Network Bulletin: March 2014 network bulletin - OXHP · 2014-03-03 · Front & Center 15 Network Bulletin: March 2014 For more information call 877.842.3210, or visit UnitedHealthcareOnline.com

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: March 2014

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: March 2014

Front & Center UnitedHealthcare Commercial

UnitedHealthcare Reimbursement Policy

UnitedHealthcare Medicare Solutions

UnitedHealthcare Community Plan

Doing Business BetterUnitedHealthcare Pharmacy

UnitedHealthcare Claims, Billing & Coding

UnitedHealthcare Affiliates

UnitedHealthcare Military & Veterans

Clinical Updates

Front & Center• Creating a Path for Greater Care

• UnitedHealthcare Code Lookup Tool Now Available

• UnitedHealthcare West Network: Notice of New 2014 Physician, Health Care Professional, Facility and Ancillary Provider Capitated Administrative Guide – Effective July 1, 2014

• Medicare Advantage to Require Prior Authorization for IMRT, SRS and SBRT as of April 1

• Enhanced HIPAA Edits to be Applied to Claim Submissions, Effective April 23

• Injectable Chemotherapy Prior Authorization Program for Florida Providers Effective May 17

• HelpingImproveProviders’AccesstotheAdvanceNotificationList

• Credentialing Plan Changes Effective April 1, 2014

• Women’s Preventive Health Care FAQ Now Available

• Phasing Out Mail Delivery of PRA

• UnitedHealthcare West Medicare Advantage Radiology and Cardiology Prior Authorization Program Update

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UnitedHealthcare Commercial

Network Bulletin: March 2014 For more information call 877.842.3210, or visit UnitedHealthcareOnline.com3

HOME

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• UnitedHealthcare Oncology Clinical Trial Reviews

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

HOME


• Revision to Anesthesia Policy – Alternate Anesthesia Codes Reported by the Surgeon

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HOME


• Rights and Responsibilities for Medicare Members

• Advance Directives

• Claim Liability Changes for All UnitedHealthcare Medicare Advantage Plans

• UnitedHealthcare Medicare Advantage Coverage Summary Updates

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HOME


• Sleep Test Optimization Program - Phase 2

• Provider Disclosure of Ownership Form Now Online


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HOME


• Updated 2014 UnitedHealthcare Military & Veterans TRICARE Provider Handbook Available April 1, 2014

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Doing Business Better

8

HOME

Network Bulletin: March 2014 For more information call 877.842.3210, or visit UnitedHealthcareOnline.com

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UnitedHealthcare Pharmacy


• UnitedHealthcare Expands Provider Relationship With Linkia, LLC/Hanger, Inc.: Provider for Orthotic and Prosthetic Services

• UnitedHealth Premium® Results Available to Public

• MPPR for Diagnostic Cardiovascular and Ophthalmology Services

• ManageYourReceivablesMoreEfficientlyOnline

• Learn About Optum Cloud Dashboard’s New Features

• ElectronicInpatientAdmissionNotifications

• UnitedHealthcareOnline.com Training


HOME


• Pharmacy Summary of PDLs

• UnitedHealthcare Pharmacy Tiering Update


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HOME


• ClarificationofProcessforProviderReimbursementRequestsAfter Members Use Consumer Account Cards


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Clinical Updates

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12

Clinical Updates• Mid-Atlantic Health Plan Pre-authorization Submissions

on UnitedHealthcareOnline.com

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HOME

Network Bulletin: March 2014 For more information call 877.842.3210, or visit UnitedHealthcareOnline.com

UnitedHealthcareAffiliates

• SignatureValue™BenefitInterpretationPolicyUpdates

• SignatureValue™ Medical Management Guideline Updates

• Oxford® Medical and Administrative Policy Updates

• UnitedHealthcare of the River Valley Preauthorization List and Policy Updates


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Front & Center

HOME

According to the Centers for Disease Control, many of the 90 percentofMedicarebeneficiarieswhovisitaphysicianatleastoncea year are not receiving their full range of recommended covered preventive services.1

These preventive exams, tests and screenings can often catch health problems early, when they may be easier and less expensive to treat. And with the Patient Protection and Affordable Care Act, Medicare beneficiariesarenowentitledtoan annual wellness visit, with no out-of-pocket costs, that includes a schedule of recommended preventive services.1

We know you’re busy, so we’re here to help.

Like you, we want your patients to be as healthy as possible. But we know it often takes extra time and effort to make sure they come in for their annual wellness visit and complete their preventive services. That’s why UnitedHealthcare is introducing a program to help keep our

members engaged and encourage them to take action on your treatment plan.The program is designed to encourage greater use of preventive health care services by supporting and working with our Medicare Advantage members to get engaged with their physicians. And it all starts by encouraging them to set up an annual wellness visit. Here’s how it works:

1. Your patients who are our members will receive ongoing communication and be offered an incentive to complete their annual wellness visit. We will communicate directly with our Medicare Advantage members about the importance of taking proactive steps to keep their health on track.

Creating a Path for Greater Care Front & Center


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HOME TABLE OF CONTENTS

Front & Center



2. You will have easy access to actionable patient data and reporting. Our reports will provide you with meaningful data when you need it, with simple access to both patient-level and practice-level data.

3. Physicians can earn additional compensation.Your practice may be eligible for additional incentives compensation for exceeding quality-based performance targets. And since we know it takes extra time for you to review patient health and complete assessment forms, we also offer additional administrative compensation

4. You can take advantage of tools and resources designed to support your practice. Our practice-based support solutions may help save time and effort for your administrative staff. We’ll provide tools, resources and support to maximize your efforts to help improve patient outcomes, while encouraging patients to take a more proactive role in their health.

Let’s team up to get members on the right path to wellness.

Better health starts with taking steps in the right direction. UnitedHealthcare is committed to helping you improve the health of our Medicare Advantage members through the rewards and support offered through the program.

To learn more, contact your local UnitedHeathcare Network team today.

1 “Enhancing Use of Clinical Preventive Services Among Older Adults,” Center for Disease Prevention, 2011. http://www.cdc.gov/aging/pdf/clinical_preventive_services_closing_the_gap_report.pdf

Creating a Path for Greater Care

Front & Center



UnitedHealthcare Code Lookup Tool Now Available

The UnitedHealthcare Code Lookup Tool is now available. It enables providers to map an ICD-9 code to an ICD-10 code, and map an ICD-10 code to an ICD-9 code.

The tool was developed using the Centers for Medicare and Medicaid Services (CMS) General Equivalence Mappings (GEMs) as a baseline, focusing on the high volume codes most frequently submitted to UnitedHealthcare claim platforms. UnitedHealthcare used the knowledgeofateamofcertifiedcoders,nurses,physicians and other representatives across all areas of UnitedHealthcare to identify additional mappings from a broader clinical context than the CMS GEMs.

The Code Lookup Tool can be accessed from the UnitedHealthcareOnline.com ICD-10 Outreach site in the “Tools” section. NOTE: The UnitedHealthcare Code Lookup Tool is not a substitute for native coding (i.e. using the most current ICD-10 manual to remediate).

Send questions regarding the Code Look-up Tool to [email protected].

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Front & Center



UnitedHealthcare West Network: Notice of New 2014 Physician, Health Care Professional, Facility and Ancillary Provider Capitated Administrative Guide – Effective July 1, 2014

The UnitedHealthcare West Capitated Administrative Guide is being updated for 2014, and will be published and available on uhcwest.com as of April 1, 2014.

The Guide will be effective July 1, 2014, for all physicians, health care professionals, facilities and ancillary providers participating in the UnitedHealthcare West network. For those providers joining the network on or after April 1, 2014, the Guide will be effective immediately.

The 2013 UnitedHealthcare West Provider Capitated Administrative Guide will continue to be available to view and print at uhcwest.com. A summary list of important updates to the 2014 version of the Guide will be posted in the May Network Bulletin. To distinguish between administrative rules applicable to UnitedHealthcare products and products formerly knownasPacifiCareCommercialandPacifiCare/SecureHorizons Medicare products, we will

use a reference to UnitedHealthcare West. The following legal entities are included in the reference to UnitedHealthcare West: UHC of California doing business as UnitedHealthcare of California, UnitedHealthcare of Oklahoma, Inc., UnitedHealthcare ofOregon,Inc.,UnitedHealthcareBenefitsofTexas,Inc.,UnitedHealthcareofWashington,Inc.,PacifiCareofArizona,Inc.,PacifiCareofColorado,Inc.,PacifiCareof Nevada, Inc., and UnitedHealthcare Services, Inc. The products offered by these legal entities have been rebranded.PacifiCareHealthSystems,LLCremainsasa stand-alone legal entity. Behavioral health products are provided by U.S. Behavioral Health Plan, California or United Behavioral Health.

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Front & Center



Medicare Advantage health plans will require prior authorization for Intensity Modulated Radiation Therapy (IMRT), Stereotaxic Radiosurgery (SRS) and Stereotactic Body Radiation Therapy (SBRT) when administered in an outpatient setting, effective April 1, 2014.

Additional details about the program will be posted at UnitedHealthcareOnline.com > Clinical Resources > Cancer – Oncology > Medicare Advantage Therapeutic Radiation.

Medicare Advantage IMRT, SRS and SBRT prior authorization training and live question and answer sessions will be hosted by WebEx in March. See theabovewebsitesforspecificscheduledatesandregistration details.

Medicare Advantage to Require Prior Authorization for IMRT, SRS and SBRT as of April 1

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Front & Center



Enhanced HIPAA Edits to be Applied to Claim Submissions, Effective April 23

Effective April 23, 2014, UnitedHealthcare will apply an enhanced level of Health Insurance Portability and Accountability Act (HIPAA) edits to professional (837p) and institutional (837i)claimssubmittedelectronicallytomostUnitedHealthcareandaffiliatepayer IDs.*

Please review the complete list of enhanced edits periodically for modifications that may occur prior to implementation. 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. The goal will be fewer denied claims and less interruption to revenue streams.

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

It is 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.

Visit UnitedHealthcareOnline.com for more information about tracking your electronic claims.

Rejections that may occur from the enhanced edits will appear at a clearinghouse level. Your Electronic Data Interchange (EDI) vendor or clearinghouse should beyourfirstpointofcontactforassistanceregardingthese edits or to resolve rejections.

For more information, please contact EDI Support:

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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

* Exceptions: Harvard Pilgrim (04271), Medica HealthCare Plans (78857), Preferred Care Partners (65088), The Alliance (88461) and TRICARE West (99726)

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mailto:ediproviderassistance%40oxhp.com?subject=

Front & Center



Injectable Chemotherapy Prior Authorization Program for Florida Providers Effective May 17

Effective May 17, 2014, providers in Florida who are billing for outpatient injectable chemotherapy for members being treated for a cancer diagnosis insured by one of the following health plans are required to obtain prior authorization for services:

• Neighborhood Health Partnership (NHP)

• UnitedHealthcare – excluding indemnity/preferred partners organization (PPO) members

• UnitedHealthcare Community Plan – excluding UnitedHealthcare at Home and UnitedHealthcare Health & Home Connection members

UnitedHealthcare’s Injectable Chemotherapy Prior Authorization program will be managed by CareCore National’s Oncology Division and providers will be able to obtain injectable chemotherapy authorizations on CareCore’s website.

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 via WebEx.

Registration details will be posted in April to: UnitedHealthcareOnline.com > Clinician Resources > Cancer – Oncology > Florida Chemotherapy Prior Authorization Program.

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Front & Center



HelpingImproveProviders’AccesstotheAdvanceNotificationList

Advancenotification/Priorauthorizationisnolongerrequiredforcapsuleendoscopyorhyperbaric oxygen treatment for UnitedHealthcare Commercial and Medicare Advantage members. In addition, more than 100 codes were removed from the UnitedHealthcare Commercial list and more than 200 codes were removed from the Medicare Advantage list.

ManyotherimprovementstotheAdvanceNotificationprocess have been implemented as well:

• Last November, UnitedHealthcareOnline.com wasenhancedtoonlyacceptnotificationforservicesthat are only on the prior authorization list, as wellas providing an automated way to provide approvaldecisions for certain services.

• TheAdministrativeGuide’sAdvanceNotificationListmoved online.

• To ensure that the most up-to-date codes are alwayseasily available at any time without the need for aphone call, UnitedHealthcare has posted the AdvanceNotificationrequirementsforUnitedHealthcareCommercial and Medicare Advantage plans to our

website at UnitedHealthcareOnline.com > Clinician Resources > Advance & Admission Notification Requirements. UnitedHealthCareOnline.com canacceptthenotificationsonline.

• On Jan. 1, 2014, additional enhancements weremade to expand services that can be approved inan effort to improve turnaround time in decisions.

• In 2015, we will make additional improvementsthat will continue to help improve turnaround timesfor decisions. Some of those changes will consistof additional procedure codes being removedfromtheAdvanceNotificationListandcontinuedenhancements to UnitedHealthcareOnline.comthat will provide automated decisions on anexpanded set of services.

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UnitedHealthcare reviews and updates our Credentialing Plan at least every two years to ensure continued compliance with all state and federal regulatory requirements and NCQA Accreditation requirements.

The 2014 Credentialing Plan and State and Federal Regulatory Addendum will be effective April 1, 2014. Here are some of the key changes:

• Removed references to the Healthcare Integrity and Protection Data Bank as it has been merged into the National Practitioner Data Bank;

• Revised composition of the Credentialing Committee to match current practice;

• Added Medical Directors as Committee members;

• Clarifiedlanguagerelatedtolicensurerequirementsto further align with contract language; and

• Added a reference to possible denial of credentialing/recredentialing based on history of Quality of Care concerns and/or history of malpractice settlements.

Credentialing Plan Changes Effective April 1, 2014

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Front & Center



Inordertocontinueeffortstoidentifyandimplementadministrativesimplificationsforyourpractice, we will phase out mail delivery of paper remittance advice (PRA) and only distribute remittance advice electronically. You will continue to receive electronic remittance advice (ERA) via an electronic transaction as usual, but you will no longer receive PRAs beginning 31 days afterthefirstpaymentwassenttoyouafterDec.15,2013.

Forexample,ifthefirstpaymentwesentyouafter Dec. 15, 2013 was on Jan. 10, 2014, your last day to receive PRAs would be Feb. 10, 2014 (31 calendar days later).

Only providers who have signed up for electronic remittance advice (ERA) will no longer receive PRAs. If you did not enroll in ERA, you will continue to receive PRAs as usual.

This will be effective only in the states of Kansas, Maryland, Michigan, Nebraska, New Jersey, New York, Ohio, Texas, Washington and Wisconsin.

You can, however, always view, save and print PRA at UnitedHealthcareOnline.com at any time.

If you do not have a user ID and password to access the site, click here: UnitedHealthcareOnline.com or call 866-842-3278.

Phasing Out Mail Delivery of PRA

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Front & Center



Women’s Preventive Health Care FAQ Now Available

To view up-to-date frequently asked questions (FAQ) regarding women’s preventive health care, please go to:

https://www.unitedhealthcareonline.com/ccmcontent/ProviderII/UHC/en-US/Assets/ProviderStaticFiles/ProviderStaticFilesPdf/Clinician%20Resources/Womens%20Health/FAQ_Womens_Preventive_Care_Services.pdf

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Beginning April 1, 2014, participating physicians, facilities and other health care professionals who are subject to the Administrative Guide and the UnitedHealthcare West Non-Capitated Supplement and practice in Arizona, Oklahoma, Oregon, Texas and Washington, must obtain prior authorization for certain outpatient radiology procedures before they are rendered to UnitedHealthcare West Medicare Advantage members. Those states, as well as Colorado, must also do the same for cardiology procedures before they are rendered to UnitedHealthcare West Medicare Advantage members.

Important points to remember, effective April 1, 2014:

• Radiology Prior Authorization Requirements - Effective April 1, 2014, ordering providers who are subject to the Administrative Guide and the UnitedHealthcare West Non-Capitated Supplement and practice in Arizona, Oklahoma, Oregon, Texas and Washington health care providers will use a new phone number and website to

obtain a prior authorization number and notify UnitedHealthcare prior to scheduling certain CT, MRI, MRA, PET scan, Nuclear Medicine, and Nuclear Cardiology procedures for UnitedHealthcare West Medicare Advantage members. Rendering providers mustconfirmthatacoveragedecisionhasbeenmadebefore rendering these procedures or payment for their services may be denied.

A complete listing of CPT codes for which prior authorization is required is available at UnitedHealthcareOnline.com > Clinician Resources > Radiology > Medicare Advantage Radiology Prior Authorization Program >Authorization Resources: Reference Materials > Radiology Prior Notification/Authorization CPT Code List.

UnitedHealthcare West Medicare Advantage Radiology and Cardiology Prior Authorization Program Update

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UnitedHealthcare is standardizing our radiology and cardiology prior authorization requirements.

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Please note that prior authorization is not required for any advanced imaging procedure that is rendered in the emergency room, urgent care center, observation unit or during an inpatient stay.

• Cardiology Prior Authorization Requirements - Effective April 1, 2014, ordering providers who are subject to the Administrative Guide and the UnitedHealthcare West Non-Capitated Supplement and practice in Arizona, Colorado, Oklahoma, Oregon, Texas and Washington must obtain prior authorization before scheduling diagnostic catheterizations, electrophysiology implants, echocardiograms and stress echocardiograms for UnitedHealthcare West Medicare Advantage members. Rendering providers must confirmthatacoveragedecisionhasbeenissuedbeforerendering the cardiology procedure or payment for the services may be denied.

A complete listing of CPT codes for which prior authorization is required is available at UnitedHealthcareOnline.com > Clinician Resources > Cardiology > Medicare Advantage Cardiology Prior Authorization Program > Important Program Information: 2014 Cardiology Prior Authorization Table and CPT Code Crosswalk.

Prior authorization for diagnostic catheterizations, echocardiograms and stress echocardiograms is required foroutpatientandoffice-basedservicesonly.Priorauthorization for electrophysiology implants is required for outpatient,office-basedandinpatientservices.Cardiologyprocedures rendered and appropriately billed in an emergency room, urgent care center or inpatient setting, except for electrophysiology implants, which requires prior authorization during an inpatient stay, do not require prior authorization.


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Additionally, effective April 1, 2014:• Providers must complete the prior authorization

processandconfirmthatacoveragedecisionhas been made as follows:

• Online at UnitedHealthcareOnline.com >Notifications/Prior Authorizations > Radiology Notification & Authorization – Submission & Status;

• Online at UnitedHealthcareOnline.com >Notifications/Prior Authorizations > Cardiology Notification & Authorization – Submission & Status; or

• Call 866-889-8054, 7 a.m. to 7 p.m. local time, Monday through Friday

• Failure to complete the prior authorization process or verify that a coverage determination has been issued before rendering an advanced outpatient imaging or cardiology procedure that is subject to prior authorization requirements will result in an administrative claim reimbursement reduction, in part or in full. Members cannot be billed for administratively denied services.

• An authorization number is issued for both approved and clinically denied prior authorizations. A clinical denial will be issued if it is determined during the clinical coverage review process that the service does not meet medical necessity criteria.

• The clinical denial will be communicated by a letter faxed to the provider and a letter mailed to the UnitedHealthcare West Medicare Advantage member. Members can be billed for claims that are clinically denied if you obtain adequate written consent from the member prior to rendering the service.

• Additional information regarding the requirements to follow can be found in the Outpatient Radiology Prior Authorization Protocol for Medicare Advantage Customers and the Cardiology Prior Authorization Protocol for Medicare Advantage Customers. These protocols are outlined in the Administrative Guide as well.

The guide is available at UnitedHealthcareOnline.com > Tools & Resources > Policies, Protocols & Guides > Administrative Guides.


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Training Opportunity

If you still have questions after reviewing this information, please join us for a live question and answer telephone conference

• 12 p.m. (CST) on March 18, 2014

• 2 p.m. (CST) on March 20, 2014

• 4 p.m. (CST) on March 26, 2014

Please register to attend the conference at:

• UnitedHealthcareOnline.com > Clinician Resources > Radiology > Medicare Advantage Radiology Prior Authorization Program or

• UnitedHealthcareOnline.com > Clinician Resources > Cardiology > Medicare Advantage Cardiology Prior Authorization Program

If you have questions, please contact your UnitedHealthcare Network Management representative, or Provider Services at 800-637-5792, or email [email protected], or [email protected].

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mailto:cardiology%40customerelation.com?subject=

UnitedHealthcare Oncology Clinical Trial Reviews

UnitedHealthcare requires prior authorization for participation in oncology clinical trials and we have assigned a dedicated team to review these requests. A provider can use one of the following ways to contact us to request coverage for an oncology clinical trial:

Phone: 866-936-6002Email: [email protected] Fax: 855-250-2102

All requests for a clinical trial require review of the clinical trial and the member’s coverage document. The coverage document may allow coverage for the clinical trial – covering the costs of routine care, but may exclude costs for the investigational item, device or service. The provider will be informed in writing of the coverage review outcome. A brief summary of the member’s clinical condition, clinical trial details, documents showing institutional review board approval and sponsorship by the approved source is necessary for a clinical trial review.




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

Policy Title Policy Type Effective Date Medical Policy Update Bulletin

CLARIFICATION

Abnormal Uterine Bleeding and Uterine Fibroids Medical Policy Jan. 1, 2014 Feb. 2014

UPDATED/REVISED

Bone and Soft Tissue Healing and Fusion Enhancement Products

Medical Policy Apr. 1, 2014 Mar. 2014

Botulinum Toxins A and B Drug Policy Feb. 1, 2014 Jan. 2014

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

Deep Brain Stimulation Medical Policy Feb. 1, 2014 Jan. 2014

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

Coverage Determination Guideline

Feb. 1, 2014 Jan. 2014

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For complete details on the new and/or revised policies and guidelines listed in the following table, 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.





Electrical Stimulation and Electromagnetic Therapy for Wounds

Medical Policy Feb. 1, 2014 Jan. 2014

Electrical Stimulation for the Treatment of Pain and Muscle Rehabilitation


Emergency Health Services and Urgent Care Center Services


Apr. 1, 2014 Feb. 2014Mar. 2014

Gastrointestinal Motility Disorders, Diagnosis and Treatment


Genetic Testing for Hereditary Breast and/or Ovarian Cancer Syndrome (HBOC)


Infertility Diagnosis and Treatment Medical Policy Feb. 1, 2014 Jan. 2014

Manipulation Under Anesthesia Medical Policy Mar. 1, 2014 Feb. 2014

Occipital Neuralgia and Cervicogenic, Cluster and Migraine Headaches

Drug Policy Feb. 1, 2014 Jan. 2014

Ophthalmologic Policy: Vascular Endothelial Growth Factor (VEGF) Inhibitors

Drug Policy Feb. 1, 2014 Jan. 2014

Orthognathic (Jaw) Surgery Coverage Determination Guideline

Jan. 1, 2014 Jan. 2014

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

Sensory Integration Therapy and Auditory Integration Training

Medical Policy Mar. 1, 2014 Feb. 2014


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Sodium Hyaluronate Medical Policy Mar. 1, 2014 Feb. 2014

Standing Systems Medical Policy Mar. 1, 2014 Feb. 2014

Stelara (Ustekinumab) Drug Policy Feb. 1, 2014 Jan. 2014

Surgical and Ablative Procedures for Venous InsufficiencyandVaricoseVeins


Temporomandibular Joint Disorders Medical Policy Mar. 1, 2014 Feb. 2014

Vagus Nerve Stimulation Medical Policy Feb. 1, 2014 Jan. 2014

REPLACED

Auditory Integration Training Medical Policy Mar. 1, 2014 Feb. 2014

Durable Medical Equipment and Related Supplies, Prosthetics and Orthotics

Utilization Review Guideline Feb. 1, 2013 Jan. 2014

High Ligation and Endomechanical Ablation for Varicose Veins


Mandibular Disorders Medical Policy Mar. 1, 2014 Feb. 2014

Sensory Integration Therapy Medical Policy Mar. 1, 2014 Feb. 2014

Surgical and Ablative Procedures for Venous InsufficiencyandVaricoseVeins


Mar. 1, 2014 Feb. 2014


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Temporomandibular Joint Services Coverage Determination Guideline

Mar. 1, 2014 Feb. 2014

RETIRED

Experimental, Investigational, and Unproven Services


Feb. 1, 2014 Feb. 2014

Home Health Care Coverage Determination Guideline

Jan. 1, 2014 Jan. 2014

Infertility Services Coverage Determination Guideline

Jan. 1, 2014 Jan. 2014

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

eventofaninconsistencyorconflictbetweentheinformationinthisBulletinandthepostedpolicy,theprovisionsofthepostedpolicyprevail.

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Unless otherwise noted, these reimbursement policies apply to servicesreported using the 1500 Health Insurance Claim Form (CMS-1500) or itselectronic equivalent or its successor form. UnitedHealthcare reimbursementpolicies do not address all factors that affect reimbursement for servicesrenderedtoUnitedHealthcaremembers,includingmemberbenefitplandocuments, UnitedHealthcare medical policies and the UnitedHealthcarePhysician, Health Care Professional, Facility and Ancillary ProviderAdministrative Guide. Meeting the terms of a particular reimbursement policy isnot a guarantee of payment. Once implemented the policies may be viewed intheir entirety at UnitedHealthcareOnline.com > Tools & Resources > Policiesand Protocols > Reimbursement Policies-Commercial. In the event ofaninconsistencyorconflictbetweentheinformationprovidedintheNetworkBulletin and the posted policy, the provisions of the posted policy prevail.




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35 Network Bulletin: March 2014


For more information call 877.842.3210, or visit UnitedHealthcareOnline.com

The current Anesthesia Policy denies anesthesia current procedure terminology (CPT) codes 00100-01999 (excluding 01953 and 01996) when reported by the physician who also reports the surgical or medical procedure. Effective Q2 of 2014, edits will be added to deny anesthesia CPT codes identifiedasalternateanesthesiacodeswithintheAmericanSocietyofAnesthesiologists (ASA) Guide for Surgery/Anesthesia CPT Codes 2014 Crosswalk®, when reported by the physician who also reports the surgical or medical procedure. Alternate anesthesia codes are used to specify the anatomic locationoftheprocedure,theageofthepatientorotherfactorsthatinfluencethecode selection. Per the American Medical Association (AMA), if a physician personally performs the regional or general anesthesia for a surgical procedure that they alsoperform,modifier47shouldbeappendedtothesurgicalcode,andnocodesfrom the Anesthesia section of the CPT code book should be used. Please refer to theAMApublication,CodingwithModifiers,fourthedition,forfurtherinformation.


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Revision to Anesthesia Policy – Alternate Anesthesia Codes Reported by the Surgeon

Rights and Responsibilities for Medicare Members

UnitedHealthcare members have certain rights and responsibilities which are intended to help uphold the quality of care and services they receive from you.

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




These rights and responsibilities can be found at: https://www.uhcmedicaresolutions.com/health-plans/medicare-advantage-plans/resources-plan-material/ma-medicare-forms/medicare-rights-center.html

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Advance Directives

The federal Patient Self-Determination Act (PSDA) gives individuals the legal right to make choices about their medical care in advance of an incapacitating illness or injury through an advance directive.

Under this act, physicians and other health care professionals, including hospitals, skilled nursing facilities, hospices, home health agencies and others must provide written information to patients about state law, advance treatment directives, the patients’ right to accept or refuse treatment, and your own policies regarding advance directives. Whenever possible, please suggest your patients execute an advance directive and a limited durable power of attorney. UnitedHealthcare also informs our members about advance directives through our member handbooks and other communications.

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Claim Liability Changes for All UnitedHealthcare Medicare Advantage Plans

Tohelpmembersunderstandtheirfinancialresponsibilityfornon-coveredservices,UnitedHealthcare has taken steps to help ensure Medicare claims processing procedures are more consistently administered. As referenced in UnitedHealthcare’s provider administrative manuals, members are not responsible when not given appropriate Advanced Notice for non-covered services.

In February 2012, these changes were enacted on a go-forward basis with no related retroactive claims processing.Pleasecheckthemember’sspecificbenefittoidentify if a particular service is covered. If a service is not covered, member liability is appropriate when an Advanced Notice of Non-coverage (ANN) has been provided to the member prior to service delivery. When the ANN has been properly executed and providers are submitting charges on behalf of the member, the related claim(s) mustbesubmittedwitheitheraGAorGYmodifiertodemonstrate to UnitedHealthcare that the provider has informed the member of the non-covered service and that the member has agreed to take responsibility for charges related to the service. It is important to remember prior to providing the service or submitting a claim with eitherofthesemodifiers,physiciansandotherhealthcareprofessionalsmustobtainwrittenaffirmationfromthemember acknowledging that the service to be rendered is

not covered and that the member will accept responsibility for these charges. UnitedHealthcare has posted a sample template of this form on UnitedHealthcareOnline.com >Tools & Resources > Policies, Protocols and Guides > Protocols to guide providers in establishing appropriate documentation of member responsibility for charges.

Effective on or after March 19, 2014, non-covered servicesappendedwiththeGYModifierwillfollowthesamelogicastheGAModifier,totheextentpossible. UnitedHealthcare now requires an ANN for UnitedHealthcare Medicare Advantage members for all non-covered services.

The form and instructions can be found at UnitedHealthcareOnline.com. Please contact the Provider Service Center at 877-837-1882 or your Physician Advocate with questions.

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UnitedHealthcare Medicare Advantage Coverage Summary Updates

For complete details on the revised policies listed in the following table, 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.

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Policy Title Approval Date Update Bulletin

REVISED

Gastroesophageal and Gastrointestinal (GI) Services and Procedures Dec. 17, 2013 Jan. 2014

Medications/Drugs (Outpatient/Part B) Dec. 17, 2013 Jan. 2014

Mental Health Services and Procedures Dec. 17, 2013 Jan. 2014

Neurologic Services and Procedures Dec. 17, 2013 Jan. 2014

Respiratory Therapy, Pulmonary Rehabilitation and Pulmonary Services Dec. 17, 2013 Jan. 2014

Speech Generating Devices Dec. 17, 2013 Jan. 2014

Spine Procedures Dec. 17, 2013 Jan. 2014

RETIRED

Percutaneous Vertebroplasty and Percutaneous Kyphoplasty Dec. 17, 2013 Jan. 2014

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

Sleep Test Optimization Program - Phase 2

Effective April, 15 2014, new prior authorization requirements will take effect for polysomnography and portable monitoring for sleep-related breathing disorders for UnitedHealthcare Community Plan members in the states of: Arizona, Delaware, Mississippi, Pennsylvania, and Wisconsin. For Massachusetts and Washington, these new requirements will become effective May 15, 2014.

Prior authorization will be required for attended sleep testing performed in a health care facility. Unattended sleep testing performed out of center will NOT require prior authorization.

Whether the requested sleep test requires prior authorization with medical necessity review is based on the site of service. Procedure codes for attended sleep testing which would require prior authorization include CPT 95805, 95807, 95808, 95810 and 95811.

Details on how to arrange home sleep testing:

UnitedHealthcare has contracted with Sleep Central, a division of Rotech Healthcare Inc., to deliver the home

sleep testing device to the member’s home, provide instructions and phone support, and deliver the test result usinganetworkofboard-certifiedsleepmedicine physicians who perform the test interpretation. Sleep Central has clinicians on staff 24 hours a day, seven days a week to assist with home sleep testing questions.

Contact Sleep Central Monday through Friday, 9 a.m. to 7 p.m. (CST) at 866-688-2981. If you have prior authorization questions, please contact your local network management representative or Provider Services at 877-842-3210 or go to UHCCommunityPlan.com.




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Provider Disclosure of Ownership Form Now Online

The online disclosure form went live in the following UnitedHealthcare Community Plan markets on Jan. 1, 2014: Tennessee, New Mexico, Hawaii, Mississippi, New Jersey, Washington, Florida, Nebraska, Kansas, Rhode Island, Maryland, New York, Iowa, Michigan and Massachusetts.

UnitedHealthcare Community Plan continues to monitor state Medicaid requirements for managed care collection of the disclosure forms. If your state is not listed, collection of the form by managed Medicaid plans is not a requirement at this time.

Online completion of this form allows UnitedHealthcare Community Plan providers in these states an easier way to accessandcompletethenecessarydatafieldsaccurately. EchoSign is a web-based application that provides deliverytracking,confirmationandeSignaturecapabilities.

The application: • Requires no software installation to receive or sign

important notices, network communications, contracts and amendments; and

• Provides a convenient online audit trail that is safe, private and secure.

Knowledge Based Authentication (KBA) will be used when a signature is required. KBA protection, which is used by financialinstitutionsallovertheworld,allowsadvancedsecurity as to who opens and signs a contract or amendment.

With KBA, you will be asked for basic personal information, including the last four digits of your social security number, then a series of question pages will appear that are related to who the signer is and what property may have been owned. Once the signer has answered all the KBA questions correctly, they will see the page to continue with the signing process. Once the Disclosure of Ownership has been successfully submitted you will receive an automated messageofconfirmation.

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Disclosure of Ownership Forms can now be completed securely online through a partnership with EchoSign. The Disclosure of Ownership form is a federal requirement applicable to all providers that contract with a State Medicaid Agency.

Updated 2014 UnitedHealthcare Military & Veterans TRICARE Provider Handbook Available April 1, 2014

The UnitedHealthcare Military & Veterans TRICARE Provider Handbook is being updated and the new edition will be available on April 1, 2014. Once published, the changes in the Handbook will be effective on July 1, 2014 for currently contracted providers and immediately for providers newly contracted on or after April 1, 2014.

The TRICARE Handbook is located on UnitedHealthcareOnline.com > Tools & Resources > Policies, Protocols and Guides > TRICARE Provider Handbook; as well as on UHCMilitaryWest.com > Providers > Provider Handbook.

A summary list of changes to the Handbook will also be posted once it is published on April 1, 2014 for your convenience.



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UnitedHealthcare Expands Provider Relationship With Linkia, LLC/Hanger, Inc.: Provider for Orthotic and Prosthetic Services

As part of the UnitedHealthcare effort to improve and expand the orthotic and prosthetic (O&P) network of providers, UnitedHealthcare has contracted with Linkia, LLC. Linkia, a subsidiary of Hanger, Inc. is a specialty health care company dedicated to O&P management and care. UnitedHealthcare has developed a strategic relationship with Linkia, LLC/Hanger, Inc. to help reduce out-of-network services, reduce member out-of-pocket expenses, while maintaining quality and consistency of O&P services for the member. Due tothestructureofmanybenefitplans,members who receive services provided by an out-of-network O&P provider may incurincreasedfinancialliabilityandbe exposed to higher out-of-pocket expenses, and no quality requirements. By referring members to Linkia, LLC/Hanger, Inc., members can be assured quality and cost savings.

Communications have been developed to educate referring physicians and members on the advantages and requirements of utilizing O&P services to in-network providers. Referring physicians who have referred patients for O&P services from non-participating providers will receive letters notifying them of in-network O&P options. Services can be directed to Linkia, LLC/Hanger, Inc., UnitedHealthcare’s strategic O&P provider.

Please contact Linkia, LLC/Hanger, Inc. at: www.linkia.com or call 877-754-6542 to locate a clinic location in your area. Orthotic and Prosthetic providers, including regional and local providers for your area may be found by visiting UnitedHealthcareOnline.com.




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UnitedHealth Premium® Results Available to Public

Most UnitedHealth Premium physician designations were published to our online websites such as myuhc.com on Jan. 8, 2014. The publication date for physicians in Connecticut, Delaware, New Jersey, New York, Pennsylvania and Rhode Island will be April 2, 2014.

NotificationsofnewUnitedHealthPremium designationsforqualityandcostefficiencywere mailed to physicians in November 2013. The physicians’ letters included instructions on how to access their full suite of UnitedHealth Premium assessment reports at UnitedHealthcareOnline.com. Physicians may also submit reconsideration requests through the site.

The public designation display date allowed time for physicians to submit reconsiderations before the results were available to the public. As is our practice, physicians may submit a reconsideration request at any time during the review cycle.

For more information, go to UnitedHealthcareOnline.com and select “UnitedHealth Premium®” onthetopnavigationbartofindresources and tools that explain the program, send us an email though the Contact Premium Program link, or call 866-270-5588.

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MPPR for Diagnostic Cardiovascular and Ophthalmology Services

The Centers for Medicare & Medicaid Services (CMS) expanded its Multiple Procedure Payment Reduction (MPPR) policy to cover diagnostic cardiovascular and ophthalmology procedures. The MPPRs on diagnostic cardiovascular and ophthalmology procedures apply when multiple services are provided to the same patient on the same day.

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The MPPRs apply independently to cardiovascular and ophthalmology services, as well as technical component services, and the technical component of global services. ThepolicyappliestoproceduresidentifiedwithaMultipleProcedure (MP) indicator 6 (diagnostic cardiovascular) and 7 (diagnostic ophthalmology) on the CMS National Physician Fee Schedule. UnitedHealthcare Medicare plans will align with CMS guidance and implement the new MPPR for Diagnostic Cardiovascular and Ophthalmology Services Policy, effective with claims reported with dates of service on and after May 1, 2014. For cardiovascular services, full payment is made for the technical component service with the highest payment under the Medicare Physician Fee Schedule (MPFS). Payment is made at 75 percent for subsequent technical component services provided by the same physician or multiple physicians in the same group practice to the same patient on the same day.

For ophthalmology services, full payment is made for the technical component service with the highest payment under the MPFS. Payment is made at 80 percent for subsequent technical component services provided by the same physician or by multiple physicians in the same group practice to the same patient on the same day. For more information, go to:

For more information, go to: UnitedHealthcare reimbursement policyhttps://www.unitedhealthcareonline.com/ccmcontent/ProviderII/UHC/en-US/Main%20Menu/Tools%20&%20Resources/Policies%20and%20Protocols/Medicare%20Advantage%20Reimbursement%20Policies/M/MPPRDiagnosticHeartEye.pdf

CMS MLNhttp://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM7848.pdf





ManageYourReceivablesMoreEfficientlyOnline

With Electronic Payments and Statements (EPS)youcanreceivepaymentsfivetoseven days faster through direct deposit and eliminate trips to the bank.

Enroll your practice or facility in EPS for faster claim payments.It’snocosttoprovideroffices,healthcarefacilitiesandbillingoffices.Onceyou’reenrolled, you’ll receive your reimbursement electronically for all EPS-supported UnitedHealthcare products.

Read an overview of EPS, watch a short video or attend a live webcast to learn more. For answers to your questions or assistance with registration, call the EPS Help Desk at 866-842-3278, option 5 to speak with a representative.

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Learn About Optum Cloud Dashboard’s New Features

We’llintroduceyoutotheEligibility&BenefitsCenter and the Claims Management Application in one convenient webinar. Webinars are offered every Wednesday and Thursday. In these 30 minute instructor-led webinars, you will learn about:

Eligibility&BenefitsCenter• Check eligibility for all lines of business

• Getin-andout-of-networkbenefitinformationformostUnitedHealthcare members. You will be linked to other websites as needed.

• ReviewCoordinationofBenefitsinformation

• Select additional copay and coinsurance categories to display

Claims Management• Flag claims to view them automatically each

time you login

• View line level and claim level remark codes

• Getacleardefinitionofpaymentallocation

Time is available after the webinar for questions and answers.

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UnitedHealthcareOnline.com Training

Learn how you can accomplish more with less time and effort using UnitedHealthcareOnline.com.

In our 60–minute webinar, you will:

• Learnhowtonavigatethewebsite,andfindreferencematerials and resources such as medical andreimbursement policies and quick reference guides

• Get an overview of our most-used functions suchascheckingeligibilityandbenefits,statusupdates,submittingnotifications,aswellasclaimsandreconsideration requests

• Receive best practice examples, tips and shortcuts tomakedoingbusinesswithusmoreefficient

• Get answers to your questions.

Space is limited, so register today for one of the live sessions.

Electronic Inpatient AdmissionNotifications

You can use the Electronic Data Interchange (EDI) 278N to submit notificationsfromyourpracticemanagement system for UnitedHealthcare, UnitedHealthcare Medicare Solutions and UnitedHealthcare Community Plan.

For more information, go to Admission Notification(278N), contact your clearinghouse/vendor or UnitedHealthcare at 888-804-0663 or [email protected].

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mailto:278n%40uhc.com?subject=

Pharmacy Summary of PDLs

UnitedHealthcare is providing a new tool that cansimplifyfindingmedicationsthatprovidea good value at a lower cost to members.

Unlike traditional Prescription Drug Lists (PDLs) and formularies, this summary of PDLs details information from all four UnitedHealthcare pharmacy groups - Medicare, Medicaid, Commercial and OptumRx. Medications that are preferred across all four groups are highlighted and should provide members lower costs, even if members switch from one group to another.




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The summary of PDLs has at least one common preferred medication in many of the top treatment classes.

Guide to symbols:

* Value to end member or government (either federal or state)

Here is a sample showing the guide and a representative class:

Pharmacy Summary of PDLs

Medicare Commercial Medicaid OptumRxCholesterol Lowering AgentsAtorvastatin

Lovastatin

Pravastatin

Simvastatin

Crestor

Livalo

Niacin ext-rel (Niaspan) B/G

Vytorin

The Summary of PDLs can be found at UnitedHealthcareOnline.com > Tools and Resources > Pharmacy Resources > UnitedHealthcare or the Optum Cloud.

The PDL for the Texas UnitedHealthcare Community Plan for CHIP and Medicaid members is available at the Vendor Drug Program at txvendordrug.com/pdl.Updates. The PDL and prior authorization process were posted in January 2014 and further updates are slated for July 2014.

Preferred across all four UnitedHealthcare lines of business.

Best value* in class Least value* in class

Good value* in class NotonPDL/formularyorexcludedfrombenefitcoverage.

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UnitedHealthcare Pharmacy Tiering Update

Olysio, a new protease inhibitor used in combination therapy to treat members with Hepatitis C infection, has moved from Tier 3 to Tier 2 on both the Advantage and Traditional Commercial Prescription Drug Lists (PDLs), effective Feb. 7, 2014.

Olysio is a specialty medication included in the designated specialty pharmacy network program which requires the use of OptumRx specialty pharmacy for most members to receive in-network coverage. In addition, Olysio requires priorauthorizationtodeterminebenefitcoverageand ensure appropriate use.

This information only applies to UnitedHealthcare integrated commercialclientswhosepharmacybenefitadministration has moved or is moving from Medco/ESI to OptumRx in 2013 aswellasnewpharmacybenefitbusinessbeginningin2013.It does not apply to direct commercial business (OptumRx direct business without UnitedHealthcare medical coverage) ornon-HMOlegacyPacifiCareorUnitedHealthcarepublicsector integrated commercial business that has been administered by OptumRx prior to Jan. 1, 2013.

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Before submitting requests for reimbursement on claims after a member has used the Consumer Account Card (CAC) for the claim, please check your billing systems to determine what partial payment you may have already received from the member.

This will help us to pay you more promptly. Please note on the submittal what the payment was for, such as copay, coinsurance, deductible, etc. Include debit card transaction information (transaction number, etc.) with the claim submission.

When processing claims, we compare the business name from the card swipe terminal and the provider name on the claim. Please check these names to see if they match and adjust the card swipe terminal as needed.

If you have questions, please review claim submission protocol at UnitedHealthcareOnline.com under the Claims & Payment menu or call us at 877-842-3210.


ClarificationofProcessforProvider Reimbursement Requests After Members Use Consumer Account Cards



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Mid-Atlantic Health Plan (M.D.IPA & Optimum Choice) network physicians, health care professionals and their staff can now submit and check the status of a preauthorization request on UnitedHealthcareOnline.com.

The exception is for physical, occupational, speech, and other therapy-related services. Preauthorization requests for these services cannot be submitted at this time through UnitedHealthcareOnline.com.

For more information, please visit UnitedHealthcareOnline.com > Tools & Resources > Training & Education > UnitedHealthcareOnline.com Notification/Preauthorization Function Overview

Clinical Updates

Mid-Atlantic Health Plan Pre-authorization Submissions on UnitedHealthcareOnline.com



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Continued >

Clinical Update



Mid-Atlantic Health Plan Pre-authorization Submissions on UnitedHealthcareOnline.com

The following list of services will requirement preauthorization for the Mid Atlantic Health Plan (M.D.IPA and Optimum Choice) effective for dates of service on or after April 15, 2014.

Category CPT code Notes

Cosmetic & Resonstructive 11922 Effective 4/15/14










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Clinical Update





















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Clinical Update





Orthognathic Surgery 21299 Effective 4/15/14




Joint Replacement 23473 Effective 4/15/14








Septoplasty/Rhinoplasty 30400 Effective 4/15/14




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Clinical Update









33369 Effective 4/15/14

69320 Effective 4/15/14

Potentially Unproven Services

Cosmetic & Resonstructive

Bariatric Surgery 0312T Effective 4/15/14






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Clinical Update




A0436

E0601

E2511

Effective 4/15/14

Effective 4/15/14

Effective 4/15/14

Non-Emergency Transport-Air

Durable Medical Equipment

Durable Medical Equipment

Prosthetics L5990

Prosthetics L6010

Q2026

Q2027 Effective 4/15/14Cosmetic & Resonstructive

Cosmetic & Resonstructive S2202 Effective 4/15/14

Home Care – Nutritional, Skilled Nursing, Private Duty Nursing S9208 Effective 4/15/14

Home Care – Nutritional, Skilled Nursing, Private Duty Nursing S9433 Effective 4/15/14

Home Care – Nutritional, Skilled Nursing, Private Duty Nursing T1000 Effective 4/15/14

Home Care – Nutritional, Skilled Nursing, Private Duty Nursing T1002 Effective 4/15/14

T1003

T1005Home Care – Nutritional, Skilled Nursing, Private Duty Nursing

Prosthetic V2629

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Cosmetic & Resonstructive

Home Care – Nutritional, Skilled Nursing, Private Duty Nursing

Effective 4/15/14. Purchase cost or a cumulative rental cost over $1000.00


Effective 4/15/14

Effective 4/15/14

Effective 4/15/14




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ForcompletedetailsontherevisedSignatureValueBenefitInterpretation Policy listed in the following table, please refer to the monthly SignatureValue™BenefitInterpretationPolicy Update Bulletin at UHCWest.com > Provider Log In > Library > Resource Center > Guidelines & Interpretation Manuals.


SignatureValue™BenefitInterpretationPolicy Updates




Policy Title Applicable State(s) Effective Date Policy Update Bulletin

NEW

Transgender: Gender Identity Disorder/Gender Dysphoria California Jan. 1, 2014 Jan. 2014

UPDATED/REVISED

Autism Spectrum Disorder Texas Feb. 1, 2014 Jan. 2014

Complementary and Alternative Medicine All (California, Oklahoma, Oregon, Texas, & Washington)

Feb. 1, 2014 Jan. 2014

Dental Care and Oral Surgery All Feb. 1, 2014 Jan. 2014

Maternity and Newborn Care California Feb. 1, 2014 Jan. 2014

Mental Health: Inpatient Mental Health All Feb. 1, 2014 Jan. 2014

Mental Health: Outpatient Mental Health California Mar. 1, 2014 Feb. 2014

Pervasive Developmental Disorder California Feb. 1, 2014 Jan. 2014

SignatureValue™BenefitInterpretationPolicyUpdates

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Policy Title Applicable State(s) Effective Date Policy Update Bulletin

Physician Services: Primary Care and Specialist Visits California Mar. 1, 2014 Feb. 2014

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

All Feb. 1, 2014 Jan. 2014

Surgery: Cosmetic, Reconstructive or Plastic Surgery California Feb. 1, 2014 Jan. 2014

REPLACED/RETIRED

TransgenderReassignmentSupplementalBenefit California Jan. 1, 2014 Jan. 2014

Note:Theappearanceofaserviceorprocedureonthislistdoesnotimplythatcoverageisprovidedfortheserviceorprocedure.Intheeventofaninconsistencyorconflict between the information provided in this Bulletin and the posted policy, the provisions of the posted policy prevail.

SignatureValue™BenefitInterpretationPolicyUpdates

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Policy Title Effective Date Policy Update Bulletin

UPDATED/REVISED

Abnormal Uterine Bleeding and Uterine Fibroids Feb. 1, 2014 Feb. 2014

Autism Spectrum Disorder Feb. 1, 2014 Feb. 2014

Blepharoplasty, Blepharoptosis, and Brow Ptosis Repair Mar. 1, 2014 Feb. 2014

Bone or Soft Tissue Healing and Fusion Enhancement Products Mar. 1, 2014 Feb. 2014

Cosmetic and Reconstructive Procedures Mar. 1, 2014 Feb. 2014

Custodial and Skilled Care Services Mar. 1, 2014 Feb. 2014

Deep Brain Stimulation Mar. 1, 2014 Feb. 2014

Electrical Stimulation and Electromagnetic Therapy for Wounds Feb. 1, 2014 Jan. 2014

Electrical Stimulation for the Treatment of Pain and Muscle Rehabilitation Feb. 1, 2014 Jan. 2014

Gastrointestinal Motility Disorders, Diagnosis and Treatment Feb. 1, 2014 Jan. 2014

SignatureValue™ Medical Management Guideline Updates

For complete details on the new and/or revised SignatureValue Medical Management Guidelines policies 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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Policy Title Effective Date Policy Update Bulletin


Feb. 1, 2014 Jan. 2014

Home Health Mar. 1, 2014 Feb. 2014

Infertility Diagnosis and Treatment Feb. 1, 2014 Jan. 2014

Manipulation Under Anesthesia Mar. 1, 2014 Feb. 2014

Occipital Neuralgia and Headache Feb. 1, 2014 Feb. 2014

Orthognathic (Jaw) Surgery Mar. 1, 2014 Feb. 2014

Panniculectomy and Body Contouring Procedures Mar. 1, 2014 Feb. 2014

Private Duty Nursing Mar. 1, 2014 Feb. 2014

Sensory Integration Therapy and Auditory Integration Training Mar. 1, 2014 Feb. 2014

Sodium Hyalurononate Mar. 1, 2014 Feb. 2014

Standing Systems Mar. 1, 2014 Feb. 2014

SurgicalandAblativeProceduresforVenousInsufficiency and Varicose Veins

Mar. 1, 2014 Feb. 2014

Vagus Nerve Stimulation Mar. 1, 2014 Feb. 2014

REPLACED/RETIRED

Gender Identity Disorder Treatment (Sex Transformation) Jan. 1, 2014 Jan. 2014

SignatureValue™ Medical Management Guideline Updates

Note: The appearance 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 inconsistencyorconflictbetweentheinformationprovidedinthisBulletinandthepostedpolicy,theprovisionsofthepostedpolicyprevail.

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Oxford® Medical and Administrative Policy Updates

For complete details on the new and/or revised policies listed in the table below, refer to the monthly Policy Update Bulletin at OxfordHealth.com > Providers > Tools & Resources > Practical Resources > Medical and Administrative Policies > Policy Update Bulletin.

Policy Title Policy Type Effective Date

Policy Update Bulletin

UPDATED/REVISED

Drug Policy Format & Indexing Changes Clinical Policy Mar. 1, 2014 Feb. 2014

Actimmune (Interferon Gamma-1b) Clinical Policy Mar. 1, 2014 Feb. 2014

Requests for In-Network Exceptions Administrative Policy Feb. 1, 2014 Jan. 2014

UPDATED/REVISED

Abnormal Uterine Bleeding and Uterine Fibroids Clinical Policy Feb. 1, 2014 Jan. 2014Feb. 2014

Agents for Migraine - Triptans Clinical Policy Feb. 1, 2014 Jan. 2014

Assistant Surgeon Policy Reimbursement Policy Jan. 1, 2014 Jan. 2014

TAKE NOTE

NEW

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Oxford Medical and Administrative Policy Updates



UPDATED/REVISED

Assisted Administration of Clotting Factors and Coagulant Blood Products

Clinical Policy Mar. 1, 2014 Feb. 2014

Autism Administrative Policy Feb. 1, 2014 Jan. 2014

B Bundle Code Policy Reimbursement Policy Jan. 1, 2014 Jan. 2014

Bilateral Procedures Reimbursement Policy Jan. 1, 2014 Jan. 2014

Biologics in the Treatment of Skin, Joint and Gastrointestinal Conditions

Clinical Policy Feb. 1, 2014 Jan. 2014

Blepharoplasty, Blepharoptosis and Brow Ptosis Repair Clinical Policy Feb. 1, 2014 Jan. 2014

Botulinum Toxins A and B Clinical Policy Feb. 1, 2014 Jan. 2014

Campath (Alemtuzumab) Clinical Policy Feb. 1, 2014 Jan. 2014

Cardiology Procedures for CareCore National Arrangement Clinical Policy Apr. 1, 2014 Jan. 2014 Feb. 2014Mar. 2014

CardiologyProceduresRequiringPrecertification Clinical Policy Apr. 1, 2014 Jan. 2014 Feb. 2014Mar. 2014

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

Mar. 1, 2014 Feb. 2014

Compounds and Bulk Powders Clinical Policy Feb. 1, 2014 Jan. 2014

Contraceptives Clinical Policy Feb. 1, 2014 Jan. 2014

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UPDATED/REVISED

Co-Surgeons; Team Surgeon Policy Reimbursement Policy Jan. 1, 2014 Jan. 2014

Deep Brain Stimulation Clinical Policy Feb. 1, 2014 Jan. 2014

Drug Coverage Criteria - New and Therapeutic Equivalent Medications


Mar. 1, 2014 Feb. 2014

Drug Coverage Guidelines Clinical Policy Feb. 1, 2014 Jan. 2014

Mar. 1, 2014 Feb. 2014

Electrical Stimulation and Electromagnetic Therapy for Wounds Clinical Policy Mar. 1, 2014 Feb. 2014

Electrical Stimulation for the Treatment of Pain and Muscle Rehabilitation


Mar. 1, 2014 Feb. 2014

Elidel® (Pimecrolimus) and Protopic® (Tacrolimus) Clinical Policy Feb. 1, 2014 Jan. 2014

Forteo (Teriparatide) Clinical Policy Feb. 1, 2014 Jan. 2014

Fulyzaq (Crofelemer) Clinical Policy Feb. 1, 2014 Jan. 2014

Gastrointestinal Motility Disorders, Diagnosis and Treatment Clinical Policy Mar. 1, 2014 Feb. 2014

Gattex (Teduglutide [Rdna Origin]), for Injection, for Subcutaneous Use



Clinical Policy Mar. 1, 2014 Feb. 2014

Global Days Policy Reimbursement Policy Jan. 1, 2014 Jan. 2014

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https://www.oxhp.com/secure/policy/post_pin_comm_feb14.pdf







UPDATED/REVISED

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


Hip Resurfacing Arthroplasty Clinical Policy Feb. 1, 2014 Jan. 2014

Home Health Care Clinical Policy Mar. 1, 2014 Feb. 2014

Icatibant (Firazyr) and C1 Esterase Inhibitors Human (Berinert and Cinryze)


Implantable Beta-Emitting Microspheres for Treatment of Malignant Tumors


InfertilityProceduresRequiringNotification and/orPrecertification


Injectable Chemotherapy Drugs: Application of NCCN Clinical Practice Guidelines


Inpatient Consultations Reimbursement Policy Feb. 1, 2014 Jan. 2014

Maximum Frequency Per Day Reimbursement Policy Jan. 21, 2014 Jan. 2014

Feb. 1, 2014 Jan. 2014

Moderate Sedation Policy Reimbursement Policy Jan. 1, 2014 Jan. 2014

Mar. 1, 2014 Feb. 2014

Multiple Procedures Policy Reimbursement Policy Jan. 1, 2014 Jan. 2014

Occipital Neuralgia and Cervicogenic Cluster and Migraine Headaches


Onfi(Clobazam) Clinical Policy Feb. 1, 2014 Jan. 2014

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UPDATED/REVISED

Oral Chemotherapy Drugs: Application of NCCN Clinical Practice Guidelines


Orthognathic (Jaw) Surgery Clinical Policy Mar. 1, 2014 Feb. 2014

PrecertificationExemptionsforOutpatientServices Administrative Policy Apr. 1, 2014 Jan. 2014Feb. 2014Mar. 2014

Preexisting Condition Administrative Policy Feb. 1, 2014 Jan. 2014

Prolonged Services Policy Reimbursement Policy Feb. 1, 2014 Jan. 2014

Protocol for Providing Advance Notice to Commercial Customers when Involving Non-Participating Providers in Customers’ Care

Administrative Policy Apr. 1, 2014 Jan. 2014Feb. 2014Mar. 2014

Radiopharmaceuticals and Contrast Media Clinical Policy Feb. 1, 2014 Jan. 2014

Repository Corticotropin Injection (H.P. Acthar Gel) Clinical Policy Mar. 1, 2014 Feb. 2014

Sandostatin LAR Depot (Octreotide Acetate) Clinical Policy Feb. 1, 2014 Jan. 2014

Sandostatin Subcutaneous Formulation (Octreotide Acetate) Clinical Policy Feb. 1, 2014 Jan. 2014

Selzentry (Maraviroc) Clinical Policy Feb. 1, 2014 Jan. 2014

Sensory Integration Therapy and Auditory Integration Training Clinical Policy Mar. 1, 2014 Feb. 2014

Signifor (Pasireotide Diaspartate) Clinical Policy Feb. 1, 2014 Jan. 2014

Stelara (Ustekinumab) Clinical Policy Feb. 1, 2014 Jan. 2014

Stribild™ (Elvitegravir/Cobicistat/Emtricitabine/Tenofovir Disoproxil Fumarate)


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https://www.oxhp.com/secure/policy/post_pin_comm_jan14.pdf






UPDATED/REVISED

Telemedicine Policy Reimbursement Policy Jan. 1, 2014 Jan. 2014

Temporomandibular Joint Disorders Clinical Policy Mar. 1, 2014 Feb. 2014

Topical Retinoids (Pharmaceutical Treatment of Acne) Clinical Policy Feb. 1, 2014 Jan. 2014

Transcranial Magnetic Stimulation Clinical Policy Feb. 1, 2014 Jan. 2014

Transportation Services Clinical Policy Feb. 1, 2014 Jan. 2014

Treatment of Infertility Clinical Policy Feb. 1, 2014 Jan. 2014

Treatment of Infertility for Connecticut Groups Clinical Policy Feb. 1, 2014 Jan. 2014

Treatment of Infertility for New Jersey Large Groups Clinical Policy Feb. 1, 2014 Jan. 2014

Treatment of Infertility for New Jersey Small Groups Clinical Policy Feb. 1, 2014 Jan. 2014

Treatment of Infertility for New York Large and Small Group Clinical Policy Feb. 1, 2014 Jan. 2014

Truvada (Emtricitabine/Tenofovir Disoproxil Fumarate) Clinical Policy Feb. 1, 2014 Jan. 2014

Vagus Nerve Stimulation Clinical Policy Feb. 1, 2014 Jan. 2014


Note: The appearance of a service or procedure on this list does not imply that Oxford provides coverage for the service or procedure. In the event of an inconsistencyorconflictbetweentheinformationprovidedinthisBulletinandthepostedpolicy,theprovisionsofthepostedpolicyprevail.

Oxford HMO products are underwritten by Oxford Health Plans (NY), Inc., Oxford Health Plans (NJ), Inc. and Oxford Health Plans (CT), Inc. Oxford insurance products are underwritten by Oxford Health Insurance, Inc.

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UnitedHealthcare of the River Valley Preauthorization List and Policy Updates

For complete details on the new and/or revised policies and guidelines listed in the table below, refer to the monthly Policy Update Bulletin at UHCRiverValley.com > Providers > Coverage Policy Library > Policy Update Bulletin. These updates apply to UnitedHealthcare of the River Valley commercial and hawk-i plan membership only; they do not apply to members enrolled in a River Valley Ohio product or South Carolina product.

Policy Title Effective Date Coverage Policy Update Bulletin

NEW

Ophthalmologic Policy - Vascular Endothelial Growth Factor (VEGF) Inhibitors

May 1, 2014 Mar. 2014

Routine Foot Care Mar. 1, 2014 Feb. 2014

UPDATED/REVISED

Bone and Soft Tissue Fusion Enhancement Products Apr. 1, 2014 Mar. 2014

Botulinum Toxins A and B Mar. 1, 2014 Feb. 2014

Campath Feb. 1, 2014 Jan. 2014

Deep Brain Stimulation Feb. 1, 2014 Jan. 2014

Electrical Stimulation and Electromagnetic Therapy for Wounds Mar. 1, 2014 Feb. 2014

Electrical Stimulation for the Treatment of Pain and Muscle Rehabilitation Feb. 1, 2014 Jan. 2014

Mar. 1, 2014 Feb. 2014

Epiduroscopy, Epidural Lysis of Adhesions and Functional Anesthetic Discorgraphy

Feb. 1, 2014 Jan. 2014

http://www.dev.uhcrivervalley.com/Providers/Coverage_Policy_Library/Policy_Update_Bulletin.html






UnitedHealthcare of the River Valley Prior Authorization List and Policy Updates


Femoroacetabular Impingement Syndrome Feb. 1, 2014 Jan. 2014

Gastrointestinal Motility Disorders, Diagnosis and Treatment Feb. 1, 2014 Jan. 2014


Feb. 1, 2014 Jan. 2014

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

Mar. 1, 2014 Feb. 2014

Home Health Care Mar. 1, 2014 Feb. 2014

Manipulation Under Anesthesia Mar. 1, 2014 Feb. 2014

Occipital Neuralgia and Cervicogenic, Cluster and Migraine Headaches Feb. 1, 2014 Jan. 2014

Oncology Medication Clinical Coverage Policy Feb. 1, 2014 Jan. 2014

Orthognathic and Jaw Surgery Mar. 1, 2014 Feb. 2014

Sandostatin®/ Sandostatin LAR® Depot (Octreotide Acetate) Mar. 1, 2014 Feb. 2014

Sensory Integration Therapy and Auditory Integration Training Mar. 1, 2014 Feb. 2014

Sodium Hyaluronate Mar. 1, 2014 Feb. 2014

Standing Systems Mar. 1, 2014 Feb. 2014

Stelara® (Ustekinumab) Mar. 1, 2014 Feb. 2014

SurgicalandAblativeProceduresforVenousInsufficiency and Varicose Veins

Mar. 1, 2014 Feb. 2014

Surgical Treatment for Spine Pain Feb. 1, 2014 Jan. 2014

Temporomandibular Joint Disorders Mar. 1, 2014 Feb. 2014

Vagus Nerve Stimulation Feb. 1, 2014 Jan. 2014





REPLACED/RETIRED

Biologics (Injection) for the Treatment of Skin, Joint and Gastrointestinal Conditions

Feb. 1, 2014 Feb. 2014

Cimizia (Certolizumab Pegol) Jan. 1, 2014 Jan. 2014

Compounded Medications Feb. 1, 2014 Feb. 2014

UnitedHealthcare of the River Valley Prior Authorization List and Policy Updates

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

InsurancecoverageprovidedbyUnitedHealthcareInsuranceCompanyoritsaffiliates.HealthplancoverageprovidedbyUnitedHealthcareofCalifornia,UnitedHealthcareofColorado,Inc.,UnitedHealthcareofOregon,Inc.,andUnitedHealthcareofWashington,Inc.orotheraffiliates.AdministrativeservicesprovidedbyUnitedHealthCareServices,Inc.oritsaffiliates.

Network Bulletin: March 2014 network bulletin - OXHP · 2014-03-03 · Front & Center 15 Network Bulletin: March 2014 For more information call 877.842.3210, or visit UnitedHealthcareOnline.com

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