network bulletin: september 2016 network bulletin network bulletin: november 2013 - volume 58 table...
TRANSCRIPT
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: September 2016
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Network Bulletin: November 2013 - Volume 582
Table of Contents
For more information, call 877.842.3210 or visit UnitedHealthcareOnline.com
2 Network Bulletin: September 2016
Front & Center
• Communication Effectiveness Survey
• New and Updated Link Applications
• Tune in to UHC On Air
• Termination of the ICD-10 Code Look-up Tool
• Tell Us About Your Service Experience
• Cardiology Program Procedure CodeUpdate – Effective Oct. 1, 2016
• Changes in Call Reference Number Procedures
• Changes in Advance Notification andPrior Authorization Requirements
• Prior Authorization Requirement for CertainSurgical Procedures Expanding to IncludeUnitedHealthcare Community Plan membersin Delaware and Additional Procedures –Effective Oct. 1, 2016 in Most States
UnitedHealthcare Commercial
• UnitedHealthcare Compass Network toWelcome Harken Health Members in 2017
• A Reminder about the Neighborhood HealthPartnership Prior Authorization Policy
• UnitedHealthcare Medical Policy, Drug Policy andCoverage Determination Guideline Updates
UnitedHealthcare Commercial Reimbursement Policies
• Policy Revision to Nonphysician HealthCare Professionals Billing Evaluationand Management Codes
UnitedHealthcare Community Plan
• Outpatient Injectable Chemotherapy PriorAuthorization Program for UnitedHealthcareCommunity Plan in Ohio, Michigan,Mississippi and Wisconsin
• UnitedHealthcare Medical Policy & CoverageDetermination Guideline Updates
UnitedHealthcare Medicare Solutions
• Transitional Care Management and MedicationReconciliation Post-Discharge — Complete to MeetQuality Standards and Improve Patient Health
• Medication Reconciliation Post-Discharge forFacilities — Support Closing This Open CareOpportunity to Help Prevent Readmissions
• Revision to Reimbursement Policy —Durable Medical Equipment Chargesin a Skilled Nursing Facility
• Policy Reminder on NonphysicianHealth Care Professionals BillingEvaluation and Management Codes
• Correct Reporting of Modifiers onIpsilateral Organs or Structures
• New Policy–Patient DischargeStatus for Type of Bill
• National Medicare Education Week: Helpingto Make Medicare Easier to Understand
• UnitedHealthcare Medicare AdvantageCoverage Summary Updates
• 2017 Medicare Advantage Service Area Reductions
UnitedHealthcare Military & Veterans
• Avoid Delays by Using the LatestCare Request Form
Doing Business Better
• Online Preventive Health Program Availablefor Information on Depression, Alcohol andDrug Abuse/Addiction and ADHD
• Evidenced-Based Clinical Practice Guidelines
• Reminder on Case and DiseaseManagement Programs
UnitedHealthcare Affiliates
• Oxford® Medical and Administrative Policy Updates
• SignatureValue/UnitedHealthcare Benefits Plan ofCalifornia Benefit Interpretation 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: September 2016
Communication Effectiveness Survey
Front & Center
TABLE OF CONTENTS
We understand the volume of communications you receive from payers on a wide variety of topics and want to do whatever we can to streamline those you receive from UnitedHealthcare as well as improve those we do send. Please take a few moments to answer our brief three-question survey so we can continue to improve our communications to you.
The survey is available online at uhcresearch.az1.qualtrics.com/jfe/form/SV_a2TkHLsEbvfxGgB. Thank you!
Network Bulletin: November 2013 - Volume 5844 For more information, call 877.842.3210
or visit UnitedHealthcareOnline.comNetwork Bulletin: September 2016
TABLE OF CONTENTS
We are introducing new and updated applications on Link – your gateway to UnitedHealthcare’s online tools and resources. The following chart shows an overview of these applications.
Application Description Availability
Prior Authorization and Notification
New standalone application with prior authorization and notification functionality identical to what is available on the Eligibility & Benefits application
Available now; anyone who previously used prior authorization/notification functionality in UnitedHealthcareOnline.com or Link has access.
eligibilityLinkNew applications that will offer enhanced features not available on the current Link applications, as well as a redesigned user interface that is faster and easier to use
In phases; all UnitedHealthcareOnline.com users will have access to the new applications by the end of this year.
claimsLink
My Practice Profile (formerly Provider Data Management)
Updated application that will enable you to view and update your care provider demographic and practice data online. You can also use My Practice Profile to complete your required quarterly attestation to the accuracy of your demographic information.
All Link users currently have the application on their dashboard and can use it to submit Disclosure of Ownership and Management forms for Medicaid.Additional functionality will be rolled out in phases through next year.
Prior Authorization and Notification Based on feedback from care providers, prior authorization and notification functionality is now available in its own application. Identical functionality will continue to be available on the Eligibility & Benefits application.
Everyone who used notification/prior authorization functionality on UnitedHealthcareOnline.com or Link has access to the Prior Authorization and Notification application on their Link dashboard; you may need to scroll to the bottom of your screen to see the application. If you need access to the application, please ask your organization’s ID administrator to update your role through the User ID & Password Management application on Link.
Front & Center
New and Updated Link Applications
Next Article >
Front & Center
Network Bulletin: November 2013 - Volume 5855 For more information, call 877.842.3210
or visit UnitedHealthcareOnline.comNetwork Bulletin: September 2016
TABLE OF CONTENTS
eligibilityLink and claimsLink The new eligibilityLink and claimsLink applications will help make it faster and easier to perform online transactions using Link.
eligibilityLink has features you already use on the Eligibility & Benefits application, plus:
• Start your inquiry from the Link dashboard without opening the application
• Redesigned screens based on feedback from Link users
• View previous plans – up to 18 months in the past
claimsLink combines many features of the Claims Management and Claims Reconsideration applications, plus:
• Redesigned screens based on feedback from Link users
• Switch to eligibilityLink without re-entering the member information
• Create a new claim reconsideration request or view an existing one from the claim detail screen
• Create your own claim view by selecting which information is displayed
These new applications will not launch to all UnitedHealthcareOnline.com users at the same time; when they are available to you, we will email you with more details and information about webinar training sessions. When you have access to the new applications, you will see a pop-up box inviting you to try the new Link applications if you use Eligibility & Benefits, Claim Status or Claim Reconsideration functions on UnitedHealthcareOnline.com. After you have tried eligibilityLink or claimsLink twice, another pop-up box will invite you to make the new Link application your permanent view – which would make it the tool you use for all related transactions and you will no longer have access to the corresponding UnitedHealthcareOnline.com functions.
The Eligibility & Benefits, Claims Management and Claims Reconsideration applications on Link will continue to be available into 2017, along with the new eligibilityLink and claimsLink applications. More new features are in progress, and we will continue to make improvements based on the feedback we receive from users.
New and Updated Link Applications
Next Article >
Front & Center
Network Bulletin: November 2013 - Volume 5866 For more information, call 877.842.3210
or visit UnitedHealthcareOnline.comNetwork Bulletin: September 2016
TABLE OF CONTENTS
My Practice Profile The updated My Practice Profile application (formerly called Provider Data Management) will allow you to view and update* the care provider demographic data that UnitedHealthcare has for your practice, including:
• Office addresses, hours and locations
• Languages spoken
• Phone, fax and website information
• Ages and genders served
• And more
You can also use My Practice Profile to complete your required quarterly attestation to the accuracy of your demographic information. For a reminder about attestation requirements, please review page 96 of the 2016 Administrative Guide.
Users will receive new features in the My Practice Profile application* in phases starting this month. You will receive an email notification when the upgraded application has been added to your dashboard.
To update the care provider or practice data displayed in My Practice Profile, your organization’s ID administrator must grant you submission/updating rights through the User ID & Password Management application on Link.
My Practice Profile is currently only available to individual care providers and practices. Future functionality will include the ability to upload roster files.
Learn MoreIf you’re new to Link, you can get more information about using it at UnitedHealthcareOnline.com > Quick Links > Learn More.
If you have questions, please call the UnitedHealthcare Connectivity Help Desk at 866-842-3278, option 3, 7 a.m. – 9 p.m. Central Time, Monday through Friday.
* Care providers who participate with UnitedHealthcare Community Plan of Hawaii should not use My Practice Profile to update demographic information. Instead, please call 888-980-8728 to make demographic updates.
New and Updated Link Applications
Next Article >
Front & Center
Network Bulletin: November 2013 - Volume 5877 For more information, call 877.842.3210
or visit UnitedHealthcareOnline.comNetwork Bulletin: September 2016
TABLE OF CONTENTS
Starting Sept. 12, we are introducing UHC On Air — your source for live and on-demand video broadcasts created specifically for UnitedHealthcare care providers. This innovative new tool features video broadcasts on topics relevant to you, including:
• National and local topics that affect how we do business together
• New UnitedHealthcare programs and quality initiatives
• Training for our online tools
• The latest updates on operational and clinical topics
• And much more
We’ve designed UHC On Air to deliver live broadcasts that give you the opportunity to interact with our speakers and ask questions. And on-demand programs are available for you to view at your convenience — 24 hours a day, from any device.
How to Access UHC On AirOn Sept. 12, Link users will be able to access UHC On Air by selecting the UHC On Air application tile on their Link dashboard. Please note that the application tile may be toward the bottom of your screen. After you select the application, you’ll be redirected to the UHC On Air tool. Explore the UHC News Now channel for national UnitedHealthcare information, or select your state-specific channel for local programming.
To access Link, sign in to UnitedHealthcareOnline.com using your Optum ID. If you aren’t registered for UnitedHealthcareOnline.com and Link, please go to UnitedHealthcareOnline.com and select New User in the top right corner.
Browser RequirementsUHC On Air may be accessed using the following Web browsers:
• Internet Explorer 9 and above (Internet Explorer 11 only starting October 2016)
• Firefox 45–47
• Chrome 41
• Safari 7 and above
If you use a different browser, you may have problems accessing UHC On Air. For security reasons, we recommend using the newest version of Adobe Flash Player. Pop-up blockers must be disabled and JavaScript should be enabled.
Tune in to UHC On Air
Front & Center
Network Bulletin: November 2013 - Volume 5888 For more information, call 877.842.3210
or visit UnitedHealthcareOnline.comNetwork Bulletin: September 2016
TABLE OF CONTENTS
Sept. 30, 2016 will be the last day of operation for the 10th revision of the International Classification of Diseases (ICD-10) Code Look-up Tool (CLT) made available by UnitedHealthcare. The CLT was developed in response to the U.S. Department of Health and Human Services Oct. 1, 2015 compliance date for health care providers, health plans and health care clearinghouses to transition to ICD-10. The CLT was designed to help care providers adopt ICD-10 during the transition period. Now, almost a year into the use of ICD-10, its functionality and its utility have diminished and does not justify the expense necessary to maintain the tool with the new ICD-10 codes that will take effect on Oct. 1, 2016.
UnitedHealthcare thanks care providers for their efforts in making the transition to ICD-10 a success and for the care you provide on behalf of our members.
Termination of the ICD-10 Code Look-up Tool
Front & Center
Network Bulletin: November 2013 - Volume 5899 For more information, call 877.842.3210
or visit UnitedHealthcareOnline.comNetwork Bulletin: September 2016
TABLE OF CONTENTS
Each year, we ask for your participation in our Physician and Practice Manager Satisfaction Study. The survey provides insights about your experiences working with us and gives us the information we need to identify what is working well and what may need improvement. We depend on care providers to help us identify opportunities to enhance our services. Last year’s provider feedback led to several enhancements in the services that matter most to you, including expansion of our Provider Advocate field teams to help be more responsive to your practice needs.
Survey invitations will be sent in September to a random sample of physicians and practice managers. If you receive an invitation to participate in this year’s study, we hope you will take a few minutes to complete the survey and share your experiences and perspectives. Your opinions are important to us. As an appreciation for your participation, you may choose to enter a drawing for one of five prizes. Thank you.
Tell Us About Your Service Experience
Front & Center
Network Bulletin: November 2013 - Volume 581010 For more information, call 877.842.3210
or visit UnitedHealthcareOnline.comNetwork Bulletin: September 2016
TABLE OF CONTENTS
Effective Oct. 1, 2016, UnitedHealthcare will update the procedure code list for Cardiology Notification/Prior Authorization programs.
Claims with dates of service on or after Oct.1, 2016 are subject to these changes. The following CPT code will be added to the Cardiology Notification and Prior Authorization list.
CPT Code Description
33270
Insertion or replacement of permanent subcutaneous implantable defibrillator system, with subcutaneous electrode, including defibrillation threshold evaluation, induction of arrhythmia, evaluation of sensing for arrhythmia termination, and programming or reprogramming of sensing or therapeutic parameters, when performed.
The full list of procedure codes requiring Notification or Prior Authorization in 2016 is available at UnitedHealthcareOnline.com > Clinician Resources > Cardiology. From this web page, select Cardiology Notification & Prior Authorization for Commercial plans; select Medicare Advantage Cardiology Prior Authorization Program for Medicare plans; or select UnitedHealthcare Community Plan Cardiology Prior Authorization Program for Medicaid plans. The same procedure code list is used for all UnitedHealthcare plans. The procedure code list is under the “Resources: Reference Materials” section.
Cardiology Program Procedure Code Update – Effective Oct. 1, 2016
Changes in Call Reference Number Procedures
Effective Aug. 1, UnitedHealthcare provider call representatives will no longer provide a 14-digit or 16-digit reference number. Call representatives will offer the last four digits of the reference number to help reduce administrative burden, streamline our processes, reduce defects and save time. If a callback is required, call representatives will be able to assist callers if the four-digit reference number is given along with the member’s ID. Issues can still be researched and escalated by using a member ID and the last four digits.
Front & Center
Network Bulletin: November 2013 - Volume 581111 For more information, call 877.842.3210
or visit UnitedHealthcareOnline.comNetwork Bulletin: September 2016
TABLE OF CONTENTS
Effective for dates of service on or after Oct. 1, 2016, the following procedure codes will no longer require prior authorization for several services in the Home Health Services category for Medicare Solutions (including UnitedHealthcare West, Care Improvement Plus, Preferred Care Partners, UnitedHealthcare Community Plan Medicare Advantage, and UnitedHealthcare Connected (MMP) Plans). Please refer to the Oct. 1, 2016 Advanced Notification & Prior Authorization Requirements at UnitedHealthcareOnline.com and UHCCommunityPlan.com.
Service Category CPT Codes
Home Health S9123 S9124 S9474 G0299 G0300 G0163 G0164
Effective for dates of service on or after Oct. 1, 2016, the following procedure codes will require prior authorization for UnitedHealthcare Community Plan in Louisiana.
Service Category CPT Codes
BRCA Testing 81162 81211 81212 81213 81214 81216 81217
The most up-to-date Advance Notification lists are available online:
• UnitedHealthcare Medicare Solutions – UnitedHealthcareOnline.com > Clinician Resources > Advance &Admission Notification
• UnitedHealthcare Community Plan – UHCCommunityPlan.com > For Health Care Professionals > Select your State.
Changes in Advance Notification and Prior Authorization Requirements
Front & Center
Network Bulletin: November 2013 - Volume 581212 For more information, call 877.842.3210
or visit UnitedHealthcareOnline.comNetwork Bulletin: September 2016
TABLE OF CONTENTS
As a reminder, we are expanding our prior authorization requirement for certain surgical procedures to be covered in an outpatient hospital setting to include additional procedures, effective Oct. 1, 2016 in most states as part of our shared commitment to the Triple Aim of better care, better health and lower costs for UnitedHealthcare members. On Oct. 1, 2016, we will also implement this requirement for UnitedHealthcare Community Plan in Delaware to include the full list of codes that are currently in scope for this requirement, as well as the additional procedures listed below.
When you request prior authorization for these procedures, we will work with you based on the terms of the member’s benefit plan to determine whether the site of service is medically necessary or whether the procedure might safely and effectively be performed in a more cost-effective setting such as a network ambulatory surgery center. Coverage determinations take into account the availability of a participating facility, specialty requirements, physician privileges and whether a member has individual needs that require more intensive services.
You do not need to request prior authorization to perform these procedures in a network ambulatory surgery center, unless the patient is a member of a plan that already requires it to evaluate medical necessity of the procedure in any setting.
• Physicians must request prior authorization to perform certain surgical procedures in an outpatienthospital setting.
• The requirement applies to many UnitedHealthcare Commercial members in most states andUnitedHealthcare Community Plan members in Arizona, Maryland, New Mexico, New York, Pennsylvania,Rhode Island, Tennessee and Washington.
• For dates of service on or after Oct. 1, 2016, the requirement will also apply to UnitedHealthcareCommunity Plan in Delaware.
• In states where this prior authorization requirement is in place, the following procedure codes will be includedbeginning with dates of service on or after Oct. 1, 2016, except in Illinois, where the effective date is Dec. 1, 2016:
Cardiovascular 36561 36590
Cosmetic and Reconstructive 13101 13132 14040 14060 14301 21552 21931
Ear, Nose and Throat (ENT) Procedures 21320 30140 30520 69436 69631
Hernia 49505
Opthalmology 65426 65730 65855 66170 66761 67028 67036 67040 67228 67311 67312
Urology 54161 55040 55700
Miscellaneous 20680
Important clarification: In previous communications about this requirement, CPT code 66180 was included. Prior authorization will not be required for CPT code 66180.
Prior Authorization Requirement for Certain Surgical Procedures Expanding to Include UnitedHealthcare Community Plan members in Delaware and Additional Procedures – Effective Oct. 1, 2016 in Most States
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Front & Center
Network Bulletin: November 2013 - Volume 581313 For more information, call 877.842.3210
or visit UnitedHealthcareOnline.comNetwork Bulletin: September 2016
TABLE OF CONTENTS
Site of service medical necessity reviews are part of our prior authorization process that supports member benefit plans and state Medicaid guidelines requiring care to be medically necessary as well as cost-effective. Ambulatory surgery centers frequently offer significant cost savings compared with a hospital setting, which can help many of our members save on out-of-pocket costs. Ambulatory surgery centers may provide more convenient care experiences for patients, as well.
As health care continues to evolve and consumers increasingly demand a wider range of quality, cost effective options for their health care services, we anticipate a continued focus on place of service. We encourage you to review network ambulatory surgery centers in your area and obtain privileges with those centers that best meet your needs and your patients’ needs.
For more details, please go to UnitedHealthcareOnline.com > Tools & Resources > Policies, Protocols and Guides > Protocols > Prior Authorization for Outpatient Surgical Procedures FAQ.
If you have questions, please contact your local Network Management representative or call the Provider Services number on the back of the member’s UnitedHealthcare ID card. Thank you.
Prior Authorization Requirement for Certain Surgical Procedures Expanding to Include UnitedHealthcare Community Plan members in Delaware and Additional Procedures – Effective Oct. 1, 2016 in Most States
Network Bulletin: November 2013 - Volume 581414 For more information, call 877.842.3210
or visit UnitedHealthcareOnline.comNetwork Bulletin: September 2016
Harken Health™ members will be able to access UnitedHealthcare Compass Network for individual coverage in 2017. Please accept Harken Health members as part of your agreement with UnitedHealthcare.
This network will be known as Harken Compass Network in Georgia and Illinois. The Harken Health model offers members access to a relationship-based primary care experience, supported by insurance, but focused on access to local, personalized care.
Beginning in 2017, Harken Health members will be required to get a referral from their primary care provider (PCP) to see a care provider in UnitedHealthcare’s Compass Network. The Harken Health member’s PCP coordinates the member’s care and initiates online electronic referrals to other network specialists prior to the member seeking care.
Specialist Responsibilities for Referrals
• Validate an active referral is on file before seeing patients. You can use the Harken Health provider portal at provider.harkenhealth.com
• Obtain the required prior authorization as outlined on provider.harkenhealth.com > Prior Authorizations and Notifications
• Maintain contact with Harken Health Center PCPs to:
– Coordinate care and make recommendations,as necessary
– Request a referral if one is not found on file or before the referral expires
– I nform the Harken Health Center PCP when additional care is needed by a different specialist
UnitedHealthcare Compass Network to Welcome Harken Health Members in 2017
UnitedHealthcare Commercial
TABLE OF CONTENTS
Next Article >
UnitedHealthcare Commercial
Network Bulletin: November 2013 - Volume 581515 For more information, call 877.842.3210
or visit UnitedHealthcareOnline.comNetwork Bulletin: September 2016
TABLE OF CONTENTS
For referral requirement questions, contact Harken Health at 800-797-9921. Some services do not require a referral under federal law.
Harken Health members in group plans will continue to be able to use UnitedHealthcare’s Choice Plus Network in 2017. Referrals to care providers in this network are not required.
Following is information to help you care for your patients who are members of these benefit plans.
Reimbursement Reimbursement for covered services provided to Harken Health members is made per the terms of your participation agreement with UnitedHealthcare.
Member Eligibility Here is an example of a Harken Health member ID card for 2017. To confirm member eligibility, please visit provider.harkenhealth.com or call Harken Health at 800-797-9921.
UnitedHealthcare Compass Network to Welcome Harken Health Members in 2017
Next Article >
ILLINOIS INDIVIDUAL
MEMBERSHIP NUMBER: 434240484494 Rx BIN: 610279 PCN: 9999 Rx GRP: HARKEN
FirstLast Name
Call Us Anytime at800.797.9921
First Name, Last NameMEMBERSHIP NUMBER: 44444444444
PLAN: Care Bronze Copay
EFFECTIVE DATE: 12.12.16
PCP REQUIRED
Questions? 800.797.9921
harkenhealth.com
$4,000
$100
$100
$0 after deductible
Referral required
PO Box 30521 Salt Lake City, UT84130, USA
Free Primary Care Visits at Harken Health Centers
COSTS
CLAIMS
PAYER ID: 43313
GROUP NO: xxxxxxxx
Harken Health Insurance Company
Providers call XXX.XXX.XXX for Optum Behavioral Health
DEDUCTIBLE: SPECIALIST:
URGENT CARE:
ER VISIT
Compass Plus
MEMBERSHIP NUMBER: 434240484494 Rx BIN: 610279 PCN: 9999 Rx GRP: HARKEN
FirstLast Name
Call Us Anytime at800.797.9921
First Name, Last NameMEMBERSHIP NUMBER: 44444444444
PLAN: Care Bronze Copay
EFFECTIVE DATE: 12.12.16
PCP REQUIRED
Questions? 800.797.9921
harkenhealth.com
$4,000
$100
$100
$0 after deductible
Referral required
PO Box 30521 Salt Lake City, UT84130, USA
Free Primary Care Visits at Harken Health Centers
COSTS
CLAIMS
PAYER ID: 43313
GROUP NO: xxxxxxxx
Harken Health Insurance Company
DEDUCTIBLE: SPECIALIST:
URGENT CARE:
ER VISIT
Compass Plus Behavioral Health
UnitedHealthcare Commercial
Network Bulletin: November 2013 - Volume 581616 For more information, call 877.842.3210
or visit UnitedHealthcareOnline.comNetwork Bulletin: September 2016
TABLE OF CONTENTS
UnitedHealthcare Compass Network to Welcome Harken Health Members in 2017
Notification Submission Harken Health follows UnitedHealthcare’s clinical policies for inpatient notification and prior authorization, with one prior authorization exception: screening colonoscopies (CPT 45378).
Clinical policies can be found in the UnitedHealthcare Administrative Guide at UnitedHealthcareOnline.com > Policies, Protocols and Guides > Administrative Guides. To submit inpatient notification or prior authorization requests, please go to provider.harkenhealth.com or call 800-797-9921.
Claims Submission Please submit claims for Harken Health members under Payer ID 43313 to:
Harken Health P.O. Box 30521 Salt Lake City, UT 84130
Visit provider.harkenhealth.com or call Harken Health at 800-797-9921 to check claims status.
You can also visit provider.harkenhealth.com to see additional information, including Harken Health member rights and responsibilities and care and disease management services.
If you have questions, please call Harken Health at 800-797-9921 or contact your UnitedHealthcare Provider Advocate or Network Management representative. Thank you.
UnitedHealthcare Commercial
Network Bulletin: November 2013 - Volume 581717 For more information, call 877.842.3210
or visit UnitedHealthcareOnline.comNetwork Bulletin: September 2016
TABLE OF CONTENTS
Neighborhood Health Partnership requires prior authorization for all observation codes. Information on Prior Authorization can be found in the Neighborhood Health Partnership Advance Notification Guide at UnitedHealthcareOnline.com > Clinician Resources > Advance & Admission Notification Requirements.
On June 1, 2016, Neighborhood Health Partnership began migrating to the UnitedHealthcare core systems. Details on this migration were published in the May 2016 Network Bulletin.
Due to a system issue resulting from the migration, it may appear that observation codes do not require prior authorization when using UnitedHealthcareOnline.com to submit a prior authorization request for migrated members. This is a system issue only and does not indicate a change to the observation code prior authorization policy that has been in place since before the migration.
We are working to resolve the issue quickly by Oct. 1, 2016. If you receive a message stating that prior authorization is not required for an observation code, please contact Neighborhood Health Partnership Provider Services at 877-842-3210.
A Reminder about the Neighborhood Health Partnership Prior Authorization Policy
UnitedHealthcare Commercial
Network Bulletin: November 2013 - Volume 581818 For more information, call 877.842.3210
or visit UnitedHealthcareOnline.comNetwork Bulletin: September 2016
TABLE OF CONTENTS
For complete details on the policy updates listed in the following table, please refer to the August 2016 Medical Policy Update Bulletin at UnitedHealthcareOnline.com > Tools & Resources > Policies, Protocols and Guides > Medical & Drug Policies and Coverage Determination Guidelines > Medical Policy Update Bulletin.
Policy Title Policy Type Effective Date
UPDATED/REVISED
17-Alpha-Hydroxyprogesterone Caproate (Makena™ and 17P) Drug Sept. 1, 2016
Breast Reconstruction Post Mastectomy CDG Sept. 1, 2016
Chemosensitivity and Chemoresistance Assays in Cancer Medical Aug. 1, 2016
Cosmetic and Reconstructive Procedures CDG Sept. 1, 2016
Cytological Examination of Breast Fluids for Cancer Screening Medical Sept. 1, 2016
Discogenic Pain Treatment Medical Aug. 1, 2016
Electrical Bioimpedance for Cardiac Output Measurement Medical Aug. 1, 2016
Home Health Care CDG Sept. 1, 2016
Magnetic Resonance Spectroscopy (MRS) Medical Aug. 1, 2016
Neuropsychological Testing Under the Medical Benefit Medical Sept. 1, 2016
Obstructive Sleep Apnea Treatment Medical Oct. 1, 2016
Omnibus Codes Medical Oct. 1, 2016
Ophthalmologic Policy: Vascular Endothelial Growth Factor (VEGF) Inhibitors Drug Aug. 1, 2016
Pectus Deformity Repair CDG Sept. 1, 2016
Preventive Care Services CDG Oct. 1, 2016
Rhinoplasty and Other Nasal Surgeries CDG Sept. 1, 2016
Skilled Care and Custodial Care Services CDG Aug. 1, 2016
Spinal Ultrasonography Medical Aug. 1, 2016
Total Knee Replacement Surgery (Arthroplasty) Medical Sept. 1, 2016
Transcatheter Heart Valve Procedures Medical Sept. 1, 2016
Note: The inclusion of a service or procedure on this list does not imply that UnitedHealthcare provides coverage for the service or procedure. In the event of an inconsistency or conflict between the information in this bulletin and the posted policy, the provisions of the posted policy prevail.
UnitedHealthcare Medical Policy, Drug Policy and Coverage Determination Guideline Updates
Network Bulletin: November 2013 - Volume 581919 For more information, call 877.842.3210
or visit UnitedHealthcareOnline.comNetwork Bulletin: September 2016
UnitedHealthcare Commercial Reimbursement Policies
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 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 inconsistency between the information provided in the Network Bulletin and the posted policy, the posted policy prevails.
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UnitedHealthcare Commercial Reimbursement Policies
Network Bulletin: November 2013 - Volume 582020 For more information, call 877.842.3210
or visit UnitedHealthcareOnline.comNetwork Bulletin: September 2016
TABLE OF CONTENTS
According to the Centers for Medicare & Medicaid Services (CMS), Evaluation and Management (E/M) services are reimbursable to certain nonphysician practitioners, limited to nurse practitioners, clinical nurse specialists, certified nurse midwives and physician assistants. Additionally, CPT coding guidelines provide instruction to select the code that accurately identifies the service performed.
Effective in December 2016, UnitedHealthcare will revise the Nonphysician Health Care Professionals Billing E/M Codes Policy, which denies reimbursement of CPT codes 99201-99499 when reported by specific nonphysician health care professionals. To better align with CMS and CPT, UnitedHealthcare will extend this policy to the following additional nonphysician health care professionals:
• Optician
• Surgical technician
• Doctor of Naprapathy
• Massage therapist
• Acupuncturist
These health care professionals may consider reviewing the CPT and Healthcare Common Procedure Coding System (HCPCS) national code sets to select a more accurate code that describes the services they provide.
Policy Revision to Nonphysician Health Care Professionals Billing Evaluation and Management Codes
Network Bulletin: November 2013 - Volume 582121 For more information, call 877.842.3210
or visit UnitedHealthcareOnline.comNetwork Bulletin: September 2016
Outpatient Injectable Chemotherapy Prior Authorization Program for UnitedHealthcare Community Plan in Ohio, Michigan, Mississippi and Wisconsin
UnitedHealthcare Community Plan
Effective Oct. 1, 2016, UnitedHealthcare Community Plan members in Ohio, Mississippi, Michigan and Wisconsin will require prior authorization for injectable outpatient chemotherapy drugs given for a cancer diagnosis.
This requirement has been in place for UnitedHealthcare’s Commercial members since June 1, 2015.
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 miscellaneous Healthcare 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 a UnitedHealthcare Community Plan member in Ohio, Mississippi, Michigan or Wisconsin received injectable chemotherapy drugs in an outpatient setting July 1, 2016 through Sept. 30, 2016, you do not need to submit a prior authorization request until a new chemotherapy drug will be administered. We will authorize the chemotherapy regimen the member was receiving prior to Oct. 1, 2016 and the authorization will be effective until Sept. 30, 2017.
To request prior authorization, go to UnitedHealthcareOnline.com > Notifications/Prior Authorizations > Oncology Authorizations Submission & Status or call 866-889-8054.
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UnitedHealthcare Community Plan
Network Bulletin: November 2013 - Volume 582222 For more information, call 877.842.3210
or visit UnitedHealthcareOnline.comNetwork Bulletin: September 2016
TABLE OF CONTENTS
UnitedHealthcare Community Plan Medical Policy & Coverage Determination Guideline Updates
For complete details on the policy updates listed in the following table, please refer to the August 2016 Medical Policy Update Bulletin at UHCCommunityPlan.com > For Health Care Professionals > Select Your State > Provider Information > UnitedHealthcare Community Plan Medical Policies and Coverage Determination Guidelines.
Policy Title Policy Type Effective Date
ICD-9 CROSSWALK REMOVAL
Breast Reconstruction Post Mastectomy CDG Oct. 1, 2016
Breast Reduction Surgery CDG Oct. 1, 2016
Chromosome Microarray Testing Medical Oct. 1, 2016
Clinical Trials CDG Oct. 1, 2016
Embolization of the Ovarian and Iliac Veins for Pelvic Congestion Syndrome Medical Oct. 1, 2016
Epidural Steroid and Facet Injections for Spinal Pain Medical Oct. 1, 2016
Gender Dysphoria (Gender Identity Disorder) Treatment CDG Oct. 1, 2016
Hepatitis Screening Medical Oct. 1, 2016
High Frequency Chest Wall Compression Devices Medical Oct. 1, 2016
Light and Laser Therapy for Cutaneous Lesions and Pilonidal Disease Medical Oct. 1, 2016
Manipulation Under Anesthesia Medical Oct. 1, 2016
Neurophysiologic Testing Medical Oct. 1, 2016
Occipital Neuralgia and Headache Treatment Medical Oct. 1, 2016
Pectus Deformity Repair CDG Oct. 1, 2016
Proton Beam Radiation Therapy Medical Oct. 1, 2016
Sodium Hyaluronate Medical Oct. 1, 2016
UPDATED/REVISED
Breast Reconstruction Post Mastectomy CDG Sept. 1, 2016
Chemosensitivity and Chemoresistance Assays in Cancer Medical Aug. 1, 2016
Cosmetic and Reconstructive Procedures CDG Sept. 1, 2016
Cytological Examination of Breast Fluids for Cancer Screening Medical Oct. 1, 2016
Discogenic Pain Treatment Medical Aug. 1, 2016
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UnitedHealthcare Community Plan
Network Bulletin: November 2013 - Volume 582323 For more information, call 877.842.3210
or visit UnitedHealthcareOnline.comNetwork Bulletin: September 2016
TABLE OF CONTENTS
UnitedHealthcare Community Plan Medical Policy & Coverage Determination Guideline Updates
Policy Title Policy Type Effective Date
UPDATED/REVISED
Electrical Bioimpedance for Cardiac Output Measurement Medical Aug. 1, 2016
Embolization of the Ovarian and Iliac Veins for Pelvic Congestion Syndrome Medical Sept. 1, 2016
Emergency Health Services and Urgent Care Center Services (Maryland Only) CDG Sept. 1, 2016
Home Health Care CDG Oct. 1, 2016
Light and Laser Therapy for Cutaneous Lesions and Pilonidal Disease Medical Sept. 1, 2016
Magnetic Resonance Spectroscopy (MRS) Medical Aug. 1, 2016
Neuropsychological Testing Under the Medical Benefit Medical Oct. 1, 2016
Obstructive Sleep Apnea Treatment Medical Oct. 1, 2016
Omnibus Codes Medical Oct. 1, 2016
Pectus Deformity Repair CDG Sept. 1, 2016
Private Duty Nursing Services (PDN) CDG Sept. 1, 2016
Rhinoplasty and Other Nasal Surgeries CDG Sept. 1, 2016
Skilled Care and Custodial Care Services CDG Aug. 1, 2016
Spinal Ultrasonography Medical Aug. 1, 2016
Total Knee Replacement Surgery (Arthroplasty) Medical Sept. 1, 2016
Transcatheter Heart Valve Procedures Medical Sept. 1, 2016
Note: The inclusion of a service or procedure on this list does not imply that UnitedHealthcare provides coverage for the service or procedure. In the event of an inconsistency or conflict between the information in this bulletin and the posted policy, the provisions of the posted policy prevail.
Network Bulletin: November 2013 - Volume 582424 For more information, call 877.842.3210
or visit UnitedHealthcareOnline.comNetwork Bulletin: September 2016
UnitedHealthcare Medicare SolutionsTransitional Care Management and Medication Reconciliation Post-Discharge — Complete to Meet Quality Standards and Improve Patient Health
Transitional care management (TCM) and medication reconciliation post-discharge are important care opportunities that you can close to help prevent inpatient readmissions and make a difference to your patients’ health. When you provide these services, you meet the Centers for Medicare & Medicaid Services (CMS) reimbursement guidelines and complete the Healthcare Effectiveness Data Information Set (HEDIS) medication reconciliation post-discharge measure.
TCM services are the follow-up services you provide to your patients after they’ve been discharged from a hospital. Medication reconciliation is part of TCM and must be done within 30 days of an inpatient facility discharge. The goal of medication reconciliation is to:
• Address medication errors or duplications.
• Educate your patients on their new medications and side effects.
• Lower the risk for adverse interactions.
When completing medication reconciliation as part of TCM, you may be eligible for reimbursement using these CPT codes:
• 99495 for TCM services that involve moderate complexity decision-making; or
• 99496 for TCM services with high complexity decision-making
UnitedHealthcare supports your efforts to address these open care opportunities for our Medicare Advantage Plan members. To learn more about medication reconciliation, please visit UnitedHealthcareOnline.com > Tools & Resources > Medicare > PATH > Transitional Care Management with Medication Reconciliation Post-Discharge. For more information about how we can support your patients who are our members, please contact your UnitedHealthcare representative.
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UnitedHealthcare Medicare Solutions
Network Bulletin: November 2013 - Volume 582525 For more information, call 877.842.3210
or visit UnitedHealthcareOnline.comNetwork Bulletin: September 2016
TABLE OF CONTENTS
Medication Reconciliation Post-Discharge for Facilities — Support Closing This Open Care Opportunity to Help Prevent Readmissions
UnitedHealthcare recognizes the key role that facilities play in protecting the health and safety of our Medicare Advantage Plan members after an inpatient stay. Together, we can help your patients avoid medication-related issues upon discharge and help avoid unnecessary readmissions. To assist us in reaching this goal, please send us our members’ discharge medication lists immediately after discharge.
When you send us this information, we’ll use it to meet Healthcare Effectiveness Data Information Set (HEDIS) guidelines for the medication reconciliation post-discharge measure. HEDIS requires a review of the medication prescribed to our members at an inpatient facility and a comparison against the medication they were taking prior to admission. This review must take place within 30 days of discharge.
We can receive discharge medication lists in one of these ways:
• Electronic Medical Record (EMR) — If your EMR includes a discharge medication list and is accessible by both nursing and administrative staff, then we can get the information on our own if you’ve granted access to UnitedHealthcare.
• Secure Fax — Immediately upon our member’s discharge, please send UnitedHealthcare the member’s discharge summary and medication list by secure fax to 844-563-5990.
• Email — Submit the member’s discharge summary and medication list by email to [email protected].
UnitedHealthcare will contact you if we don’t receive this information within three days.
When you provide us with the discharge medication information, we will compare the medications from the discharge summary with the member’s current medications and discuss with the member, as needed, to determine if there are discrepancies. If there are any differences noted or the member has questions regarding medications, we will work with the member’s care provider.
To learn more about medication reconciliation, please visit UnitedHealthcareOnline.com > Tools & Resources > Medicare > PATH > Medication Reconciliation Post-Discharge. For more information about how we can support your patients who are our members, please contact your UnitedHealthcare representative.
UnitedHealthcare Medicare Solutions
Network Bulletin: November 2013 - Volume 582626 For more information, call 877.842.3210
or visit UnitedHealthcareOnline.comNetwork Bulletin: September 2016
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Revision to Reimbursement Policy — Durable Medical Equipment Charges in a Skilled Nursing Facility
UnitedHealthcare Medicare Advantage Plan is updating the Durable Medical Equipment Charges in a Skilled Nursing Facility policy to include parental and enteral (PEN) supplies and equipment.
This update is effective with claims processed on and after Dec. 1, 2016. The inclusion of these PEN services will help ensure that UnitedHealthcare Medicare Advantage Plan is in compliance with the Skilled Nursing Facility Consolidated Billing Guidelines. These guidelines are outlined by the Centers for Medicare & Medicaid Services (CMS) and state that separate reimbursement for these services when provided in a Part A-covered SNF confinement (place of service 31) is not separately reimbursable.
This reimbursement policy applies to all network and non-network physicians or other qualified health care professionals. The revision and corresponding system enhancement will only apply to services reported using the CMS-1500 form (or successor form) or its electronic equivalent.
Policy Reminder on Nonphysician Health Care Professionals Billing Evaluation and Management CodesEffective with claims processed on and after Dec. 14, 2016, UnitedHealthcare Medicare Advantage plans will implement prospective editing to the Nonphysician Health Care Professionals Billing Evaluation and Management Codes policy to deny reimbursement of CPT codes 99201-99499 when reported by a nonphysician care provider other than those defined by CMS.
The new prospective editing will apply to services reported using the CMS-1500 form (or successor form) or its electronic equivalent.
According to the Centers for Medicare & Medicaid Services (CMS), Evaluation and Management (E/M) services are reimbursable to certain nonphysician practitioners. These care providers are limited to nurse practitioners, clinical nurse specialists, certified nurse midwives and physician assistants. Additionally, CPT coding guidelines provide instruction to select the code that accurately identifies the service performed.
UnitedHealthcare Medicare Solutions
Network Bulletin: November 2013 - Volume 582727 For more information, call 877.842.3210
or visit UnitedHealthcareOnline.comNetwork Bulletin: September 2016
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Correct Reporting of Modifiers on Ipsilateral Organs or Structures
When the same anatomical modifier is submitted on a National Correct Coding Initiative (NCCI) Procedure to Procedure (PTP) code pair, the NCCI PTP edit will no longer be bypassed. This change will become effective for claims processed on or after Dec. 14, 2016. The change will allow compliance with the Centers for Medicare & Medicaid Services (CMS) Medicare NCCI correct coding standards.
Modifiers recognized by UnitedHealthcare UnitedHealthcare Medicare Advantage plans in the Rebundling and NCCI Editing policy follow the CMS Medicare NCCI designated modifiers for PTP edits: 24, 25, 57, 58, 59, 78, 79, 91, E1, E2, E3, E4, LC, LD, LM, LT, RC, RI, RT, TA, T1, T2, T3, T4, T5, T6, T7, T8, T9, FA, F1, F2, F3, F4, F5, F6, F7, F8, F9, XE, XP, XS and XU.
Each CMS Medicare NCCI edit has a modifier indicator assigned to it. A modifier indicator of “0” indicates that a modifier cannot be used to bypass the edit. A modifier indicator of “1” indicates that an NCCI designated modifier can be used to allow both of the reported services or procedures.
According to the CMS Medicare NCCI Coding Policy Manual, most edits involving paired organs or structures have NCCI PTP modifier indicators of “1” because the two codes of the code pair edit may be reported if performed on the contralateral organs or structures. However, if performed on the ipsilateral organ or structure, most of these code pairs should not be reported with the following NCCI-associated modifiers unless there is a specific coding rationale to bypass the edit: E1, E2, E3, E4, LC, LD, LM, LT, RC, RI, RT, TA, T1, T2, T3, T4, T5, T6, T7, T8, T9, FA, F1, F2, F3, F4, F5, F6, F7, F8, and F9. The existence of the NCCI PTP edit indicates that the two codes generally cannot be reported together unless the two corresponding procedures are performed at two separate patient encounters or on two separate anatomic locations.
UnitedHealthcare Medicare Solutions
Network Bulletin: November 2013 - Volume 582828 For more information, call 877.842.3210
or visit UnitedHealthcareOnline.comNetwork Bulletin: September 2016
TABLE OF CONTENTS
New Policy – Patient Discharge Status for Type of Bill
UnitedHealthcare Medicare Advantage plans will implement a new policy, effective Dec. 14, 2016, to help ensure alignment between the Patient Discharge Status and Type of Bill code submitted. This policy will deny facility claims submitted on a UB-04 (or successor form) or the electronic equivalent where the Patient Discharge Status is not supported by the Type of Bill submitted.
According to Centers for Medicare & Medicaid Services (CMS) guidelines for completing and submitting a UB-04 (or the electronic equivalent), a care provider must assign a Patient Discharge Status code that aligns with the Type of Bill submitted to avoid claim rejections, denials and/or recoveries.
A Type of Bill reflective of an ongoing stay should align with a Patient Discharge Status reflective of a continued stay. Likewise, a Type of Bill reflective of a discharge should align with a Patient Discharge Status of where the patient was discharged to.
UnitedHealthcare Medicare Solutions
Network Bulletin: November 2013 - Volume 582929 For more information, call 877.842.3210
or visit UnitedHealthcareOnline.comNetwork Bulletin: September 2016
TABLE OF CONTENTS
National Medicare Education Week: Helping to Make Medicare Easier to Understand
National Medicare Education Week, created by UnitedHealthcare, will be celebrated Sept. 15–21 to raise awareness of the importance of providing clear information about Medicare and help empower your patients to make informed, confident decisions about their Medicare coverage. The number of people in need of clear information about Medicare is growing as more baby boomers become eligible for Medicare.
National Medicare Education Week is observed each year from Sept. 15–21, one month before the Medicare open enrollment period from Oct. 15 – Dec. 7.
You can participate by:
• Visiting MedicareMadeClear.com, where you can find information about the week, RSVP for events that will be held in select cities, and learn about Medicare.
• Asking your Provider Advocate for materials to share with your patients.
Supporters of the 2016 education week include: Walgreens; National Association of Area Agencies on Aging; AARP®; Caregiver Action Network; SilverSneakers®; local health care providers; senior centers; and other organizations nationwide.
2017 Medicare Advantage Service Area ReductionsWe will be sending official non-renewal notices by Oct. 2, 2016 to UnitedHealthcare Medicare Advantage members across the country who will be impacted by service area reductions in 2017. The non-renewal notice will give members information about their special election period eligibility for 2017 coverage. The majority of care providers and facilities contracted for UnitedHealthcare Medicare Advantage products will not be affected by these changes.
To learn more and access frequently asked questions, please visit UnitedHealthcareOnline.com > Tools & Resources > Medicare, or contact your local Network Account Manager or Provider Advocate.
UnitedHealthcare Medicare Solutions
Network Bulletin: November 2013 - Volume 583030 For more information, call 877.842.3210
or visit UnitedHealthcareOnline.comNetwork Bulletin: September 2016
TABLE OF CONTENTS
UnitedHealthcare Medicare Advantage Coverage Summary Updates
For complete details on the policy updates listed in the following table, please refer to the August 2016 Medicare Advantage Coverage Summary Update Bulletin at UnitedHealthcareOnline.com > Tools & Resources > Policies, Protocols and Guides > UnitedHealthcare Medicare Advantage Coverage Summaries > Update Bulletin.
Policy Title
UPDATED/REVISED (Approved on July 26, 2016)
Blepharoplasty and Related Procedures
Complementary and Alternative Medicine
Cosmetic and Reconstructive Procedures
Cryosurgery for Prostate Cancer
Extracranial-Intracranial (EC-IC) Arterial Bypass Surgery
Fabric Wrapping of Abdominal Aneurysms
Glaucoma Surgical Treatments
Hearing Screening and Audiologist Services
Hyperbaric Oxygen Therapy
Pain Management and Pain Rehabilitation
Thermogenic Therapy
Transvenous (Catheter) for Pulmonary Embolectomy
Vision Services, Therapy and Rehabilitation
Note: The inclusion of a service or procedure to this list does not imply that UnitedHealthcare provides coverage for the service or procedure. 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.
Network Bulletin: November 2013 - Volume 583131 For more information, call 877.842.3210
or visit UnitedHealthcareOnline.comNetwork Bulletin: September 2016
Avoid Delays by Using the Latest Care Request Form
Starting Oct. 1, 2016 UnitedHealthcare Military & Veterans will only accept current care request submission forms. Help avoid delays in care for TRICARE beneficiaries by submitting care request forms online, or by downloading the most recent fax form from UHCMilitaryWest.com. If you use an outdated care request submission form, the request will be returned to you.
Submit care requests electronically at UHCMilitaryWest.com
Log in to your secure account at UHCMilitaryWest.com and choose “Submit Referral or Authorization Request” to start. The online form will always be up-to-date.
To submit by fax, download the Referral/Authorization Request Form at UHCMilitaryWest.com
Please make sure to use the latest submission form at UHCMilitaryWest.com > Providers > Find a Form > Medical-Surgical Referrals and Authorizations > Referral/Authorization Request Form.
Please send fax care requests individually with a cover sheet whenever possible. For multiple care requests in one fax, please use the separator sheet at UHCMilitaryWest.com > Providers > Find a Form > Medical-Surgical Referrals and Authorizations > Batch Fax Barcode Separator Sheet for Care Requests. Using this sheet between each individual request will help keep the requests separate for processing.
Go to UHCMilitaryWest.com > Providers > Referrals and Prior Authorizations to learn more about the care request submission process. If you have questions, please contact your Provider Advocate. Thank you.
UnitedHealthcare Military & Veterans
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Network Bulletin: November 2013 - Volume 583232 For more information, call 877.842.3210
or visit UnitedHealthcareOnline.comNetwork Bulletin: September 2016
Online Preventive Health Program Available for Information on Depression, Alcohol and Drug Abuse/Addiction and ADHD
United Behavioral Health has developed an online preventive health program that offers information and practice tools to support your treatment of patients with major depressive disorder, alcohol and drug abuse/addiction and attention-deficit/hyperactivity disorder (ADHD). A convenient, reliable and free source of pertinent health information, the preventive health program includes a library of articles addressing aspects of each condition; information about co-morbid conditions; links to nationally recognized practice guidelines; a printable self-appraisal to use or refer your patients to; and a listing of support resources for you, your patients and their families. Physicians and other health care professionals may access the program at liveandworkwell.com/member/prevention/.
Doing Business Better
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Doing Business Better
Network Bulletin: November 2013 - Volume 583333 For more information, call 877.842.3210
or visit UnitedHealthcareOnline.comNetwork Bulletin: September 2016
TABLE OF CONTENTS
Evidenced-Based Clinical Practice Guidelines
UnitedHealthcare uses evidenced-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 been significant changes to the guidelines marked with an asterisk in the following chart.
Topic Organization
Acute Myocardial Infarction with ST Elevation American College of Cardiology /American Heart Association
Acute Myocardial Infarction without ST Elevation American College of Cardiology /American Heart Association
Asthma National Heart, Lung and Blood Institute
Attention Deficit Hyperactivity Disorder (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 American College of Cardiology/American Heart Association
Chronic Obstructive Lung Disease* Global Initiative for Chronic Obstructive Lung Disease (GOLD)
Depression/Major Depressive Disorder American Psychiatric Association
Diabetes* American Diabetes Association
Dietary Guidelines* U.S. Department of Health and Human Services
Heart Failure American College of Cardiology/American Heart Association
Hemophilia and von Willebrand Disease World Federation of Hemophilia and National Heart, Lung & Blood Institute
Human Immuno-deficiency Virus (HIV) HIV Medicine Association of the Infectious Diseases Society of America
Hyperbilirubinemia in Newborns American Academy of Pediatrics
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Doing Business Better
Network Bulletin: November 2013 - Volume 583434 For more information, call 877.842.3210
or visit UnitedHealthcareOnline.comNetwork Bulletin: September 2016
TABLE OF CONTENTS
Topic Organization
Hypertension Panel Members Appointed to the Eighth Joint National Committee (JNC8)
Lifestyle Management to Reduce Cardiovascular Risk
American Heart Association/American College of Cardiology
Obesity American Heart Association/American College of Cardiology/The Obesity Society
Physical Activity U.S. Department of Health and Human Services
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
Stable Ischemic Heart Disease American College of Cardiology/American Heart Association et al.
Substance Use Disorders American Psychiatric Association/PsychiatryOnline Guideline Watch
Tobacco Use U.S. Department of Health and Human Services
Evidenced-Based Clinical Practice Guidelines
Doing Business Better
Network Bulletin: November 2013 - Volume 583535 For more information, call 877.842.3210
or visit UnitedHealthcareOnline.comNetwork Bulletin: September 2016
TABLE OF CONTENTS
Reminder on Case and Disease Management Programs
As a reminder, UnitedHealthcare offers case and disease management programs to support care providers’ treatment plans and assist members in managing their conditions. Using medical, pharmacy and behavioral health claims data, our predictive model systems help us identify members who are at high risk and directs them to our programs.
Patients also can be identified at time of hospital discharge via a Health Risk Assessment, Nurseline referral, or member or caregiver referral. If you have patients who are UnitedHealthcare members who would benefit from case or disease management, you can refer them to the appropriate program by calling the number on the back of the member’s health insurance ID card.
Participation in these programs is voluntary. Upon referral, each member is assessed for the appropriate level of care for their individual needs. Programs vary depending on the member’s benefit plan.
Case Management At the core of case management is identifying high-cost, complex, at-risk members who can benefit from these services. We partner with members and their physicians or other health care professionals to facilitate health care access and decisions that can have a dramatic impact on the quality and affordability of their health care.
Specifically, our programs are designed to assist in ensuring individuals:
• Receive evidenced-based care
• Have necessary self-care skills and/or caregiver resources
• Have the right equipment and supplies to perform self-care
• Have requisite access to the health care delivery system
• Are compliant with medications and the physician’s treatment plan
Our case managers are registered nurses who engage the appropriate internal, external or community-based resources needed to address members’ health care needs. When appropriate, we provide referrals to other internal programs such as disease management, complex condition management, behavioral health, employee assistance and disability. Case management services are voluntary and a member can opt out at any time.
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Doing Business Better
Network Bulletin: November 2013 - Volume 583636 For more information, call 877.842.3210
or visit UnitedHealthcareOnline.comNetwork Bulletin: September 2016
TABLE OF CONTENTS
Disease Management Programs We offer disease management programs designed to provide members with specific conditions the appropriate level of intervention.
Depending on the member’s health plan and benefit plan design, disease management programs vary and may include:
• Coronary artery disease
• Diabetes
• Heart failure
• Asthma
• Chronic obstructive pulmonary disease
• Cancer
• High risk pregnancy
• Kidney disease
• Acute MI1
• Hemophilia*
* Limited to eligible UnitedHealthcare River Valley and Neighborhood Health Program members.
Our programs include:
• Screening for depression and helping members access the appropriate resources.
• Addressing lifestyle-related health issues and referring to programs for weight management, nutrition, smoking cessation, exercise, diabetes care and stress management.
• Helping members understand and manage their condition and its implications.
• Education on how to reduce risk factors, maintain a healthy lifestyle, and adhere to treatment plans and medication regimens.
Reminder on Case and Disease Management Programs
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Doing Business Better
Network Bulletin: November 2013 - Volume 583737 For more information, call 877.842.3210
or visit UnitedHealthcareOnline.comNetwork Bulletin: September 2016
TABLE OF CONTENTS
For some programs, members may receive:
• A comprehensive assessment by specialty-trained registered nurses to determine the appropriate level and frequency of interventions.
• Educational mailings, newsletters and tools such as a HealthLog to assist them in tracking their physician visits, health status and recommended targets or other screenings.
• Information on gaps in care and encouragement to discuss treatment plans, goals and results with the physician.
• Physicians with patients in moderate intensity programs may receive information on their patient’s care opportunities.
• Transitional case management when high risk patients are discharged from a hospital
• Outbound calls for the highest risk individuals to address particular gaps in care. You will be notified when patients are identified for the high-risk program.
These programs complement the physician’s treatment plan, reinforce instructions you may have provided, and offer support for healthy lifestyle choices.
Reminder on Case and Disease Management Programs
Network Bulletin: November 2013 - Volume 583838 For more information, call 877.842.3210
or visit UnitedHealthcareOnline.comNetwork Bulletin: September 2016
UnitedHealthcare AffiliatesOxford® Medical and Administrative Policy Updates
For complete details on the policy updates listed in the following table, please refer to the August 2016 Policy Update Bulletin at OxfordHealth.com > Providers > Tools & Resources > Medical Information > Medical and Administrative Policies > Policy Update Bulletin.
TABLE OF CONTENTS
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UnitedHealthcare Affiliates
Network Bulletin: November 2013 - Volume 583939 For more information, call 877.842.3210
or visit UnitedHealthcareOnline.comNetwork Bulletin: September 2016
TABLE OF CONTENTS
Policy Title Policy Type Effective Date
UPDATED/REVISED
17-Alpha-Hydroxyprogesterone Caproate (Makena™ and 17P) Clinical Sept. 1, 2016
Apheresis Clinical Aug. 1, 2016
B Bundle Codes Reimbursement Aug. 1, 2016
Behavioral Health Services Administrative Sept. 1, 2016
Breast Reconstruction Post Mastectomy Clinical Sept. 1, 2016
Bronchial Thermoplasty Clinical Aug. 1, 2016
Cosmetic and Reconstructive Procedures Clinical Sept. 1, 2016
Drug Coverage Criteria - New and Therapeutic Equivalent Medications Clinical Sept. 1, 2016
Drug Coverage Guidelines Clinical Sept. 1, 2016
Durable Medical Equipment, Orthotics and Prosthetics Multiple Frequency Reimbursement Sept. 1, 2016
Global Days Reimbursement Sept. 1, 2016
Home Traction Therapy Clinical Aug. 1, 2016
Injection and Infusion Services Reimbursement Aug. 8, 2016
Light and Laser Therapy for Cutaneous Lesions and Pilonidal Disease Clinical Sept. 1, 2016
Maximum Frequency Per Day Reimbursement Aug. 8, 2016
Meniscus Implant and Allograft Clinical Aug. 1, 2016
Molecular Profiling to Guide Cancer Treatment Clinical Aug. 1, 2016
Motorized Spinal Traction Clinical Aug. 1, 2016
Multiple Procedures Reimbursement Aug. 8, 2016
Obstructive Sleep Apnea Treatment Clinical Oct. 1, 2016
Oxford® Medical and Administrative Policy Updates
Next Article >
UnitedHealthcare Affiliates
Network Bulletin: November 2013 - Volume 584040 For more information, call 877.842.3210
or visit UnitedHealthcareOnline.comNetwork Bulletin: September 2016
TABLE OF CONTENTS
Policy Title Policy Type Effective Date
UPDATED/REVISED
Pectus Deformity Repair Clinical Sept. 1, 2016
Pediatric and Neonatal Critical and Intensive Care Services Reimbursement Aug. 8, 2016
Sept. 1, 2016
Preventive Care Services Clinical Oct. 1, 2016
Preventive Medicine and Screening Reimbursement Aug. 8, 2016
Private Duty Nursing Services (PDN) Clinical Sept. 1, 2016
Procedure and Place of Service Reimbursement Aug. 8, 2016
Rhinoplasty and Other Nasal Surgeries Clinical Sept. 1, 2016
Site of Service Guidelines for Certain Outpatient Surgical Procedures Clinical Oct. 1, 2016
T Status Codes Reimbursement Sept. 1, 2016
Time Span Codes Reimbursement Aug. 8, 2016
Total Knee Replacement Surgery (Arthroplasty) Clinical Sept. 1, 2016
Transcatheter Heart Valve Procedures Clinical Sept. 1, 2016
Umbilical Cord Blood Harvesting and Storage for Future Use Clinical Aug. 1, 2016
Urgent Care Reimbursement Aug. 1, 2016
Note: The inclusion of a service or procedure to this list does not imply that Oxford provides coverage for the service or procedure. 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., OxfordHealth Plans (NJ), Inc. and Oxford Health Plans (CT), Inc. Oxford insurance products areunderwritten by Oxford Health Insurance, Inc.
Oxford® Medical and Administrative Policy Updates
UnitedHealthcare Affiliates
Network Bulletin: November 2013 - Volume 584141 For more information, call 877.842.3210
or visit UnitedHealthcareOnline.comNetwork Bulletin: September 2016
TABLE OF CONTENTS
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 August 2016 SignatureValue/UnitedHealthcare Benefits Plan of California Benefit Interpretation Policy Update Bulletin at UHCWest.com > Provider Log In > Library > Resource Center > Guidelines & Interpretation Manuals.
Policy Title
UPDATED/REVISED (Effective Sept. 1, 2016)
Abortions
Ambulance Transportation
Blood and Blood Products
Emergency and Urgent Services
Experimental and Investigational Services
Hearing Services
Inpatient Hospital Services
Outpatient Hospital Services
Transplantation Services
REPLACED (Effective Sept. 1, 2016)
Outpatient Pulmonary Rehabilitation
Note: The inclusion of a service or procedure to this list does not imply that UnitedHealthcare provides coverage for the service or procedure. 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 Affiliates
Network Bulletin: November 2013 - Volume 584242 For more information, call 877.842.3210
or visit UnitedHealthcareOnline.comNetwork Bulletin: September 2016
TABLE OF CONTENTS
SignatureValue/UnitedHealthcare Benefits Plan of California Medical Management Guideline Updates
For complete details on the policy updates listed in the following table, please refer to the August 2016 SignatureValue/UnitedHealthcare Benefits Plan of California Medical Management Guidelines Update Bulletin at UHCWest.com > Provider Log In > Library > Resource Center > Guidelines & Interpretation Manuals.
Title Effective Date
NEW
Pulmonary Rehabilitation Sept. 1, 2016
UPDATED/REVISED
Breast Reconstruction Post Mastectomy Sept. 1, 2016
Breast Reduction Surgery Sept. 1, 2016
Chemosensitivity and Chemoresistance Assays in Cancer Aug. 1, 2016
Cosmetic and Reconstructive Procedures Sept. 1, 2016
Cytological Examination of Breast Fluids for Cancer Screening Sept. 1, 2016
Discogenic Pain Treatment Aug. 1, 2016
Electrical Bioimpedance for Cardiac Output Measurement Aug. 1, 2016
Magnetic Resonance Spectroscopy (MRS) Aug. 1, 2016
Neuropsychological Testing Under the Medical Benefit Sept. 1, 2016
Obstructive Sleep Apnea Treatment Oct. 1, 2016
Omnibus Codes Oct. 1, 2016
Pectus Deformity Repair Sept. 1, 2016
Preventive Care Services Oct. 1, 2016
Rhinoplasty and Other Nasal Surgeries Sept. 1, 2016
Spinal Ultrasonography Aug. 1, 2016
Total Knee Replacement Surgery (Arthroplasty) Sept. 1, 2016
Transcatheter Heart Valve Procedures Sept. 1, 2016
Note: The inclusion of a service or procedure to this list does not imply that UnitedHealthcare provides coverage for the service or procedure. 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.
Network Bulletin: September 2016Doc#: PCA-1-002910-08092016_08192016
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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