. 1, 2015 Dec. 2014 Jan. 2015

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

Utilization Review Guideline

Feb. 1, 2015 Nov. 2014Dec. 2014Jan. 2015

Simponi Aria (Golimumab) Drug Policy Mar. 1, 2015 Dec. 2014 Jan. 2015

Vimizim (Elosulfase Alfa) Drug Policy Jan. 1, 2015 Oct. 2014Nov. 2014Dec. 2014

UPDATED/REVISED

Actemra (Tocilizumab) Drug Policy Dec. 1, 2014 Nov. 2014

Alemtuzumab Drug Policy Jan. 1, 2015 Dec. 2014

Autologous Chondrocyte Implantation in the Knee Medical Policy Dec. 1, 2014 Nov. 2014

Bariatric Surgery Medical Policy Dec. 1, 2014 Nov. 2014

Breast Reconstruction Post Mastectomy Coverage Determination Guideline

Dec. 1, 2014 Nov. 2014

BreastRepair/Reconstruction Not Following Mastectomy

Coverage Determination Guideline

Dec. 1, 2014 Nov. 2014

Cardiovascular Disease Risk Tests Medical Policy Dec. 1, 2014 Nov. 2014

Clotting Factors and Coagulant Blood Products Drug Policy Jan. 1, 2015 Dec. 2014

Computed Tomographic Colonography Medical Policy Jan. 1, 2015 Dec. 2014


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Durable Medical Equipment, Orthotics, Ostomy Supplies, Medical Supplies and Repairs/Replacements


Jan. 1, 2015 Dec. 2014

Electrical Stimulation for the Treatment of Pain and Muscle Rehabilitation

Medical Policy Dec. 1, 2014 Nov. 2014

Fecal DNA Testing Medical Policy Dec. 1, 2014 Dec. 2014

Femoroacetabular Impingement Syndrome Medical Policy Jan. 1, 2015 Dec. 2014

Hearing Aids and Devices Including Wearable, Bone-Anchored and Semi-Implantable

Medical Policy Jan. 1, 2015 Dec. 2014

Human Epidermal Growth Factor Receptor 2 (HER2) Targeting Drugs

Drug Policy Dec. 1, 2014 Nov. 2014

Immune Globulin (IVIG and SCIG) Drug Policy Jan. 1, 2015 Dec. 2014

Intensity-Modulated Radiation Therapy Medical Policy Jan. 1, 2015 Nov. 2014 Dec. 2014

Intensive Behavioral Therapy for Autism Spectrum Disorder


Minimally Invasive Procedures for GastroesophagealRefluxDisease(GERD)


Omnibus Codes Medical Policy Jan. 1, 2015 Dec. 2014

Ophthalmologic Policy: Vascular Endothelial Growth Factor (VEGF) Inhibitors

Drug Policy Dec. 1, 2014 Nov. 2014

Orencia (Abatacept) Drug Policy Dec. 1, 2014 Nov. 2014

Preventive Care Services Coverage Determination Guideline

Jan. 1, 2015 Dec. 2014

Remicade(Infliximab) Drug Policy Dec. 1, 2014 Nov. 2014

Sandostatin (Octreotide Acetate) Drug Policy Jan. 1, 2015 Dec. 2014

Speech Therapy Coverage Determination Guideline

Dec. 1, 2014 Nov. 2014

Stelara (Ustekinumab) Drug Policy Jan. 1, 2015 Dec. 2014

Vagus Nerve Stimulation Medical Policy Dec. 1, 2014 Nov. 2014





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RadiologyandCardiologyNotification/PriorAuthorizationProtocols for the State of Rhode Island Effective Feb 1, 2015 – Training Opportunity

EffectiveFeb.1,2015providerspracticinginRhodeIslandmustprovidenotificationpriorto scheduling a planned service that is subject to UnitedHealthcare’s Outpatient Radiology Notification/PriorAuthorizationProtocolandCardiologyNotification/PriorAuthorizationProtocols.

These protocols include a prior authorization requirement that applies when a UnitedHealthcare Commercial or UnitedHealthcareCommunityPlanmember’sbenefitdocument requires health services to be medically necessary in order to be covered. As such, once notificationofaplannedserviceisreceived,CareCoreNational, LLC, a company with which UnitedHealthcare has contracted, will conduct a clinical coverage review if the member’sbenefitdocumentrequireshealthservicestobemedically necessary in order to be covered. • TheRadiologyNotification/PriorAuthorization

ProtocolandCardiologyNotification/PriorAuthorization Protocol for Commercial customers are located in UnitedHealthcare’s Physician, Health Care Professional, Facility and Ancillary Provider 2014 Administrative Guide for Commercial and Medicare Advantage Products (“Administrative Guide”). The Administrative Guide is available at UnitedHealthcareOnline.com > Tools & Resources > Policies, Protocols & Guides > Administrative Guides. Additional information regarding these protocols is also available in the November 2014 Network Bulletin.

• The Cardiology Prior Authorization protocol for UnitedHealthcare Community Plan member is located on UnitedHealthcareOnline.com > Clinician Resources > Cardiology > UnitedHeatlhcare Community Plan Cardiology Prior Authorization Program. Additional information regarding this protocol is also available in the November 2014 Network Bulletin at UnitedHealthcareOnline.com > Network Bulletin.

Training OpportunitiesIf you still have questions after reviewing this information, please join us for a live question and answer telephone conferences:• Jan. 13, 2015

• Jan. 22, 2015

You can register to attend the conference at: UnitedHealthcareOnline.com > Clinician Resources > Radiology. UnitedHealthcareOnline.com > Clinician Resources > Cardiology

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ImportantChangesinAdvanceNotificationand Prior Authorization Requirements

Effective for dates of service on or after Jan 1, 2015, advancenotificationorpriorauthorizationrequirementsfor certain services have been made for the following states: Florida, Hawaii, Iowa, Louisiana, Massachusetts, Mississippi, New Mexico, Rhode Island and Tennessee.

The most up-to-date list of procedures that will continue to require advancenotificationorpriorauthorization,aswellastheeffectivedate for each state for UnitedHealthcare Community Plan, can be found at UnitedHealthcareOnline.com > Tools & Resources > UnitedHealthcare Community Plan Resources.

The added codes are:Category: Home Health CareAdded Codes: Y1004, Y1004

Somemembershavebenefitplansthatprovideforpre-serviceclinical coverage reviews, while others do not. The process to requestadvancenotificationorpriorauthorizationisthesame,regardlessofthetypeofbenefitplan,andwillnotchange.


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ImportantChangesinAdvanceNotificationand Prior Authorization Requirements

If you are planning to perform a service on the standardized list, please notify us in advance. We will let you know if a clinical coverage review is required for that service and ask you to submit the necessary information to complete the review. Once a coverage determination is made, we will share that decision with you so you and your patient can make informed decisions before services are performed. We determine coverage consistent with the member’s benefitplan.

Please keep in mind that while receipt of an approved advancenotificationorpriorauthorizationforservicesconfirmscoverage,itdoesnotguaranteeorauthorizepayment. Payment of covered services is subject to the terms and conditions of your contract with UnitedHealthcareandthemember’shealthbenefit plan in effect at the time services are rendered, including but not limited to exclusions, limitations, conditions, patient eligibility, medical policies and claim processing requirements.


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

Medical Policy & Coverage Determination Guideline Updates



TAKE NOTE


Availability of the Community Plan Medical Policy Update Bulletin

All N/A Jan. 2015

UPDATED/REVISED

Autologous Chondrocyte Transplantation in the Knee Medical Policy Jan. 1, 2015 Nov. 2014Dec.2014

Bariatric Surgery Medical Policy Jan. 1, 2015 Nov. 2014Dec.2014

Breast Reconstruction Post Mastectomy Coverage Determination Guideline

Jan. 1, 2015 Nov. 2014Dec.2014

BreastRepair/Reconstruction Not Following Mastectomy


Jan. 1, 2015 Nov. 2014Dec.2014

Cardiovascular Disease Risk Tests Medical Policy Jan. 1, 2015 Nov. 2014Dec.2014

Computed Tomographic Colonography Medical Policy Feb. 1, 2015 Dec. 2014Jan. 2015

Durable Medical Equipment, Orthotics, Ostomy Supplies, Medical Supplies andRepairs/Replacements


Feb. 1, 2015 Dec. 2014Jan. 2015


Medical Policy Jan. 1, 2015 Nov. 2014Dec.2014


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Medical Policy & Coverage Determination Guideline Updates



Fecal DNA Testing Medical Policy Feb. 1, 2015 Dec. 2014Jan. 2015

Femoroacetabular Impingement Syndrome Medical Policy Feb. 1, 2015 Dec. 2014Jan. 2015


Medical Policy Feb. 1, 2015 Dec. 2014Jan. 2015

Intensity-Modulated Radiation Therapy Medical Policy Jan. 1, 2015 Nov. 2014Dec.2014



Minimally Invasive Procedures for Gastroesophageal RefluxDisease(GERD)


Omnibus Codes Medical Policy Feb. 1, 2015 Dec. 2014Jan. 2015

Vagus Nerve Stimulation Medical Policy Jan. 1, 2015 Nov. 2014Dec.2014




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Changes to the Cardiology Prior Authorization Protocol for Rhode Island Medicaid Members Effective Feb. 1, 2015

Effective Feb. 1, 2015, select cardiology procedures will require prior authorization.

Providers must notify UnitedHealthcare prior to scheduling diagnostic catheterizations, electrophysiology implants, echocardiograms and stress echocardiograms for UnitedHealthcare Community Plan members). The cardiologyproceduresforwhichadvancednotification is required are:• Diagnostic catheterizations

• Electrophysiology implants

• Echocardiograms

• Stress echocardiograms

A complete listing of the current procedural terminology (CPT)codesforwhichnotificationisrequiredcanbefound at UnitedHealthcareOnline.com > Clinician Resources > Cardiology > Medicaid Cardiology Prior Authorization Program > Important Program Information > UnitedHealthcare Community Plan Cardiology Prior Authorization CPT Code Crosswalk.

More information regarding this protocol for UnitedHealthcare Community Plan members is available in the November 2014 Network Bulletin or at UnitedHealthcareOnline.com > Clinician Resources > Cardiology > UnitedHealthcare Community Plan Cardiology Prior Authorization Program.

We will host live question and answer conference calls to further explain the new requirements on:• Jan. 13, 2015

• Jan. 22, 2015

To register, go to: UnitedHealthcareOnline.com > Clinician Resources > Radiology UnitedHealthcareOnline.com > Clinician Resources > Cardiology

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Unless otherwise noted, these reimbursement policies apply to services reported using the 1500 Health Insurance Claim Form (CMS-1500) or its electronic equivalent or its successor form. UnitedHealthcare reimbursement policies do not address all factors that affect reimbursement for services rendered to UnitedHealthcare members,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.


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The Centers for Medicare and Medicaid Services (CMS) has created four new healthcare commonprocedurecodingsystem(HCPCS)modifierstoselectivelyidentifysubsetsofmodifier59 (distinct procedural services) for use, effective Jan. 1, 2015. They are:

• XE Separate Encounter: A service that is distinctbecause it occurred during a separate encounter.

• XP Separate Practitioner: A service that is distinctbecause it was performed by a different physician.

• XS Separate Structure: A service that isdistinct because it was performed on a separateorgan/structure.

• XU Unusual Non-Overlapping Service: A servicethat is distinct because it does not overlap usualcomponents of the main service.

Thesemodifiers,collectivelyreferredtoasX{EPSU}modifiers,definespecificsubsetsofmodifier59.Like CMS,UnitedHealthcarewillcontinuetorecognizemodifier59; however, current procedural terminology (CPT) instructionsstatethatmodifier59shouldnotbeusedwhenamoredescriptivemodifierisavailable.Inaddition,theX{EPSU}modifiersaremoreselectiveversionsofmodifier59soitwouldbeincorrecttoincludebothmodifiersonthesame line.

CMSwillcontinuetorecognizemodifier59butmayselectivelyrequireamorespecificX{EPSU}modifierforbilling certain codes at high risk for incorrect billing. For example, a particular national correct coding initiative (NCCI) procedure to procedure code pair edit may be identifiedaspayableonlywiththeXEseparateencountermodifierbutnotthe59orotherX{EPSU}modifiers.

UnitedHealthcarewillrecognizethesenewmodifiers,effective for dates of service on and after Jan. 1, 2015. PleasereferencethefollowingtabletofindoutwhenthenewmodifierswillbeconsideredinadministeringtheUnitedHealthcare’s reimbursement policies.

New“X”ModifiersandImpacttoUnitedHealthcare Commercial Reimbursement Policies

Policy

X{EPSU} Modifiers considered in lieu of Modifier 59

Effective for claims with dates of service Jan. 1, 2015 processed on or after these dates:

Anesthesia XE and XU Feb. 15, 2015

Bilateral XS Jan. 1, 2015

CCI Editing XE, XP, XS, and XU Jan. 1, 2015

Laboratory Services

XE, XP, XS, and XU Feb. 15, 2015

Maximum Frequency Per Day

XE, XS, and XU Jan. 1, 2015

Obstetrical XE, XS, and XU Feb. 15, 2015

Pediatric and Neonatal Critical & Intensive Care Services

XE, XS and XU New policy becomes effective March 1, 2015 DOS

Procedure toModifier


Professional-Technical Component


Radiology Multiple Imaging Reduction

XE Jan. 1, 2015

Rebundling XE, XP, XS, and XU Feb. 15, 2015

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Introducing a New Civilian Referral Request Form

To improve both the quality and clarity of provider requests, UnitedHealthcare Military & Veterans has enhanced our Civilian Referral Request Form used to submit requests for care.

The new form has been redesigned to be more precise and intuitive for providers when requesting care for specialty referrals, outpatient,inpatient,anddurablemedicalequipment(DME)/homehealth requests. The previous form will continue to be accepted until Feb. 1, 2015.

Changes include:• Added Date of Service to top of form to indicate desired

beginning date of service.

• AdditionofEpisodeofCareFieldtoallowspecificEOCselection (link to table below).

• AddedBenefitsNumberalongwithSponsorSSNandcheckboxes to indicate selection.

• Added option to use NPI and indicator for which number isprovided (NPI or TIN).

• Addeddefinitionof“Urgent”totopofformtolimitusetosituations where care is needed within 72 hours.

Effective Feb. 1, 2015 any referral requests submitted on the outdated form will be rejected, with a request to utilize the new form.

UnitedHealthcare Military & Veterans

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Effective Feb. 25, 2015, UnitedHealthcare will apply additional WEDI Strategic National Implementation Process (SNIP) HIPAA edits to professional (837p) and institutional (837i) claims submitted electronically to most UnitedHealthcare andaffiliatepayer 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.com.

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 identify and correct rejected information prior to the claim’s acceptance into our adjudication system for processing. Thebenefitwillbefewerdeniedclaimsandlessinterruptiontorevenue streams.

Enhanced HIPAA Claim Edits Planned for February 2015


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The primary impact to you will come from edits that will validate code sets (such as diagnosis, procedure and modifiercodes)atapre-adjudicationlevel.Thenew edits and the complete list of enhanced edits have been distributed to clearinghouses and software vendors.

It’s important to check all of your claim submission reports regularly. Claims may be rejected by your clearinghouse or UnitedHealthcare; therefore, you may receive multiple reports per submission.

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)

Enhanced HIPAA Claim Edits Planned for February 2015

UnitedHealthcare Commercial, UnitedHealthcare Medicare Solutions and UnitedHealthcare West

EDI issue reporting form or 800-842-1109

UnitedHealthcare Community Plan [email protected] or 800-210-8315

UnitedHealthcare Oxford [email protected] or 800-599-4334

UnitedHealthcare Medicare Solutions Coinsurance Calculation Reminder for Providers

For all AARP MedicareComplete products, coinsurance should be calculated as follows:

1. Forservicesreimbursedviaaservice-specificcontracted rate, or on a fee-for-service basis:coinsurance is based on the contracted rate orbilled amount, whichever is less or as agreedupon in the provider contract

2. For services reimbursed under a downstreamcapitation agreement, between your organizationand a provider of the service, and where paymentisnotissuedforeachspecificservicerendered:Coinsurance is based on the MedicareAllowable Rate for the locality in which theservice is rendered.

This method of coinsurance calculation is consistent withthedefinitionof“coinsurance”foundinmembermaterials, i.e., the Evidence of Coverage, and the methodology intended for all UnitedHealthcare Medicare Advantage products nationwide. Additionally, as the coinsurance calculation is a critical portionoftheExplanationofBenefits(EOB)sentto the member, the correct set up and consistent calculation of coinsurance may reduce member appeals and complaints to Medicare.

To learn more, please visit uhcwest.com > Provider > Library > [State] > Publications > Provider Communication Highlights or contact your local Network Account Manager or Provider Advocate.

mailto:ac_edi_ops%40uhc.com?subject=

mailto:ediproviderassistance%40oxhp.com?subject=


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Coverage Determinations and Utilization Management Decisions

At UnitedHealthcare, coverage decisions on health care services are based on the member’s benefitdocumentsandapplicablestateandfederal requirements. For Commercial members, this includes the contract the member’s employer plan sponsor has with UnitedHealthcare. For Medicare Advantage members, this includes but is not limited to, national coverage determinations, local coverage determinations and general Medicare coverage guidelines.

The coverage decisions are made based on:• For Commercial members, the appropriateness of

care and services and the existence of coverage asdefinedwithinthecontractourCommercialmember’semployer has with UnitedHealthcare or;

• ForMedicareAdvantagemembers,thedefinitionof“reasonable and necessary” within Medicare coverage regulations and guidelines.

The staff of UnitedHealthcare, its delegates, and the physicians making these coverage decisions are not compensated or otherwise rewarded for issuing non-coverage decisions. UnitedHealthcare and its delegates do not offer incentives to physicians or utilization management decision makers to encourage underutilization of care or services or to encourage barriers to care and service. Hiring, promoting or terminating practitioners or other individuals is not based on the likelihood or perceived likelihood that the individual will support or tend to support thedenialofbenefits.

UnitedHealthcare Negotiates National Contract with Medway Air Ambulance, Inc. for Fixed-Wing Air Ambulance Services

As part of UnitedHealthcare’s strategy to improve the air ambulance network available to our members and facilities, UnitedHealthcare has contracted Medway Air Ambulance for nationwide domestic air ambulance trips in order to reduce medical spend while ensuring quality and consistent service to our members. Due to the structure of many benefit plans, members who receive services provided by a non-network air ambulance provider may incur increased financial liability and be exposed to higher out-of-pocket expenses.

Medway Air Ambulance can be reached at 800-233-0655. Please refer patients to in-network air ambulance providers, such as Medway, as outlined in your network participation agreement.

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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 of the River Valley Preauthorization List and Policy Updates

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

Policy Title Effective Date Coverage Policy Update Bulletin

TAKE NOTE

Annual CPT® and HCPCS Code Updates Jan. 1, 2015 Jan. 2015

Availability of the River Valley Policy Update Bulletin N/A Jan. 2015

NewPreauthorizationRequirementsforRadiology/AdvancedOutpatient Imaging Procedures

Feb. 16, 2015 Nov. 2014Dec. 2014Jan. 2015

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

TBD (Delayed) Nov. 2014

NEW


Feb. 1, 2015 Nov. 2014Dec. 2014Jan. 2015

Radiology/AdvancedOutpatientImagingProcedures Feb. 16, 2015 Nov. 2014Dec. 2014Jan. 2015

UPDATED/REVISED

Actemra® (Tocilizumab) Jan. 1, 2015 Dec. 2014

Autologous Chondrocyte Transplantation in the Knee Dec. 1, 2014 Nov. 2014

Bariatric Surgery Dec. 1, 2014 Nov. 2014

Breast Reconstruction Post-Mastectomy Jan. 1, 2015 Dec. 2014

BreastRepair/Reconstruction(NotFollowingMastectomy) Jan. 1, 2015 Dec. 2014

Cardiology - Diagnostic Catheterization, Electrophysiology (EP) Implants, Echocardiogram and Stress Echocardiogram

Jan. 1, 2015 Dec. 2014

Cardiovascular Disease Risk Tests Dec. 1, 2014 Nov. 2014

Computed Tomographic Colonography Jan. 1, 2015 Dec. 2014


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UnitedHealthcare of the River Valley Prior Authorization List and Policy Updates

Policy Title Effective Date Coverage Policy Update Bulletin


Dec. 1, 2014 Nov. 2014

Fecal DNA Testing Dec. 1, 2014 Dec. 2014

Femoroacetabular Impingement Syndrome Jan. 1, 2015 Dec. 2014

Hearing Aids and other Devices Including Wearable, Bone Anchored and Semi-Implantable

Jan. 1, 2015 Dec. 2014

Hereditary Angioedema (HAE), Treatment and Prophylaxis Dec. 1, 2014 Nov. 2014

Human Epidermal Growth Factor Receptor 2 (HER2) Targeting Drugs

Jan. 1, 2015 Dec. 2014

Intensity-Modulated Radiation Therapy Jan. 1, 2015 Nov. 2014Dec. 2014

Intensive Behavioral Therapy for the Treatment of Autism Spectrum Disorder

Dec. 1, 2014 Nov. 2014


Dec. 1, 2014 Nov. 2014

Omnibus Codes Jan. 1, 2015 Dec. 2014

Oncology Medication Clinical Coverage Policy Dec. 1, 2014 Nov. 2014

Ophthalmologic Policy - Vascular Endothelial Growth Factor (VEGF) Inhibitors

Jan. 1, 2015 Dec. 2014

Orencia® (Abatacept) Jan. 1, 2015 Dec. 2014

Pectus Deformity Repair Dec. 1, 2014 Nov. 2014

Preventive Care Services Jan. 1, 2015 Dec. 2014

Remicade®(Infliximab) Jan. 1, 2015 Dec. 2014

Routine Foot Care Jan. 1, 2015 Dec. 2014

Vagus Nerve Stimulation Dec. 1, 2014 Nov. 2014




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Policy Title Applicable State(s) Effective Date

Update Bulletin

TAKE NOTE

AvailabilityoftheSignatureValue™BenefitInterpretation Policy Update Bulletin

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

Jan. 2015

NEW

Transgender:GenderIdentityDisorder/GenderDysphoria Treatment

Oregon Jan. 1, 2015 Dec. 2014

UPDATED/REVISED

Biofeedback All Jan. 1, 2015 Dec. 2014

Change in Membership Status and Continuity of Care All Jan. 1, 2015 Dec. 2014

Chemotherapy California, Oklahoma, & Texas Jan. 1, 2015 Dec. 2014

Clinical Trials: Routine Costs in Clinical Trials All Jan. 1, 2015 Dec. 2014

Dental Care and Oral Surgery All Jan. 1, 2015 Dec. 2014

Developmental Delay and Learning Disabilities All Nov. 1, 2014 Nov. 2014

Durable Medical Equipment (DME), Prosthetics, CorrectiveAppliances/Orthotics(NonFootOrthotics)and Medical Supplies Grid

All Dec. 1, 2014 Nov. 2014

Experimentaland/orInvestigationalProcedures,Items,and Treatments

All Dec. 1, 2014 Nov. 2014

Hearing: Hearing Screening, Hearing Examinations and Hearing Aids

All Jan. 1, 2015 Dec. 2014

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.


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SignatureValue™BenefitInterpretation Policy Updates

Policy Title Applicable State(s) Effective Date

Update Bulletin

Hospice Care and Services All Jan. 1, 2015 Dec. 2014

Immunizations/Vaccinations All Dec. 1, 2014 Nov. 2014

Inpatient Hospital Services All Dec. 1, 2014 Nov. 2014

Maternity and Newborn Care All Jan. 1, 2015 Dec. 2014

Outpatient Hospital Services All Dec. 1, 2014 Nov. 2014

Radiology: Diagnostic and Therapeutic Radiology Services

All Jan. 1, 2015 Dec. 2014

Sexual Dysfunction: Erectile Dysfunction (Impotence) All Jan. 1, 2015 Dec. 2014

Surgery: Cosmetic, Reconstructive or Plastic Surgery All Dec. 1, 2014 Nov. 2014

Vision: Vision Care and Services All Nov. 1, 2014 Oct. 2014Nov. 2014

RETIRED

Hospital Observation: Observation Care (Outpatient Hospital)

All Dec. 1, 2014 Dec. 2014

Ostomy: Ostomy Supplies All Dec. 1, 2014 Nov. 2014

Ostomy Supplies Grid All Dec. 1, 2014 Dec. 2014

Surgery: Orthognathic Surgery All Nov. 1, 2014 Nov. 2014

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 in this Network Bulletin and the posted policy, the posted policy will prevail.


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Policy Title Effective Date Update Bulletin

TAKE NOTE

Annual CPT® and HCPCS Code Updates Jan. 1, 2015 Jan. 2015

Availability of the SignatureValue™ Medical Management Guidelines Update Bulletin

N/A Jan. 2015

NEW

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

Feb. 1, 2015 Nov. 2014Dec. 2014Jan. 2015

UPDATED/REVISED

Autologous Chondrocyte Transplantation in the Knee Dec. 1, 2014 Nov. 2014

Bariatric Surgery Dec. 1, 2014 Nov. 2014

Blepharoplasty, Blepharoptosis, and Brow Ptosis Repair Dec. 1, 2014 Nov. 2014

Breast Reconstruction Post Mastectomy Dec. 1, 2014 Nov. 2014

Jan. 1, 2015 Dec. 2014

Breast Reduction Surgery Dec. 1, 2014 Nov. 2014

BreastRepair/ReconstructionNotFollowingMastectomy Dec. 1, 2014 Nov. 2014

Jan. 1, 2015 Dec. 2014

Cardiovascular Disease Risk Tests Dec. 1, 2014 Nov. 2014

Computed Tomographic Colonography Jan. 1, 2015 Dec. 2014

Cosmetic and Reconstructive Procedures Dec. 1, 2014 Nov. 2014

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.


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SignatureValue™ Medical Management Guideline Updates

Policy Title Effective Date Update Bulletin

Durable Medical Equipment and Related Supplies, Prosthetics and Orthotic Policy

Jan. 1, 2015 Dec. 2014


Dec. 1, 2014 Nov. 2014

Fecal DNA Testing Dec. 1, 2014 Dec. 2014

Femoroacetabular Impingement Syndrome Jan. 1, 2015 Dec. 2014

Gynecomastia Treatment Dec. 1, 2014 Nov. 2014


Jan. 1, 2015 Dec. 2014

Home Health Care Nov. 1, 2014 Nov. 2014

Intensity-Modulated Radiation Therapy Jan. 1, 2015 Nov. 2014Dec. 2014


Dec. 1, 2014 Nov. 2014


Dec. 1, 2014 Nov. 2014

Obstructive Sleep Apnea Treatment Dec. 1, 2014 Nov. 2014

Omnibus Codes Jan. 1, 2015 Dec. 2014

Orthognathic (Jaw) Surgery Dec. 1, 2014 Nov. 2014

Panniculectomy and Body Contouring Procedures Dec. 1, 2014 Nov. 2014

Pectus Deformity Repair Dec. 1, 2014 Nov. 2014

Preventive Care Services Jan. 1, 2015 Dec. 2014

Rhinoplasty and Repair of Vestibular Stenosis Dec. 1, 2014 Nov. 2014

Surgical and Ablative Procedures for Venous InsufficiencyandVaricoseVeins

Dec. 1, 2014 Nov. 2014

Vagus Nerve Stimulation Dec. 1, 2014 Nov. 2014Dec. 2014




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Oxford® Medical and Administrative Policy Updates


Policy Update Bulletin

UPDATED/REVISED


Availability of the Oxford® Policy Update Bulletin All N/A Jan. 2015

SpecificHCPCSModifiersforDistinct Procedural Services

Reimbursement Policy

Jan. 1, 2015 Dec. 2014

NEW

Accreditation Requirements for Radiologists and Radiology Centers

Administrative Policy Dec. 1, 2014 Nov. 2014


Clinical Policy Feb. 1, 2015 Dec. 2014

UPDATED/REVISED

Abortions (Therapeutic and Elective) Clinical Policy Jan. 1, 2015 Dec. 2014

Ambulance Policy Reimbursement Policy

Dec. 1, 2014 Nov. 2014

AssignmentofBenefitstoNon-NetworkProviders Administrative Policy Dec. 1, 2014 Nov. 2014

Autism Clinical Policy Dec. 1, 2014 Nov. 2014

Autologous Chondrocyte Transplantation in the Knee

Clinical Policy Jan. 1, 2015 Dec. 2014

Bariatric Surgery Clinical Policy Jan. 1, 2015 Dec. 2014

Breast Reconstruction Post Mastectomy Clinical Policy Jan. 1, 2015 Dec. 2014

BreastRepair/Reconstruction (Not Following a Mastectomy)


Cardiovascular Disease Risk Tests Clinical Policy Jan. 1, 2015 Dec. 2014

TAKE NOTE

For complete details on thenewand/orrevisedpolicies 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.

https://www.oxhp.com/secure/policy/post_pin_comm_nov14.pdf





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Oxford Medical and Administrative Policy Updates



UPDATED/REVISED

Claims Recovery Administrative Policy Jan. 1, 2015 Dec. 2014

Clinical Review Policy Administrative Policy Jan. 1, 2015 Dec. 2014

Clotting Factors and Coagulant Blood Products Clinical Policy Jan. 1, 2015 Dec. 2014

Core Decompression for Avascular Necrosis Clinical Policy Dec. 1, 2014 Nov. 2014

Credentialing Guidelines: Participation in the Radiology Network

Administrative Policy Dec. 1, 2014 Nov. 2014

Diabetes Supply Coverage Administrative Policy Dec. 1, 2014 Dec. 2014

Diabetes Supply Coverage for New Jersey Small Group and Individual Plans

Administrative Policy Dec. 1, 2014 Dec. 2014

Diabetic Insulins Clinical Policy Jan. 1, 2015 Dec. 2014

Dialysis Services Administrative Policy Dec. 1, 2014 Dec. 2014

Drug Coverage Criteria - New and Therapeutic Equivalent Medications

Clinical Policy Dec. 1, 2014 Nov. 2014

Jan. 1, 2015 Dec. 2014

Drug Coverage Guidelines Clinical Policy Oct. 15, 2014 Oct. 2014 Addendum Nov. 2014

Dec. 1, 2014 Nov. 2014

Jan. 1, 2015 Dec. 2014

Durable Medical Equipment, Orthotics and Prosthetics Multiple Frequency


Dec. 1, 2014 Nov. 2014



Emergency Room Visits Administrative Policy Dec. 1, 2014 Dec. 2014

Experimental/InvestigationalTreatment Administrative Policy Dec. 1, 2014 Dec. 2014

Experimental/InvestigationalTreatmentforNJPlans Administrative Policy Dec. 1, 2014 Dec. 2014

ExtendedBenefitsforTotalDisability Administrative Policy Jan. 1, 2015 Dec. 2014

Fecal DNA Testing Clinical Policy Dec. 1, 2014 Dec. 2014

Formula & Specialized Food Administrative Policy Dec. 1, 2014 Dec. 2014








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UPDATED/REVISED

From - To Date Policy Reimbursement Policy

Dec. 1, 2014 Nov. 2014

GeneticTestingforHereditaryBreastand/orOvarian Cancer Syndrome (HBOC)


Global Days Policy Reimbursement Policy

Dec. 1, 2014 Nov. 2014

Hospice Care Administrative Dec. 1, 2014 Dec. 2014

Human Menopausal Gonadotropins (hMG) Used in the Treatment of Infertility


In-OfficeLaboratoryTestingandProceduresList Clinical Policy Dec. 1, 2014 Nov. 2014

Lyme Disease Clinical Policy Dec. 1, 2014 Nov. 2014

Maximum Frequency Per Day Policy Reimbursement Policy

Dec. 1, 2014 Nov. 2014

Jan. 1, 2015 Dec. 2014

Medical Supplies Administrative Policy Dec. 1, 2014 Dec. 2014

Members Outside of the United States Administrative Policy Jan. 1, 2015 Dec. 2014



Moderate Sedation Policy Reimbursement Policy

Jan. 1, 2015 Dec. 2014

Neurophysiologic Testing Clinical Policy Dec. 1, 2014 Nov. 2014

Nonphysician Health Care Professionals Billing Evaluation and Management Codes Policy


Dec. 1, 2014 Nov. 2014

Obstetrical Policy Reimbursement Policy

Dec. 1, 2014 Nov. 2014

Obstructive Sleep Apnea Treatment Clinical Policy Dec. 1, 2014 Nov. 2014

Omnibus Codes Clinical Policy Dec. 1, 2014 Nov. 2014

Jan. 1, 2015 Dec. 2014

Oral Anti-Diabetic Agents (Janumet, Januvia, Janumet XR, Invokana, Farxiga)


Orencia (Abatacept) - Intravenous Infusion Clinical Policy Jan. 1, 2015 Dec. 2014

Osteochondral Grafting of Knee Clinical Policy Dec. 1, 2014 Nov. 2014














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UPDATED/REVISED

Oxford's Outpatient Imaging Self-Referral Policy Clinical Policy Dec. 1, 2014 Nov. 2014

Jan. 1, 2015 Dec. 2014

Panniculectomy and Body Contouring Procedures Clinical Policy Dec. 1, 2014 Nov. 2014

Pectus Deformity Repair Clinical Policy Dec. 1, 2014 Nov. 2014

Preexisting Condition Administrative Policy Jan. 1, 2015 Dec. 2014

Prescription Drug Quantity Duration (QD) and Quantity Level Limitations (QLL)


Preventive Care Services Clinical Policy Jan. 1, 2015 Dec. 2014

Prosthetics Administrative Policy Dec. 1, 2014 Dec. 2014

Proton Pump Inhibitors Clinical Policy Jan. 1, 2015 Dec. 2014

Radiation Therapy Procedures for CareCore National Arrangement


Radiation Therapy Procedures RequiringPrecertification


Radiopharmaceuticals and Contrast Media Clinical Policy Dec. 1, 2014 Nov. 2014

Refractive Services Administrative Policy Dec. 1, 2014 Dec. 2014

Remicade(Infliximab) Clinical Policy Jan. 1, 2015 Dec. 2014

Supply Policy Reimbursement Policy

Jan. 1, 2015 Dec. 2014

Transcatheter Heart Valve Procedures Clinical Policy Dec. 1, 2014 Nov. 2014

Transcutaneous Electrical Nerve Stimulation (TENS) for the Treatment of Nausea and Vomiting


Transitional Care Administrative Policy Jan. 1, 2015 Dec. 2014

Treatment of Infertility for New Jersey Large Groups Clinical Policy Dec. 1, 2014 Nov. 2014

Vagus Nerve Stimulation Clinical Policy Jan. 1, 2015 Dec. 2014

Virtual Upper Gastrointestinal Endoscopy Clinical Policy Dec. 1, 2014 Nov. 2014

Vision Services Clinical Policy Jan. 1, 2015 Dec. 2014

Visual Information Processing Evaluation and Orthoptic and Vision Therapy












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Network Bulletin: November 2013 - Volume 58 For more information call 877.842.3210, or visit UnitedHealthcareOnline.com4343 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: January 2015Doc#: PCA15345_20141218




UPDATED/REVISED

Warming Therapy and Ultrasound Therapy for Wounds


RETIRED

Biofeedback Clinical Policy Jan. 1, 2015 Jan. 2015

Oxygen Therapy and Equipment Clinical Policy Jan. 1, 2015 Jan. 2015

SmokingCessationforEssentialHealthBenefitGroups (Chantix, Nicotrol NS, Nicotrol Inhaler)




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.


Network Bulletin: January 2015 network bulletinassets.fiercemarkets.net/public/unitedhealthbulletin.pdf · Net rticle 3 Network Bulletin: November 2013 - olume 58 For more information

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