October 2017 Network Bulletin - UnitedHealthcare Online · PDF file3 Network Bulletin: November 2013 - Volume 58 3 For more information, call 877.842.3210 or visit UnitedHealthcareOnline.com

Important updates 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: October 2017

enter

Oct. 3, 2017: An update was made to the Addition to Drug Testing Policy article on page 26.

Network Bulletin: November 2013 - Volume 582

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For more information, call 877.842.3210 or visit UnitedHealthcareOnline.com

2 Network Bulletin: October 2017

Front and Center• Delay in Implementation of the Revision to the

Consultation Services Reimbursement Policy

• Updating Demographic Information

• Improving Vaccination Rates with Influenza andPneumococcal Vaccine Standing Orders

• UHCprovider.com Update

• Tell Us What You Think of Our Communications

• Review at Launch Drug Program forUnitedHealthcare Commercial and CommunityPlan Members – Effective Jan. 1, 2018

• Pharmacy Update – Notice of Changes to PriorAuthorization Requirements and Coverage Criteriafor UnitedHealthcare Commercial and Oxford

• Outpatient Injectable Chemotherapy PriorAuthorization Program for All Savers MembersSmall Group Fully Insured and Self-Funded

• Introducing Guest Ally – A Tool to HelpImprove the Patient Experience

• Changes in Advance Notification andPrior Authorization Requirements

• Dental Clinical Policy & CoverageGuideline Updates

• Notification/Prior Authorization Requirement forChimeric Antigen Receptor T-cell (CAR-T) Therapy

UnitedHealthcare Commercial• Paperless Delivery Option Available for

Most Commercial Claim Letters

• Medical Record Review – ACA-CoveredCommercial Plans for 2017 Dates of Service

• Updates to Coverage Requirementsfor Specialty Medications

• UnitedHealthcare Genetic and Molecular LabTesting Notification/Prior Authorization Requirement

• Neighborhood Health Partnership andUnitedHealthcare of the River Valley CommercialBusiness Changes in Advance Notification and PriorAuthorization Requirements – Effective Oct. 1, 2017

• Provider Remittance Advice for HealthReimbursement Accounts to Include More Detail

• Site of Service Review for Ipilimumab (Yervoy, J9228)

• UnitedHealth Premium® DesignationProgram Updates

• UnitedHealthcare Medical Policy, MedicalBenefit Drug Policy and CoverageDetermination Guideline Updates

UnitedHealthcare Commercial Reimbursement Policies

• Addition to the Drug Testing Policy

UnitedHealthcare Community Plan• UnitedHealthcare Community Plan

Launches a Dual Special Needs Program– UnitedHealthcare Dual Complete

• Reminder on Prior Authorization Requirementsfor Medical Injectable Drugs

• Prior Authorization Medication Requirement

• Updates to Prior Authorization Requirementsfor Specialty Medications for UnitedHealthcareCommunity Plan Members – Effective Jan. 1, 2018

• UnitedHealthcare Community Plan MedicalPolicy, Medical Benefit Drug Policy andCoverage Determination Guideline Updates

UnitedHealthcare Medicare Solutions• UnitedHealthcare Medicare Advantage

Coverage Summary Updates

• UnitedHealthcare Medicare AdvantagePolicy Guideline Updates

Doing Business Better • HEDIS Season Is Almost Here: How You

Can Help Us Collect Medical Records

• Hospital Data Exchange for Improved TransitionalCare and Readmission Reduction

UnitedHealthcare Affiliates • SignatureValue/UnitedHealthcare Benefits Plan of

California Benefit Interpretation Policy Updates

• Oxford® Medical and Administrative Policy Updates

• SignatureValue/UnitedHealthcare Benefits Plan ofCalifornia Medical Management Guideline Updates

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

or visit UnitedHealthcareOnline.comNetwork Bulletin: October 2017

Front & Center

Delay in Implementation of the Revision to the Consultation Services Reimbursement PolicyWe previously announced that certain revisions to the Consultation Services Reimbursement Policy would become effective for UnitedHealthcare Commercial members on Oct. 1, 2017. In an effort to give care providers more time to adjust to potential changes in their submission of procedure codes for consultation services, UnitedHealthcare will be delaying implementation of the revisions to the Reimbursement Policy for services reported with consultation codes 99241-99245 and 99251-99255.

Additional updates relating to this policy will be shared in future editions of the Network Bulletin at UHCprovider.com.

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Please help us make sure our members are seeing the correct information for your office. When you submit demographic updates, list only those addresses where a member may make an appointment and see the care provider. On-call and substitute care providers who are not regularly available to provide covered services at an office or practice location should not be listed at that address. This helps us ensure our directories are accurate and meet Centers for Medicare & Medicaid Services (CMS) requirements.

How to View and Update Your InformationIf you have access to the updated My Practice Profile app on Link, you can use the app to update your care provider demographic information and complete data attestations. The app is now available to most practices with less than 30 physicians. To access My Practice Profile, sign in to Link by clicking on the Link button in the top right corner of UHCprovider.com, then select My Practice Profile.

If you don’t yet have access to My Practice Profile, here’s how you can submit your demographic data updates:

• Fax or email us the Care Provider Paper Demographic Information Update Form or the Group/OrganizationDemographic Information Update available at UHCprovider.com > Menu > Find a Care Provider.

• Call 877-842-3210 and say “health care professional services,” and then say “demographic changes.”

If you don’t yet have access to the app, Provider Data Attestation Representatives and Provider Advocates will also work with your organization to review demographic information and complete attestations.

If you submit more than five addresses for an individual care provider or don’t indicate new patient acceptance, we’ll call you to make sure we’re processing your information correctly.

If you have questions, please send an email to [email protected].

Updating Demographic Information

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Improving Vaccination Rates with Influenza and Pneumococcal Vaccine Standing Orders

Physician recommendations and standing orders have been shown to significantly affect immunization rates, according to studies by the Centers for Disease Control and Prevention (CDC) and the Community Preventive Services Task Force. As influenza season begins, we’re asking for you to help to improve immunization rates by implementing standing orders for influenza vaccinations among patients age 6 months and older and pneumococcal vaccinations for patients age 65 and older who do not have a contraindication. Thank you for making updates to the standing orders used by your practice.

For information about standardized tools to assist you and your practice, visit the Immunization Action Coalition website at immunize.org. To learn more about implementing standing orders, go to immunize.org/standing-orders.

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UHCprovider.com is your new home for the latest news, policy information and access to Link self-service tools. The new site will replace UHCWest.com and UnitedHealthcareOnline.com. For FAQs and other information about UHCprovider.com, visit UHCprovider.com > Menu > Resource Library > News and Network Bulletin > Welcome to UHCprovider.com. To access the Link dashboard from UHCprovider.com, click the Link button in the upper right corner.

UnitedHealthcareOnline.com will still be available into 2018, but some transactions have been retired and replaced by new Link apps. Plus, we’ve retired a lot of the site content, which means:

• We’re no longer adding pages, attachments or new information to UnitedHealthcareOnline.com except on the home page.Important news will be posted on UHCprovider.com and UnitedHealthcareOnline.com until the site is completely retired.

• We have removed information from UnitedHealthcareOnline.com and substituted hyperlinks to the appropriate sections ofUHCprovider.com.

UHCprovider.com was designed with your feedback in mind, but our job isn’t done. Tell us how we’re doing by clicking the Feedback button on the right side of any screen or complete one of our surveys. Your opinions will help us continue to improve so we can better meet your needs.

UHCprovider.com Update

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Tell Us What You Think of Our Communications

As a regular reader of The Network Bulletin, your opinion is important to us. We’d like to get your thoughts about The Bulletin and UnitedHealthcare communications related to network changes, quality initiatives and other issues. Please take a few minutes today to complete the survey online at uhcresearch.az1.qualtrics.com/jfe/form/ SV_08sAsRnUY2Kb153. Thank you for your time.

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Review at Launch Drug Program for UnitedHealthcare Commercial and Community Plan Members – Effective Jan. 1, 2018

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The U.S. Food and Drug Administration (FDA) is approving medications at an accelerated pace, and we want to make it easier for care providers to manage our members’ access to new drug therapies as they become available. That’s why we’re implementing Review at Launch.

What’s IncludedReview at Launch will apply to newly FDA-approved, physician-administered drugs covered under the member’s medical benefit for the following plans:

• UnitedHealthcare Commercial plans, including:

– All Savers

– UnitedHealthcare of the Mid-Atlantic

– UnitedHealthcare Oxford

– Neighborhood Health Partnership

– UnitedHealthcare of the River Valley

• UnitedHealthcare Community Plan benefit plans except Dual-SNP benefit plans.

It won’t apply to UnitedHealthcare of the West benefit plans or UnitedHealthcare Medicare Advantage benefit plans, including Dual-SNP plans administered by Community Plan.

How Review at Launch WorksBeginning Jan. 1, 2018, we’ll maintain a list of new-to-market medications and a related policy that care providers can access online. We’ll add certain new drugs to the Review at Launch list and policy as soon as they’re approved by the FDA. Drugs will remain on the Review at Launch list until we communicate otherwise. The Review at Launch list and policy will be posted on UHCprovider.com.

For medications on the Review at Launch list, we strongly encourage you to request pre-service coverage reviews so you can check whether a medication is covered before providing services. Some benefit plans may not cover certain medications under the medical benefit or may not cover them right away. Clinical coverage reviews can also help to avoid starting a patient on therapy that may later be denied due to lack of medical necessity. Please note that if you request a pre-service coverage review, you must wait for our determination before rendering the service. If you do not wait for our determination before rendering the service, the claim may be denied and you cannot bill the member for the service. In the event the determination is made that the new-to-market medication is not covered under the member’s benefit plan, the claim will be denied. You may bill members for non-covered services in accordance with the terms of your contract with UnitedHealthcare, UnitedHealthcare’s protocols and any applicable state requirements.

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Review at Launch Drug Program for UnitedHealthcare Commercial and Community Plan Members – Effective Jan. 1, 2018

To request a pre-service coverage review, go to UnitedHealthcareOnline.com > Claims & Payments > Claim Estimator > Pre-Determination of Benefits. Or call the number on the member’s health plan ID card.

Coverage reviews will take into consideration the terms of the member’s benefit plan, applicable state Medicaid guidelines, FDA-approved labeling and available clinical evidence. We encourage you to submit any information you would like us to consider when requesting a pre-service coverage review. Regardless of whether you request a pre-service review, claims will be denied if the new-to-market medication is not covered under the member’s benefit plan or if medical necessity criteria aren’t met.

If you have any questions, please call the Provider Services number on the member’s ID card.

Pharmacy Update – Notice of Changes to Prior Authorization Requirements and Coverage Criteria for UnitedHealthcare Commercial and Oxford

A Pharmacy Bulletin outlining upcoming new or revised clinical programs and implementation dates is now available online for UnitedHealthcare Commercial. Go to UHCprovider.com/pharmacy.

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Effective Jan 1, 2018, All Savers members will require prior authorization for injectable outpatient chemotherapy drugs given for a cancer diagnosis.

Prior authorization will be required for:

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

• Chemotherapy injectable drugs that have a Q code

• Chemotherapy injectable drugs that have not yet received an assigned code and will be billed under a miscellaneousHealthcare Common Procedure Coding System (HCPCS) code

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

• Adding a new injectable chemotherapy drug to a regimen

If an All Savers member received injectable chemotherapy drugs in an outpatient setting Oct. 1, 2017 through Dec. 31, 2017, you don’t need to submit a prior authorization request until a new chemotherapy drug is administered. We’ll authorize the chemotherapy regimen that the member was receiving prior to Jan. 1, 2018, and the authorization will be effective until Dec. 31, 2018.

Outpatient Injectable Chemotherapy Prior Authorization Program for All Savers Members Small Group Fully Insured and Self-Funded

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Introducing Guest Ally – A Tool to Help Improve the Patient Experience

The Optum Innovation Research & Development (IRD) team has developed a survey tool to help care providers improve patient experiences by collecting feedback from patients during their office visit. The tool, called Guest Ally, doesn’t replace the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey or other regulatory surveys, but is intended to give you a quick feedback anytime you need it. To learn more, visit bit.ly/guestally and then enter your Optum ID to watch a brief informational video.

Optum IRD is enrolling care provider offices interested in piloting the prototype and providing feedback. Benefits are available to offices that participate.

If you’re interested and want to learn more, send an email to [email protected] or call 763-957-6785.

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TexasFor dates of service on or after Jan. 1, 2018, the following procedure codes will require prior authorization for UnitedHealthcare Community Plan of Texas CHIP and STAR (Medicaid Plans):

Category Code

BRCA Genetic Testing 81162 81213

For dates of service on or after Jan. 1, 2018, the following procedure code will require prior authorization for UnitedHealthcare Community Plan of Texas CHIP, STAR and STAR PLUS (Medicaid Plans):

Category Code

Home Health Care G0162

For dates of service on or after Jan. 1, 2018, the following procedure codes will require prior authorization for UnitedHealthcare Community Plan of Texas CHIP, STAR, STAR PLUS, and STAR Kids (Medicaid Plans):

Category Codes

Orthotics/Prosthetic Greater than $500 L1812 L1820 L1830 L1831 L1836 L1847

MissouriFor dates of service on or after Jan. 1, 2018, the following procedure codes will require prior authorization for UnitedHealthcare Community Plan of Missouri (Medicaid Plan):

Category Codes With Diagnosis

Gender Dysphoria Treatment

55970 55980 N/A

11950 11951 11952 11954 11980 14000 1400114021 14040 14041 14060 14061 14301 1575715758 15775 15776 15777 15780 15781 1578215783 15787 15788 15789 15792 15793 1581915824 15825 15826 15828 15829 15832 1583315834 15835 15836 15837 15838 15839 1587615878 15879 17380 20926 21083 21087 2112021122 21173 21270 21899 31599 31750 3189945399 45999 58999 64856 64892 64896 6930090785 96372

F64.0, F64.1, F64.2, F64.8, F64.9, Z87.890

Nebraska For dates of service on or after Jan. 1, 2018, the following procedure code will require prior authorization for UnitedHealthcare Community Plan of Nebraska (Medicaid Plan):

Category Code

Enteral Services B4155

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Changes in Advance Notification and Prior Authorization Requirements

The most up-to-date Advance Notification lists are available online:

• UHCprovider.com > Prior Authorization and Notification Resources > AdvanceNotification and Plan Requirement Resources

• UnitedHealthcare Community Plan – UHCCommunityPlan.com > For Health CareProfessionals > Select your state.

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For complete details on the policy updates listed in the following table, please refer to the September 2017 UnitedHealthcare Dental Policy Update Bulletin at UHCprovider.com > Menu > Policies and Protocols > Dental Clinical Policies and Coverage Guidelines > Dental Policy Update Bulletins.

Policy Title Policy Type Effective Date

NEW

National Standardized Dental Claim Utilization Review Criteria

Utilization Review Guideline Oct. 1, 2017

UPDATED/REVISED

Medically Necessary Orthodontic Treatment

Coverage Guideline Oct. 1, 2017

Oral Surgery: Alveoloplasty and Vestibuloplasty

Coverage Guideline Sept. 1, 2017

Oral Surgery: Miscellaneous Surgical Procedures

Clinical Policy Oct. 1, 2017

Oral Surgery: Non-Pathologic Excisional Procedures

Coverage Guideline Sept. 1, 2017

Oral Surgery: Orthodontic Related Procedures

Clinical Policy Sept. 1, 2017

Note: The inclusion of a dental service (e.g., procedure or technology) on this list does not imply that UnitedHealthcare provides coverage for the dental service. In the event of an inconsistency or conflict between the information in this bulletin and the posted policy, the provisions of the posted policy prevail.

Dental Clinical Policy & Coverage Guideline Updates

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We’re updating our coverage review requirement for transplants to include chimeric antigen receptor T-cell (CAR-T) therapy. CAR-T therapy is a form of adoptive cell transfer that’s shown promise in the treatment of certain hematologic malignancies.

For dates of service on or after Jan. 1, 2018, we’ll require notification/prior authorization for CAR-T therapy or related services, including outpatient or inpatient evaluation and the CAR-T outpatient or inpatient episode. This update applies to UnitedHealthcare Commercial, Medicare Advantage and Community Plan members.

While notification/prior authorization is not required for dates of service prior to Jan. 1, 2018, we strongly encourage care providers to request coverage reviews prior to administering CAR-T therapy. Some benefit plans may not cover CAR-T therapy under the medical benefit or may not cover it right away. Clinical coverage reviews can also help avoid starting a patient on therapy that might later be denied due to lack of medical necessity.

The Centers for Medicare & Medicaid Services (CMS) has not issued coverage guidance for CAR-T therapy. Prior to Jan. 1, 2018 for UnitedHealthcare Medicare Advantage Plan members, care providers are encouraged to seek a pre-determination.

We’re implementing coverage reviews for CAR-T therapy to provide our members access to care that’s medically appropriate and because CAR-T therapy carries certain risks. Coverage reviews for CAR-T therapy will be managed by Optum Transplant Resource Services through the same process as the transplant of tissue or organs. Care providers must contract with Optum Transplant Resource Services to receive prior authorization and bill for CAR-T therapy.

As with all notification/prior authorization requirements, if you provide any CAR-T services without first completing the notification/prior authorization process, the claim may be denied. Members can’t be billed for services denied due to failure to complete the notification/prior authorization process.

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Notification/Prior Authorization Requirement for Chimeric Antigen Receptor T-cell (CAR-T) Therapy



UnitedHealthcare CommercialPaperless Delivery Option Available for Most Commercial Claim Letters

The new Paperless Delivery Options app on the Link dashboard was launched to password owners to enable them to turn off the paper delivery of mail for claims letters that are found in Document Vault. You can receive daily or weekly summary emails for the letters placed in Document Vault for you.

Document Vault is a tool, found on the Link header, that contains claim letters for most UnitedHealthcare Commercial claims. Letters are stored in Document Vault for six months; letters older than 6 months are available in the claimsLink app until they are 18 months old. With Document Vault, you can search and filter letters by file name, claim number, provider name, creation date, member ID or tax ID number (TIN).

How to Access Paperless Delivery Options

To sign in to Link, go to UHCprovider.com and click on the Link button in the top right corner. After you sign in, select the Paperless Delivery Options tile. The Paperless Delivery Options app is available to Link password owners.

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We’re required by the Department of Health & Human Services (HHS), under the Affordable Care Act (ACA), to submit complete diagnostic information about members enrolled in certain Commercial ACA-covered health plans. This means we may be requesting medical records from you to comply with this requirement from Dec. 4, 2017 through March 16, 2018.

What This Means to You

If you’re selected for a medical record review, UnitedHealthcare will ask you to provide information for 2017 dates of service for a certain number of your patients. To reduce the potential for administrative burden on your office, we use the records received through this request for other appropriate health care operation, for example, monitoring compliance with HEDIS© measures.

We have engaged Optum and CIOX Health (CIOX) to conduct these medical record reviews, coordinate record retrieval and clinical coding reviews on UnitedHealthcare’s behalf. They will request records for members in Commercial ACA-covered health plans.

What You Will Need to Do

All requested medical records and documentation will need to be completed March 16, 2018 to meet the HHS deadline for these record requests. This is unlike Medicare record requests you may have had in the past, as we need to adhere to a tighter window with one retrieval wave for our UnitedHealthcare Commercial members.

Medical Record Documentation Required:

When you get the medical record request, you’ll be asked to provide the following documentation:

• Consult notes

• Discharge summary

• Emergency Department records

• History and physical notes

• Operative and pathology notes

• Patient demographics sheet

• Physical, speech, and/or occupational therapist reports

• Physician orders

• Problem list

• Procedure notes/reports

• Progress notes and/or SOAP notes for face-to-face office visit

• Signature Log*

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Medical Record Review – ACA-Covered Commercial Plans for 2017 Dates of Service

*HHS requires us to validate care providers’ signatures and qualifications for each medicalrecord we review. It’s important you provide a signature log with credentials toidentify signatures of physicians, physician assistants and nurse practitioners whoare mentioned in or have annotated medical records.

If you have any questions about the scheduling of the medical record review:

• Call CIOX Health at 877-445-9293, between 7 a.m. to 8 p.m., Central Time, Mondaythrough Friday

• Email [email protected]

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We’re making some updates to our coverage requirements for certain specialty medications for many of our UnitedHealthcare Commercial members. We’re implementing these requirements to provide our members access to care that’s medically appropriate as we work toward the Triple Aim of improving health care services, health outcomes and overall cost of care.

Changes include implementing notification/prior authorization requirements for one medication and expanding some existing requirements for another. These requirements will apply whether members are new to therapy or have already been receiving these medications. If you administer any of these medications without first completing the notification/prior authorization process, the claim may be denied. Members can’t be billed for services denied due to failure to complete the notification/prior authorization process.

What’s Changing for UnitedHealthcare Commercial Plans

The following requirements will apply to UnitedHealthcare Commercial plans, including affiliate plans such as UnitedHealthcare of the Mid Atlantic, UnitedHealthcare of the River Valley, UnitedHealthcare Oxford and Neighborhood Health Partnership. For dates of service on or after Jan. 1, 2018, we’ll require notification/prior authorization for the following drugs:

• Ilaris™ (canakinumab) – This drug is approved by the U.S. Food and Drug Administration (FDA) for the treatment of severalrare inflammatory diseases. UnitedHealthcare is implementing a prior authorization review as part of our comprehensiverare disease management strategy.

• Ocrevus (ocrelizumab) – This drug is approved by the FDA for the treatment of multiple sclerosis and already has a priorauthorization requirement in place. We’ll now be reviewing the requested site of service for members who are receivingtheir infusion in the outpatient hospital for medical necessity.

Clinical Coverage Reviews

Clinical coverage reviews will be conducted as part of our prior authorization process if the member’s benefit plan requires that services be medically necessary to be covered. The reviews will evaluate whether the drug is appropriate for the individual member, taking into account:

• Our drug coverage policy

• Medically necessary site of service

• Dosage recommendation from the FDA-approved labeling

Additional criteria also may be considered. We encourage you to submit any information you would like reviewed as part of your prior authorization request. When a coverage determination is made, we’ll inform you and the member of the coverage determination. If an adverse determination is made, we’ll provide you appeal information.

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Updates to Coverage Requirements for Specialty Medications

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Updates to Coverage Requirements for Specialty Medications

Submitting Notification/Prior Authorization Requests

To submit notification/prior authorization requests for these medications, please use one of the following methods:

• Go to UHCprovider.com/priorauth

• Call the Provider Services phone number on the back of the member’s health careidentification card.

• Send your request by fax.

For UnitedHealthcare Commercial plans, access forms at UHCProvider.com/priorauth. Some states require the notification/prior authorization to be submitted on a designated request form.

When Making Referrals

If you’re referring a member to other care providers for these medications, we encourage you to refer to in-network care providers. If a non-participating care provider prescribes treatment, members may pay higher out-of-pocket costs. Members who don’t have out-of-network benefits may be responsible for the entire cost of services obtained from non-participating care providers.

For more information about the notification/prior authorization requirements for specialty medications, please refer to the Provider Administrative Guide at UHCprovider.com > Menu> Administrative Guides and Manuals.

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Starting Nov. 1, 2017, we’re requiring a new online notification/prior authorization process for genetic and molecular lab tests for UnitedHealthcare Commercial benefit plan members. These tests may offer treatment options for some patients and we want to support the use of appropriate proven testing, while keeping patient safety a priority.

This means that certain tests will require ordering care providers to request notification/prior authorization through this process before the lab tests can be reimbursed:

• Tier 1 Molecular Pathology Procedures

• Tier 2 Molecular Pathology Procedures

• Genomic Sequencing Procedures

• Multianalyte Assays with Algorithmic Analyses that include Molecular Pathology Testing

• These CPT® codes:

– 0001U

– 0004M - 0008M

– 81161 - 81421

– 81423 - 81479

– 81507

– 81519

– 81545 - 81599

– 0009M (prior authorization required starting Jan. 1, 2018)

– S3870 (prior authorization required starting Jan. 1, 2018)

The ordering care provider will sign in to Link and complete the online notification/prior authorization process for tests included in the Genetic and Molecular Lab Test requirement:

• Sign in to Link by going to UHCprovider.com and clicking on the Link button in the top right corner.

• Choose the Genetic and Molecular Test app in Link.

• Fill out the requested information.

Care providers will be able to choose the test and the lab to perform the test, but only if the lab registers their tests for the process.

If your request meets UnitedHealthcare’s clinical and coverage guidelines, you’ll get a decision when you submit your request online. If more information or clinical documentation is needed, we’ll contact you.

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UnitedHealthcare Genetic and Molecular Lab Testing Notification/Prior Authorization Requirement

Beacon Laboratory Benefit Solutions, Inc. (BeaconLBS), a lab services management company working on behalf of UnitedHealthcare, will register participating labs for the process and manage the online notification/prior authorization request system. Clinical coverage reviews conducted as part of our prior authorization process for these tests will be based on UnitedHealthcare’s clinical policy requirements for coverage. Care providers can also call BeaconLBS at 800-377-8809 to start the notification/prior authorization process.

The notification/prior authorization requirement is for UnitedHealthcare Commercial benefit plan members. However, it doesn’t apply to care providers in Florida who are subject to the Laboratory Benefit Management Program.

Contact BeaconLBS at 800-377-8809 if you have questions about registering tests for the process.

If you would like more information about the new process, including live and on-demand training schedules, please visit UHCprovider.com > Prior Authorization and Notification Resources > Genetic and Molecular Lab Testing, or contact us at [email protected].

Neighborhood Health Partnership and UnitedHealthcare of the River Valley Commercial Business Changes in Advance Notification and Prior Authorization Requirements – Effective Oct. 1, 2017

As a reminder, for dates of service on or after Oct. 1, 2017, the Neighborhood Health Partnership and UnitedHealthcare of the River Valley Commercial plans will launch changes in their prior authorization/notification requirements. Elective inpatient admission requirements will continue and are not affected by these changes. These changes were announced in the July Network Bulletin.

As part of this change, OrthoNet, an orthopedic specialty benefit management company, will begin performing prior authorization request reviews for certain orthopedic procedures. As such, when you request prior authorization for certain procedures, you may receive letters or notices that contain both UnitedHealthcare and OrthoNet logos.

For more information on which procedures will now require notification/prior authorization for these plans, please visit UHCprovider.com/priorauth > Advance Notification and Plan Requirement Resources and select “Neighborhood Health Partnership Advance Notification Guide effective Oct. 1 2017” or “UnitedHealthcare of the River Valley Advance Notification Procedure Codes effective Oct. 1 2017” from the Plan Requirement Resource list.

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As of Oct. 28, 2017, more claim detail will be added to remittances from UnitedHealthcare members who have health reimbursement accounts (HRAs).

You will receive a separate remittance for HRA claims, which may indicate:

• Charge amount

• Claim adjustment amount

• Patient responsibility

• Group code and claim adjustment reason code, for example:

– OA 23 – Other adjustments – the effect of prior payer(s) adjudication including payments and/or adjustments.

– PR 187 – Patient responsibility – consumer spending account payments (includes, but is not limited to, flexiblespending account, health savings account, health reimbursement account, etc.)

• Remittance Advice Remark code, for example:

– N510 – A current inquiry shows the member’s consumer spending account does not contain sufficient funds to coverthe member’s liability for this claim/service. Actual payment from the consumer spending account will depend on theavailability of funds and determination of eligible services at the time of payment processing.

– N520 – Payment made from a consumer spending account

If you are enrolled in Electronic Payments and Statements (EPS) and look at your PRA online, these details will be included.

If you have any questions about these enhancements, call the phone number on the member ID card or PRA. If you’re receiving Electronic Remittance Advice (835) and have questions, please contact EDI Support at 800-842-1109 or via our EDI Transaction Support form.

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Provider Remittance Advice for Health Reimbursement Accounts to Include More Detail



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UnitedHealthcare previously announced in the August Network Bulletin that beginning Nov. 1, 2017, UnitedHealthcare’s coverage policy for high dose (>3mg/kg) Ipilimumab (Yervoy), Healthcare Common Procedure Coding System (HCPCS) code J9228, will include site of service coverage information and that UnitedHealthcare will conduct site of service reviews for high dose Yervoy in some cases. Due to the recently published changes in the treatment of adjuvant melanoma, UnitedHealthcare will no longer be updating our coverage policy for high dose Yervoy to include site of service information and site of service reviews will not occur for high dose Yervoy.

Have questions? Send an email to [email protected].

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Site of Service Review for Ipilimumab (Yervoy, J9228)

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Key Dates:

• Assessment letters mailed to Premium-eligible physicians: July 6, 2017

• Public display date: Sept. 6, 2017

• Reconsideration end date: Nov. 13, 2017

Updated UnitedHealth Premium® designations now display on our public websites. We’ll continue to accept and review reconsideration requests as long as they’re submitted on or before Nov. 13, 2017. We’ll make any applicable change to your publicly-displayed designation.

New Website for Premium Materials

UHCprovider.com is your new home for Premium news and for all methodology materials. You’ll still access your Premium assessment reports, submit reconsiderations and contact the Premium program by signing in at the current UnitedHealthcareOnline.com link. Remember to update your bookmarks for accessing Premium materials and news at UHCprovider.com > Menu > Reports and Quality Programs > UnitedHealth Premium Program. To sign in to Link or register for access, visit UHCprovider.com and click on Link in the top right corner.

For more information about UnitedHealth Premium and the methodology, go to UHCprovider.com > Menu > Reports and Quality Programs > UnitedHealth Premium Program or call 866-270-5588.

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UnitedHealth Premium® Designation Program Updates



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UnitedHealthcare Medical Policy, Medical Benefit Drug Policy and Coverage Determination Guideline Updates

For complete details on the policy updates listed in the following table, please refer to the September 2017 Medical Policy Update Bulletin at UHCprovider.com > Menu > Policies and Protocols > Commercial Policies > Commercial Medical & Drug Policies and Coverage Determination Guidelines > Medical Policy Update Bulletins.


NEW

Carrier Testing for Genetic Diseases Medical Nov. 1, 2017

Laser Interstitial Thermal Therapy Medical Oct. 1, 2017

Molecular Oncology Testing for Cancer Diagnosis, Prognosis, and Treatment Decisions Medical Nov. 1, 2017

Pharmacogenetic Testing Medical Nov. 1, 2017

Whole Exome and Whole Genome Sequencing Medical Nov. 1, 2017

UPDATED/REVISED

Abnormal Uterine Bleeding and Uterine Fibroids Medical Nov. 1, 2017

Anemia Drugs: Darbepoetin Alfa, Epoetin Alfa, and Methoxy Polyethylene Glycol-Epoetin Beta Drug Oct. 1, 2017

Apheresis Medical Oct. 1, 2017

Chromosome Microarray Testing Medical Oct. 1, 2017

Computed Tomographic Colonography Medical Sept. 1, 2017

Core Decompression for Avascular Necrosis Medical Sept. 1, 2017

Durable Medical Equipment, Orthotics, Ostomy Supplies, Medical Supplies and Repairs/Replacements CDG Oct. 1, 2017

Emergency Health Services and Urgent Care Center Services CDG Oct. 1, 2017

Epidural Steroid and Facet Injections for Spinal Pain Medical Oct. 1, 2017

Fetal Aneuploidy Testing Using Cell-Free Fetal Nucleic Acids in Maternal Blood Medical Oct. 1, 2017

Functional Endoscopic Sinus Surgery (FESS) Medical Oct. 1, 2017

Gender Dysphoria Treatment Medical Oct. 1, 2017

Gene Expression Tests for Cardiac Indications Medical Nov. 1, 2017

Genetic Testing for Hereditary Cancer Medical Nov. 1, 2017

Habilitative Services for Essential Health Groups CDG Oct. 1, 2017

Hepatitis Screening Medical Oct. 1, 2017

High Frequency Chest Wall Compression Devices Medical Sept. 1, 2017

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Immune Globulin (IVIG and SCIG) Drug Oct. 1, 2017

Intravenous Enzyme Replacement Therapy (ERT) for Gaucher Disease Drug Sept. 1, 2017

Lithotripsy for Salivary Stones Medical Sept. 1, 2017

Maximum Dosage Drug Nov. 1, 2017

Nerve Graft to Restore Erectile Function During Radical Prostatectomy Medical Sept. 1, 2017

Ocrevus™ (Ocrelizumab) Drug Nov. 1, 2017

Office Based Program URG Oct. 1, 2017

Omnibus Codes Medical Oct. 1, 2017

Ophthalmologic Policy: Vascular Endothelial Growth Factor (VEGF) Inhibitors Drug Oct. 1, 2017

Panniculectomy and Body Contouring Procedures Medical Nov. 1, 2017

Plagiocephaly and Craniosynostosis Treatment Medical Sept. 1, 2017

Prosthetic Devices, Wigs, Specialized, Microprocessor or Myoelectric Limbs CDG Oct. 1, 2017

Sandostatin®/Sandostatin LAR® Depot (Octreotide Acetate) Drug Oct. 1, 2017

Sodium Hyaluronate Medical Oct. 1, 2017

Synagis® (Palivizumab) Drug Oct. 1, 2017

Transcatheter Heart Valve Procedures Medical Nov. 1, 2017

Unicondylar Spacer Devices for Treatment of Pain or Disability Medical Sept. 1, 2017

Vimizim® (Elosulfase Alfa) Drug Sept. 1, 2017

REPLACED

Genetic Testing Medical Nov. 1, 2017

Molecular Profiling to Guide Cancer Treatment Medical Nov. 1, 2017

Note: The inclusion of a health service (e.g., test, drug, device or procedure) on this list does not imply that UnitedHealthcare provides coverage for the health service. In the event of an inconsistency or conflict between the information in this bulletin and the posted policy, the provisions of the posted policy prevail.

UnitedHealthcare Medical Policy, Medical Benefit Drug Policy and Coverage Determination Guideline Updates

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Unless otherwise noted, the following reimbursement policies apply to services reported using the 1500 Health Insurance Claim Form (CMS-1500) or its electronic equivalent or its successor form. UnitedHealthcare reimbursement policies do not address all factors that affect reimbursement for services rendered to UnitedHealthcare members, including legislative mandates, member benefit coverage documents, UnitedHealthcare medical or drug policies, and the UnitedHealthcare Care 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 UHCprovider.com > Menu > Policies and Protocols > Commercial Policies > Reimbursement Policies for Commercial Plans. In the event of an inconsistency between the information provided in the Network Bulletin and the posted policy, the posted policy prevails.

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Addition to the Drug Testing Policy

This article was updated on Oct. 3, 2017.

Effective for claims with dates of service on or after Jan.1, 2018, there will be an addition to the Drug Testing Policy that will apply an annual limit for presumptive and definitive drug tests. The policy will apply a frequency limitation of 18 dates of service for presumptive drug tests (80305, 80306, 80307) and 18 dates of service for definitive drug tests (G0480, G0481, G0482, G0483, G0659) submitted by the same or different provider. The revision will apply to UnitedHealthcare Commercial members.

Drug testing services that are determined to be court ordered and/or funded by a county, state or federal agency will continue to be denied. For additional information, refer to the Services and Modifiers Not Reimbursable to Healthcare Professionals Policy.



UnitedHealthcare Community Plan

UnitedHealthcare Community Plan Launches a Dual Special Needs Program — UnitedHealthcare Dual Complete

Effective Jan. 1, 2018, UnitedHealthcare Community Plan will begin to serve eligible members in a new Dual Special Needs Plan (DSNP) — UnitedHealthcare Dual Complete, a Medicare Advantage plan — in the following seven states and counties:

• Iowa – Dallas, Jasper, Madison, Marshall, Polk, Story, Warren

• Michigan – Berrien, Branch, Gratiot, Hillsdale, Tuscola,Washtenaw

• Missouri – Boone, Buchanan, Callaway, Cass, Christian,Clay, Crawford, Dade, Dallas, DeKalb, Franklin, Gasconade,Greene, Jackson, Jasper, Jefferson, Johnson, Laclede, Lafayette,Lawrence, Lincoln, Miller, Newton, Osage, Platte, Polk, Ray, St.Charles, St. Francois, St. Louis, St. Louis City, Ste. Genevieve,Stone, Taney, Warren, Washington, Webster, Wright.

• Nebraska – Cass, Douglas, Lancaster, Sarpy

• North Carolina – statewide

• Oklahoma – Canadian, Cleveland, Kingfisher, Lincoln, Logan,McClain, Oklahoma, Pottawatomie

• Virginia – statewide

This is a Medicare Advantage plan for members who qualify for both Medicare and Medicaid. DSNPs are a specialized type of Medicare Advantage Prescription Drug Plan (MAPD) and must follow existing Centers for Medicare & Medicaid Services (CMS) rules. DSNPs must:

• Adhere to required MAPD benefits

• Limit enrollment to Medicaid recipients (dually eligible –Medicare and Medicaid),

• Provide Part D benefits, and

• Offer targeted clinical programs, benefits, and services.

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UnitedHealthcare Community Plan Launches a Dual Special Needs Program — UnitedHealthcare Dual Complete

The UnitedHealthcare Dual Complete program will reimburse claims, according to your UnitedHealthcare contractual Medicare Advantage payment appendix. UnitedHealthcare Community Plan will communicate more details about the program in the coming weeks. Please visit UHCCommunityPlan.com > For Health Care Professionals > Select your state > Dual Complete Program.

For more information about this program, please contact your network account manager or advocate.

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Reminder on Prior Authorization Requirements for Medical Injectable Drugs

For injectable medications that require prior authorization, all Healthcare Common Procedure Coding System (HCPCS) and CPT codes related to the drug require prior authorization, even when unclassified codes (J3490, J3590, or C9399) or temporary C-Codes need to be used. Current injectable medications that require prior authorization and may be billed with an unclassified code or C-code include, but are not limited to, Exondys 51TM, SpinrazaTM, OcrevusTM, and Radicava™. Correct coding rules dictate that assigned and permanent codes should be used instead of unclassified and temporary codes when available.

Beginning Jan.1, 2018, we’ll include applicable C-Codes on our Notification/Prior Authorization Requirement lists and in our medical benefit drug policies. C-codes for injectable medications that currently require prior authorization include:

• Exondys 51 – C9484

• Radicava – C9493

• Ocrevus – C9494

• Spinraza – C9489

• Unclassified Code – C9399

If you have questions, contact Provider Services at the number on the back of the member’s ID card.

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Beginning Jan. 1, 2018, UnitedHealthcare Community Plan will require prior authorization for the following codes for hydoxyprogesterone caproate (Makena):

• Q9985

• Q9986

This requirement applies to members who are new to therapy and members currently on the medication. Hydroxyprogesterone caproate (using either J1725 or J2675) has required prior authorization for some time. The prior authorization requirement is being extended to include the new Q codes.

Prior authorization for codes noted above will be required in these states:

• Arizona

• California

• Hawaii

• Iowa

• Maryland

• Michigan

• Nebraska

• New Jersey

The prior authorization requirement for this medication does not apply to UnitedHealthcare Dual Complete® plans.

If the prior authorization process is not completed prior to the administration of this medication, your claim will be denied. Care providers can’t bill members for services that are denied due to failure to complete the prior authorization process.

You can request prior authorization two ways:

• Visit UHCprovider.com/priorauth.

• Complete a prior authorization form and fax it with the necessary medical records to the fax number at the top of the priorauthorization form. Forms are available at UHCCommunityPlan.com > For Health Care Professionals > Select yourstate > Provider Forms.

If you have any questions, please call the Provider Services number on the back of the patient’s member ID card.

Prior Authorization Medication Requirement

Next Article >

• New Mexico

• New York

• Pennsylvania

• Rhode Island

• Tennessee

• Texas

• Virginia

• Washington




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• Prior authorization requirements for certain specialty medications are expanding to include UnitedHealthcareCommunity Plan members in Hawaii.

• Brineura™ will be added to the list of specialty medications that require prior authorization forUnitedHealthcare Community Plan members in all states where Brineura is covered under the medical benefit.

We’re making some updates to our coverage review requirements for specialty medications for UnitedHealthcare Community Plan members. We require prior authorization for certain medications covered under the medical benefit because it’s important to us to provide our members access to services that are medically appropriate.

These requirements apply whether patients are new to therapy or have already been receiving the medication. They don’t apply to UnitedHealthcare Dual Complete® plans.

Coverage of specialty medications is also dependent on state Medicaid program decisions. Certain state Medicaid programs may choose to cover a drug through the state’s fee-for-service program and not the managed care organizations such as UnitedHealthcare, or they may provide other coverage guidelines and protocols. We encourage you to verify benefits before submitting the prior authorization request or administering the medication.

It’s important for care providers to understand these requirements. If you administer any of these medications without first completing the prior authorization process, the claim may be denied. Members can’t be billed for services denied due to failure to complete the prior authorization process.

What’s New for UnitedHealthcare Community Plan Members in HawaiiFor dates of service on or after Jan. 1, 2018, we’re expanding prior authorization requirements for the following medications to include UnitedHealthcare Community Plan members in Hawaii:

• Soliris® (eculizumab)

• Radicava™ (edaravone)

• Brineura (cerliponase alfa)

• Lemtrada (alemtuzumab)

• Ocrevus (ocrelizumab)

• Probuphine (buprenorphine)

• Nucala (mepolizumab)

• Cinqair (reslizumab)

• Exondys 51 (eteplirsen)

• Spinraza (nusinersen)

• Acthar gel (repository corticotropin injection)

Updates to Prior Authorization Requirements for Specialty Medications for UnitedHealthcare Community Plan Members – Effective Jan. 1, 2018

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Updates to Prior Authorization Requirements for Specialty Medications for UnitedHealthcare Community Plan Members – Effective Jan. 1, 2018

• Immune Globulins – IVIG and SCIG (Intravenous Immunoglobulin and Subcutaneousimmunoglobulin)

• Botulinum Toxins (Botox, Dysport, Myobloc, Xeomin)

• Cerezyme (imiglucerase)

• Elelyso (taliglucerase alfa)

These requirements are already in place in other states where specialty medications are covered under the medical benefit for Medicaid members.

New for All States: Prior Authorization Requirement for BrineuraWe’re also adding Brineura to the list of medications that require prior authorization for UnitedHealthcare Community Plan members in all states where Brineura is covered under the medical benefit. The United States Food and Drug Administration (FDA) recently approved Brineura for the treatment of late infantile neuronal ceroid lipofuscinosis type 2 (CLN2).

The Prior Authorization Process for Specialty MedicationsAll HCPCS and CPT codes related to these drugs will require prior authorization, regardless of place of service. Clinical coverage reviews conducted as part of our prior authorization process will evaluate whether the drug is appropriate for the individual member, taking into account:

• Our drug coverage policy

• Applicable state Medicaid guidelines

• The member’s treatment history

• Dosage recommendation from FDA-approved labeling

Additional criteria also may be considered. We encourage you to submit any information you would like us to review as part of your prior authorization request. When a coverage determination is made, we’ll inform you and the member of the coverage determination. If an adverse determination is made, we’ll provide you appeal information.

Submitting Prior Authorization RequestsTo request prior authorization for these medications, please use one of the following methods:

• Go to UHCprovider.com/priorauth.

• Call the Provider Services phone number on the back of the member’s health careidentification card.

• Send your request by fax. Access forms at UHCCommunityPlan.com >For Health Care Professionals > Select your state > Provider Forms

When Making ReferralsIf you’re referring one of our members to other care providers for these medications, we encourage you to refer to in-network care providers.

If you have any questions, please call the Provider Service number on the back of the member’s ID card.

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TABLE OF CONTENTS

UnitedHealthcare Community Plan Medical Policy, Medical Benefit Drug Policy and Coverage Determination Guideline Updates

For complete details on the policy updates listed in the following table, please refer to the September 2017 Medical Policy Update Bulletin at UHCprovider.com > Menu > Policies and Protocols > Community Plan Policies > Medical & Drug Policies and Coverage Determination Guidelines > Medical Policy Update Bulletins.


NEW

Brineura™ (Cerliponase Alfa) Drug Nov. 1, 2017

Laser Interstitial Thermal Therapy Medical Oct. 1, 2017

Lemtrada (Alemtuzumab) Drug Oct. 1, 2017

Pharmacogenetic Testing Medical Dec. 1, 2017

Soliris® (Eculizumab) Drug Oct. 1, 2017

Spinraza™ (Nusinersen) (for Pennsylvania Only) Drug Oct. 1, 2017

Whole Exome and Whole Genome Sequencing Medical Dec. 1, 2017

UPDATED/REVISED

17-Alpha-Hydroxyprogesterone Caproate (Makena™ and 17P) Drug Nov. 1, 2017

Abnormal Uterine Bleeding and Uterine Fibroids Medical Nov. 1, 2017

Apheresis Medical Oct. 1, 2017

Benlysta® (Belimumab) Drug Nov. 1, 2017

Chemosensitivity and Chemoresistance Assays in Cancer Medical Oct. 1, 2017

Chromosome Microarray Testing Medical Oct. 1, 2017

Computed Tomographic Colonography Medical Sept. 1, 2017

Core Decompression for Avascular Necrosis Medical Sept. 1, 2017

Denied Drug Codes – Pharmacy Benefit Drugs Policy Drug Nov. 1, 2017

Durable Medical Equipment, Orthotics, Ostomy Supplies, Medical Supplies and Repairs/Replacements CDG Oct. 1, 2017

Emergency Health Services and Urgent Care Center Services (Maryland Only) CDG Nov. 1, 2017

Epidural Steroid and Facet Injections for Spinal Pain Medical Oct. 1, 2017

Fetal Aneuploidy Testing Using Cell-Free Fetal Nucleic Acids in Maternal Blood Medical Nov. 1, 2017

Functional Endoscopic Sinus Surgery (FESS) Medical Oct. 1, 2017

Gender Dysphoria Treatment Medical Oct. 1, 2017

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TABLE OF CONTENTS

UnitedHealthcare Community Plan Medical Policy, Medical Benefit Drug Policy and Coverage Determination Guideline Updates


Genetic Testing for Hereditary Cancer Medical Nov. 1, 2017

Hepatitis Screening Medical Oct. 1, 2017

High Frequency Chest Wall Compression Devices Medical Sept. 1, 2017

Home Health Care CDG Oct. 1, 2017

Immune Globulin (IVIG and SCIG) Drug Oct. 1, 2017

Infliximab (Remicade®, Inflectra™, Renflexis™) Drug Oct. 1, 2017

Intravenous Enzyme Replacement Therapy (ERT) for Gaucher Disease Drug Sept. 1, 2017

Lithotripsy for Salivary Stones Medical Sept. 1, 2017

Maximum Dosage Drug Nov. 1, 2017

Nerve Graft to Restore Erectile Function During Radical Prostatectomy Medical Sept. 1, 2017

Neuropsychological Testing Under the Medical Benefit Medical Oct. 1, 2017

Ocrevus™ (Ocrelizumab) Drug Nov. 1, 2017

Omnibus Codes Medical Oct. 1, 2017

Ophthalmologic Policy: Vascular Endothelial Growth Factor (VEGF) Inhibitors Drug Oct. 1, 2017

Osteochondral Grafting Medical Oct. 1, 2017

Panniculectomy and Body Contouring Procedures CDG Nov. 1, 2017

Plagiocephaly and Craniosynostosis Treatment Medical Sept. 1, 2017

Prosthetic Devices, Specialized, Microprocessor or Myoelectric Limbs CDG Oct. 1, 2017

Repository Corticotropin Injection (H.P. Acthar Gel®) Drug Oct. 1, 2017

Rituxan® (Rituximab) Drug Nov. 1, 2017

Sandostatin®/Sandostatin LAR® Depot (Octreotide Acetate) Drug Oct. 1, 2017

Skilled Care and Custodial Care Services CDG Oct. 1, 2017

Sodium Hyaluronate Medical Nov. 1, 2017

Stelara® (Ustekinumab) Drug Nov. 1, 2017

Synagis® (Palivizumab) Drug Oct. 1, 2017

Transcatheter Heart Valve Procedures Medical Nov. 1, 2017

Unicondylar Spacer Devices for Treatment of Pain or Disability Medical Sept. 1, 2017

Vimizim® (Elosulfase Alfa) Drug Sept. 1, 2017


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UnitedHealthcare Medicare Solutions

UnitedHealthcare Medicare Advantage Coverage Summary Updates

For complete details on the policy updates listed in the following table, please refer to the September 2017 Medicare Advantage Coverage Summary Update Bulletin at UHCprovider.com > Menu > Policies and Protocols > Medicare Advantage Policies > Coverage Summaries > Coverage Summary Update Bulletins.

Policy Title

UPDATED/REVISED (Approved on Aug. 15, 2017)

Cochleostomy with Neurovascular Transplant for Meniere’s Disease

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

Educational Programs

Experimental Procedures and Items, Investigational Devices and Clinical Trials

Home Health Services and Home Health Visits

Hospital Services (Inpatient and Outpatient)

Impotence Treatment

Infertility Services

Mobility Assistive Equipment (MAE)

Observation Care (Outpatient Hospital)

Radiologic Therapeutic Procedures

Rehabilitation: Medical Rehabilitation (OT, PT and ST, including Cognitive Rehabilitation)

Vision Services, Therapy and Rehabilitation


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The following UnitedHealthcare Medicare Advantage Policy Guidelines have been updated to reflect the most current clinical coverage rules and guidelines developed by the Centers for Medicare & Medicaid Services (CMS). The updated policies are available for your reference at UHCprovider.com > Menu > Policies and Protocols > Medicare Advantage Policies > UnitedHealthcare Medicare Advantage Policy Guidelines.

Policy Title

UPDATED/REVISED (Approved on Aug. 9, 2017)

Anterior Segment Aqueous Drainage Device

Artificial Hearts and Related Devices (NCD 20.9)

Blood Platelet Transfusions (NCD 110.8)

Blood Transfusions (NCD 110.7)

Clinical Diagnostic Laboratory Services

Corneal Topography

Electrical Nerve Stimulators (NCD 160.7)

Electrosleep Therapy (NCD 30.4)

Excision of Rectal Tumor

Extracorporeal Immunoadsorption (ECI) Using Protein A Columns (NCD 20.5)

Heart Transplants (NCD 260.9)

High Dose Rate Electronic Brachytherapy

Institutional and Home Care Patient Education Programs (NCD 170.1)

Intensive Behavioral Therapy for Cardiovascular Disease (NCD 210.11)

Intrapulmonary Percussive Ventilator (IPV) (NCD 240.5)

Jetrea® (Ocriplasmin)

Lung Volume Reduction Surgery (Reduction Pneumoplasty) (NCD 240.1)

Neuromuscular Electrical Stimulation (NMES) (NCD 160.12)

Osteopathic Manipulations (OMT)

Pediatric Liver Transplantation (NCD 260.2)

Percutaneous Image-Guided Lumbar Decompression for Lumbar Spinal Stenosis (NCD 150.13)

Phaco-Emulsification Procedure – Cataract Extraction (NCD 80.10)

Scalp Hypothermia During Chemotherapy to Prevent Hair Loss (NCD 110.6)

UnitedHealthcare Medicare Advantage Policy Guideline Updates

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UnitedHealthcare Medicare Advantage Policy Guideline Updates

Policy Title

Screening for Depression in Adults (NCD 210.9)

Supplies Used in the Delivery of Transcutaneous Electrical Nerve Stimulation (TENS) and Neuromuscular Electrical Stimulation (NMES) (NCD 160.13)

Transcutaneous Electrical Nerve Stimulation (TENS) for Acute Post-Operative Pain (NCD 10.2)

Tumor Treatment Field Therapy

Vertebral Augmentation Procedure (VAP)/Percutaneous Vertebroplasty

Zoledronic Acid (Zometa® & Reclast®)

RETIRED (Approved on Aug. 9, 2017)

Radiofrequency Treatment for Urinary Incontinence


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Doing Business Better

HEDIS Season Is Almost Here: How You Can Help Us Collect Medical Records

Each year UnitedHealthcare collects Health Effectiveness Data and Information Set (HEDIS) information from participating care providers to help support the care you provide to UnitedHealthcare members. By working together, we can help members manage existing medical conditions and be more engaged with their preventive health.

Beginning in January 2018, we may contact you to request member-specific medical records. These members may belong to any UnitedHealthcare health plan. We know this process can be time-consuming so we’ve developed some tips to help make the record collection process go smoothly:

HEDIS Collection Tips• Submit accurate and timely claims for every office visit.

• Be specific on diagnosis coding and always use the mostappropriate diagnosis code available.

• Submit diagnosis codes that address the patient’sdocumented history. These codes should be documented fornew patients on the initial visit claim.

• Document all care and all services billed in the patient’smedical record.

• If your office is contacted for a medical records request,please respond within five business days.

• Review the following resources listed for more specificinformation on the HEDIS measures.

To view the PATH Adult, Pediatric and Women’s Health Reference Guides, please visit UHCprovider.com/path.

For more information on National Committee for Quality Assurance (NCQA) HEDIS technical specifications, go to ncqa.org > HEDIS & Quality Measurement.

Thank you for collaborating with us on this important initiative. If you have questions or concerns about HEDIS, please contact your UnitedHealthcare representative.

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Doing Business Better



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Hospital Data Exchange for Improved Transitional Care and Readmission Reduction

Timely and efficient post-discharge transitional care plays a critical role in keeping our members healthy after an inpatient or emergency event. When you share Admission/Discharge/Transfer (ADT) and discharge summary data with UnitedHealthcare, you can help facilitate improved transitional care workflows, prevent unnecessary readmissions for your patients and avoid costly readmission penalties for your facility.

In 2017, the National Committee for Quality Assurance (NCQA) introduced three new HEDIS measures aimed at improving coordination of care before and after a hospital visit occurs:

• Hospitalizations for Potentially Preventable Conditions (HPC) – For members age 67 and older, defined as therate of discharges for an ambulatory care sensitive condition (ACSC) per 1,000 members and takes into account therisk-adjusted ratio of observed to expected discharges for an ACSC by condition. ACSC diagnoses include acuteconditions such as bacterial pneumonia, UTI, cellulitis and pressure ulcers, as well as chronic conditions such as diabetes,COPD, asthma, hypertension and heart failure.

• Medication Reconciliation Post-Discharge (MRP) – Requires UnitedHealthcare, a care provider and/or pharmacistto review the medications prescribed to a patient during an inpatient event and compare them with the medications takenbefore admission. This review must take place within 30 days of discharge for members age 18 and older and can helpimprove adherence to the patient’s post-discharge treatment plan and lower the risk for adverse interactions that mayresult in readmission.

• Plan All-Cause Readmissions (PCR) – For members age 65 and older, reflects the number of acute inpatient staysfollowed by an unplanned, acute readmission for any diagnosis within 30 days.

UnitedHealthcare has implemented new programs in partnership with the care provider community that focus on data-sharing to drive timely and comprehensive follow-up post-discharge. It’s important for our hospital partners to share ADT notifications and discharge summaries with UnitedHealthcare when one of our members visits the hospital. ADT notifications and discharge summaries are standard message types used regularly in communication between Electronic Health Records (EHRs). Our technical team will facilitate an implementation discussion to help determine the easiest way to share this data from an EHR and will provide the necessary support to enable connectivity. As a next step, please email [email protected] to engage a technical resource. If we do not receive the necessary information within three days of discharge, one of our clinical or non-clinical staff will contact you to obtain it.

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mailto:%20clinical_transformation%40uhc.com?subject=



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UnitedHealthcare Affiliates

SignatureValue/UnitedHealthcare Benefits Plan of California Benefit Interpretation Policy Updates

For complete details on the policy updates listed in the following table, please refer to the September 2017 SignatureValue/UnitedHealthcare Benefits Plan of California Benefit Interpretation Policy Update Bulletin at UHCprovider.com > Menu > Policies and Protocols > Commercial Policies > UnitedHealthcare SignatureValue/UnitedHealthcare Benefits Plan of California Benefit Interpretation Policies > Benefit Interpretation Policy Update Bulletins.

Policy Title

REVISED (Effective Oct. 1, 2017)

Ambulance Transportation

Developmental Delay and Learning Disabilities

Preventive Care Services

Transplantation Services


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TABLE OF CONTENTS

April

For complete details on the policy updates listed in the following table, please refer to the September 2017 Policy Update Bulletin at OxfordHealth.com > Providers > Tools & Resources > Medical Information > Medical and Administrative Policies > Policy Update Bulletin.


NEW

Advanced Practice Provider Evaluation and Management Procedures Reimbursement Oct. 1, 2017

Carrier Testing for Genetic Diseases Clinical Nov. 1, 2017

Drug Testing Reimbursement Oct. 1, 2017

Follow-Up Care Rendered in an Emergency Room Site of Service Administrative Nov. 1, 2017

Laser Interstitial Thermal Therapy Clinical Oct. 1, 2017

Molecular Oncology Testing for Cancer Diagnosis, Prognosis, and Treatment Decisions Clinical Nov. 1, 2017

Multiple Procedure Payment Reduction (MPPR) for Diagnostic Cardiovascular and Ophthalmology Procedures Reimbursement Nov. 1, 2017

Pharmacogenetic Testing Clinical Nov. 1, 2017

Whole Exome and Whole Genome Sequencing Clinical Nov. 1, 2017

UPDATED/REVISED

Abortions (Therapeutic and Elective) Administrative Oct. 1, 2017

Anemia Drugs: Darbepoetin Alfa, Epoetin Alfa, and Methoxy Polyethylene Glycol-Epoetin Beta Clinical Oct. 1, 2017

Apheresis Clinical Oct. 1, 2017

Assignment of Benefits & Balance Billing Administrative Oct. 1, 2017

Autism Administrative Oct. 1, 2017

Behavioral Health Services Administrative Oct. 1, 2017

Chemosensitivity and Chemoresistance Assays in Cancer Clinical Oct. 1, 2017

Chromosome Microarray Testing Clinical Oct. 1, 2017

Cytological Examination of Breast Fluids for Cancer Screening Clinical Sept. 1, 2017

Discogenic Pain Treatment Clinical Sept. 1, 2017

Oxford® Medical and Administrative Policy Updates

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TABLE OF CONTENTS



Drug Coverage Criteria - New and Therapeutic Equivalent Medications Clinical Oct. 1, 2017

Drug Coverage Guidelines ClinicalAug. 9, 2017

Oct. 1, 2017

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

Administrative Oct. 1, 2017

Electrical Bioimpedance for Cardiac Output Measurement Clinical Sept. 1, 2017

Epidural Steroid and Facet Injections for Spinal Pain Clinical Oct. 1, 2017

Functional Endoscopic Sinus Surgery (FESS) Clinical Oct. 1, 2017

Gender Dysphoria Treatment Clinical Oct. 1, 2017

Gene Expression Tests for Cardiac Indications Clinical Nov. 1, 2017

Genetic Testing for Hereditary Cancer Clinical Nov. 1, 2017

Home Health Care Clinical Oct. 1, 2017

Immune Globulin (IVIG and SCIG) Clinical Oct. 1, 2017

Intravenous Enzyme Replacement Therapy (ERT) for Gaucher Disease Clinical Sept. 1, 2017

Magnetic Resonance Spectroscopy (MRS) Clinical Sept. 1, 2017

Neuropsychological Testing Under the Medical Benefit Clinical Oct. 1, 2017

Occipital Neuralgia and Headache Treatment Clinical Sept. 1, 2017

Office Based Program Clinical Oct. 1, 2017

Omnibus Codes Clinical Oct. 1, 2017

Orthopedic Services Administrative Oct. 1, 2017

Osteochondral Grafting Clinical Oct. 1, 2017

Prosthetic Devices, Wigs, Specialized, Microprocessor or Myoelectric Limbs Administrative Oct. 1, 2017

Routine Foot Care Clinical Oct. 1, 2017

Sandostatin LAR® Depot (Octreotide Acetate) Clinical Oct. 1, 2017

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Skilled Care and Custodial Care Services Administrative Oct. 1, 2017

Synagis® (Palivizumab) Clinical Oct. 1, 2017

Total Artificial Heart Clinical Sept. 1, 2017

Urgent Care Reimbursement Dec. 1, 2017

Vision Services (Including Refractive Surgery) Administrative Oct. 1, 2017

REPLACED

Genetic Testing Clinical Nov. 1, 2017

Molecular Profiling to Guide Cancer Treatment Clinical Nov. 1, 2017

Refractive Surgeries Clinical Oct. 1, 2017

Note: The inclusion of a health service (e.g., test, drug, device or procedure) on this list does not imply that Oxford provides coverage for the health service. In the event of an inconsistency or conflict between the information in this bulletin and the posted policy, the provisions of the posted policy prevail.

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

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TABLE OF CONTENTS

April

For complete details on the policy updates listed in the following table, please refer to the September 2017 SignatureValue/UnitedHealthcare Benefits Plan of California Medical Management Guidelines Update Bulletin at UHCprovider.com > Menu > Policies and Protocols > Commercial Policies > UnitedHealthcare SignatureValue/ UnitedHealthcare Benefits Plan of California Medical Management Guidelines > Medical Management Guideline Update Bulletins.

Policy Title Effective Date

NEW

Carrier Testing for Genetic Diseases Nov. 1, 2017

Laser Interstitial Thermal Therapy Oct. 1, 2017

Molecular Oncology Testing for Cancer Diagnosis, Prognosis, and Treatment Decisions Nov. 1, 2017

Pharmacogenetic Testing Nov. 1, 2017

Whole Exome and Whole Genome Sequencing Nov. 1, 2017

UPDATED/REVISED

Abnormal Uterine Bleeding and Uterine Fibroids Nov. 1, 2017

Apheresis Oct. 1, 2017

Chromosome Microarray Testing Oct. 1, 2017

Computed Tomographic Colonography Sept. 1, 2017

Core Decompression for Avascular Necrosis Sept. 1, 2017

Epidural Steroid and Facet Injections for Spinal Pain Oct. 1, 2017

Fetal Aneuploidy Testing Using Cell-Free Fetal Nucleic Acids in Maternal Blood Oct. 1, 2017

Functional Endoscopic Sinus Surgery (FESS) Oct. 1, 2017

Gender Dysphoria Treatment Excluding California Oct. 1, 2017

Gene Expression Tests for Cardiac Indications Nov. 1, 2017

Genetic Testing for Hereditary Cancer Nov. 1, 2017

Hepatitis Screening Oct. 1, 2017

High Frequency Chest Wall Compression Devices Oct. 1, 2017

Lithotripsy for Salivary Stones Sept. 1, 2017

Nerve Graft to Restore Erectile Function During Radical Prostatectomy Sept. 1, 2017

Omnibus Codes Oct. 1, 2017

SignatureValue/UnitedHealthcare Benefits Plan of California Medical Management Guideline Updates

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TABLE OF CONTENTS

SignatureValue/UnitedHealthcare Benefits Plan of California Medical Management Guideline Updates

Policy Title Effective Date

Panniculectomy and Body Contouring Procedures Nov. 1, 2017

Plagiocephaly and Craniosynostosis Treatment Sept. 1, 2017

Sodium Hyaluronate Oct. 1, 2017

Transcatheter Heart Valve Procedures Nov. 1, 2017

Unicondylar Spacer Devices for Treatment of Pain or Disability Sept. 1, 2017

REPLACED

Genetic Testing Nov. 1, 2017

Molecular Profiling to Guide Cancer Treatment Nov. 1, 2017


Network Bulletin: November 2013 - Volume 584444 Network Bulletin: October 2017

Doc#: PCA-1-007871-09082017_09202017

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

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October 2017 Network Bulletin - UnitedHealthcare Online · PDF file3 Network Bulletin: November 2013 - Volume 58 3 For more information, call 877.842.3210 or visit UnitedHealthcareOnline.com

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