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Network Bulletin: January 2017

network bulletin Important updates from UnitedHealthcare to health care professionals and facilities

enter

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.

Table of Contents

Front & Center •

Star Ratings Show Close Collaboration between UnitedHealthcare and Care Providers

•

Electronic Remittance Advice Enhancement

•

Preferred Drug List Changes

•

2017 UnitedHealthcare Care Provider Administrative Guide Available Jan. 1, 2017*

•

New Prior Authorization Requirements for Injectable Medications

•

Notification/Prior Authorization Requirement for Administration of Xolair® (omalizumab) – Effective April 1, 2017

•

UnitedHealthcare Exchange Reminder for 2017

Outpatient Injectable Chemotherapy Prior Authorization Program for UnitedHealthcare Community Plan in Delaware, New Jersey, New York, Pennsylvania and Texas

•

New Overpayment Refund/Notification Form

•

Changes in Advance Notification and Prior Authorization Requirements

UnitedHealthcare Community Plan Medical Policy & Coverage Determination Guideline Updates

•

Pharmacy Update on Coverage Criteria for UnitedHealthcare Commercial and Oxford Plans

•

Evaluation and Management Reimbursement Policy for Professional Claims

•

Dental Clinical Policy & Coverage Guideline Updates

UnitedHealthcare Commercial •

Notification/Prior Authorization Requirement for Certain Office-Based Procedures to be Covered in Other Sites of Service – Effective April 1, 2017

•

Health Reimbursement Account Payments and Remittances to be Delivered Electronically in February

•

Eligibility and Benefit EDI 270/271 Transactions: Change for Non-Embedded CDH Plans

•

UnitedHealthcare Hospital Quality Program – Results Available on myHealthcare Cost Estimator

•

Coding Update to Facility Outpatient Procedure Grouper Mapping

•

UnitedHealthcare Shared Services Expansion for GEHA

•

Expansion of Radiology and Cardiology Notification/Prior Authorization Protocols to All Savers Plans (Offered Offexchange) - Effective April 1, 2017

•

UnitedHealthcare Medical Policy, Drug Policy and Coverage Determination Guideline Updates

UnitedHealthcare Commercial Reimbursement Policies •

UnitedHealthcare Community Plan

Moderate Sedation Reimbursement Policy

Network Bulletin: November 2013 - Volume 58 Network Bulletin: January 2017

UnitedHealthcare Medicare Solutions •

Virtual Visits

•

Place of Service 32/33 Professional Services Member Cost-Share

•

Medicare Advantage Prior Authorization Reduction Pilot Program: Radiation Therapy Requirements

•

UnitedHealthcare Medicare Advantage Coverage Summary Updates

•

UnitedHealthcare Medicare Advantage Policy Guideline Updates

UnitedHealthcare Military & Veterans •

Beneficiary Waiver Required When Billing for Services Not Covered by TRICARE

•

TRICARE’s Telemental Health Care Benefits

Doing Business Better •

Virtual Card Payment Option Available for Small Practices

•

Direct Deposit Available through UHCWest.com

UnitedHealthcare Affiliates •

Reminder: Upcoming Changes to OneNet Claim Status Search and OneNet Medical Runout

•

Cancer Support Program for Oxford Fully-Insured Members

•

Expansion of UnitedHealthcare of the River Valley Ohio Radiology and Cardiology Notification/Prior Authorization Protocols - Effective April 1, 2017

•

ignatureValue/UnitedHealthcare Benefits Plan of S California Benefit Interpretation Policy Updates

•

SignatureValue/UnitedHealthcare Benefits Plan of California Medical Management Guideline Updates

•

Oxford® Medical and Administrative Policy Updates

For more information, call 877.842.3210 or visit UnitedHealthcareOnline.com

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Front & Center

Star Ratings Show Close Collaboration between UnitedHealthcare and Care Providers On Oct. 12, 2016, the Centers for Medicare & Medicaid Services (CMS) published 2017 Star Ratings1 (2018 payment year) for UnitedHealthcare Medicare Advantage plans. UnitedHealthcare scored impressive results, with 11 UnitedHealthcare contracts earning a Star Rating of 4.0; 11 contracts receiving a 4.5 Star rating and 2 contracts achieving a 5.0 Star rating out of 5.0 overall Stars. For 2017 Star Ratings (2018 payment year), we expect 84 percent of members will be in plans with four stars or higher. Used to rate the quality of Medicare Advantage plans, Star Ratings measure plan performance across categories such as clinical quality, health plan operations and member satisfaction. Our high ratings reflect our delivery of a better health care experience for members through strong customer service, clinical quality and access to care. The results also illustrate the success of our collaboration with care providers to support improved member care through data-sharing, electronic chart collection, financial incentives and practice-based support. Some of the ways we work with you and other health care professionals include: •

Our Practice-Based Support program, which helps practices schedule appointments with our members, provides end-to-end management with closing clinical open care opportunities, offers follow-ups and referrals, and delivers face-to-face care management with high-risk members

•

Our Retail Pharmacy Engagement program, which identifies medication adherence opportunities and concerns and helps address them through member coaching and education

•

Our coordinated processes and new technology to support HEDIS data collection so we can effectively gather, track and document closure of clinical care opportunities

Continued >

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< Continued

Our goal is to continue developing innovative solutions that can help transform the face of health care. By working together, we can further support member involvement in their own well-being, helping them use their health plan benefits to get the appropriate care at the right time. Thank you for your role in our Star Ratings success.

Front & Center Star Ratings Show Close Collaboration between UnitedHealthcare and Care Providers

Medicare evaluates plans based on a 5-star rating system. Star Ratings are calculated each year and may change from one year to the next. Go to Medicare.gov for more information on Star Ratings. Medicare Fact Sheet, 2017 Star Ratings

Network Bulletin: November 2013 - Volume 58 Network Bulletin: January 2017

For more information, call 877.842.3210 or visit UnitedHealthcareOnline.com

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Front & Center

2017 UnitedHealthcare Care Provider Administrative Guide Available Jan. 1, 2017*

The 2017 UnitedHealthcare Care Provider Administrative Guide contains some important changes you’ll want to review. The following list is a high-level summary of selected updates to the Guide; it is not intended nor should it be interpreted to represent every update or the details of any update. Please refer to the Guide for the complete text and detailed updates. This essential resource for physicians, hospitals, facilities and other health care providers is posted on UnitedHealthcareOnline.com. Be sure to save the link to your Favorites or download it today. In our continuous effort to respond to your feedback, you’ll see some changes to the Administrative Guide for 2017: •

Information has been organized into new chapter titles to help make navigation easier

•

Page headers with the chapter name on every page for easier navigation

•

Helpful tips that summarize information or connect you directly online

•

Glossary added to offer clarity of common terms

Also New in the 2017 Guide: • Leased Network in Maine: The Leased Network arrangement in Maine is ending effective March 31, 2017. Beginning April 1, 2017, the network will be directly contracted and credentialed through UnitedHealthcare. •

Oxford Navigate Individual Plan: Effective Jan. 1, 2017, UnitedHealthcare Oxford Navigate Individual plans will be added to the UnitedHealthOne Individual Plans Supplement and excluded from the Oxford Supplement.

•

Administrative Terminations for Inactivity: Effective April 1, 2017, we’ll begin to administratively terminate a care provider: – If we receive oral notification that a practitioner is no longer with the practice, and – We make three attempts to obtain documentation confirming the practitioner’s departure but do not receive the requested documentation, and – Claims have not been submitted by that practitioner under that practice’s tax identification number(s) (TINs) during the six months prior to either the date we received oral notification that the practitioner has left the practice or the effective date of departure given to us, whichever is sooner.

•

OneNet PPO Medical Network Closure: The OneNet Supplement was revised to reflect the closure of the OneNet PPO medical network on March 15, 2016, and the continued operations of the OneNet Workers’ Compensation Network. The workers’ compensation network is now accessed exclusively by employers and administrators contracted with Procura Management, Inc., an Optum Company. Run out processing of OneNet medical claims will end on March 15, 2017.

Continued >

Network Bulletin: November 2013 - Volume 58 Network Bulletin: January 2017

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< Continued

Front & Center 2017 UnitedHealthcare Care Provider Administrative Guide Available Jan. 1, 2017*

or a paper copy of the UnitedHealthcare Administrative Guide, contact your Network F Management representative, Physician Advocate or Hospital and Facility Advocate. We recommend accessing the Guide online to take full advantage of automated search, interactive table of contents and hyperlinks. Visit UnitedHealthcareOnline.com > Tools & Resources > Protocols, Policies and Guides > Administrative Guides. In addition, you can sign up to receive the Network Bulletin electronically at uhc-networkbulletin.com/registration. * Except as otherwise noted, the new Guide is effective on April 1, 2017 for currently contracted care providers and effective immediately for care providers newly contracted on or after Jan. 1, 2017. This Guide applies to UnitedHealthcare Commercial and Medicare Solutions products only.

Network Bulletin: November 2013 - Volume 58 Network Bulletin: January 2017

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Front & Center Notification/Prior Authorization Requirement for Administration of Xolair® (omalizumab) – Effective April 1, 2017

For dates of service on or after April 1, 2017, UnitedHealthcare Commercial plans are implementing a notification/prior authorization requirement for the medication Xolair (omalizumab). This is part of our ongoing efforts to give our members access to services that are medically appropriate, while working toward the Triple Aim of better care, better outcomes and lower costs of care. When we receive notification for the administration of Xolair, we’ll determine if the member’s benefit plan requires services to be medically necessary in order to be covered. If so, we’ll conduct a clinical coverage review as part of our prior authorization process. Once we receive all necessary information, we’ll inform you and the member of the coverage determination within 15 calendar days and review times may vary depending on state regulations. If coverage is approved, care providers may purchase and directly bill UnitedHealthcare for this medication. This updated requirement will now apply to UnitedHealthcare Commercial plans effective April 1, 2017. This will align with current notification/prior authorization requirements for UnitedHealthcare of the Mid-Atlantic, UnitedHealthcare Oxford, Neighborhood Health Partnership and UnitedHealthcare of the River Valley. If you don’t complete the notification/prior authorization process before administering Xolair, claims may be denied, and the member can’t be billed for the service. To submit notification/prior authorization requests, please use one of the following methods: •

Go to UnitedHealthcareOnline.com > Notifications/Prior Authorizations > Notification/Prior Authorizations Submission. Using UnitedHealthcareOnline.com is an easy way to initiate notification and is the preferred option for many practices.

•

Call the Provider Services phone number on the back of the member’s health care identification card.

•

Complete a prior authorization form and fax to 866-756-9733. Forms are available at UnitedHealthcareOnline.com > Tools & Resources > Forms > Clinical/Pharmacy. Please note some states require the prior authorization to be submitted on a designated request form.

As a reminder, a similar notification/prior authorization requirement will take effect Feb. 1, 2017, for the medication Exondys-51™. This was announced in the December Network Bulletin. For more information about the notification/ prior authorization requirements for specialty medications, please refer to the Physician, Health Care Professional, Facility and Ancillary Provider Administrative Guide at UnitedHealthcareOnline.com > Tools & Resources > Policies, Protocols and Guides > Administrative Guides. Thank you.

Network Bulletin: November 2013 - Volume 58 Network Bulletin: January 2017

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Front & Center UnitedHealthcare Exchange Reminder for 2017

Last year, we announced that UnitedHealthcare will only be participating in a small number of individual exchange markets in 2017 where we believe we can offer sustainable products and services. We have shared information about our 2017 individual and individual exchange participation through local communications to affected care providers and sent letters to members. Our decision to leave many individual markets in 2017 does not affect members in other products, including our group Commercial, Medicare and Medicaid members. We remain committed to expanding the number of people we serve in these markets and look forward to continuing to work with care providers to deliver even greater value to our Commercial, Medicare and Medicaid members in the future. As always, if you have questions or concerns regarding a memberâ€™s coverage status, please call Provider Services at 877-842-3210 to get up-to-date information prior to providing care. If one of your patients, who is a member, has questions, please ask them to call the number on the back of their health care ID card.

New Overpayment Refund/Notification Form Health care providers are required to report and return Medicare and Medicaid overpayments within 60 days of identifying any overpayment received within the past six years, according to Section 6402(a), Â§1128J(d) of the Affordable Care Act (ACA). UnitedHealthcare provides an Overpayment Refund Notification Form to use if you identify an overpaid claim. This allows you to comply with your obligation to return overpayments, while also helping to ensure that your overpayment refunds will be processed quickly and appropriately allocated to the overpaid claims. The form also lets you use statistical sampling methodology to calculate your overpayment if a specific patient list or overpaid claim amount is not available for all overpaid claims due to sampling. For more information about this process, please see our 2017 Provider Administrative Guide, Chapter 8: Our Claims Process, in the Overpayments section. The Overpayment Refund Notification Form is available at UnitedHealthcareOnline.com > Tools & Resources > Forms > Claim > Overpayment Refund/Notification Form.

Network Bulletin: November 2013 - Volume 58 Network Bulletin: January 2017

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Front & Center Changes in Advance Notification and Prior Authorization Requirements

Beginning April 1, 2017, the following codes will no longer require prior authorization for UnitedHealthcare Commercial plans (UnitedHealthcare Mid Atlantic Health Plan, Navigate, UnitedHealthOne, UnitedHealthcare Commercial, UnitedHealthcare West): Category

Codes

Potentially Unproven Services

33418, 33419

Effective for dates of service on or after April 1, 2017, the following procedure code will require prior authorization for UnitedHealthcare Community Plan of Tennessee. This procedure code was previously announced in the July Network Bulletin for dates of service on or after Oct. 1, 2016. Prior authorization requirements for this procedure code will be implemented on April 1, 2017: Category

Codes

Orthotics/Prosthetic > $500

L6026

Effective for dates of service on or after April 1, 2017, the following procedure codes will require prior authorization for UnitedHealthcare Community Plan of Louisiana: Category

Codes

Abortion

59830, 59850, 59851, 59852, 59855, 59856, 59857

Effective for dates of service on or after April 1, 2017, the following procedure code will require prior authorization for UnitedHealthcare Senior Care Options (HMO SNP): Category

Codes

Durable Medical Equipment

E0766

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Network Bulletin: November 2013 - Volume 58 Network Bulletin: January 2017

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Effective for dates of service on or after April 1, 2017, the following procedure codes will require prior authorization for UnitedHealthcare Community Plan of Pennsylvania: Category

Codes

Gender Dysphoria Treatment with diagnosis F64.0, F64.1, F64.2, F64.8, F64.9, Z87.890

11950

11951

11952

11954

11980

14000

14001

14021

14040

14041

14060

14061

14301

15757

15758

15775

15776

15777

15780

15781

15782

15783

15787

15788

15789

15792

15793

15819

15824

15825

15826

15828

15829

15832

15833

15834

15835

15836

15837

15838

15839

15876

15878

15879

17380

20926

21083

21087

21120

21122

21173

21270

21899

31599

31750

31899

45399

45999

58999

64856

64892

64896

69300

90785

96372

19303

19304

53410

53430

54125

54520

54660

54690

55175

55180

56625

56800

56805

57110

57335

58661

58720

58940

15750

58150

58180

58260

58262

58290

58291

58541

58542

58543

58544

58550

58552

58553

58554

58570

58571

58572

58573

Front & Center Changes in Advance Notification and Prior Authorization Requirements

Effective for dates of service on or after April 1, 2017, the following procedure codes will require prior authorization for UnitedHealthcare Commercial Plans (UnitedHealthcare Mid Atlantic Health Plan, Navigate, Neighborhood Health Partnership (NHP), UnitedHealthcare of the River Valley, UnitedHealthOne, UnitedHealthcare Commercial Legacy, UnitedHealthcare West): Category

Codes

Gender Dysphoria Treatment with diagnosis F64.0, F64.1, F64.2, F64.8, F64.9, Z87.890

14000

14001

14021

14041

15750

15757

15758

19303

19304

20926

53410

53430

54125

54520

54660

54690

55175

55180

56625

56800

56805

57110

57335

58661

58720

58940

64856

64892

64896

Effective for dates of service on or after April 1, 2017, the following procedure codes will require prior authorization for UnitedHealthcare Community Plans of Delaware, Kansas, New York, Ohio, Tennessee, and Rhode Island: Category

Codes

Gender Dysphoria Treatment with diagnosis F64.0, F64.1, F64.2, F64.8, F64.9, Z87.890

14000

14001

14021

14041

15750

15757

15758

19303

19304

20926

53410

53430

54125

54520

54660

54690

55175

55180

56625

56800

56805

57110

57335

58661

58720

58940

64856

64892

64896

58150

58180

58260

58262

58290

58291

58541

58542

58543

58544

58550

58552

58553

58554

58570

58571

58572

58573 Continued >

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Network Bulletin: November 2013 - Volume 58 Network Bulletin: January 2017

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< Continued

Effective for dates of service on or after April 1, 2017, the following procedure codes will require prior authorization for UnitedHealthcare Community Plan of Maryland:

Front & Center Changes in Advance Notification and Prior Authorization Requirements

Category

Codes

Dermatologic

11100

11402

11422

11403

11406

62270

62320

62321

62322

62323

64633

64635

Muscular/Skeletal

27096

64479

64483

64490

64493

Respiratory

31579

Neurologic

When we receive notification, we’ll determine if the member’s benefit plan requires covered services to be medically necessary. If so, we’ll evaluate the medical necessity of the site of service as part of our prior authorization process. Coverage determinations will take into account whether the patient has a need for more intensive services and whether the office has the equipment necessary to deliver the service. In many cases, a physician’s office is medically appropriate for patients and may offer them more convenient care experiences, as well as meaningful savings on out-of-pocket costs compared with other sites of service. If you don’t provide notification/request prior authorization as required, claims will be denied. Members can’t be billed for services that are denied on the basis that you did not comply with our notification/prior authorization protocols. UnitedHealthcare continues to focus on site of service as part of our clinical review process, as we work toward the Triple Aim of better care, better health and better costs for our members. Site of service medical necessity reviews align with our member benefit plan requirements that services, including sites of service, be medically necessary, including cost-effective. •

We encourage you to take advantage of our online process for providing notification to save you time. Or call the number on the back of your patient’s health plan ID card. For more information, please go to UnitedHealthcareOnline.com > Tools & Resources > Policies, Protocols and Guides > Protocols > Notification/Prior Authorization Requirement for Certain Office-Based Procedures to be Covered in Other Sites of Service.

If you have questions, please contact your local Network Management representative or call the Provider Services number on the back of the member’s ID card.

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Network Bulletin: November 2013 - Volume 58 Network Bulletin: January 2017

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UnitedHealthcare Commercial

Health Reimbursement Account Payments and Remittances to be Delivered Electronically in February

Effective Feb. 12, 2016, UnitedHealthcare will electronically deliver remittances and payments from UnitedHealthcare members who have health reimbursement accounts (HRAs). If you currently receive electronic remittance advice (ERA/835) via your clearinghouse, the remittance will include the following when you receive payment from UnitedHealthcare and the potential HRA payment funds have not yet been verified: •

Payer Name: UnitedHealthcare Services, Inc.

•

Remark code N367 — the claim information has been forwarded to a Consumer Spending Account processor for review; e.g. an HRA

You will receive a separate electronic remittance for confirmed HRA payments and the ERA/835 will indicate: •

Remark code N520 — payment made from a Consumer Spending Account

If you are enrolled in Electronic Payments & Statements (EPS), you will begin receiving electronic funds transfer (EFT) from UnitedHealthcare members who have HRAs. The ERA/835 delivered online via EPS will contain the information outlined above. Not receiving payments or statements electronically? Take action today. Not enrolled in EPS Enrolled in ERA, not EFT Not enrolled to receive ERA/835 via your clearinghouse

Enroll in Electronic Payments and Statements (EPS) Contact your clearinghouse to set up electronic receipt of ERA

Enrollment in EPS activates EFT, turns off mail delivery of paper checks and remittances, and provides for online delivery of ERAs for most UnitedHealthcare plans and for HRA payments. You can learn more about EPS online or call 877-620-6194. If you have any questions about this enhancement, please contact EDI Support at 800-842-1109 or via our EDI Transaction Support form.

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Network Bulletin: November 2013 - Volume 58 Network Bulletin: January 2017

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UnitedHealthcare Commercial

Eligibility and Benefit EDI 270/271 Transactions: Change for Non-Embedded CDH Plans

Effective Oct. 11, 2016, UnitedHealthcare updated Electronic Data Interchange (EDI) 271 transaction responses for members in Consumer-Driven Health (CDH) plans with non-embedded deductibles and out-of-pocket (OOP) maximums. It is important for you to understand these changes to accurately determine your patientsâ€™ financial responsibility when collecting fees in your office. Previously, if you submitted a 270 EDI eligibility inquiry for a patient with a non-embedded CDH plan, the 271 EDI response messages listed both individual and family benefit amounts, regardless of whether the member was in an individual or family plan. To reduce unnecessary information, the 271 response now only lists individual benefit amounts for an individual plan, or family benefit amounts for a family plan. To learn more about these updates and how they affect you, visit UnitedHealthcareOnline.com > Tools & Resources > EDI Education for Electronic Transactions > Eligibility & Benefit Inquiry & Response (270/271) > 2017 Updates to Eligibility and Benefits EDI Transactions. If you have questions, contact UnitedHealthcare EDI Support at 800-842-1109 or via our EDI Transaction Support Form.

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Network Bulletin: November 2013 - Volume 58 Network Bulletin: January 2017

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UnitedHealthcare Commercial

UnitedHealthcare Hospital Quality Program – Results Available on myHealthcare Cost Estimator

In May 2017, we’ll send updated Hospital Quality Program Quality Rating Reports to eligible hospitals based on refreshed claims data. In advance of this, we’ll continue to accept through January 2017 reconsiderations for the reports mailed to you in January 2016. Members can find hospital quality information through the myHealthcare Cost Estimator tool. This online and mobile app gives members the transparency they need to help them understand health care costs and quality ratings for specific care providers and hospitals. The tool includes a five-star relative quality rating and comparative cost information for hospitals. The information from Hospital Quality Program Quality Rating Reports is used to create the quality indicators within myHealthcare Cost Estimator. UnitedHealthcare’s Hospital Quality Program provides comparative quality information to help members make informed health care choices about hospitals. The program results are based on key measures for acute care hospitals that include common inpatient conditions and procedures. For more information, go to UnitedHealthcareOnline.com > Clinician Resources > Performance Measurement & Reporting > Hospital Quality Program. If you have any questions, call 866-270-5588 or email hospitalqualityprogram@uhc.com.

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Network Bulletin: November 2013 - Volume 58 Network Bulletin: January 2017

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UnitedHealthcare Commercial

Coding Update to Facility Outpatient Procedure Grouper Mapping

Effective Jan. 1, 2017, the following code updates will be made to the UnitedHealthcare 2016 Outpatient Procedure Grouper (OPG) mapping: •

Expired codes — 39 OPG 0-10 codes expire on Dec. 31, 2016. The codes will be deleted from the UnitedHealthcare OPG Exhibit effective Jan. 1, 2017. 7 OPG unlisted codes expire and will be deleted as well.

•

Newly Published codes — 67 OPG 0-10 codes will be added to the UnitedHealthcare OPG Exhibit effective Jan. 1 2017. 9 OPG unlisted codes will be added as well.

There are no other grouper level assignment changes to existing codes. For reimbursement under the OPG, UnitedHealthcare requires the appropriate line level CPT/Healthcare Common Procedure Coding System (HCPCS) code in addition to the revenue code when billing for outpatient procedures. The updated 2016 UnitedHealthcare OPG Exhibit is available at UnitedHealthcareOnline.com > Claims & Payments > Outpatient Procedure Grouper (OPG). The second tab of the updated OPG Exhibit illustrates the changes from the Oct. 1, 2016 version to the Jan. 1, 2017 version.

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Network Bulletin: November 2013 - Volume 58 Network Bulletin: January 2017

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UnitedHealthcare Commercial

UnitedHealthcare Shared Services Expansion for GEHA

Through a shared services arrangement, UnitedHealthcare provides access to the UnitedHealthcare Options PPO Network to Government Employees Health Association (GEHA) members.* On Jan. 1, 2017, GEHA will begin accessing UnitedHealthcare Options PPO provider contracts in North Carolina and South Carolina. Conifer Health Solutions provides inpatient medical and mental health utilization management for the GEHA membership, and UnitedHealthcare has delegated inpatient Utilization Management Services for this membership (e.g., notification, initial determination, inpatient care management and appeals) to Conifer Health Solutions. Conifer Health Solutions uses MCG guidelines and is URAC-accredited in Health Utilization Management. GEHA is the second-largest national health plan for civilian federal employees. Please check the back of the memberâ€™s ID card for contact information. For eligibility, summary of benefits, outpatient precertification requirements and claim status, call the self-service line at 877-343-1887 or email uhss@umr.com.

* Currently in Alabama, Alaska, Arkansas, Colorado, Washington D.C., Delaware, Hawaii, Idaho, Indiana, Iowa, Louisiana, Maryland, Mississippi, Montana, Minnesota, Nebraska, New Mexico, North Dakota, Ohio, Oklahoma, South Dakota, Tennessee, Texas, Utah, Virginia, West Virginia, Wisconsin, Wyoming.

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Network Bulletin: November 2013 - Volume 58 Network Bulletin: January 2017

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UnitedHealthcare Commercial

Expansion of Radiology and Cardiology Notification/Prior Authorization Protocols to All Savers Plans (Offered Off-exchange) - Effective April 1, 2017

Effective April 1, 2017, care providers must provide notification prior to scheduling a planned service that is subject to UnitedHealthcare’s Outpatient Radiology Notification/Prior Authorization Protocol and Cardiology Notification/Prior Authorization Protocols for a UnitedHealthcare All Savers (offered off-exchange) member. These members can be identified by their ID cards. These protocols include a prior authorization requirement that applies when a UnitedHealthcare member’s benefit document requires health services to be medically necessary to be covered. Once notification has been received, we’ll conduct a clinical coverage review if the member’s benefit document requires health services to be medically necessary to be covered. he Radiology Notification/Prior Authorization Protocol and Cardiology Notification/Prior Authorization Protocol for T UnitedHealthcare Commercial customers are located in UnitedHealthcare’s Physician, Health Care Professional, Facility and Ancillary Provider 2017 Administrative Guide for Commercial and Medicare Advantage Products (“Administrative Guide”). The Administrative Guide is available at UnitedHealthcareOnline.com > Tools & Resources > Policies, Protocols & Guides > Administrative Guides. Additional information also is available at UnitedHealthcareOnline.com > Clinician Resources > Radiology and UnitedHealthcareOnline.com > Clinician Resources > Cardiology.

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Network Bulletin: November 2013 - Volume 58 Network Bulletin: January 2017

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UnitedHealthcare Commercial

UnitedHealthcare Medical Policy, Drug Policy and Coverage Determination Guideline

For complete details on the policy updates listed in the following table, please refer to the December 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

Medical

Jan. 1, 2017

Drug

Feb. 1, 2017

Medical

Jan. 1, 2017

Ocrevus (Ocrelizumab)

Drug

Jan. 1, 2017

Probuphine® (Buprenorphine)

Drug

Jan. 1, 2017

Respiratory Interleukins (IL)

Drug

Jan. 1, 2017

CDG

Jan. 1, 2017

Medical

Dec. 1, 2016

Blepharoplasty, Blepharoptosis and Brow Ptosis Repair

CDG

Feb. 1, 2017

Botulinum Toxins A and B

Drug

Jan. 1, 2017

Breast Reconstruction Post Mastectomy

CDG

Jan. 1, 2017

Breast Repair/Reconstruction Not Following Mastectomy

CDG

Jan. 1, 2017

Medical

Jan. 1, 2017

Clinical Trials

CDG

Jan. 1, 2017

Clotting Factors and Coagulant Blood Products

Drug

Jan. 1, 2017

Continuous Glucose Monitoring and Insulin Delivery for Managing Diabetes

Medical

Jan. 1, 2017

Discogenic Pain Treatment

Medical

Jan. 1, 2017

Electrical Stimulation for the Treatment of Pain and Muscle Rehabilitation

Medical

Jan. 1, 2017

CDG

Jan. 1, 2017

Epiduroscopy, Epidural Lysis of Adhesions and Functional Anesthetic Discography

Medical

Dec. 1, 2016

Femoroacetabular Impingement Syndrome

Medical

Dec. 1, 2016

NEW Electric Tumor Treatment Field Therapy Exondys 51™ (Eteplirsen) Gender Dysphoria Treatment ®

UPDATED/REVISED Ambulance Services Balloon Sinus Ostial Dilation

Chromosome Microarray Testing

Emergency Health Services and Urgent Care Center Services

Continued >

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TABLE OF CONTENTS

< Continued

Policy Title

Policy Type

Effective Date

UPDATED/REVISED

UnitedHealthcare Commercial

UnitedHealthcare Medical Policy, Drug Policy and Coverage Determination Guideline

Fetal Aneuploidy Testing Using Cell-Free Fetal Nucleic Acids in Maternal Blood

Medical

Jan. 1, 2017

Glaucoma Surgical Treatments

Medical

Jan. 1, 2017

Gonadotropin Releasing Hormone Analogs

Drug

Jan. 1, 2017

Habilitative Services for Essential Health Groups

CDG

Jan. 1, 2017

Hearing Aids and Devices Including Wearable, BoneAnchored and Semi-Implantable

Medical

Feb. 1, 2017

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

URG

Jan. 1, 2017

Intensity-Modulated Radiation Therapy

Medical

Jan. 1, 2017

Neurophysiologic Testing

Medical

Jan. 1, 2017

Omnibus Codes

Medical

Jan. 1, 2017

Preventive Care Services

CDG

Jan. 1, 2017

Prosthetic Devices, Wigs, Specialized, Microprocessor or Myoelectric Limbs

CDG

Feb. 1, 2017

Rehabilitation Services (Outpatient)

CDG

Jan. 1, 2017

Sandostatin®/Sandostatin LAR® Depot (Octreotide Acetate)

Drug

Dec. 1, 2016

Stelara® (Ustekinumab) Injection for Intravenous Infusion

Drug

Jan. 1, 2017

Transcatheter Heart Valve Procedures

Medical

Jan. 1, 2017

Vagus Nerve Stimulation

Medical

Jan. 1, 2017

CDG

Jan. 1, 2017

RETIRED/REPLACED Gender Dysphoria (Gender Identity Disorder) Treatment

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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, Protocols and Guides > 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

Moderate Sedation Reimbursement Policy

The current UnitedHealthcare Moderate Sedation reimbursement policy for Commercial plans will be retired effective Jan. 1, 2017. Per the 2017 CPT book, moderate sedation codes 99143-99145 and 99148-99150 have been deleted and replaced by new CPT codes 99151-99157. Additionally, Appendix G in the 2016 CPT book, which included a list of codes that include moderate sedation, is not included in the 2017 CPT book.

The new moderate sedation CPT codes may be reported separately with the codes formerly listed in Appendix G; therefore UnitedHealthcare will no longer maintain a separate reimbursement policy for moderate sedation services. Other existing UnitedHealthcare reimbursement policies will continue to apply Centers for Medicare & Medicaid Services (CMS) and/or American Medical Association (AMA) sourced editing to moderate sedation services reported under the new CPT codes.

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Network Bulletin: November 2013 - Volume 58 Network Bulletin: January 2017

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UnitedHealthcare Community Plan

Electronic Remittance Advice Enhancement UnitedHealthcare Community Plan recently enhanced the member data included in ERA/835 files. Previously, the Electronic Remittance Advice (ERA) contained the state-assigned Medicaid identification number in the NM*109 segment and the UnitedHealthcare member identification number in the REF*1W segment. Now, the NM*109 contains the member identification number as submitted on the claim and is qualified by â€˜MIâ€™ in the NM*108. There is no longer an additional member number in the REF segment. If either the submitted member identification number or the member name does not match our records, the ERA will contain an additional patient/insured NM1 segment with the member identification number and/or member name on file with UnitedHealthcare. If you have any questions, please contact your electronic data interchange (EDI) clearinghouse vendor, call UnitedHealthcare Community Plan at 800-210-8315 or email ac_edi_ops@uhc.com.

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Network Bulletin: November 2013 - Volume 58 Network Bulletin: January 2017

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UnitedHealthcare Community Plan

Preferred Drug List Changes

UnitedHealthcare Community Plan routinely evaluates prescription benefit coverage to offer members clinically- and cost-effective medications. As a result, the UnitedHealthcare Community Plan Preferred Drug List (PDL) is updated each quarter.

•

Lantus

•

Avonex - current users will be grandfathered

•

Rebif - current users will be grandfathered

•

Enbrel (NY EPP plan only)

The following PDL changes are effective this quarter:

•

Proair and Proventil (LA and FL CHIP only)

Effective Jan. 1, 2017, changes were implemented that will affect our Medicaid/CHIP members in the following states and programs: Arizona, Florida Healthy Kids, Hawaii, Louisiana*, Maryland, New Jersey, New Mexico, New York, Ohio and Rhode Island. or Medicaid/CHIP members in Louisiana, the *F changes take effect Feb. 1, 2017. For state-specific PDL details, visit UHCCommunityPlan.com > For Health Care Professionals > State > Pharmacy Program.

The following medications have been added to the PDL as preferred or co-preferred, effective Jan. 1, 2017: •

Delzicol

•

Cosentyx with prior authorization

•

Linzess with prior authorization

•

Plegridy with prior authorization

•

Odefsey

•

Varubi

•

Veltassa with prior authorization

PDL changes: The following medications were removed from the PDL on Jan. 1, 2017. Members taking these medications will need to switch to an alternative medication on the PDL:

•

Dificid with prior authorization

•

Impavido with prior authorization

•

Venclexta with prior authorization

•

Lialda

•

Cabometyx with prior authorization

•

Pentasa

•

Cetylev with supply limit

•

Actoplus Met

•

Actoplus Met XR

Alogliptin, Alogliptin/ Metformin, Alogliptin/ Pioglitazone with step therapy

•

Duetact

•

Urea 10% and 20% cream, 10% lotion

•

Tradjenta

•

Jentadueto

Simponi and Stelara with prior authorization (NY EPP plan only)

•

Onglyza

•

Basaglar

•

Kombiglyze

Continued >

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< Continued

PDL changes:

UnitedHealthcare Community Plan

Preferred Drug List Changes

Member Current Medication

Alternate Medication

Comments

Mesalamines Lialda Pentasa

Transition all users to: • Apriso • Delzicol

Exception: Pentasa will remain on the Arizona PDL

Transition all users to: • Metformin IR • Metformin ER (glucophage XR) • Pioglitazone • Glimepiride

Exception: Actoplus Met (not XR) will remain on the Louisiana PDL Exception: Actoplus Met and Actoplus Met XR will remain on the Arizona PDL

Multiple Sclerosis Interferons Avonex Rebif

Current users grandfathered, transition all new users to: • Plegridy

Does not apply to members in Arizona

Albuterols Proair Proventil

Transition all users to: • Ventolin HFA

Applies to Louisiana and Florida CHIP ONLY

TNF Agents Enbrel

Current users grandfathered, Transition all new users to: • Humira • Cimizia • Stelara • Simponi

Applies to New York EPP ONLY

Tradjenta Jentadueto Onglyza Kombiglyze

Transition all users to: • Alogliptin • Alogliptin/metformin

Does not apply to members in Arizona

Diabetes Combination Drugs: Actoplus Met Actoplus Met XR Duetact

The following medications are being removed from the PDL effective Jan. 1, 2017. Current utilizers of these medications will have until April 1, 2017 to switch to an alternative medication on the PDL. •

Lantus Vial

•

Lantus Solostar

•

Levemir Vial*

•

Levemir Flextouch*

*Note: Therapeutic transition required. Medication is currently non-preferred. Current users will need to switch to a preferred medication.

Continued >

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< Continued

Member Current Medication

Alternate Medication

Comments

Transition all users to preferred insulins: • Toujeo • Basaglar

UnitedHealthcare Community Plan

Preferred Drug List Changes

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Basal Insulins Lantus Vial Lantus Solostar Levemir Vial Levemir Flextouch

Network Bulletin: November 2013 - Volume 58 Network Bulletin: January 2017

– Change effective Jan. 1, 2017 for new users and transition begins on Jan. 1, 2017 for current users – Lantus and Levemir users will have a 90-day transition period to switch by April 1, 2017 – As of April 1, 2017, Lantus and Levemir products will not be covered

Does not apply to members in Arizona

For more information, call 877.842.3210 or visit UnitedHealthcareOnline.com

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UnitedHealthcare Community Plan

New Prior Authorization Requirements for Injectable Medications

Effective April 1, 2017, UnitedHealthcare Community Plan will require prior authorization for the following injectable medications. The prior authorization requirement applies to members new to therapy and members currently on these medications. •

Cinqair® (reslizumab) and Nucala® (mepolizumab) are indicated for the add-on maintenance treatment of patients with severe asthma who have an eosinophilic phenotype.

•

Ocrevus™ (ocrelizumab) is indicated for the treatment of primary progressive multiple sclerosis and relapsing/remitting multiple sclerosis.

•

Probuphine® (buprenorphine) subdermal implant is indicated for the maintenance treatment of opioid dependence in patients who have achieved and sustained prolonged clinical stability on low-to-moderate doses of a transmucosal buprenorphine-containing product (i.e., doses of no more than 8 mg per day of buprenorphine sublingual tablet equivalent).

This applies to UnitedHealthcare Community Plan members in the following states: Arizona

Delaware

Florida

Louisiana

Maryland

Michigan

New York

Ohio

Mississippi

Nebraska

New Jersey

New Mexico

Pennsylvania

Rhode Island

Tennessee

Texas

Please note that the prior authorization requirement for Probuphine does not apply to Mississippi. The prior authorization requirement for these medications does not apply to the following UnitedHealthcare Community Plan plans: •

UnitedHealthcare Dual Complete® plans

•

Medicare-Medicaid Enrollees (MME) – UnitedHealthcare Connected® for MyCare Ohio – UnitedHealthcare Connected® (in Texas) – UnitedHealthcare Senior Care Options (in Massachusetts)

If the prior authorization process is not completed prior to the administration or insertion of these medications, your claim will be denied. Care providers cannot bill members for services that are denied due to failure to complete the prior authorization process. You can request prior authorization in two ways:

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•

Sign in to UnitedHealthcareOnline.com and go to Notifications/Prior Authorizations > Notification/Prior Authorization Submission.

•

Complete a prior authorization form and fax it with the necessary medical records to the fax number at the top of the prior authorization form. Forms are available at UHCCommunityPlan.com > For Health Care Professionals > Select your state > Provider Forms. If you have any questions, please call the Provider Services number on the back of your patient’s member ID card.

Network Bulletin: November 2013 - Volume 58 Network Bulletin: January 2017

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UnitedHealthcare Community Plan

Outpatient Injectable Chemotherapy Prior Authorization Program for UnitedHealthcare Community Plan in Delaware, New Jersey, New York, Pennsylvania and Texas

Effective Jan. 1, 2017, UnitedHealthcare Community Plan members in New Jersey, Texas and Delaware will require prior authorization for injectable outpatient chemotherapy drugs given for a cancer diagnosis. Effective Feb. 1, 2017, UnitedHealthcare Community Plan members in Pennsylvania and New York 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 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 New Jersey, Texas or Delaware received injectable chemotherapy drugs in an outpatient setting Oct. 1, 2016 through Dec. 31, 2016, you do not need to submit a prior authorization request until a new chemotherapy drug is administered. We will authorize the chemotherapy regimen the member was receiving prior to Jan. 1, 2017, and the authorization will be effective until Dec. 31, 2017. If a UnitedHealthcare Community Plan member in Pennsylvania or New York received injectable chemotherapy drugs in an outpatient setting Nov. 1, 2016 through Jan. 31, 2017, you do not need to submit a prior authorization request until a new chemotherapy drug is administered. We will authorize the chemotherapy regimen the member was receiving prior to Feb. 1, 2017, and the authorization will be effective until Jan. 31, 2018. To complete a prior authorization request, go to UnitedHealthcareOnline.com > Notifications/Prior Authorizations > Oncology Authorizations Submission & Status. For more information or to request prior authorization by phone, call 866-889-8054.

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UnitedHealthcare Community Plan

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 December 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

Electric Tumor Treatment Field Therapy

Medical

Feb. 1, 2017

Gender Dysphoria Treatment

Medical

Jan. 1, 2017

Balloon Sinus Ostial Dilation

Medical

Dec. 1, 2016

Blepharoplasty, Blepharoptosis, and Brow Ptosis Repair

CDG

Feb. 1, 2017

Breast Reconstruction Post Mastectomy

CDG

Jan. 1, 2017

Breast Repair/Reconstruction Not Following Mastectomy

CDG

Jan. 1, 2017

Chromosome Microarray Testing

Medical

Feb. 1, 2017

Continuous Glucose Monitoring and Insulin Delivery for Managing Diabetes

Medical

Feb. 1, 2017

Discogenic Pain Treatment

Medical

Feb. 1, 2017

Electrical Stimulation for the Treatment of Pain and Muscle Rehabilitation

Medical

Feb. 1, 2017

Emergency Health Services and Urgent Care Center Services (Maryland Only)

CDG

Dec. 1, 2016

Epiduroscopy, Epidural Lysis of Adhesions and Functional Anesthetic Discography

Medical

Dec. 1, 2016

Femoroacetabular Impingement Syndrome

Medical

Dec. 1, 2016

Fetal Aneuploidy Testing Using Cell-Free Fetal Nucleic Acids in Maternal Blood

Medical

Jan. 1, 2017

Glaucoma Surgical Treatments

Medical

Feb. 1, 2017

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

Medical

Feb. 1, 2017

Intensity-Modulated Radiation Therapy

Medical

Feb. 1, 2017

NEW

UPDATED/REVISED

Continued >

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< Continued

Policy Title

Policy Type

Effective Date

Neurophysiologic Testing

Medical

Feb. 1, 2017

Omnibus Codes

Medical

Prosthetic Devices, Specialized, Microprocessor or Myoelectric Limbs

CDG

Feb. 1, 2017

Transcatheter Heart Valve Procedures

Medical

Feb. 1, 2017

Vagus Nerve Stimulation

Medical

Jan. 1, 2017

CDG

Jan. 1, 2017

UPDATED/REVISED

UnitedHealthcare Community Plan

UnitedHealthcare Community Plan Medical Policy & Coverage Determination Guideline Updates

34 34

Jan. 1, 2017 Feb. 1, 2017

RETIRED/REPLACED Gender Dysphoria (Gender Identity Disorder) Treatment

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UnitedHealthcare Medicare Solutions

Virtual Visits On Jan. 1, 2017, UnitedHealthcare will begin offering Virtual Visits to our group Medicare Advantage plan members* to help reduce costs for low-acuity care. UnitedHealthcare will work with Doctor on Demand and American Well to deliver covered Virtual Visit services to UnitedHealthcare plan members. Virtual Visits will be covered by UnitedHealthcare when they include the diagnosis and treatment of low-acuity medical conditions for members through real-time, interactive audio and video telecommunication and transmissions. Benefits coverage doesn’t include email, fax or standard telephone calls (without video interaction) or telehealth/telemedicine visits that occur within medical facilities defined as originating facilities by the Centers for Medicaid & Medicare Services. Virtual Visits offer plan members another choice in how to access health care. Not all medical conditions can be treated through these visits. Virtual Visits physicians will alert patients if they need to see a doctor for in-person treatment. The plan member’s Virtual Visit cost for services rendered by Doctor on Demand and American Well share will be $0 in 2017. If you are part of a medical group in a capitation/delegation arrangement with UnitedHealthcare Group Medicare Advantage HMO, UnitedHealthcare will take financial responsibility for the cost of the Virtual Visit. We’d like to learn more from you about your organization’s awareness, development and implementation of a Virtual Visit service option. If you’d like to learn more about these Visits or how to provide them to UnitedHealthcare plan members, please contact your Physician Advocate. * Group Medicare Advantage plan members are those with plan ID cards carrying either of the following brand names: UnitedHealthcare Group Medicare Advantage (HMO) or UnitedHealthcare Group Medicare Advantage (PPO).

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UnitedHealthcare Medicare Solutions

Place of Service 32/33 Professional Services Member Cost-Share

As a reminder, members are responsible for cost-sharing associated with covered professional services they receive when billed with a place of service code 32 (nursing facility) or 33 (custodial care facility), per the terms of their benefit plan. This member cost-share will be detailed on the Provider Remittance Advice you receive for the billed services.

Medicare Advantage Prior Authorization Reduction Pilot Program: Radiation Therapy Requirements In the December Network Bulletin article “Pilot Program Eliminates Most Prior Authorization Requirements for Eligible Medicare Advantage Members – Effective Jan. 1, 2017,” the link for radiation therapy prior authorization lists was missing. Benefit plans with changes to prior authorization requirements taking effect Jan. 1, 2017, will be listed in the prior authorization lists at UnitedHealthcareOnline.com > Clinician Resources > Oncology > Medicare Advantage Therapeutic Radiation > Reference Materials for radiation therapy services.

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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 December 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 Nov. 15, 2016) Age Related Macular Degeneration (AMD) Therapy (Macugen速, Lucentis速, Avastin速, EYLEA速) Cosmetic and Reconstructive Procedures Family Planning (Birth Control) Foot Care Services Hearing Aids, Auditory Implants and Related Procedures Hyperbaric Oxygen Therapy Ostomy Supplies Positron Emission Tomography (PET)/Combined PET-CT (Computed Tomography) Radiologic Therapeutic Procedures Services While Confined/Incarcerated Spine Procedures Vertebral Artery Surgery

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UnitedHealthcare Medicare Solutions

UnitedHealthcare Medicare Advantage Policy Guideline Updates

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 UnitedHealthcareOnline.com > Tools & Resources > Policies, Protocols and Guides > UnitedHealthcare Medicare Advantage Policy Guidelines.

Policy Title UPDATED/REVISED (Approved on Nov. 9, 2016) Cardiointegram (CIG) as an Alternative to Stress Test or Thallium Stress Test (NCD 20.27) Challenge Ingestion Food Testing (NCD 110.12) Chelation Therapy for Treatment of Atherosclerosis (NCD 20.21) Diagnostic Endocardial Electrical Stimulation (Pacing) (NCD 20.12) Displacement Cardiography (NCD 20.24) Electrocardiographic (EKG) Services (NCD 20.15) Epidural Injection Erythropoiesis Stimulating Agents (ESAs) in Cancer and Related Neoplastic Conditions (NCD 110.21) Erythropoietin Stimulating Agent (ESA) Ethylenediamine-Tetra-Acetic (EDTA) Chelation Therapy for Treatment of Atherosclerosis (NCD 20.22) External Electrocardiographic Recording Hair Analysis (NCD 190.6) HIS Bundle Study (NCD 20.13) Hyperbaric Oxygen Therapy (NCD 20.29) Infrared Therapy Devices (NCD 270.6) Intravenous Histamine Therapy (NCD 30.6) Lymphocyte Immune Globulin, Anti-Thymocyte Globulin (Equine) (NCD 260.7) Continued >

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< Continued

Policy Title UPDATED/REVISED (Approved on Nov. 9, 2016) Molecular Pathology/Molecular Diagnostics/Genetic Testing

UnitedHealthcare Medicare Solutions

Peridex CAPD Filtration Set (NCD 230.13) Plethysmography (NCD 20.14) Qualitative Drug Testing for Indications Other Than Mental Health

UnitedHealthcare Medicare Advantage Policy Guideline Updates

Screening for Hepatitis C Virus (HCV) in Adults (NCD 210.13) Screening for Sexually Transmitted Infections (STIs) and High-Intensity Behavioral Counseling (HIBC) to Prevent STIs (NCD 210.10) Services Provided for the Diagnosis and Treatment of Diabetic Sensory Neuropathy with Loss of Protective Sensation (aka Diabetic Peripheral Neuropathy) (NCD 70.2.1) Transfer Factor for Treatment of Multiple Sclerosis (NCD 160.20) Transportation Services Ultrafiltration Monitor (NCD 230.14) Ultrafiltration, Hemoperfusion, and Hemofiltration (NCD 110.15) Vagus Nerve Stimulation (VNS) (NCD 160.18) RETIRED (Approved on Nov. 9, 2016) Transformation Surgery

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UnitedHealthcare Military & Veterans

Beneficiary Waiver Required When Billing for Services Not Covered by TRICARE To help TRICARE beneficiaries manage their care and understand their benefits, TRICARE network providers must notify beneficiaries in advance when they receive a service not covered by TRICARE. TRICARE won’t reimburse for non-covered services and network providers can only bill beneficiaries for those services if the beneficiary signs a waiver of non-covered services. The signed waiver confirms that the beneficiary has agreed in advance to pay for non-covered services. Providers must keep copies of all signed beneficiary waivers. Waiver of Non-Covered Services Form The TRICARE Beneficiary Liability Form (Waiver of Non-Covered Services) documents that the beneficiary is properly informed in advance that TRICARE does not cover a particular service and agrees in writing to be financially responsible for all costs associated with the non-covered services. he form is available at UHCMilitaryWest.com > T Providers > Find a Form > TRICARE Beneficiary Liability Form (Waiver of Non-Covered Services). Providers do not need to use this exact form. However, a general statement of financial liability doesn’t satisfy TRICARE’s requirement.

Continued >

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< Continued

A valid waiver of non-covered TRICARE services must include the following in writing:

UnitedHealthcare Military & Veterans

Beneficiary Waiver Required When Billing for Services Not Covered by TRICARE

41 41

•

Confirmation that the rendering provider is a network provider

•

A listing of the specific non-covered service or procedure

•

Notification that the service or procedure is not covered by TRICARE

•

The statement that, before the services are provided, the beneficiary understands the listed services are not covered by TRICARE and agrees to be financially responsible for the non-covered services

•

The beneficiary’s signature and date More information on TRICARE coverage and the Waiver of Non-Covered Services requirement is in the TRICARE Provider Handbook at UHCMilitaryWest.com > Providers > Provider Resources > Provider Handbook. If you have questions, please contact your Provider Advocate.

Network Bulletin: November 2013 - Volume 58 Network Bulletin: January 2017

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UnitedHealthcare Military & Veterans

TRICARE’s Telemental Health Care Benefits

TRICARE is using interactive technology to help connect beneficiaries to behavioral health services where traditional in-person behavioral health care may not be readily available. To support access to telemental health services, UnitedHealthcare Military & Veterans established a network of originating sites and a network of offsite, distant providers. Beneficiaries make an appointment at an originating site and use interactive audio and video to connect with a distant TRICARE-authorized behavioral health provider for all aspects of behavioral health services, including evaluation, treatment or referral for additional care. Find an originating site at UHCMilitaryWest.com > Find Care > Behavioral Health Facilities & Clinician Search and select “Telemental Health.” TRICARE’s policies can help you manage the behavioral health care for TRICARE beneficiaries and help you avoid issues that may affect your claims. For claims to process correctly, TRICARE defines how the service is delivered from an originating site: 1. Telemental health care may only be delivered at a designated originating site. These originating sites are in offices and other locations where authorized TRICARE providers already offer professional medical or psychological services and have the capability to connect remotely with behavioral health care providers. A beneficiary’s home is not an originating site. Therefore, phone calls or use of applications like Skype or FaceTime from a beneficiary’s home would not be authorized. 2. Originating sites offer beneficiaries and distant providers two-way, real-time communications using audio and video. Telemental health care policies are in the TRICARE Policy Manual, Chapter 7, Section 22.1 (manuals.tricare.osd.mil). Active duty service members will need a referral for any type of behavioral health care, including telemental health. TRICARE Prime active duty family members and retirees do not need a referral or authorization to set a telemental health appointment with a distant provider, as long as that appointment is one of the first eight behavioral health sessions in a fiscal year. RICARE’s telemental health services are not available to beneficiaries who live overseas, are enrolled in the U.S. T Family Health Plan or use TRICARE For Life. Beneficiaries can find more information on using the telemental health benefit at UHCMilitaryWest.com > Beneficiaries > Behavioral Health Programs. If you have questions about telemental health care services, please contact your Provider Advocate.

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Doing Business Better

Virtual Card Payment Option Available for Small Practices Electronic Payments and Statements (EPS) offers electronic funds transfer (EFT) by direct deposit and electronic remittance advice (ERA). Now, you have the additional option of Virtual Card Payments (VCP) for UnitedHealthcare Commercial, Medicare and Medicaid plans. VCP offers a secure electronic payment method that uses credit card-based payment technology. After enrollment, you’ll receive one or more mailers with a card number for your first payment (actual cards are not issued). For all subsequent payments, you’ll receive an email notification only and you can process your payment with the same card number. As with direct deposit, you’ll no longer receive paper remittance advices and can access your information on the EPS website or enroll to receive 835 files for auto posting. User-friendly online remittance advice can be saved, viewed or printed to post payments manually. More information about payment posting is available at WelcometoEPS.com. You can also view a video to see how the website works or register for an instructor-led webcast.

Continued >

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< Continued

VCP Compared to Direct Deposit Both options allow you to receive payments and remittances five to seven days faster than with paper and reduce your risk for lost, misrouted or stolen checks. Additionally, you may be able to eliminate lock box fees if you have any. The following table highlights the differences between direct deposit and VCP:

Doing Business Better

Direct Deposit

VCP

• No credit card processing fees from your merchant processor

Virtual Card Payment Option Available for Small Practices

• Money is deposited directly into the account(s) you designate.

• VCP has maximum payment and card balance amounts ($50,000; $100,000 respectively), which may cause some payments to be issued on paper.

• Payments and remittances can be separated by NPI and/or payer. • UnitedHealthcare cannot withdraw funds to recoup overpayments. • An internet connection is required to access remittance advice.

• Credit card processing fees apply (confirm amount with your merchant processor). • You will receive a separate card number for each payer ID that provides payments. • There is no need to share your bank account information to receive VCP. • You must have a credit card machine to process your payments and an internet connection to access your remittance advice.

To learn more or enroll, please visit UnitedHealthcareOnline.com > Quick Links > Electronic Payments and Statements. Or you can call 877-620-6194 to speak with an EPS representative.

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Network Bulletin: November 2013 - Volume 58 Network Bulletin: January 2017

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Doing Business Better

Direct Deposit Available through UHCWest.com

UnitedHealthcare has an exciting opportunity for Signature Value and Medicare and Retirement claim providers. Direct deposit is available now by enrolling through UHCWest.com. Visitors then should navigate to: •

Services and Tools

•

Electronic Payments Enrollment Process

Please complete the e-form and e-mail a voided check or bank letter to phs_eft@uhc.com. Only one registration is needed per tax identification number. Care providers can enroll for access to UHCWest.com by: •

Going to “Log In” as a Provider

•

Selecting Register – “No User ID”

•

Selecting “Register with UnitedHealthcare ID or Tax ID”

•

Completing registration and clicking submit

UnitedHealthcare HIPAA 835 electronic remittance advice may be activated through your existing clearinghouse. The payer ID is 95959 for UnitedHealthcare West.

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Network Bulletin: November 2013 - Volume 58 Network Bulletin: January 2017

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UnitedHealthcare Affiliates

Reminder: Upcoming Changes to OneNet Claim Status Search and OneNet Medical Runout Starting Feb. 23, 2017, the OneNet Claim Status Search on UnitedHealthcareOnline.com will only display claims for employers and third-party administrators accessing the OneNet Workers’ Compensation Network through Procura Management, Inc. (Procura), an Optum Company. You’ll no longer be able to view past OneNet PPO medical claim pricing or workers’ compensation claims for former clients other than Procura. (Please see the December Network Bulletin for more information on these changes.) All OneNet medical claim runout processing will end on March 15, 2017. If you have any OneNet medical claims with dates of service prior to March 15, 2016 that still require pricing, please submit them to: OneNet PPO / MAPSI Claims, P.O. Box 934, Frederick, MD 21705-0934. This post office box will be closed on March 15, 2017, and we will no longer accept claim submissions by EDI as of Feb. 8, 2017. Please contact the appropriate payer directly after March 15, 2017 with any claim-related questions. Payment of these claims will be subject to the payer’s timely filing requirements. Workers’ compensation claims should not be sent directly to OneNet or Procura. Submit these claims to the injured worker’s employer or workers’ compensation carrier or administrator. For more information, contact OneNet Customer Care at 800-342-3289.

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Network Bulletin: November 2013 - Volume 58 Network Bulletin: January 2017

For more information, call 877.842.3210 or visit UnitedHealthcareOnline.com

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UnitedHealthcare Affiliates

Cancer Support Program for Oxford Fully-Insured Members

At UnitedHealthcare, we continually evaluate the needs of our members and offer programs and services to help our members live healthier lives. As a result of this effort, we are pleased to offer the Cancer Support program to members of our Oxford fully-insured medical plans, beginning Jan. 1, 2017. The program seeks to provide additional support to Oxford members who have been diagnosed with cancer. It offers these members and their caregivers direct phone access to oncology-trained nurses and social workers. The Cancer Support team provides cancer information and guidance in navigating the health care system, and it helps members achieve optimal clinical outcomes. The team will work with the member’s physician for the best implementation of the treatment plan. We understand the complex needs of cancer patients and we know those needs vary by patient. The Cancer Support program offers members access to a new level of personal assistance dedicated to each member. The team works to help members prevent and manage symptoms and side effects before they become severe. It educates members to help them make informed decisions about their care and take an active role in their treatment. The team’s goal is to help members remain productive, get healthy and stay healthy. The program is voluntary for adult and pediatric members with all types of cancer. It’s part of the fully-insured medical benefit and there is no additional charge to members. Members can self-enroll by calling 866-936-6002, or the plan may reach out to them directly. Care providers also can refer members by calling the same phone number. The Cancer Support program is already in place with Oxford self-funded clients who have chosen to make this program available to their plan participants.

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Network Bulletin: November 2013 - Volume 58 Network Bulletin: January 2017

For more information, call 877.842.3210 or visit UnitedHealthcareOnline.com

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UnitedHealthcare Affiliates

Expansion of UnitedHealthcare of the River Valley Ohio Radiology and Cardiology Notification/Prior Authorization Protocols – Effective April 1, 2017

Effective April 1, 2017, care providers must provide notification prior to scheduling a planned service that is subject to UnitedHealthcare’s Outpatient Radiology Notification/Prior Authorization Protocol and Cardiology Notification/Prior Authorization Protocols for a UnitedHealthcare of the River Valley Ohio member. These members can be identified by their ID cards. These protocols include a prior authorization requirement that applies when a UnitedHealthcare member’s benefit document requires health services to be medically necessary to be covered. Once notification of a planned service is received, we’ll conduct a clinical coverage review if the member’s benefit document requires health services to be medically necessary to be covered. he Radiology Notification/Prior Authorization Protocol and Cardiology Notification/Prior Authorization Protocol for T UnitedHealthcare Commercial members are located in UnitedHealthcare’s Physician, Health Care Professional, Facility and Ancillary Provider 2017 Administrative Guide for Commercial and Medicare Advantage Products (“Administrative Guide”). The Administrative Guide is available at UnitedHealthcareOnline.com > Tools & Resources > Policies, Protocols & Guides > Administrative Guides. For more information on these protocols, go to UnitedHealthcareOnline.com > Clinician Resources > Radiology and UnitedHealthcareOnline.com > Clinician Resources > Cardiology.

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Network Bulletin: November 2013 - Volume 58 Network Bulletin: January 2017

For more information, call 877.842.3210 or visit UnitedHealthcareOnline.com

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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 December 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

Applicable State(s)

REVISED (Effective Jan. 1, 2017) Durable Medical Equipment (DME), Prosthetics, Corrective Appliances/ Orthotics (Non-Foot Orthotics) and Medical Supplies Grid

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

Gender Dysphoria (Gender Identity Disorder) Treatment

Oregon, & Washington

Habilitative Services

All

Member Initiated Second and Third Opinion

All

Pervasive Developmental Disorder and Autism Spectrum Disorder

California

Preventive Care Services

Oklahoma, Oregon, Texas, & Washington

Rehabilitation Services (Physical, Occupational, and Speech Therapy)

All

Telemedicine/Telehealth Services/Virtual Visits

All

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Network Bulletin: November 2013 - Volume 58 Network Bulletin: January 2017

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UnitedHealthcare Affiliates

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 December 2016 SignatureValue/UnitedHealthcare Benefits Plan of California Medical Management Guidelines Update Bulletin at UHCWest.com > Provider Log In > Library > Resource Center > Guidelines & Interpretation Manuals. Policy Title

Effective Date

NEW Electric Tumor Treatment Field Therapy

Jan. 1, 2017

Gender Dysphoria Treatment Excluding California

Jan. 1, 2017

UPDATED/REVISED Balloon Sinus Ostial Dilation

Dec. 1, 2016

Breast Reconstruction Post Mastectomy

Jan. 1, 2017

Breast Repair/Reconstruction Not Following Mastectomy

Jan. 1, 2017

Chromosome Microarray Testing

Jan. 1, 2017

Continuous Glucose Monitoring and Insulin Delivery for Managing Diabetes

Jan. 1, 2017

Discogenic Pain Treatment

Jan. 1, 2017

Electrical Stimulation for the Treatment of Pain and Muscle Rehabilitation

Jan. 1, 2017

Epiduroscopy, Epidural Lysis of Adhesions and Functional Anesthetic Discography

Dec. 1, 2016

Femoroacetabular Impingement Syndrome

Dec. 1, 2016

Fetal Aneuploidy Testing Using Cell-Free Fetal Nucleic Acids in Maternal Blood

Jan. 1, 2017

Glaucoma Surgical Treatments

Jan. 1, 2017

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

Feb. 1, 2017

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

Jan. 1, 2017

Continued >

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Network Bulletin: November 2013 - Volume 58 Network Bulletin: January 2017

For more information, call 877.842.3210 or visit UnitedHealthcareOnline.com

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< Continued

UnitedHealthcare Affiliates

SignatureValue/ UnitedHealthcare Benefits Plan of California Medical Management Guideline Updates

Policy Title

Effective Date

Intensity-Modulated Radiation Therapy

Jan. 1, 2017

Intensive Behavioral Therapy for Autism Spectrum Disorder

Jan. 1, 2017

Mechanical Circulatory Support Device (MCSD)

Dec. 1, 2016

Neurophysiologic Testing

Jan. 1, 2017

Omnibus Codes

Jan. 1, 2017

Preventive Care Services

Jan. 1, 2017

Transcatheter Heart Valve Procedures

Jan. 1, 2017

Vagus Nerve Stimulation

Jan. 1, 2017

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Network Bulletin: November 2013 - Volume 58 Network Bulletin: January 2017

For more information, call 877.842.3210 or visit UnitedHealthcareOnline.com

TABLE OF CONTENTS

UnitedHealthcare Affiliates

Oxford® Medical and Administrative Policy Updates

For complete details on the policy updates listed in the following table, please refer to the December 2016 Policy Update Bulletin at OxfordHealth.com > Providers > Tools & Resources > Medical Information > Medical and Administrative Policies > Policy Update Bulletin. Policy Title

Policy Type

Effective Date

Electric Tumor Treatment Field Therapy

Clinical

Jan. 1, 2017

Exondys 51™ (Eteplirsen)

Clinical

Feb. 1, 2017

Ocrevus® (Ocrelizumab)

Clinical

Jan. 1, 2017

Probuphine® (Buprenorphine)

Clinical

Jan. 1, 2017

Respiratory Interleukins (IL) Policy

Clinical

Jan. 1, 2017

Assisted Administration of Clotting Factors and Coagulant Blood Products

Clinical

Jan. 1, 2017

Balloon Sinus Ostial Dilation

Clinical

Dec. 1, 2016

Botulinum Toxins A and B

Clinical

Jan. 1, 2017

Breast Imaging for Screening and Diagnosing Cancer

Clinical

Jan. 1, 2017

Breast Reconstruction Post Mastectomy

Clinical

Jan. 1, 2017

Breast Repair/Reconstruction Not Following Mastectomy

Clinical

Jan. 1, 2017

Clotting Factors and Coagulant Blood Products

Clinical

Jan. 1, 2017

Continuous Glucose Monitoring and Insulin Delivery for Managing Diabetes

Clinical

Jan. 1, 2017

Coordination of Benefits

Administrative

Dec. 1, 2016

Dialysis Services

Administrative

Jan. 1, 2017

Discogenic Pain Treatment

Clinical

Jan. 1, 2017

Drug Coverage Criteria - New and Therapeutic Equivalent Medications

Clinical

Jan. 1, 2017

NEW

UPDATED/REVISED

Continued >

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Network Bulletin: November 2013 - Volume 58 Network Bulletin: January 2017

For more information, call 877.842.3210 or visit UnitedHealthcareOnline.com

TABLE OF CONTENTS

< Continued

Policy Title

Policy Type

Effective Date Dec. 1, 2016

Drug Coverage Guidelines

Clinical Jan. 1, 2017

UnitedHealthcare Affiliates

Oxford® Medical and Administrative Policy Updates

Eloctate™ (Antihemophilic Factor (Recombinant), FC Fusion Protein) for Connecticut Lines of Business and New Jersey Individual Plans

Clinical

Jan. 1, 2017

Erectile Dysfunction Agents

Clinical

Jan. 1, 2017

Fetal Aneuploidy Testing Using Cell-Free Fetal Nucleic Acids in Maternal Blood

Clinical

Jan. 1, 2017

Gender Dysphoria Treatment

Clinical

Jan. 1, 2017

Glaucoma Surgical Treatments

Clinical

Jan. 1, 2017

Gonadotropin Releasing Hormone Analogs

Clinical

Jan. 1, 2017

Hip Resurfacing Arthroplasty

Clinical

Dec. 1, 2016

Hospice Care

Administrative

Jan. 1, 2017

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

Clinical

Jan. 1, 2017

In-Network Exceptions for Breast Reconstruction Surgery Following Mastectomy

Clinical

Jan. 1, 2017

Member Administrative Grievance & Appeal (Non UM) Process & Timeframes

Administrative

Dec. 1, 2016

Neurophysiologic Testing

Clinical

Jan. 1, 2017

Non-Participating Provider Consent Form Protocol

Administrative

Jan. 1, 2017

Nonphysician Health Care Professionals Billing Evaluation and Management Codes

Reimbursement

Jan. 1, 2017

Omnibus Codes

Clinical

Jan. 1, 2017

Outpatient Physical and Occupational Therapy (Optumhealth Care Solutions Arrangement)

Clinical

Jan. 1, 2017

Practitioner/Provider Administrative Claim Reconsideration and Appeal Process

Administrative

Dec. 1, 2016

Preventive Care Services

Clinical

Jan. 1, 2017

Sandostatin LAR® Depot (Octreotide Acetate)

Clinical

Jan. 1, 2017

Continued >

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Network Bulletin: November 2013 - Volume 58 Network Bulletin: January 2017

For more information, call 877.842.3210 or visit UnitedHealthcareOnline.com

TABLE OF CONTENTS

< Continued

UnitedHealthcare Affiliates

Oxford® Medical and Administrative Policy Updates

Policy Title

Policy Type

Effective Date

Stelara® (Ustekinumab) Injection for Intravenous Infusion

Clinical

Jan. 1, 2017

Synagis® (Palivizumab)

Clinical

Dec. 1, 2016

Transcatheter Heart Valve Procedures

Clinical

Jan. 1, 2017

Vagus Nerve Stimulation

Clinical

Jan. 1, 2017

Agents for Migraine - Triptans

Clinical

Jan. 1, 2017

Buprenorphine/Naloxone Products (Bunavail, Suboxone Film, Generic Buprenorphine/Naloxone)

Clinical

Jan. 1, 2017

Diabetes Medications

Clinical

Jan. 1, 2017

Diabetic Insulins

Clinical

Jan. 1, 2017

Diabetic Test Strips and Meters

Clinical

Jan. 1, 2017

Select Brand Medications

Clinical

Jan. 1, 2017

REPLACED

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

54 54

coverage provided All Savers Insurance Company or its affiliates. Health plan coverage provided by Network Bulletin: November 2013 - Insurance Volume 58 by or through UnitedHealthcare Insurance Company, UnitedHealthcare of Arizona, Inc., UHC of California DBA UnitedHealthcare ofFor California, UnitedHealthcare of Colorado, Inc., UnitedHealthcare of Oklahoma, Inc., more information, call 877.842.3210 Network Bulletin: January 2017 UnitedHealthcare of Oregon, Inc., UnitedHealthcare of Texas, Inc., UnitedHealthcare Benefits of Texas, Inc., UnitedHealthcare of Utah, Inc. and UnitedHealthcare of Network Bulletin: January 2017 Washington, Inc. or other affiliates. Administrative services provided by United HealthCare Services, Inc. OptumRx, OptumHealth Care Solutions, Inc. or its affiliates.

Doc#: PCA-1-004375-12062016_12162016

or visit UnitedHealthcareOnline.com

Behavioral health products are provided by U.S. Behavioral Health Plan, California (USBHPC), United Behavioral Health (UBH) or its affiliates.