Network Bulletin: September 2014 network bulletin

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: September 2014

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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: September 2014

Front & Center

UnitedHealthcare Reimbursement Policy

UnitedHealthcare Community Plan

Doing Business Better UnitedHealthcare Affiliates

UnitedHealthcare Military & Veterans

UnitedHealthcare Commercial

UnitedHealthcare Medicare Solutions

Front & Center• Delay of New Outpatient and Professional Therapy

Functional Reporting Requirement

• Prior Authorization Requirement for Outpatient InjectableChemotherapy for Commercial Members

• Change in Prior Authorization Requirements for InsulinPumps and Continuous Glucose Monitors

• UnitedHealthcareLaboratoryBenefit ManagementProgramStartsOct.1

• Discontinuation of the ANN Form and Changes to the ChargingCustomers for Non-covered Services Protocol

• OrthoNet to Expand Specialties Provided

• New Neonatal Resource Services Guidelines

• Electronic Payments & Statements is Expanding

• UnitedHealthcare Physician and Practice Manager Satisfaction Survey

• Hospice Services Billing and Recovery – Three YearLook-Back – Effective June 2, 2014

• UnitedHealthcare’s Medicare Advantage Part B SpecialtyDrug Prior Authorization Program Terminated

• CMS Two Midnight Rule – An Update

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

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For more information call 877.842.3210, or visit UnitedHealthcareOnline.com4

• CMS Star Ratings Quality Improvement Program

• 2015 Medicare Advantage Service Area Reductionsand Member Disenrollments

• UnitedHealthcare Medicare Advantage Coverage Summary Updates

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Network Bulletin: September 2014



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

• NewUnitedHealthcareCommercialBenefit Plans


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• UnitedHealthcare Community Plan Medical Policy &Coverage Determination Guideline Updates


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• Updated TRICARE Handbook to be Available Oct. 1

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For more information call 877.842.3210, or visit UnitedHealthcareOnline.comNetwork Bulletin: September 2014


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Doing Business Better

• Revision of Multiple Procedure Policy to IncludeProcess for Multiple Endoscopic Procedures

• Revision to the Radiology Multiple Imaging Reduction Policy – AdditionalReductions for Diagnostic Cardiovascular, Ophthalmology, & theProfessional Component of Imaging Services Announced in May

• UnitedHealthcare of the River Valley – Reimbursement Policies that Apply toCommercial Claims that are Subject to the River Valley Entities Supplement


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• Watch for Your 2015 UnitedHealth Premium DesignationAssessment Results

• Improving Quality Health Care

• New Prior Authorization Process in Texas Affects Timelinefor Requesting Peer-to-Peer Discussions

• Introducing the UnitedHealthcare Hospital Quality Program

• PriorAuthorizationandAdvanceNotificationRequirements

• Reminder Regarding Place of Service Codes Requirement

• Evidence-based Clinical Guidelines

• Upcoming Changes to Automated Decision Functionalityto Prior Authorization Submissions

• Using Network Laboratories

• Enhancements to Optum Cloud Dashboard Applications

• Information on Preventive Care and Quality Care


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UnitedHealthcare Affiliates

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UnitedHealthcareAffiliates

• UnitedHealthcare of the River Valley PreauthorizationList and Policy Updates

• SignatureValue™BenefitInterpretationPolicyUpdates

• SignatureValue™ Medical Management Guideline Updates

• UnitedHealthcare Oxford® Medical and Administrative Policy Updates


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Front & Center

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UnitedHealthcare Medicare Solutions is delaying implementation of our new Outpatient Therapy Functional Reporting requirement for reimbursement of outpatient and professional therapy services. It was originally scheduled to start for dates of service on or after Aug. 1, 2014.

When we select the revised implementation date, we will provide that information to you so your staff can be prepared to submit claims with the correct functional reporting information.

Functional reporting applies to all claims for therapy services furnished undertheMedicarePartBoutpatienttherapybenefit andtophysicaltherapy, occupational therapy, and speech-language pathology services furnished under the comprehensive outpatient rehabilitation facilitybenefit.

For more information regarding the delay of the new Outpatient Therapy Functional Reporting requirement, please contact your Provider Representative for your area. If you do not know your representative, please go to UnitedHealthcareOnline.com > Contact Us. From there, you will see a list by state of local contacts and then scroll to the bottom of the page and click Network Contacts.

Delay of New Outpatient and Professional Therapy Functional Reporting Requirement

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HOME TABLE OF CONTENTS




Prior Authorization Requirement for Outpatient Injectable Chemotherapy for Commercial Members

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Effective Dec. 1, 2014 all providers administering injectable chemotherapy to UnitedHealthcare Commercial members on an outpatient basis will be required to obtain prior authorization.

Today’s UnitedHealthcare’s drug policy which supports coverage based upon the National Comprehensive Cancer Network Drug & Biologics Compendium will be used for coverage determination.

Additional program details will be outlined in an upcoming issue of the Network Bulletin and on UnitedHealthcareOnline.com.

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We recently established a new procedure for prior authorization requests for all insulin pumps and continuous glucose monitors.

The manufacturer and model of equipment must now be provided before a prior authorization determination can be made. Having this information up front will help alleviate potential confusion between covered and non-covered devices, allowing reviewers to process submissionsmoreefficiently.

This change took effect in June 2014 and will continue as an ongoing requirement.

For more information, please visit UnitedHealthcareOnline.com

Change in Prior Authorization Requirements for Insulin Pumps and Continuous Glucose Monitors

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OnOct.1,2014,UnitedHealthcarewilllaunchtheLaboratoryBenefit ManagementProgram for fully insured Commercial members in Florida, excluding Neighborhood Health Partnership members. This program was developed to help improve affordability and quality of care for our members by managing outpatient laboratory utilization.

All outpatient laboratory services for members who are partoftheLaboratoryBenefit ManagementProgramwill be subject to new requirements including advance notification andnewmedicalpolicies.

TohelpyoupreparefortheLaboratoryBenefitManagement Program, we will be conducting one-hour webinar training sessions. Please plan to attend one of the sessions to learn more about:• Identifying members who are part of the Laboratory

Benefit ManagementProgram

• Using the Physician Decision Supportordering system

• Interpreting the Outcome Summary

To sign up for a webinar or view program details, please visit UnitedHealthcareOnline.com > Tools & Resources > Policies, Protocols and Guides > Protocols > UnitedHealthcare Laboratory Benefit Management Program. If you have questions, please contact your network account manager or Provider Advocate.

•

• To view dates and times, please visitUnitedHealthcareOnline.com > Tools& Resources > Policies, Protocols andGuides > Protocols > UnitedHealthcareLaboratoryBenefi ManagementProgram.If you have questions about the newprogram, please contact your physicianadvocate or call 800-377-8809.

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UnitedHealthcareLaboratoryBenefit ManagementProgram Starts Oct. 1

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Discontinuation of the ANN Form and Changes to the Charging Customers for Non-covered Services Protocol

As we announced on May 15, 2014, in accordance with instructions from the Centers for Medicare and Medicaid Services (CMS), UnitedHealthcare discontinued use of the Advance Notice of Non-Coverage (ANN) form and removed the document from UnitedHealthcareOnline.com.

If you, or your staff, are still using copies of the ANN Form, please discontinue use immediately.

In light of CMS’s instructions and our immediate discontinuation of the ANN Form, we are making additional changes to the Charging Customers for Non-covered Services Protocol in the Physician, Health Care Professional, Facility and Ancillary Provider Administrative Guide pertaining to Medicare Advantage members only.

Effective Dec. 1, 2014, the Protocol to follow to bill a Medicare Advantage member for non-covered services is:

• Member Consent: Although you can nolonger use the ANN Form referenced in theProtocol, you must continue to obtain theMedicare Advantage member’s written consentto seek and collect payment from the member fornon-covered services, prior to rendering thenon-covered service.

• Pre-Service Organization Determination:If you know or have reason to know that aservice that you are providing or referring foris not covered, you must request a pre-serviceorganization determination for the service fromUnitedHealthcare in order to bill the member forthat service. UnitedHealthcare must issuea determination before you render or refer for

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the non-covered service. Please note that a pre-service organization determination is not required to bill a member where the member’s Evidence of Coverage (EOC) or other related materials are clear that a service is never covered. Additional information is available on our website.

You should know or have reason to know a service may not be covered if:

• We have provided general notice through an articlein a newsletter or bulletin, or information providedon UnitedHealthcareOnline.com, (including clinicalprotocols, medical and drug policies) either thatwe will not cover a particular service or that aparticular service will be covered only under certaincircumstances not present with the member;

• We have made a determination that the plannedservices are not covered services and havecommunicated that determination to you on this or aprevious occasion; or

• CMS has published guidance, through NationalCoverage Determinations, Local CoverageDeterminations, or other CMS guidance, indicatingthat the service may not be covered in certaincircumstances. You are required to review theMedicare Coverage Center.

– A pre-service organization determination must berequestedbysubmittinganAdvanceNotificationrequest on UnitedHealthcareOnline.com > Notifications/Prior Authorizations > Notifications/Prior Authorizations Submissions.

– If after you request a pre-service organization determination we determine that the service is not covered, we will issue an Integrated Denial Notice to you and the member. The Integrated DenialNoticeinformsthememberoftheirfinancialliability and appeal rights. You must make sure the member has received the Integrated Denial Notice prior to rendering the non-covered service.


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• GA/GYModifiers: With the discontinuation of theANNForm,theGA/GYmodifiers nolongerneedtobe included on claims for non-covered services.

You must not bill a Medicare Advantage member for non-covered services in cases in which you do not comply with the terms of the Protocol noted previously. Failure to comply with the terms of the Protocol, including but not limited to failure to request a pre-service organization determination or rendering the service before UnitedHealthcare issues the pre-service organization determination, will result in an administrative claim denial. You cannot bill the member for claims that are administratively denied.

If you have questions, please contact your Provider Advocate. For more information, please see CMS’s Improper Use of Advance Notices of Non-Coverage memorandum on the CMS website. Additional information is also posted at UnitedHealthCareOnline.com > Tools & Resources > Policies, Protocols and Guides > Protocols.


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OrthoNet to Expand Specialties Provided

Oxford contracts with OrthoNet, a leading musculoskeletal management company, to manageourmusculoskeletalutilizationreviewprogramforOxfordbenefit plans.

As part of this program, OrthoNet reviews high cost professional claims and provides a claims review program focused on variant physicians to ensure services billed are supported by medical documentation. This program includes review for the following specialties: neurosurgery, orthopedic surgery, pediatric orthopedic surgery, podiatry, hand surgery, physical medicine rehab, ears, nose and throat (ENT) and plastic surgery.

Effective Jan. 1, 2015, OrthoNet will expand this program to include general surgery, cardiology and dermatology.

OrthoNet will request operative notes and/or medical recordstoprocessclaimsthatcorrespond tospecific criteria related to this program (e.g. specialty, CPT code, amount threshold).

Claims will be reviewed against the medical documentation to ensure that services billed are substantiated by the medical documentation. Any denials issued as a result of this review are considered administrative claim denials.

For information regarding this program, call Customer Service at 800-666-1353.

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Effective Jan. 1, 2015, there will be seven new Neonatal Resource Services (NRS) Medical Necessity Clinical Guidelines.

The topics of these documents are:• Apnea and Bradycardia

• Discharge Planning

• Early-Onset Neonatal Sepsis

• Feeding the Neonate

• Inhaled Nitric Oxide (iNO)

• Neonatal Abstinence syndrome (NAS)

• Thermoregulation

These new medical necessity clinical guidelines are posted here.

New Neonatal Resource Services Guidelines

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Electronic Payments & Statements is Expanding

As many providers have requested, we are working to make Electronic Payments and Statements (EPS) available for UnitedHealthcare Community Plan,* UnitedHealthcare Oxford, and UnitedHealthcare of the River Valley beginning in December. You’ll be able to view paymentsandexplanationsofbenefits (EOBs)foreachoftheseplansononewebsite.

If you are already enrolled in EPS, please note that you will need to login to EPS from Optum Health Payment Services to see payment information and EOBs for all UnitedHealthcare plans. If you do not have a user name and password for this site, please call 866- 842-3278, option 5.

If you aren’t enrolled in EPS for direct deposit and online EOBs, you can enroll online or by paper form. EPSisthemostefficient waytogetpaidandallyouneed is an internet connection. There’s no need to change your posting method and no special software is needed.

Learn more about EPS by attending an introductory webinar. For more information or assistance registering for EPS, please call 866-842-3278, option 5 or visit UnitedHealthcareOnline.com > Electronic Payments and Statements.

*Currently, enrollment in EPS applies to payments from UnitedHealthcare Commercial, UnitedHealthcare Medicare Solutions and UnitedHealthcare Community Plan of Florida, Massachusetts and Rhode Island and Long Term Care (LTC) products in Arizona, Hawaii and New Mexico. These UnitedHealthcare Community Plan states will be added in December: Arizona, Delaware, Iowa, Kansas, Maryland, Michigan, Mississippi, Nebraska, New Jersey, New York, Ohio, Pennsylvania, Tennessee, Texas, Washington and Wisconsin.

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Each year, we ask for your participation in our Physician Satisfaction Survey. Our annual survey is an important tool that provides us insight to your experience working with us.

Your opinions help us identify opportunities to enhance our services to align with your practice needs. Invitations to participate in our survey have been mailed to a random sample of UnitedHealthcare physicians and practice managers. If you have been selected to participate, we encourage you to take a few minutes to share your opinions with us and return your reply by mail or online.

As always, we appreciate your participation.

UnitedHealthcare Physician and Practice Manager Satisfaction Survey

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Hospice Services Billing and Recovery – Three Year Look-Back – Effective June 2, 2014

Billing for Services With Hospice Election

When a Medicare Advantage (MA) member elects hospice, claims for covered hospice services related to the member’s terminal illness should be billed directly to CMS. Those services may include drugs, physical care, counseling, equipment, and supplies for the terminal and related condition(s).

Original Medicare, through the Medicare administrative contractors (MACs), assumes liability for Medicare-covered services both related and unrelated to the beneficiary'shospiceconditionimmediatelyuponthedate of the hospice election through and including the last day of the month when hospice concludes, either by expiration of or by revocation of the hospice election. The MA health plan assumes responsibility for all servicesasofthefirst ofthemonthfollowingexpirationof or revocation of the hospice election.

Billing for Services Unrelated to Terminal Condition

Medicare Parts A and B covered services not related to the member’s terminal diagnosis must be billed to theapplicableMAC.UnitedHealthcareisnotfinancially responsible for these claims.

Medicare-covered claims unrelated to hospice services should be submitted directly to the applicable MAC. These contractors, not the MA health plan, are responsible for processing these claims.

As of June 2, 2014, UnitedHealthcare started a recovery effort for claims related to hospice services for which members were reimbursed. Per the Centers for Medicare and Medicaid Services (CMS) regulations, this recovery effort will cover 36 months prior to the dates of service on the reviewed claims.

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Additional services not covered by Original Medicare and unrelated to the terminal condition (also referred to as mandatory supplemental and optional supplemental) may bethefinancial responsibilityofUnitedHealthcareunderthemember’sbenefit plan.Suchservicesmayincluderoutinedentaltreatment,eyeglassesandhearingaids.Thesebenefits varybyplanandarefiled and approvedbyCMSeachyear.

Additional Resources

CMS provides guidance for billing claims to the CMS contractors for members of MA plans. Please refer to the Medicare Claims Processing Manual, Chapter 11, Section 50.

If you believe a claim submitted to UnitedHealthcare has been denied in error, please follow the claim reconsideration/appeal process outlined in the Administrative Guide. If you dispute a recovery, the process to appeal is outlined in the recovery letter you received. Non-contracted providers’ rights and member appeal rights can be found on the back of the Physician Remittance Advice or explanation ofbenefits respectively.

If you have any other questions, please call Susan Hines at 360-638-0478.

Hospice Services Billing and Recovery – Three Year Look-Back - Effective June 2, 2014

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UnitedHealthcare’s Medicare Advantage Part B Specialty Drug Prior Authorization Program Terminated

Effective immediately, UnitedHealthcare will terminate the Part B Specialty Drug Prior Authorization Program for our Medicare Advantage members.

Claims for Part B Specialty Injectable Drugs will not require prior authorization after September 1, 2014. For injectable drugs administered after September 1 for our UnitedHealthcare Medicare Advantage plan members, we will follow Medicare’s Local and National Coverage Determination policies where applicable. Our recent audit of the Medicare Advantage Part B Specialty Drug Prior Authorization Program demonstrated high compliance with our coverage policy and at this time, no longer requires the quality check.

If you would like to request an Organization Determination for a Part B Specialty Injectable Drug, you may submit your request via UnitedHealthcareOnline.com or call the telephone number on the back of the member’s ID card. If you have any questions, please call the Customer Service number on the back of the member’s ID card.

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CMS Two Midnight Rule – An Update

The Centers for Medicare & Medicaid Services (CMS) 2014 Fiscal Year Inpatient Prospective PaymentSystemFinalRuleincludesaprovisionthatclarifiedMedicareadmissionandmedicalreview criteria for hospital inpatient services, known as the Two Midnight Rule.

The Two Midnight Rule is intended to help care providers determine whether a Medicare claim should be billed under Part A (hospital insurance – inpatient) or Part B (medical insurance – outpatient).¹ As communicated previously, including in the January 2014 UnitedHealthcare Network Bulletin, UnitedHealthcare will fully integrate the Two Midnight Rule into our Medicare Advantage inpatient management medical necessity review process. Integration of the Two Midnight Rule allows UnitedHealthcare to work with our care providers to meet CMS medical necessity requirements related to inpatient admissions. Integration will occur Oct. 1, 2014.²

Based on the Two Midnight Rule, if the care provider expects the Medicare Advantage member’s medically necessary treatment will span less than two midnights, outpatient/observation status is appropriate. If a Medicare

Advantage member requires medically necessary hospital care that is expected to span two or more midnights, inpatient admission is appropriate. The Two Midnight Rule does not apply to services CMS designates as inpatient only.

To facilitate integration of the Two Midnight Rule, facilities must provide to UnitedHealthcare, the physician’s inpatient admission order, in addition to any other clinical information needed to support hospital stays that span two or more midnights. Please note that facilities that have granted UnitedHealthcare inpatient care managers onsite or remote EMR access do not need to submit clinical information to UnitedHealthcare because our care managers will access this information in the facility’s EMR system. Facilities that have fax or telephonic review processes will be required to fax a copy of the care provider’s inpatient admission

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order, when clinical information is requested by the UnitedHealthcare inpatient care manager. UnitedHealthcare will continue to use evidence-based guidelines to support consistent and clinically valid decision-making for medically necessary hospital stays, in conjunction with the Two Midnight Rule. Facilities and admitting physicians will be expected to use the Medicare inpatient admission criteria as clarified in the Two Midnight Rule when admitting a Medicare Advantage member as an inpatient for medically necessary acute care services.

Care providers are encouraged to work with UnitedHealthcare medical directors to support the provision of evidence-based and medically necessary care for our members. We will continue to work collaboratively with you as we implement the Two Midnight Rule. Should you have questions, please contact your local market medical director or nurse case manager.

References:1. Centers for Medicare & Medicaid Services. (2014). cms.gov.

Retrieved here. 2. UnitedHealthcare. (2014, January). UnitedHealthcareOnline.com.

Retrieved here.

CMS Two Midnight Rule – An Update

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CMS Star Ratings Quality Improvement Program

The Centers for Medicare & Medicaid Services (CMS) Star Ratings program is one of several national programs that measure quality of care through physician collaboration and patient engagement.

Using national clinical and service quality measures, CMS emphasizes health outcomes, preventive screenings and patient satisfaction in its Star Ratings assessments. CMS publishes Star Ratings annually to help members compare Medicare Advantage and prescription drug plans.

What is the Five-Star Quality Rating System?Health plans are scored by CMS on afive-starscaleusingacombinationof quality and performance measures. CMSdescribesafive-starratingas

“excellent,” four-star rating as “very good” and three-star as “good.”




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CMS Star Ratings Quality Improvement Program

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How are Star Ratings measured?StarRatingsmeasureperformanceforspecific timeframes.For example, the 2014 Star Ratings are based on 2012 data that was collected in 2013.

Each year, CMS adds, removes and updates performance measures. For 2013, CMS moved to weighting different quality measures, added and removed some measures, and created new thresholds for performance levels.

StarRatingsarederivedfromfive sourcesofdata:1. CMS administrative data on plan quality

and member satisfaction2. Consumer Assessment of Healthcare Providers

and Systems (CAHPS®) Survey

3. Healthcare Effectiveness Data and InformationSet (HEDIS®) measures

4. Health Outcomes Survey (HOS)5. Pharmacy and operational assessments

WhatarethebenefitsofStarRatings?Sharing Star Ratings and the member-level data behind those ratings with physicians and health care providers helps show whether members are receiving regular screenings, tests and vaccines and gauge how effectively members’ chronic conditions are managed.

We provide tools and resources like our Patient Care Opportunity Report to support physician groups and organizations in improving patient care and Star Ratings. For more information about Star Ratings, please visit UnitedHealthcareOnline.com.




2015 Medicare Advantage Service Area Reductions and Member Disenrollments

Less than one percent of our UnitedHealthcare Medicare Advantage members across the country will be impacted by service area reductions in 2015. These members will receive an official non-renewalnoticefromUnitedHealthcarebyOct.2,2014.

The non-renewal notice will give members information about their special election period eligibility for 2015 coverage and their Medicare Supplement guaranteed rights, as well as replacement plans for all Medicare Advantage organizations and Prescription Drug Plan sponsors available in their area.

In many cases, these members will receive additional outreach by phone or mail to inform them of other health plan options offered by UnitedHealthcare.

The majority of providers and facilities contracted for UnitedHealthcare Medicare Advantage products will not be affected by these changes. In most areas, we will still offer network-based Medicare Advantage plans, so provider contracts will remain in place. In markets where contracts are affected, UnitedHealthcare network account managers will contact providers with more details.

To learn more, please visit UnitedHealthcareOnline.com > Tools & Resources > Products & Services > Medicare, or contact your local Network Account Manager or Provider Advocate.

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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

UPDATED/REVISED

Arthroscopic Lavage and Debridement Treatment of the Knee(s) July 15, 2014 Aug. 2014

Biofeedback July 15, 2014 Aug. 2014

Carotid Procedures and Testing July 15, 2014 Aug. 2014

Complementary and Alternative Medicine July 15, 2014 Aug. 2014

Cryosurgery for Prostate Cancer July 15, 2014 Aug. 2014

Diathermy Treatment July 15, 2014 Aug. 2014

Durable Medical Equipment (DME), Prosthetics, Corrective Appliances/Orthotics (Non-Foot Orthotics) and Medical Supplies Grid

July 15, 2014 Aug. 2014

Durable Medical Equipment, Prosthetics, Corrective Appliances/Orthotics and Medical Supplies

July 15, 2014 Aug. 2014




Policy Title Approval Date Update Bulletin

Medications/Drugs (Outpatient/Part B) June 17, 2014 July 2014

Nutritional Therapy: Enteral and Parenteral Nutritional Therapy June 17, 2014 July 2014

Preventive Health Services and Procedures June 17, 2014 July 2014

Radiologic Diagnostic Procedures June 17, 2014 July 2014

Rehabilitation: Cardiac Rehabilitation Services (Outpatient) June 17, 2014 July 2014

Second and Third Opinions June 17, 2014 July 2014

Veteran Administration (VA)and Indian Health Services (IHS) June 17, 2014 July 2014

UnitedHealthcare Medicare Advantage Coverage Summary Updates

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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 caseofaninconsistencyorconflict betweentheinformationinthisNetworkBulletinandthepostedpolicy,theprovisionsofthepostedpolicyprevail.

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




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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.



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Policy Title Policy Type Effective Date Medical Policy Update Bulletin

NEW

Home Health Care Coverage Determination Guideline

Sept. 1, 2014 Aug. 2014

Site of Care Review Guidelines for Medical Necessity of Hospital Outpatient Facility Specialty Medication Infusion

Utilization Review Guideline

Oct. 1, 2014 July 2014Aug. 2014Sept. 2014

Soliris (Eculizumab) Drug Policy Oct. 1, 2014 July 2014Aug. 2014Sept. 2014

UPDATED/REVISED

17-Alpha-Hydroxyprogesterone Caproate (Makena™ and 17P) Drug Policy Aug. 1, 2014 July 2014

Anemia Drugs (Darbepoetin Alfa and Epoetin Alfa) Drug Policy Sept. 1, 2014 Aug. 2014

Apheresis Medical Policy Aug. 1, 2014 July 2014






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Athletic Pubalgia Surgery Medical Policy Aug. 1, 2014 July 2014

Attended Polysomnography for Evaluation of Sleep Disorders Medical Policy Aug. 1, 2014 July 2014

Benlysta (Belimumab) Drug Policy Aug. 1, 2014 July 2014

Blepharoplasty, Blepharoptosis and Brow Ptosis Repair Coverage Determination Guideline

Aug. 1, 2014 Aug. 2014

Botulinum Toxins A and B Drug Policy Sept. 1, 2014 Aug. 2014

Bronchial Thermoplasty Medical Policy Sept. 1, 2014 Aug. 2014

Chemosensitivity and Chemoresistance Assays in Cancer Medical Policy Sept. 1, 2014 Aug. 2014

Cochlear Implants Medical Policy Aug. 1, 2014 July 2014

Continuous Glucose Monitoring and Insulin Delivery for Managing Diabetes

Medical Policy July 1, 2014 July 2014

Cosmetic and Reconstructive Procedures Coverage Determination Guideline

Sept. 1, 2014 Aug. 2014

Cytological Examination of Breast Fluids for Cancer Screening Medical Policy Sept. 1, 2014 Aug. 2014

Discogenic Pain Treatment Medical Policy Sept. 1, 2014 Aug. 2014

Enzyme Replacement Therapy for Gaucher Disease Drug Policy Sept. 1, 2014 Aug. 2014

Gastrointestinal Motility Disorders, Diagnosis and Treatment Medical Policy Aug. 1, 2014 July 2014

Gender Identity Disorder/Gender Dysphoria Treatment Coverage Determination Guideline

Sept. 1, 2014 Aug. 2014





High Frequency Chest Wall Compression Devices Medical Policy Sept. 1, 2014 Aug. 2014

Home Traction Therapy Medical Policy Aug. 1, 2014 July 2014

Hospital Readmissions Quality of Care Guideline Aug. 1, 2014 Aug. 2014

HumanImmunodeficienc Virus(HIV)TropismTesting Medical Policy Aug. 1, 2014 July 2014

Immune Globulin (IVIG and SCIG) Drug Policy Sept. 1, 2014 Aug. 2014

Infertility Diagnosis and Treatment Medical Policy Aug. 1, 2014 July 2014

Light and Laser Therapy for Cutaneous Lesions and Pilonidal Disease

Medical Policy Aug. 1, 2014 July 2014

Lupron Depot/Lupron Depot-Ped (Leuprolide Acetate) Drug Policy Sept. 1, 2014 Aug. 2014

Magnetencephalography and Magnetic Source Imaging forSpecifi NeurologicalIndications

Medical Policy Aug. 1, 2014 July 2014

Magnetic Resonance Spectroscopy (MRS) Medical Policy Sept. 1, 2014 Aug. 2014

Mifeprex (Mifepristone, RU-486) Drug Policy Aug. 1, 2014 July 2014

Motorized Spinal Traction Medical Policy Aug. 1, 2014 July 2014

NeuropsychologicalTestingUndertheMedicalBenefi Medical Policy Oct. 1, 2014 Sept. 2014

Occipital Neuralgia and Headache Treatment Medical Policy Sept. 1, 2014 Aug. 2014

Omnibus Codes Medical Policy Sept. 1, 2014 Aug. 2014

Outpatient Cardiovascular Telemetry Medical Policy Aug. 1, 2014 July 2014


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Proton Beam Radiation Therapy Medical Policy Sept. 1, 2014 Aug. 2014

Repository Corticotropin Injection (H.P. Acthar Gel®) Drug Policy Aug. 1, 2014 July 2014

Skilled Care and Custodial Care Services Coverage Determination Guideline

Sept. 1, 2014 Aug. 2014

Spinal Ultrasonography Medical Policy Sept. 1, 2014 Aug. 2014

Standing Systems Medical Policy Aug. 1, 2014 July 2014

SurgicalandAblativeProceduresforVenousInsufficiencand Varicose Veins

Medical Policy Sept. 1, 2014 Aug. 2014

Synagis (Palivizumab) Drug Policy Oct. 1, 2014 Sept. 2014

Tysabri (Natalizumab) Drug Policy Aug. 1, 2014 July 2014

Umbilical Cord Blood Harvesting and Storage for Future Use Medical Policy Aug. 1, 2014 July 2014

Vagus Nerve Stimulation Medical Policy Aug. 1, 2014 July 2014

Xolair (Omalizumab) Drug Policy Sept. 1, 2014 Sept. 2014

RETIRED

Cost Effective Review (Least Costly, Medically Necessary, Medical Necessity, Reasonable and Necessary)

Quality of Care Guideline Aug. 1, 2014 Aug. 2014

Transtympanic Micropressure Medical Policy July 1, 2014 July 2014

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 eventof aninconsistencyorconflict betweentheinformationprovidedinthisbulletinandthepostedpolicy,theprovisionsofthepostedpolicywillprevail.


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NewUnitedHealthcareCommercialBenefit Plans

UnitedHealthcare will be offering new Commercialbenefit plansinselectstateseffective Jan. 1, 2015. They are:

• UnitedHealthcare Navigate portfolio of productsoffer comprehensive, patient-centered healthcarebenefits withaccesstoacustomizednetworkofcareproviders designed around local market needs andresources. Members choose a primary care physicianas their trusted partner in health care who also grantsreferrals for specialist services.

• UnitedHealthcare Charter portfolio of productsshares the same product features as Navigate but mayhave a different network of care providers designedaround local market needs and resources. Membersalso choose a primary care physician who also grantsreferrals for specialist services.

• UnitedHealthcare Compass is a new product forIndividualExchangebenefit plansandindividualbenefit plans offered off the Individual Exchange.Compass hasaspecific networkserviceareaandacustomized networkconfiguration thatreflects theneedsof targeted population. Compass also sharesthe same product features as Navigate to include aPCP selection and referral process.

For more information about each product, please go to UnitedHealthcareOnline.com > Tools & Resources > Products & Services. Please be sure to review the requirements for each product to prepare for the product launches in your state.

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UnitedHealthcare Community Plan Medical Policy & Coverage Determination Guideline Updates




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






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NEW

Home Health Care Coverage Determination Guideline

Nov. 1, 2014 Oct. 2014

Oral and Enteral Nutrition Coverage Determination Guideline

Nov. 1, 2014 Oct. 2014

UPDATED/REVISED

Apheresis Medical Policy Sept. 1, 2014 July 2014Aug. 2014

Athletic Pubalgia Surgery Medical Policy Sept. 1, 2014 July 2014Aug. 2014





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Attended Polysomnography for Evaluation of Sleep Disorders Medical Policy Sept. 1, 2014 July 2014Aug. 2014

Blepharoplasty, Blepharoptosis, and Brow Ptosis Repair Coverage Determination Guideline

Oct. 1, 2014 Aug. 2014Sept. 2014

Bronchial Thermoplasty Medical Policy Oct. 1, 2014 Aug. 2014Sept. 2014

Chemosensitivity and Chemoresistance Assays in Cancer Medical Policy Sept. 1, 2014 July 2014Aug. 2014

Clinical Trials Coverage Determination Guideline

Sept. 1, 2014 July 2014Aug. 2014

Cochlear Implants Medical Policy Sept. 1, 2014 July 2014Aug. 2014

Cosmetic and Reconstructive Procedures Coverage Determination Guideline

Oct. 1, 2014 Aug. 2014Sept. 2014

Cytological Examination of Breast Fluids for Cancer Screening Medical Policy Oct. 1, 2014 Aug. 2014Sept. 2014

Discogenic Pain Treatment Medical Policy Oct. 1, 2014 Aug. 2014Sept. 2014

Emergency Health Services and Urgent Care Center Services Coverage Determination Guideline

Oct. 1, 2014 Aug. 2014Sept. 2014

Gastrointestinal Motility Disorders, Diagnosis and Treatment Medical Policy Sept. 1, 2014 July 2014Aug. 2014





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Gender Identity Disorder/Gender Dysphoria Treatment Coverage Determination Guideline

Oct. 1, 2014 Aug. 2014Sept. 2014

High Frequency Chest Wall Compression Devices Medical Policy Oct. 1, 2014 Aug. 2014Sept. 2014

Home Traction Therapy Medical Policy Sept. 1, 2014 July 2014Aug. 2014

HumanImmunodeficiency Virus(HIV)TropismTesting Medical Policy Sept. 1, 2014 July 2014Aug. 2014


Medical Policy Sept. 1, 2014 July 2014Aug. 2014

Magnetic Resonance Spectroscopy (MRS) Medical Policy Oct. 1, 2014 Aug. 2014Sept. 2014

Magnetoencephalography and Magnetic Source Imaging for Specific NeurologicalApplications


Motorized Spinal Traction Medical Policy Sept. 1, 2014 July 2014Aug. 2014

NeuropsychologicalTestingUndertheMedicalBenefit Medical Policy Oct. 1, 2014 Aug. 2014Sept. 2014

Occipital Neuralgia and Headache Treatment Medical Policy Sept. 1, 2014 July 2014Aug. 2014

Omnibus Codes Medical Policy Oct. 1, 2014 Aug. 2014Sept. 2014





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Outpatient Cardiovascular Telemetry Medical Policy Sept. 1, 2014 July 2014Aug. 2014

Proton Beam Radiation Therapy Medical Policy Oct. 1, 2014 Aug. 2014Sept. 2014

Skilled Care and Custodial Care Services Coverage Determination Guideline

Oct. 1, 2014 Aug. 2014Sept. 2014

Spinal Ultrasonography Medical Policy Oct. 1, 2014 Aug. 2014Sept. 2014

Standing Systems Medical Policy Sept. 1, 2014 July 2014Aug. 2014

SurgicalandAblativeProceduresforVenousInsufficiency and Varicose Veins


Umbilical Cord Blood Harvesting and Storage for Future Use Medical Policy Sept. 1, 2014 July 2014Aug. 2014

Vagus Nerve Stimulation Medical Policy Sept. 1, 2014 July 2014Aug. 2014

RETIRED

Infertility Diagnosis and Treatment Medical Policy July 1, 2014 July 2014

Transtympanic Micropressure Medical Policy July 1, 2014 July 2014

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 eventofaninconsistencyorconflict betweentheinformationprovidedinthisbulletinandthepostedpolicy,theprovisionsofthepostedpolicywillprevail.

Updated TRICARE Handbook to be Available Oct. 1

The updated UnitedHealthcare Military & Veterans TRICARE Provider Handbook will be available on Oct. 1, 2014. Once published, changes in the Handbook will be effective on Jan. 1, 2015 for currently contracted providers and immediately for providers newly contracted on or after Oct. 1, 2014.

The TRICARE Handbook is located on UnitedHealthcareOnline.com > Tools & Resources > Policies, Protocols and Guides > TRICARE Provider Handbook. It is also available at uhcmilitarywest.com > Providers > Provider Handbook. Additionally, for your convenience a summary list of changes to the Handbook will be posted once it is published.



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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 UnitedHealthcaremembers,includinglegislativemandates,enrolleebenefitcoverage documents, UnitedHealthcare medical or drug policies, and the UnitedHealthcare Physician, Health Care Professional, Facility and Ancillary Provider Administrative Guide. Meeting the terms of a particular reimbursement policy is not a guarantee of payment. Once implemented the policies may be viewed in their entirety at UnitedHealthcareOnline.com > Tools & Resources > Policies and Protocols > Reimbursement Policies-Commercial. In the event of an inconsistencyorconflict betweentheinformationprovidedintheNetworkBulletinand the posted policy, the provisions of the posted policy prevail.




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45 Network Bulletin: September 2014


For more information call 877.842.3210, or visit UnitedHealthcareOnline.com

The implementation of the Multiple Procedure Policy revision to include endoscopic adjustment which was previously announced in the May 2014 Network Bulletin has been delayed until fourth quarter 2014 for Commercial plans.

To further align with the Centers for Medicare and Medicaid Services (CMS), UnitedHealthcare has implemented the CMS special multiple endoscopic rules enhancement for Medicare Advantage plans effective with dates of service after Aug. 1, 2014 as indicated in the May Network Bulletin. Effective fourth quarter 2014, the CMS special multiple endoscopic rules will be administered for Commercial plans when related endoscopic procedures are performed the same day.

For more information on the policy, please go to UnitedHealthcareOnline.com > Quick Links > May Network Bulletin > UnitedHealthcare Reimbursement section. For details on the policy changes for UnitedHealthcare Community Plan, alongwithstate-specific providernotificationbulletins, go to UHCCommunityPlan.com.

Revision of Multiple Procedure Policy to Include Process for Multiple Endoscopic Procedures

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Revision to the Radiology Multiple Imaging Reduction Policy – Additional Reductions for Diagnostic Cardiovascular, Ophthalmology, & the Professional Component of Imaging Services Announced in May

To better align with Centers for Medicare and Medicaid Services (CMS), UnitedHealthcare announced in the May 2014 Network Bulletin an enhancement to the Radiology Multiple Imaging Reduction (RMIR) Policy for Commercial plans to apply additional Multiple Procedure Payment Reductions (MPPR) to the professional component (PC) of Diagnostic Imaging procedures, and the technical component (TC) of Diagnostic Cardiovascular and Diagnostic Ophthalmology procedures.

These changes have been delayed until the fourth quarter 2014.

To promote transparency and ease in understanding across our commercial and government lines of business, UnitedHealthcare Commercial will adopt the naming convention used by UnitedHealthcare’ s Medicare Advantage in publishing these policies upon implementation.

• The existing Radiology Multiple Imaging ReductionPolicy name will be changed to the Multiple ProcedurePayment Reduction for Diagnostic Imaging.

• The MPPR reductions for the TC of DiagnosticCardiovascular and Ophthalmology Procedures willbe addressed within a new policy named MultipleProcedure Payment Reduction for DiagnosticCardiovascular and Ophthalmology Procedures.

For more information on the policy changes that will occur, please go to UnitedHealthcareOnline.com > Quick Links > May Network Bulletin > UnitedHealthcare Reimbursement section. For details on the policy changes forCommunityPlan,alongwithState-specific providernotification bulletins,gotoUHCCommunityPlan.com.

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

Participating providers that submit claims for covered services provided to commercial members that are subject to the River Valley Entities Supplement to the UnitedHealthcare Physician, Health Care Professional, Facility and Ancillary Provider Administrative Guide, please see the important information below.

Effective for commercial claims with dates of service on or after Dec.1, 2014, UnitedHealthcare of the River Valley is pleased to announce the following:

• We will adjudicate commercial claims that aresubject to the River Valley Entities Supplement inaccordance with the reimbursement policies usedby most other UnitedHealthcare commercial planslocated at UnitedHealthcareOnline.com > Tools& Resources > Policies, Protocols and Guides >Reimbursement Policies - Commercial. Pleasenote, however, that the Physical Medicine &Rehabilitation: Multiple Therapy ProcedureReduction Policy will not apply.

You may also access the reimbursement policies by clicking here.

Changes made to these reimbursement policies will be communicated via the Network Bulletin.

• We will no longer adjudicate commercial claims that are subject to the River Valley Entities Supplement in accordance with UnitedHealthcare of the River Valley’sreimbursementpolicies.You may find these policies at uhcrivervalley.com > Provider > Coverage Policy Library. These reimbursement policies will no longer be available at this location on or after Dec. 1, 2014.

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Watch for Your 2015 UnitedHealth Premium Designation Assessment Results

Physicians and practice administrators who are in markets where the UnitedHealth Premium designation program is available and practice in one of the 27 Premium-eligible medical specialties will receive their results later this fall.

Thenotification youreceivewillincludeyour assessment results along with instructions on how to access your Premium designation assessment reports. Prior to public display of the assessment results on our consumer websites, we will provide time for you to review your assessment results and request reconsideration, if applicable. Public designation display of the results will occur in early 2015.

To access your assessment results and review how your practice compares with national standards for qualityandlocalspecialty-specificcostefficiency benchmarks,visitUnitedHealthcareOnline.com > UnitedHealth Premium.

The updated Premium designations are based on a new time frame of paid claims (Jan. 1, 2011 – Feb. 28, 2014).




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Watch for Your 2015 UnitedHealth Premium Designation Assessment Results

Software changesThe program includes an update to the tools used to collect or group claims data into quality measures, episodes of care and patients. The update to Symmetry version 8.1 includes the 2013 HEDIS measures.

New specialties• Ear, Nose and Throat (ENT)

• Gastroenterology (GI)

For more information about UnitedHealth Premium, go to UnitedHealthcareOnline.com > UnitedHealth Premium or call 866-270-5588

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Improving Quality Health Care

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Driving quality improvement, improving risk score accuracy, and closing gaps in care are more critical than ever. To improve our member’s health care quality, UnitedHealthcare is reaching out to encourage members to see their doctors, and where needed, assist with scheduling.

When convenient for the member, we may offer either an in-home or health care clinic assessment to help members stay healthy and close gaps in care. In-home and health care clinic assessments are performed by licensed practitioners and are intended to supplement and support, not replace, the care you provide. At the conclusion of an in-home or health care clinic assessment, care coordination is supported in a variety of ways, including:

• Awrittensummaryoffindings andfollow-uprecommendations for the member;

• Referral to case management and diseasemanagement programs, if applicable; and

• A comprehensive written visit summary is sent tothe member’s primary care physician to ensurecontinuity of care.

It is important to note that this program does not diagnose or recommend treatment and is not a substitute for your professional medical advice to your patients.






New Prior Authorization Process in Texas Affects Timeline for Requesting Peer-to-Peer Discussions

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As of Feb. 17, 2014, changes were implemented to our prior authorization request process for Commercial members in compliance with state-regulated turnaround times in Texas.

We are now required to mail adverse determination letters within three calendar days after receiving the prior authorization request. Under the new process, peer-to-peer discussions must occur before we mail the denial letter.

Tips for submitting prior authorization information and requesting peer-to-peer discussion: • Review the guidelines explaining the supporting

information that must be submitted with your priorauthorization request under the medical policies listedon UnitedHealthcareOnline.com > Medical &Drug Policies Coverage Determination Guidelines.We will contact you to request missing information,but if we do not receive the information within twohours of the phone call, the request will be deniedbecause of lack of supporting clinical documentation.If we have all the required information, we willproceed with the review.

• Submit prior authorization requests atUnitedHealthcareOnline.com > Notificationsand Authorization Requests.

• Submit prior authorization requests early in theday to extend the amount of time you have torequest a peer-to-peer discussion, because wemail adverse determination letters at the end ofthe third calendar day.

If we receive your request for a peer-to-peer discussion after mailing you an adverse determination letter, we can still have a discussion, but we cannot overturn the original decision at that point in the process. However, if you ask, our Medical Director will facilitate an appeal for you. Or you may submit an appeal by following the instructions in the adverse determination letter.

If you have any questions, please call 860-702-5109.




Introducing the UnitedHealthcare Hospital Quality Program

The new UnitedHealthcare Hospital Quality Program provides comparative quality information to help UnitedHealthcare members make informed health care choices about hospitals. The program results are based on key measures for acute care hospitals that include common inpatient conditions and procedures.

Because members are more engaged in seeking high value health care, there is an increased demand for information to support them in making personal health care decisions. This hospital information will be provided to members to facilitate the clinical care choices they make in partnership with their physicians.

This fall we will send eligible hospitals their Hospital Quality Program Quality Rating Report, which shows their comparative quality results and the methodology used for the program. Your hospital quality information will be available to members this fall through the myHealthcare Cost Estimator tool. The myHealthcare Cost Estimator tool is an online and mobile application that gives members the transparency they need to

understandhealthcarecostsandqualityforspecific physiciansandhospitals.Thetoolprovidesafive-starrelative quality rating along with comparative cost information for hospitals.

For more information on the UnitedHealthcare Hospital Quality Program, go to UnitedHealthcareOnline.com > Clinician Resources > Performance Measurement and Reporting > Hospital Quality Program or call 866-270-5588.

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The most up-to-date list of procedures requiring AdvanceNotification orPriorAuthorizationareavailable at the following locations:

• UnitedHealthcare Commercial can be found atUnitedHealthcareOnline.com > ClinicianResources > Advance & Admission Notification.

• UnitedHealthcare and UnitedHealthcare WestMedicare Advantage Plans can be found atUnitedHealthcareOnline.com > ClinicianResources > Advance & Admission Notification.

• UnitedHealthcare Community Plans, effectiveOct. 1, 2014, can be found atUHCCommunityPlan.com > For Health CareProfessionals > Select your State. Current priorauthorization procedures will apply throughSept. 30, 2014.

• UnitedHealthcare Community Plans of Kansasand Texas, effective Jan. 1, 2015, can be found atUHCCommunityPlan.com > For Health CareProfessionals > Select your State. Currentprior authorization procedures will applythrough Dec. 31, 2014.

It is important that you continue to consult and comply with all other protocols provided in the Administrative Guide.

• Physicians, health care professionals and ancillaryproviders are responsible for providing AdvanceNotification forservicesrequiringnotificationas published on UnitedHealthcareOnline.com.Notification isrequiredatleastfive businessdaysprior to the planned service date. If services areplannedlessthanfive businessdayspriortotheservicedate,notification isrequiredassoonastheservice is scheduled.

• Facilities are responsible, prior to the date of services,forconfirming thecoverageapprovalisonfile

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PriorAuthorizationandAdvanceNotification Requirements




• Acute care hospitals, skilled nursing facilities andacute rehabilitation facilities are responsible foradmissionnotification forinpatientservicesevenif thecoverageapprovalisonfile. Notification ofeachinpatient admission must be received within 24 hoursafter actual weekday admissions (or by 5 p.m. localtimeonthenextbusinessdayif24-hournotificationwouldrequirenotification onaweekendorfederalholiday). For weekend and federal holiday admissions,notification mustbereceivedby5p.m.localtimeonthe next business day.

• Forinformationonsubmittingadmissionnotificationelectronically, please visit our Electronic AdmissionNotifications (278N)page.

• Failure to comply with the requirementsdescribed in greater detail may result in claimsbeing denied in whole or in part and, as requiredunder your agreement with us, the Customerbeing held harmless.

• Most services rendered to members enrolled inMedicare Gatekeeper Plans in the South Florida

(Broward, Miami-Dade and Palm Beach counties) and Missouri/Illinois markets require referrals and/or authorizations from the primary care physician, Physician Hospital Organization, or contracted entity such as a Managed Service Organization (MSO), dependent upon contractual arrangement.

Community Plan Medical Policy Alignment As previously communicated in the January 2014 Network Bulletin, UnitedHealthcare reminds providers that effective March 1, 2014, UnitedHealthcare Community Plan aligned our medical policies with the rest of UnitedHealthcare’s medical policies and procedures, to provide a streamlined, simplified experienceforproviderscaringformembersofour various health plans.

Services which are not covered under the plan as described in the medical policies will be denied as unproven, experimental in nature, cosmetic or not medically necessary. The member must be held harmless in accordance with the terms of your Provider Agreement.

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PriorAuthorizationandAdvanceNotification Requirements




Evidence-based Clinical Guidelines

UnitedHealthcare uses evidence-based clinical guidelines from nationally recognized sources to guide our quality and health management programs. The following clinical practice guidelines are available at UnitedHealthcareOnline.com > Tools & Resources > Policies, Protocols and Guides > Medical & Drug Policies and Coverage Determination Guidelines > Clinical Guidelines. Please note that there have beensignificant changestotheguidelinesmarkedwithanasteriskbelow.

Reminder Regarding Place of Service Codes Requirement

Place of service (POS) codes are used to specify the place where services were rendered. Reporting the incorrect POS code can result in a possible claim overpayment or underpayment.

To help improve POS reporting, claims received after Sept. 1, 2014 billed with a questionable POS will be paid with a remark code reminding the provider to be attentive to ensuring the correct POS is reflected on futureclaimssubmissions.

The POS is crucial to proper reimbursement. At this time, providers will not see any denied claims but will be reminded of the POS correct coding principle.

Topic OrganizationAcute Myocardial Infarction with ST Elevation American College of Cardiology

Foundation/American Heart Association

Acute Myocardial Infarction without ST Elevation American College of Cardiology Foundation/American Heart Association

Asthma National Heart, Lung and Blood Institute

AttentionDeficit HyperactivityDisorder(ADHD) American Academy of Child and Adolescent Psychiatry

Bipolar Disorder: Adults American Psychiatric Association

Bipolar Disorder: Children & Adolescents American Academy of Child and Adolescent Psychiatry

Cardiovascular Disease: Prevention in Women American Heart Association

Cardiovascular Disease: Secondary Prevention and Risk Reduction Therapy for Patients with Coronary and Other Atherosclerotic Vascular Disease

American College of Cardiology/American Heart Association

Cholesterol Management* National Heart, Lung and Blood Institute

Chronic Obstructive Lung Disease* Global Initiative for Chronic Obstructive Lung Disease (GOLD)

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Evidence-based Clinical Guidelines

Topic OrganizationDepression/Major Depressive Disorder American Psychiatric Association

Diabetes* American Diabetes Association

Heart Failure American College of Cardiology/American Heart Association

Hemophilia and von Willebrand Disease* World Federation of Hemophilia and National Heart, Lung & Blood Institute

HumanImmuno-deficiency Virus(HIV)* HIV Medicine Association of the Infectious Diseases Society of America

Hyperbili-rubinemia in Newborns American Academy of Pediatrics

Hypertension* National Heart, Lung and Blood Institute

Preventive Services Agency for Healthcare Research and Quality

Schizophrenia American Psychiatric Association/PsychiatryOnline Guideline Watch

Sickle Cell Disease National Heart, Lung and Blood Institute

Spinal Stenosis North American Spine Society

Substance Use Disorders American Psychiatric Association/PsychiatryOnline Guideline Watch

The information is for general reference and not intended to address every aspect of a clinical situation. Clinical discretion should be used in interpreting and applying this information to individual patients.

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UnitedHealthcare is continuing to evolve the provider self-service experience by expanding the automatic decision logic on UHCOnline that will be delivered in the fall of 2014. These changes only impact the UnitedHealthcare Commercial and UnitedHealthcare Medicare Solutionslinesofbusiness.Whilethistransitionmayinvolveinitialchangestoyourofficeprocesses, the end result will be a more consistent and streamlined provider experience.

The enhanced functionality will provide innovative solutionsandincreasedefficiencies totheAdvancedNotification ofPriorAuthorizationsubmissionprocessby expanding & evolving existing automated approval, decision,andnotification capabilities.Clinicalquestionnairesforpre-defined services,designedusing established guideline protocols from Milliman Care Guidelines, UnitedHealthcare Medical Policies, and Centers for Medicare & Medicaid Services (CMS) will enableProviderstosubmitand/orreceivenotification ofadditional clinical information to drive automated decision on UHCOnline and via live call phone agents.

Specialty Categories:• Cosmetic & Reconstructive

• Spinal Stimulator for Pain Management

• BRAC Genetic Testing

• Orthognathic Surgery

• Spinal Surgery

• Sleep Studies

• Vein Procedures

• Durable Medical Equipment (DME) -greater than $1000

• Joint Replacement

Upcoming Changes to Automated Decision Functionality to Prior Authorization Submissions

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Upcoming Changes to Automated Decision Functionality to Prior Authorization Submissions

Please plan to enroll in upcoming webinars to learn more abouttheenhancementstotheAdvancedNotification ofPrior Authorization submission process.

Please keep in mind that while receipt of an approved AdvanceNotification orPriorAuthorizationforservicesconfirms coverage,itdoesnotguaranteeorauthorizepayment. Payment of covered services is subject to the terms and conditions of your contract with UnitedHealthcareandthemember’shealthbenefitplan including but not limited to exclusions, limitations, conditions, patient eligibility, medical policies and claim processing requirements.

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Using Network Laboratories

UnitedHealthcare provides access to a broad network of laboratories. Encouraging your patients to use network laboratories will potentially lower their out-of-pocket costs. To assist you and your patients, we offer the following resources and suggested actions:

• Review UnitedHealthcare Protocols online atUnitedHealthcareOnline.com > Tools &Resources > Policies, Protocols & Guides >Protocols > Protocol for Providing Advance Noticeto Customers when Involving Non-ParticipatingProviders in Customers’ Care

• Access the current list of participating laboratoriesonline at UnitedHealthcareOnline.com > PhysicianDirectory > General Physician Directory >Select a Plan > Laboratory > Enter Zip Code >Select Laboratory.

• Discuss the importance of using UnitedHealthcare’snetwork for covered services with your patients. Ifthey have questions, direct them to MyUHC.com toaccess their individual coverage information and adirectory of laboratories.

• Encourage the use of network laboratories to optimizeyourpatients’healthcarebenefits andpossiblyreducefinancial costsincurredbygoingout-of-networkforlaboratory services.

In the unusual circumstance that your patient requires a specifc laboratoryserviceforwhichyoubelievethereisnonetwork laboratory, please work with us to coordinate care. If we are unable to identify a network laboratory that meets the needs of your patient, we will work with you to obtain the service needed out of network.

If you have any additional questions, please contact your Physician or Hospital and Facility Advocate.

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Enhancements to Optum Cloud Dashboard Applications

EligibilityandBenefits• Youcannowviewmemberidentification cards(ID)

online and print a copy for your records!

Claims Management • Move seamlessly between the Claims Management

and Claim Reconsideration applications withouthaving to re-enter information.

• You now have the ability to submitsuggestions and feedback to improve theClaims Management application.

• Claims for members enrolled in the Railroad planhave been added to the claim search feature

Claims Reconsideration• An updated message will now specify whether

a claim is closed or not found

• The application can now identify a duplicatesubmission and will bring you to your existingticket for review

• Claims for members enrolled in the Railroad plan havebeen added to the claim reconsideration tool

Quick Tips:Claim reconsideration requests are typically reviewed within 30 days. You can log in to Optum Cloud Dashboard to quickly and easily view the status of your existing requests. No phone call is required! Please refer to the Claim Reconsideration with Attachment Quick Reference Guide for instructions.

To learn more about the Optum Cloud Dashboard, visit the Optum Cloud Quick Link at UnitedHealthcareOnline.com. For assistance with registration, please call the Optum Cloud Support Center at 855-819-5909 (Monday through Friday, 7:00am to 9:00pm CST) or email [email protected]. Take advantage of free instructor-led trainings, previously recorded on-demand sessions, slide presentations and much more by clicking here.

The Optum Cloud Claim Reconsideration with or without attachments is not yet available for: TRICARE West, UMR, Midwest Security Life Insurance Company, Neighborhood Health Partnership, OneNet PPO, UnltedHealthOne and Community Health Plan of Nevada.

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mailto:optumcloudsupport%40optum.com?subject=




Information on Preventive Care and Quality Care

We have posted important information about aspects of our Quality Improvement Program to UnitedHealthcareOnline.com. We encourage you to review the following articles.

For information on timely postpartum care, please go to UnitedHealthcareOnline.com > Clinician Resources > Women’s Health > Timely Postpartum Care. Or click here.

For information on care coordination, please go to UnitedHealthcareOnline.com > Clinician Resources > Patient Safety Resources > Care Coordination. Or click here.

Form information on health management programs, please go to UnitedHealthcareOnline.com > Tools & Resources > Health Resources for Patients > Health Management Programs. Or click here.

For information on online preventive health programs for information on depression, alcohol and drugs, please go to UnitedHealthcareOnline.com > Clinician Resources > Patient Safety Resources > Online Preventive Health Program for Information on Depression, Alcohol and Drugs. Or click here.

For information on coordination of care through controlled substance monitoring, please go to UnitedHealthcareOnline.com > Clinician Resources > Patient Safety Resources > Coordination of Care through Controlled Substance Monitoring. Or click here.

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


UnitedHealthcare of the River Valley Preauthorization List and Policy Updates




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

NEW

DME, Orthotics, Ostomy Supplies, Medical Supplies and Repairs/Replacements

Sept. 1, 2014 July 2014Aug. 2014


Oct. 1, 2014 July 2014Aug. 2014 Sept. 2014

Soliris® (Eculizumab) Oct. 1, 2014 July 2014Aug. 2014 Sept. 2014

UPDATED/REVISED

17-Alpha-Hydroxyprogesterone Caproate (17P and Makena) Sept. 1, 2014 Aug. 2014

Apheresis Aug. 1, 2014 July 2014

Athletic Pubalgia Surgery Aug. 1, 2014 July 2014

Attended Polysomnography for Evaluation of Sleep Disorders Aug. 1, 2014 July 2014

Autism Spectrum Disorders - Illinois and Tennessee Aug. 1, 2014 July 2014

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UnitedHealthcare of the River Valley Prior Authorization List and Policy Updates


Benlysta® (Belimumab) Sept. 1, 2014 Aug. 2014

Breast Reduction Surgery Aug. 1, 2014 July 2014Aug. 2014

Bronchial Thermoplasty Sept. 1, 2014 Aug. 2014

Chemosensitivity and Chemoresistance Assays in Cancer Treatment Sept. 1, 2014 July 2014Aug. 2014

Aug. 1, 2014 July 2014

July 1, 2014 July 2014

Aug. 1, 2014 July 2014

Sept. 1, 2014 Aug. 2014

Sept. 1, 2014 Aug. 2014

Aug. 1, 2014 July 2014

Aug. 1, 2014 July 2014

Sept. 1, 2014 Aug. 2014

Aug. 1, 2014 July 2014

Aug. 1, 2014 July 2014

Aug. 1, 2014 July 2014

Aug. 1, 2014 July 2014

Aug. 1, 2014 July 2014

Cochlear Implants

Continuous Glucose Monitoring and Insulin Delivery for Managing Diabetes

Corneal Hysteresis and Intraocular Pressure Measurement

Cytological Examination of Breast Fluids for Cancer Screening

Discogenic Pain Treatment

Gastrointestinal Motility Disorders, Diagnosis and Treatment

Gynecomastia Treatment

High Frequency Chest Wall Compression Devices

Home Traction Therapy

HumanImmunodeficiency Virus(HIV)TropismTesting

Infertility Diagnosis and Treatment

Intensity-Modulated Radiation Therapy


Magnetic Resonance Spectroscopy (MRS) Sept. 1, 2014 Aug. 2014

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Aug. 1, 2014 July 2014MagnetoencephalographyandMagneticSourceImagingforSpecific

Aug. 1, 2014 July 2014

NeuropsychologicalTestingundertheMedicalBenefit Oct. 1, 2014 Sept. 2014

Occipital Neuralgia and Headache Treatment Sept. 1, 2014 Aug. 2014

Omnibus Codes Sept. 1, 2014 Aug. 2014

Outpatient Cardiovascular Telemetry Aug. 1, 2014 July 2014

Private Duty Nursing Services (PDN) Aug. 1, 2014 July 2014

Repository Corticotropin Injection (HP Acthar Gel®) Sept. 1, 2014 Aug. 2014

Spinal Ultrasonography Oct. 1, 2014 Aug. 2014 Sept. 2014

Standing Systems Aug. 1, 2014 July 2014

Sept. 1, 2014 Aug. 2014Surgical and Ablative Procedures for Venous

Sept. 1, 2014 Aug. 2014

Umbilical Cord Blood Harvesting and Storage for Future Use Aug. 1, 2014 July 2014

Vagus Nerve Stimulation Sept. 1, 2014 Aug. 2014

RETIRED

Air Fluidized Beds (Pressure Reducing Support Surfaces - Group 3) Sept. 1, 2014 Sept. 2014

Alternating Pressure and Low Air Loss Mattresses (Pressure Reducing Support Surfaces - Group 2)

Sept. 1, 2014 Sept. 2014


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Neurological Applications

Motorized Spinal Traction

Insufficiency and Varicose Veins

Tysabril® (Natalizumab)






Hospital Beds (Semi-Electrical and Electrical) Sept. 1, 2014 Sept. 2014

Power Mobility Assistive Equipment (Scooter/Power-Operated Vehicle, Power Wheelchair)

Sept. 1, 2014 Sept. 2014

Pressure Reducing Support Surfaces - Group 1 (e.g., Overlays, Pads) Sept. 1, 2014 Sept. 2014

Transtympanic Micropressure Aug. 1, 2014 Aug. 2014

UVB Light Cabinet for Home Phototherapy Sept. 1, 2014 Sept. 2014

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

https://www.uhcrivervalley.com/downloads/CPL/Policy_Update_Bulletin_Aug_2014.pdf



Policy Title Applicable State(s) Effective Date Update Bulletin

UPDATED/REVISED

Ambulance: Ambulance Transportation All (California, Oklahoma, Oregon, Texas, & Washington)

Sept. 1, 2014 Aug. 2014

Blood: Blood and Blood Products All Sept. 1, 2014 Aug. 2014

Durable Medical Equipment (DME) Prosthetics, Corrective Appliances/Orthotics (Non Foot Orthotics) and Medical Supplies Grid

All July 1, 2014 July 2014

Aug. 1, 2014 Aug. 2014

Sept. 1, 2014 Aug. 2014

Family Planning: Infertility Services All Aug. 1, 2014 Aug. 2014

Home Health: Home Health Care Visits All Sept. 1, 2014 Aug. 2014

Medications-Medications (Oral, Infusion, Injectable) and Off-Label Drug Use

All Aug. 1, 2014 July 1, 2014

Preventive Care Services All Aug. 1, 2014 July 1, 2014


SignatureValue™Benefit InterpretationPolicyUpdates

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




SignatureValue™ Benefit InterpretationPolicy Updates

Policy Title Applicable State(s) Effective Date Update Bulletin

All July 1, 2014 July 1, 2014

All Aug. 1, 2014 July 1, 2014

All Aug. 1, 2014 July 1, 2014

All Sept. 1, 2014 Aug. 2014

All Aug. 1, 2014 July 1, 2014

California Sept. 1, 2014 Aug. 2014

All Aug. 1, 2014 July 1, 2014

All Sept. 1, 2014 Aug. 2014

All Aug. 1, 2014 Aug. 2014

All Aug. 1, 2014 Aug. 2014

California Aug. 1, 2014 Aug. 2014

All Aug. 1, 2014 Aug. 2014

California Aug. 1, 2014 Aug. 2014

Rehabilitation: Cardiac Rehabilitation Services - Outpatient

Rehabilitation: Pulmonary Rehabilitation - Outpatient

Respite Care

Specialized Footwear: Shoes and Foot Orthotics

Temporomandibular Joint (TMJ) Disorders: Treatment of TMJ Disorders

Transgender: Gender Identity Disorder/Gender Dysphoria Treatment

Veteran’sAdministration(VA)andCoordinationofVABenefit

Wheelchairs and Accessories

RETIRED

CaregiversSolutions:ASolutionforCaregiversCoreBenefit

Caregivers Solutions: A Solution for Caregivers-Rider

Family Planning: Advanced Reproductive Therapy (ART) Rider

Family Planning: Basic Infertility Services

Family Planning: Gamete Intrafallopian Transfer (GIFT)

Osteogenic/Bone Stimulation All July 1, 2014 July 1, 2014

Note: Theappearanceofaserviceorprocedureonthislistdoesnotimplythatcoverageisprovidedfortheserviceorprocedure.Inthecaseofaninconsistencyorconflict between the information in this Network Bulletin and the posted policy, the posted policy prevails.

Next Article >



Policy Title Effective Date Update Bulletin

NEW


Oct. 1, 2014 July 2014Aug. 2014Sept. 2014

Soliris (Eculizumab) Oct. 1, 2014 July 2014Aug. 2014Sept. 2014

UPDATED/REVISED

Apheresis Aug. 1, 2014 July 2014

Athletic Pubalgia Aug. 1, 2014 July 2014

Attended Polysomnography for Evaluation of Sleep Disorders Aug. 1, 2014 July 2014

Breast Reduction Surgery Aug. 1, 2014 July 2014Aug. 2014

Bronchial Thermoplasty Sept. 1, 2014 Aug. 2014

Chemosensitivity and Chemoresistance Assay in Cancer Sept. 1, 2014 Aug. 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.

Next Article >







Clinical Trials Sept. 1, 2014 Aug. 2014

Cochlear Implants Aug. 1, 2014 July 2014

Continuous Glucose Monitoring and Insulin Delivery for Managing Diabetes July 1, 2014 July 2014

Cytological Examination of Breast Fluids for Cancer Screening Sept. 1, 2014 Aug. 2014

Discogenic Pain Treatment Sept. 1, 2014 Aug. 2014

Durable Medical Equipment and Related Supplies, Prosthetics and Orthotic Policy

Sept. 1, 2014 Aug. 2014

Gastrointestinal Motility Disorders Diagnosis and Treatment Aug. 1, 2014 July 2014

Aug. 1, 2014 July 2014

Sept. 1, 2014 Aug. 2014

Aug. 1, 2014 July 2014

Aug. 1, 2014 July 2014

Aug. 1, 2014 July 2014

Sept. 1, 2014 Aug. 2014

Aug. 1, 2014 July 2014

Aug. 1, 2014 July 2014

Gynecomastia Treatment

High Frequency Chest Wall Compression Devices

Oct. 1, 2014 Sept. 2014

Next Article >

Home Traction Therapy

Human Immunodeficiency Virus (HIV) Tropism Testing


Magnetic Resonance Spectroscopy (MRS)

Magnetoencephalography and Magnetic Source Imaging for Specific Neurological Applications

Motorized Spinal Traction

Neuropsychological Testing Under The Medical Benefit






Occipital Neuralgia and Headache Treatment Sept. 1, 2014 Aug. 2014

Omnibus Codes Sept. 1, 2014 Aug. 2014

Outpatient Cardiovascular Telemetry Aug. 1, 2014 July 2014

Private Duty Nursing Aug. 1, 2014 July 2014

Spinal Ultrasonography Sept. 1, 2014 Aug. 2014

Standing Systems Aug. 1, 2014 July 2014

Sept. 1, 2014 Aug. 2014

Aug. 1, 2014 July 2014

Vagus Nerve Stimulation Aug. 1, 2014 July 2014

RETIRED

Infertility Diagnosis and Treatment July 1, 2014 July 2014

Transtympanic Micropressure July 1, 2014 July 2014

Note: Theappearanceofaserviceorprocedureonthislistdoesnotimplythatcoverageisprovidedfortheserviceorprocedure.Inthecaseofaninconsistencyorconflict between the information in this Network Bulletin and the posted policy, the posted policy prevails.

Next Article >

Surgical and Ablative Procedures for Venous Insufficiency and Varicose Veins

Umbilical Cord Blood Harvesting and Storage for Future Use



Oxford® Medical and Administrative Policy Updates

Policy Title Policy Type Effective Date

Policy Update Bulletin

UPDATED/REVISED

Ambulance Policy Reimbursement Policy Sept. 1, 2014 Aug. 2014

Breast Imaging for Screening and Diagnosing Cancer Clinical Policy Aug. 1, 2014 July 2014

Dental and Oral Surgical Procedures Clinical Policy Aug. 1, 2014 July 2014

ServicesandModifier NotReimbursable to Healthcare Professionals

Reimbursement Policy Sept. 1, 2014 Aug. 2014

WearableCardioverter-Defibrillator Clinical Policy Aug. 1, 2014 July 2014

UPDATED/REVISED

17-Alpha-Hydroxyprogesterone Caproate (Makena™ and 17P) Clinical Policy Aug. 1, 2014 July 2014

Add On Policy Reimbursement Policy Aug. 1, 2014 July 2014

Apheresis Clinical Policy Sept. 1, 2014 Aug. 2014

NEW

For complete details on the new and/or revised policies listed in the following table refer to the monthly Policy Update Bulletin at OxfordHealth.com >

Providers > Tools & Resources > Medical Information > Medical and Administrative Policies > Policy Update Bulletin.

s





Oxford Medical and Administrative Policy Updates



Administrative Policy Aug. 1, 2014 July 2014

UPDATED/REVISED

Clinical Policy Sept. 1, 2014 Aug. 2014

Attended Polysomnography for Evaluation of Sleep Disorders Clinical Policy Sept. 1, 2014 Aug. 2014

Balance Billing Administrative Policy Sept. 1, 2014 Aug. 2014

Breast Reduction Surgery Clinical Policy Aug. 1, 2014 July 2014 Aug. 2014

Chemosensitivity and Chemoresistance Assays in Cancer Clinical Policy Sept. 1, 2014 Aug. 2014

Clinical Trials Clinical Policy Sept. 1, 2014 Aug. 2014

Cochlear Implants Clinical Policy Sept. 1, 2014 Aug. 2014

Connecticut Clinical Trials Clinical Policy Sept. 1, 2014 Aug. 2014

Corneal Hysteresis and Intraocular Pressure Measurement Clinical Policy Aug. 1, 2014 July 2014

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

Diabetic Test Strips Clinical Policy Aug. 1, 2014 July 2014

Diagnostic (Basic) Procedures for Infertility Clinical Policy Sept. 1, 2014 Aug. 2014

Drug Coverage Criteria - New and Therapeutic Equivalent Clinical Policy Aug. 1, 2014 Sept. 1, 2014

July 2014

Assignment of Benefit to Non-Network Providers

Athletic Pubalgia Surgery







UPDATED/REVISED

Drug Coverage Guidelines• Ampyra (Dalfampridine)• Androderm (Testosterone)• Androgel (Testosterone)• Aptiom (Eslicarbazepine Acetate)• Aubagio(Teriflunomide• Avonex (Interferon Beta 1a)• Axiron (Testosterone)• Betaseron (Interferon Beta 1b)• Budesonide Nasal Spray (Generic Rhinocort Aqua)• Cinryze [C1 Esterase Inhibitor (Human)]• Copaxone (Glatiramer Acetate)• Copaxone (Glatiramer Acetate) 40 mg• Epaned (Enalapril)• Exjade (Deferasirox)• Extavia (Interferon B-1b)• Ferriprox (Deferiprone)• Fortesta (Testosterone)• Gilenya (Fingolimod)• Grastek (Timothy Grass Pollen Allergen Extract)• Jakafi(Ruxolitinib)• Leuprolide Acetate (Subcutaneous) (Eligard), 1mg/0.2ml• Lotronex (Alosetron)• Lupron, Lupron-3, Lupron-4, Lupron Depot, Lupron

Implant (Leuprolide Acetate)• Mekinist (Trametinib)• Menopur (Menotropins)• Myalept (Metreleptin)• Novarel (Chorionic Gonadotropin)• Oralair (Sweet Vernal, Orchard, Perennial Rye, Timothy

and Kentucky Blue Grass Mixed Pollens Allergen Extract)• Otezla (Apremilast)

Clinical Policy Aug. 1, 2014 July 2014







UPDATED/REVISED

Drug Coverage Guidelines (continued)• Ovidrel (Chorionic Gonadotropin)• Pomalyst (Pomalidomide)• Pregnyl (Chorionic Gonadotropin)• Purixan 20 mg/ml (Mercaptopurine)• Ragwitek (Short Ragweed Pollen Allergen Extract)• Rebif (Interferon Beta-1a)• Repository Corticotrophin Injection

(H.P.Acthar Gel): Injection (Self- Administered)• Repronex (Menotropins)• Revlimid (Lenalidomide)• Sitavig (Acyclovir Buccal Tablets).• Striant (Testosterone)• Tafinla (Dabrafenib)• Tecfider (DimethylFumarate)• Testim (Testosterone Gel)• Thalomid (Thalidomide): Oral• Vecamyl (Mecamylamine)• Zelboraf (Vemurafenib)








UPDATED/REVISED

Drug Coverage Guidelines• Active-Pac/Gaba 300 (Gabapentin, Lidocaine

Hydrochloride, Menthol)• Antagon (Ganirelix)• Cetrotide (Cetrorelix Acetate)• Chorionic Gonadatropin• Clodan 0.05% (Clobetasol Proprionate)• Clodan 0.05% Kit (Clobetasol Proprionate)• Copaxone (Glatiramer Acetate) 40 mg• Crinone 8% (Progesterone)• Cyclophosph Capsules (Cyclophosphamide)• Evista (Raloxifene)• Fertinex (Urofollitropin)• HCG (Chorionic Gonadotropin)• Humegon (Menotropins)• Menopur (Menotropins)• Metrodin (Urofollitropin)• Neo-Synalar (Neomycin Sulfate and Fluocinolone)• Neo-Synalar Kit (Neomycin Sulfate and Fluocinolone)• Neuac 1.2%-5%

(Clindamycin Phosphate and Benzoyl Peroxide)• Neuac 1.2%-5% Kit

(Clindamycin Phosphate and Benzoyl Peroxide)• Novarel (Chorionic Gonadotropin)• Ovace Plus 9.8% Lotion (Sodium Sulfacetamide)• Ovidrel (Chorionic Gonadotropin)







UPDATED/REVISED

Drug Coverage Guidelines (continued)• Pergonal (Menotropins)• Pregnyl (Chorionic Gonadotropin)• Profasi (Chorionic Gonadotropin)


Durable Medical Equipment, Orthotics and Prosthetics Multiple Frequency

Reimbursement Policy Aug. 1, 2014 July 2014

Emergency Room Visits Clinical Policy Sept. 1, 2014 Aug. 2014

Enzyme Replacement Therapy for Gaucher Disease Clinical Policy Sept. 1, 2014 Aug. 2014

Extracorporeal Shock Wave Therapy (ESWT) Clinical Policy Aug. 1, 2014 July 2014

Gastrointestinal Motility Disorders, Diagnosis and Treatment Clinical Policy Sept. 1, 2014 Aug. 2014

Gender Identity Disorder/Gender Dysphoria Treatment Clinical Policy Sept. 1, 2014 Aug. 2014

Gynecomastia Clinical Policy Aug. 1, 2014 July 2014

Home Traction Therapy Clinical Policy Sept. 1, 2014 Aug. 2014

Hospice Care Clinical Policy Aug. 1, 2014 July 2014

HumanImmunodeficiency Virus(HIV)TropismTesting Clinical Policy Sept. 1, 2014 Aug. 2014

InfertilityProceduresRequiringNotification and/orPrecertification

Administrative Policy Sept. 1, 2014 Aug. 2014

In-Network Exceptions for Breast Reconstruction Surgery Following Mastectomy


Inpatient Maternity Stay and Subsequent Home Nursing Administrative Policy Aug. 1, 2014 July 2014








UPDATED/REVISED

Interim New Product Coverage Criteria Clinical Policy Aug. 1, 2014 July 2014



Macular Degeneration Treatment Procedures Clinical Policy Aug. 1, 2014 July 2014

Magnetoencephalography and Magnetic Source Imaging forSpecifi NeurologicalApplications


Maximum Frequency Per Day Reimbursement Policy Aug. 1, 2014 July 2014

Members Outside of the United States Administrative Policy Sept. 1, 2014 Aug. 2014

Motorized Spinal Traction Clinical Policy Sept. 1, 2014 Aug. 2014

New Patient Visit Policy Reimbursement Policy Aug. 1, 2014 July 2014

Occipital Neuralgia and Headache Clinical Policy Sept. 1, 2014 Aug. 2014

Omnibus Codes Clinical Policy Aug. 1, 2014 July 2014

One or More Sessions Policy Reimbursement Policy Sept. 1, 2014 Aug. 2014

Outpatient Cardiovascular Telemetry Clinical Policy Sept. 1, 2014 Aug. 2014

Physician Extenders Reimbursement Policy Sept. 1, 2014 Aug. 2014

Precertificatio ExemptionsforOutpatientServices Administrative Policy Aug. 1, 2014 July 2014

PretermLabor:Identificatio andTreatment Clinical Policy Aug. 1, 2014 July 2014

Preventive Care Clinical Policy Aug. 1, 2014 July 2014

Private Duty Nursing Clinical Policy Aug. 1, 2014 July 2014

Repository Corticotropin Injection (H.P. Acthar Gel) Clinical Policy Aug. 1, 2014 July 2014

c

n

n







UPDATED/REVISED

Sodium Hyaluronate Clinical Policy Aug. 1, 2014 July 2014

Specialized, Microprocessor or Myoelectric Limbs Clinical Policy Aug. 1, 2014 July 2014

Speech Therapy and Early Intervention Programs/Birth to Three Clinical Policy Aug. 1, 2014 July 2014

Split Surgical Package Policy Reimbursement Policy Aug. 1, 2014 July 2014

Standing Systems Clinical Policy Sept. 1, 2014 Aug. 2014

Supply Policy Reimbursement Policy Sept. 1, 2014 Aug. 2014

Clinical Policy Sept. 1, 2014 Aug. 2014SurgicalandAblativeProceduresforVenousInsufficiency

Time Span Codes Reimbursement Policy Sept. 1, 2014 Aug. 2014

Transcatheter Heart Valve Procedures Clinical Policy Aug. 1, 2014 July 2014

Transportation Services Clinical Policy Sept. 1, 2014 Aug. 2014

Transpupillary Thermotherapy Clinical Policy Aug. 1, 2014 July 2014

Treatment of Infertility Clinical Policy Sept. 1, 2014 Aug. 2014

Treatment of Infertility for Connecticut Groups Clinical Policy Sept. 1, 2014 Aug. 2014

Treatment of Infertility for New Jersey Large Groups Clinical Policy Sept. 1, 2014 Aug. 2014

Treatment of Infertility for New Jersey Small Groups and New Jersey Individual Plans


Varicose Veins


InsurancecoverageprovidedbyUnitedHealthcareInsuranceCompanyoritsaffiliates.HealthplancoverageprovidedbyUnitedHealthcareofArizona,Inc.,UnitedHealthcareofCalifornia,UnitedHealthcareofColorado,Inc.,UnitedHealthcareofOregon,Inc.,UnitedHealthcareofUtah,Inc.andUnitedHealthcareofWashington,Inc.orotheraffiliates.AdministrativeservicesprovidedbyUnitedHealthcareServices,Inc.oritsaffiliates.

80 Network Bulletin: September 2014Doc#: PCA13811_20140822





UPDATED/REVISED

Treatment of Infertility for New York Large and Small Groups Clinical Policy Sept. 1, 2014 Aug. 2014

Tysabri (Natalizumab) Clinical Policy Aug. 1, 2014 July 2014

Umbilical Cord Blood Harvesting and Storage for Future Use Clinical Policy Sept. 1, 2014 Aug. 2014

Vaccines Clinical Policy July 1, 2014 July 2014

Vagus Nerve Stimulation Clinical Policy Sept. 1, 2014 Aug. 2014

RETIRED

Transtympanic Micropressure Clinical Policy Sept. 1, 2014 Sept. 2014

Note: The appearance of a service or procedure on this list does not imply that UnitedHealthcare Oxford provides coverage for the service or procedure. In the event of aninconsistencyorconflict betweentheinformationprovidedinthisNetworkBulletinandthepostedpolicy,thepostedpolicyprevails.

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: September 2014 network bulletin

Documents