Network Bulletin: February 2015
network bulletin
An important message 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
In order to save you time as you go about your
busy day, you can click on any of the articles
below and be taken directly to that article.
You can also return to the Table of Contents
from any page in the Network Bulletin by
simply clicking “Table of Contents” in the top
right-hand corner of any page.
Front & Center
•
Update to Global Surgery Reimbursement Policy
•
Injectable Chemotherapy Prior Authorization Program
•
Credentialing Plan Changes Effective April 1, 2015
•
IMRT Prior Authorization Requirement
for Commercially Insured Members
•
Preauthorization List Additions for UnitedHealthcare
of the River Valley Commercial Members Delayed
•
Enhanced HIPAA Claim Edits Planned for March 2015
UnitedHealthcare Commercial
•
UnitedHealthcare Medical Policy, Drug Policy,
Coverage Determination Guideline and
Utilization Review Guideline Updates
UnitedHealthcare Medicare Solutions
•
UnitedHealthcare Medicare Advantage
Coverage Summary Updates
UnitedHealthcare Military & Veterans
•
E-Prescribing – Now Available
at Military Pharmacies
UnitedHealthcare Commercial
Reimbursement Policy
•
Revision to the Nonphysician Health
Care Professionals Billing Evaluation
and Management Codes Policy
•
Modifiers Being Added to Services
and Modifiers Not Reimbursable to
Health Care Professionals Policy
Doing Business Better
•
Claim Reconsideration and
Appeal Process Summary
UnitedHealthcare Affiliates
•
UnitedHealthcare of the River Valley
Preauthorization List and Policy Updates
•
SignatureValue™ Benefit
Interpretation Policy Updates
•
SignatureValue™ Medical Management
Guideline Updates
•
UnitedHealthcare Oxford® Medical and
Administrative Policy Updates
UnitedHealthcare Community Plan
•
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Medical Policy & Coverage
Determination Guideline Updates
Network Bulletin: November 2013 - Volume 58
Network Bulletin: February 2015
For more information call 877.842.3210, or visit UnitedHealthc
For more information call 877.842.3210,
or visit UnitedHealthcareOnline.com
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Front & Center
Update to Global Surgery
Reimbursement Policy
To further align with the Centers for Medicare and
Medicaid Services (CMS), UnitedHealthcare will
adopt the CMS process for modifier 78 for Medicare
Advantage plans effective April 1, 2015.
When modifier 78 is reported for a procedure having a Global Days
Value of 010 or 090, UnitedHealthcare will reimburse only for the
intraoperative percentage of the modified procedure, determined
by the intraoperative percentage listed on the CMS Medicare
Physician Fee Schedule (MPFS). This will result in payment
reductions accordingly.
According to the CMS Medicare Claims Processing Manual,
Chapter 12, Section 40.4C: “When a CPT code billed with
modifier ‘-78’ describes the services involving a return trip to the
operating room to deal with complications, pay the value of the
intra-operative services of the code that describes the treatment of
the complications. Refer to Field 18 of the MPFS to determine the
percentage of the global package for the intra-operative services.”
Policy updates to include this information will be published to
UnitedHealthcareOnline.com, and the reductions noted above will
become effective beginning April 1, 2015.
To view the policy, please go to:
UnitedHealthcareOnline.com > Tools & Resources >
Policies, Protocols and Guides > Medicare Advantage
Reimbursement Policies > Global Surgery.
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Network Bulletin: November 2013 - Volume 58
Network Bulletin: February 2015
For more information call 877.842.3210, or visit UnitedHealthc
For more information call 877.842.3210,
or visit UnitedHealthcareOnline.com
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Front & Center
Injectable Chemotherapy Prior Authorization Program
Effective June 1, 2015, providers billing for outpatient injectable chemotherapy for
UnitedHealthcare Commercial members* being treated for a cancer diagnosis are required
to obtain prior authorization for services.
UnitedHealthcare’s Injectable Chemotherapy Prior
Authorization Program will be managed by CareCore
National’s Oncology Division on our behalf and
providers will be able to obtain injectable chemotherapy
authorizations on CareCore’s website. Authorizations that follow the National Comprehensive
Cancer Network (NCCN) regimens will be approved
at the time of the request online. Requests for pediatric
chemotherapy regimens, rare cancers, or chemotherapy
regimens that are not NCCN-recommended, can also
receive a timely response if necessary supporting
documentation is provided at the time of the prior
authorization request.
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Network Bulletin: February 2015
UnitedHealthcare Injectable Chemotherapy Prior
Authorization training and live question and answer
sessions will be held by WebEx.
Registration details will be posted on our website in
April at: UnitedHealthcareOnline.com > Clinician
Resources > Cancer – Oncology > Chemotherapy
Prior Authorization Program.
*UnitedHealthcare Fully Insured and select ASO membership will require
chemotherapy prior authorization. The CareCore National website will assist
providers in identifying members that require prior authorization for chemotherapy.
For more information call 877.842.3210, or visit UnitedHealthc
For more information call 877.842.3210,
or visit UnitedHealthcareOnline.com
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Front & Center
Credentialing Plan Changes Effective April 1, 2015
UnitedHealthcare reviews and updates our Credentialing Plan at least every two years to ensure
continued compliance with all State and Federal regulatory requirements and National Committee
for Quality Assurance (NCQA) accreditation requirements.
The 2015-2016 Credentialing Plan and State and
Federal Regulatory Addendum will become effective
April 1, 2015. The following are some of the key changes:
Section 2.0 Definitions
• Material Restriction: Clarification that a restriction on
or prohibition from performing a service or procedure
typically provided by other practitioners in the same
or a similar specialty is a material restriction that will
result in termination of participation.
Section 4.0 Initial Credentialing of Licensed
Independent Practitioner Applicants
• Clarifies language regarding the impact of a license
sanction from a state where the practitioner is
licensed but is no longer in active practice. License
actions from non-practice states may result in denial/
termination unless the license action is based on
administrative issues or as a result of action taken by
another state licensing board.
To drive continuous improvement in quality through
Healthcare Effectiveness Data and Information Set
(HEDIS) and Centers for Medicare and Medicaid
Services’ Star Ratings measures and efficiency of
health care models, the credentialing entity may,
from time to time, send reports to participating
licensed independent physicians (LIPs) regarding
their performance as compared to peers. To support
physicians in their efforts, when practice patterns
are identified that may represent opportunities to
improve quality and reduce unwarranted variation,
UnitedHealthcare will identify those practice patterns
and provide identified physicians with the tools and
information to improve resource utilization in a way
consistent with evidence-based medicine guidelines.
In the event that unwarranted variation does not
improve, UnitedHealthcare may take actions up to and
including termination of participation status
The Credentialing Plan will be posted to
UnitedHealthcareOnline.com by April 1, 2015.
Section 9.5 Ongoing Monitoring
• New Section E: Quality and Efficiency Performance
Management. UnitedHealthcare has committed to our
members and care providers to support the Triple Aim
of improving the patient care experience, improving
health outcomes, and reducing the cost of health care.
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Network Bulletin: November 2013 - Volume 58
Network Bulletin: February 2015
For more information call 877.842.3210, or visit UnitedHealthc
For more information call 877.842.3210,
or visit UnitedHealthcareOnline.com
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Front & Center
IMRT Prior Authorization Requirement for
Commercially Insured Members
For several years, prior authorization for Intensity Modulated Radiation Therapy (IMRT)
CPT codes 77418 and 0073T has been required. On Jan. 1, 2015, the American Medical
Association (AMA) released CPT code changes affecting the billing for IMRT services and
codes 77418 and 0073T were deleted. Prior authorization will, as a result, be required for the
following codes, effective Jan. 1, 2015:
•
G6015: Intensity modulated treatment delivery,
single or multiple fields/arcs, via narrow spatially and
temporally modulated beams, binary, dynamic mlc, per
treatment session
•
G6016: Compensator-based beam modulation
treatment delivery of inverse planned treatment
using 3 or more high resolution (milled or cast)
compensator, convergent beam modulated fields,
per treatment session
•
77385: Intensity modulated radiation treatment
delivery, includes guidance and tracking, when
performed; simple
•
77386: Intensity modulated radiation treatment
delivery, includes guidance and tracking, when
performed; complex
These codes impact Commercial members of the following
health plans:
• UnitedHealthcare
•
UnitedHealthcare West
•
UnitedHealthcare of the Mid-Atlantic
•
UnitedHealthcare Plan of the River Valley
•
Neighborhood Health Partnership
Please use the G6015 and G6016 codes when billing for
IMRT services in 2015.
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Network Bulletin: February 2015
Prior authorization requests approved in 2014 with an
authorized date range, including services in 2015, are not
affected. A claims crosswalk table will be used to process
claims for CPT codes G6015, G6016, 77385 and 77386,
when an authorization is in place for 77418 and/or 0073T
for authorized dates of service in 2015. Services that are
billed that do not fall within the authorized date range will
require prior authorization.
Revised IMRT fax cover sheets that include
the new CPT codes for IMRT services (G6015,
G6016, 77385 and 77386) are available on at
UnitedHealthcareOnline.com > Clinician Resources
> Oncology > Intensity Modulated Radiation Therapy >
Related Links.
The clinical questions and list of diagnosis codes that
do not require additional clinical information have been
updated to reflect our revised IMRT clinical policy. Prior authorization requests submitted after Jan. 1, 2015
will not be accepted if submitted on the 2014 IMRT fax
cover sheets.
The most efficient way to request prior authorization for
IMRT is to complete the appropriate IMRT clinical form and
fax cover sheet and fax your request.
You may also request prior authorization for IMRT at
UnitedHealthcareOnline.com.
For more information call 877.842.3210, or visit UnitedHealthc
For more information call 877.842.3210,
or visit UnitedHealthcareOnline.com
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Front & Center
Preauthorization List Additions for UnitedHealthcare
of the River Valley Commercial Members Delayed
Previously announced changes have been delayed until further notice for UnitedHealthcare
of the River Valley commercial members and participating providers that are subject to the
River Valley Entities Supplement. Updates regarding the changes will be included in a future
issue of the Network Bulletin.
In the November 2014 Network Bulletin, we announced a
new requirement with respect to certain radiology services
that would become effective Feb. 16, 2015 for River Valley
commercial members and participating providers that are
subject to the River Valley Entities Supplement.
Given the delay and until further notice, providers will not
be required to obtain preauthorization prior to rendering
certain advanced imaging procedures provided to River
Valley Commercial members, including: Computerized
Tomography (CT), Magnetic Resonance Imaging (MRI),
Magnetic Resonance Angiography (MRA), PositronEmission Tomography (PET), Nuclear Medicine and
Nuclear Cardiology.
You can find information about the
preauthorization requirements at
UHCRiverValley.com > Preauthorizations >
Procedures, DME, and Other Services
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Network Bulletin: November 2013 - Volume 58
Network Bulletin: February 2015
For more information call 877.842.3210, or visit UnitedHealthc
For more information call 877.842.3210,
or visit UnitedHealthcareOnline.com
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Front & Center
Enhanced HIPAA Claim Edits Planned for March 2015
Effective March 25, 2015, UnitedHealthcare will apply additional WEDI Strategic National
Implementation Process (SNIP) HIPAA edits to professional (837p) and institutional (837i)
claims submitted electronically to most UnitedHealthcare and affiliate payer IDs.* These
are new edits that were not applied with the edit enhancements released in 2014. For more
information on current and previous edit releases, visit the Enhanced Claim Edits section of
UnitedHealthcareOnline.
Because the new edits will be applied on a
pre-adjudication basis, an increase in the number
of claim rejections may occur. This will enable you to
identify and correct rejected information prior to the claim’s
acceptance into our adjudication system for processing.
The benefit will be fewer denied claims and less interruption
to revenue streams.
The primary impact to you will come from edits that
will validate code sets (such as diagnosis, procedure
and modifier codes) at a pre-adjudication level. The
new edits have been distributed to clearinghouses and
software vendors.
It’s important to check all of your claim submission reports
regularly. Claims may be rejected by your clearinghouse
or UnitedHealthcare; therefore, you may receive multiple
reports per submission. View tracking your electronic
claims to learn more about reports and rejections.
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Network Bulletin: November 2013 - Volume 58
Network Bulletin: February 2015
Rejections that may occur from the enhanced edits will
appear at a clearinghouse level. Your Electronic Data
Interchange (EDI) vendor or clearinghouse should be your
first point of contact for assistance regarding these edits or
to resolve rejections. For assistance from UnitedHealthcare,
please contact EDI Support:
UnitedHealthcare Commercial,
UnitedHealthcare Medicare Solutions
and UnitedHealthcare West
EDI issue reporting form
or 800-842-1109
UnitedHealthcare Community Plan
[email protected]
or 800-210-8315
UnitedHealthcare Oxford
[email protected]
or 800-599-4334
* Excluded: Harvard Pilgrim (04271), Medica HealthCare Plans (78857), Preferred
Care Partners (65088), the Alliance (88461) and TRICARE West (99726)
For more information call 877.842.3210, or visit UnitedHealthc
For more information call 877.842.3210,
or visit UnitedHealthcareOnline.com
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UnitedHealthcare Commercial
UnitedHealthcare Medical Policy, Drug
Policy, Coverage Determination Guideline
and Utilization Review Guideline Updates
For complete details on the policy updates listed in
the table on the following page, please refer to
the monthly Medical Policy Update Bulletin at
UnitedHealthcareOnline.com > Tools
& Resources > Policies, Protocols and Guides >
Medical & Drug Policies and Coverage Determination
Guidelines > Medical Policy Update Bulletin.
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Network Bulletin: November 2013 - Volume 58
Network Bulletin: February 2015
For more information call 877.842.3210, or visit UnitedHealthc
For more information call 877.842.3210,
or visit UnitedHealthcareOnline.com
TABLE OF CONTENTS
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Policy Title
Policy Type
Effective
Date
Medical Policy
Update Bulletin
Balloon Sinus Ostial Dilation
Medical Policy
April 1, 2015
Jan. 2015
Feb. 2015
Entyvio (Vedolizumab)
Drug Policy
March 1, 2015
Dec. 2014
Jan. 2015
Feb. 2015
Hysterectomy for Benign Conditions
Medical Policy
April 1, 2015
Jan. 2015
Feb. 2015
Simponi Aria (Golimumab)
Drug Policy
March 1, 2015
Dec. 2014
Jan. 2015
Feb. 2015
Deep Brain Stimulation
Medical Policy
Feb. 1, 2015
Jan. 2015
Electrical Stimulation and Electromagnetic Therapy
for Wounds
Medical Policy
Feb. 1, 2015
Jan. 2015
Epiduroscopy, Epidural Lysis of Adhesions and
Functional Anesthetic Discography
Medical Policy
Feb. 1, 2015
Jan. 2015
Hip Resurfacing Arthroplasty
Medical Policy
Feb. 1, 2015
Jan. 2015
Implantable Beta-Emitting Microspheres for
Treatment of Malignant Tumors
Medical Policy
Feb. 1, 2015
Jan. 2015
Infertility Diagnosis and Treatment
Medical Policy
Feb. 1, 2015
Jan. 2015
Mechanical Stretching and Continuous
Passive Motion Devices
Medical Policy
Feb. 1, 2015
Jan. 2015
Nerve Graft to Restore Erectile Function
Medical Policy
Feb. 1, 2015
Jan. 2015
Obstructive Sleep Apnea Treatment
Medical Policy
Feb. 1, 2015
Jan. 2015
Omnibus Codes
Medical Policy
Feb. 1, 2015
Jan. 2015
Preventive Care Services
Coverage
Determination
Guideline
Feb. 15, 2015
Jan. 2015
Prosthetic Devices, Wigs, Specialized,
Microprocessor or Myoelectric Limbs
Coverage
Determination
Guideline
Feb. 1, 2015
Jan. 2015
NEW
UnitedHealthcare
Commercial
UnitedHealthcare
Medical Policy, Drug
Policy, Coverage
Determination
Guideline and
Utilization Review
Guideline Updates
UPDATED/REVISED
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Network Bulletin: November 2013 - Volume 58
Network Bulletin: February 2015
For more information call 877.842.3210, or visit UnitedHealthc
For more information call 877.842.3210,
or visit UnitedHealthcareOnline.com
TABLE OF CONTENTS
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UnitedHealthcare
Commercial
UnitedHealthcare
Medical Policy, Drug
Policy, Coverage
Determination
Guideline and
Utilization Review
Guideline Updates
Policy Title
Policy Type
Effective
Date
Medical Policy
Update Bulletin
Radiofrequency Therapy and Tibial Nerve
Stimulation for Urinary Disorders
Medical Policy
Feb. 1, 2015
Jan. 2015
Sensory Integration Therapy and Auditory
Integration Training
Medical Policy
Feb. 1, 2015
Jan. 2015
Surgical Treatment for Spine Pain
Medical Policy
Feb. 1, 2015
Jan. 2015
Temporomandibular Joint Disorders
Medical Policy
Jan. 1, 2015
Jan. 2015
Transcranial Magnetic Stimulation
Medical Policy
Feb. 1, 2015
Jan. 2015
Autism Spectrum Disorder
Utilization
Review
Guideline
Jan. 1, 2015
Jan. 2015
Intrastromal Corneal Ring Segments
Medical Policy
Jan. 1, 2015
Jan. 2015
RETIRED
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 between the information provided in this Network Bulletin and the posted policy, the posted policy prevails.
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Network Bulletin: November 2013 - Volume 58
Network Bulletin: February 2015
For more information call 877.842.3210, or visit UnitedHealthc
For more information call 877.842.3210,
or visit UnitedHealthcareOnline.com
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UnitedHealthcare Medicare Solutions
UnitedHealthcare Medicare Advantage
Coverage Summary Updates
For complete details on the updated/revised policies listed
in the table on the following page, please refer to the Medicare
Advantage Coverage Summary Update Bulletin at
UnitedHealthcareOnline.com> Tools & Resources > Policies,
Protocols and Guides > UnitedHealthcare Medicare Advantage
Coverage Summaries > Update Bulletin.
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Network Bulletin: November 2013 - Volume 58
Network Bulletin: February 2015
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or visit UnitedHealthcareOnline.com
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Policy Title
Approval Date
Update Bulletin
Chemotherapy, and Associated Drugs and Treatments
Dec. 16, 2014
Jan. 2015
Family Planning (Birth Control)
Dec. 16, 2014
Jan. 2015
Foot Care Services
Dec. 16, 2014
Jan. 2015
Hearing Aids, Auditory Implants and Related Procedures
Dec. 16, 2014
Jan. 2015
Hyperbaric Oxygen Therapy
Dec. 16, 2014
Jan. 2015
Nasal and Sinus Procedures
Dec. 16, 2014
Jan. 2015
Orthopedic Procedures, Devices and Products
Dec. 16, 2014
Jan. 2015
Ostomy Supplies
Dec. 16, 2014
Jan. 2015
Positron Emission Tomography (PET)/Combined PET-CT
(Computed Tomography)
Dec. 16, 2014
Jan. 2015
Services While Confined/Incarcerated
Dec. 16, 2014
Jan. 2015
Spine Procedures
Dec. 16, 2014
Jan. 2015
Transplants – Organ and Tissue Transplants
Dec. 16, 2014
Jan. 2015
Uterine Services and Procedures
Dec. 16, 2014
Jan. 2015
Vertebral Artery Surgery
Dec. 16, 2014
Jan. 2015
UPDATED/REVISED
UnitedHealthcare
Medicare Solutions
UnitedHealthcare
Medicare Advantage
Coverage Summary
Updates
Note: The inclusion of a service or procedure on this list does not imply that UnitedHealthcare provides coverage for the service or procedure. In the event
of an inconsistency between the information provided in this Network Bulletin and the posted policy, the posted policy prevails.
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Network Bulletin: November 2013 - Volume 58
Network Bulletin: February 2015
For more information call 877.842.3210, or visit UnitedHealthc
For more information call 877.842.3210,
or visit UnitedHealthcareOnline.com
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UnitedHealthcare Community Plan
Medical Policy & Coverage Determination
Guideline Updates
For complete details on the policy updates listed in the table
on the following page, please refer to the monthly
Medical Policy Update Bulletin at
UHCCommunityPlan.com > Provider Information >
Medical Policies and Coverage Determination Guidelines for
Community Plan.
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Network Bulletin: November 2013 - Volume 58
Network Bulletin: February 2015
For more information call 877.842.3210, or visit UnitedHealthc
For more information call 877.842.3210,
or visit UnitedHealthcareOnline.com
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Next Article >
Policy Title
Policy Type
Effective
Date
Medical Policy
Update Bulletin
Deep Brain Stimulation
Medical Policy
March 1, 2015
Jan. 2015
Feb. 2015
Electrical Stimulation and Electromagnetic
Therapy for Wounds
Medical Policy
March 1, 2015
Jan. 2015
Feb. 2015
Epiduroscopy, Epidural Lysis of Adhesions and
Functional Anesthetic Discography
Medical Policy
March 1, 2015
Jan. 2015
Feb. 2015
Hip Resurfacing Arthroplasty
Medical Policy
March 1, 2015
Jan. 2015
Feb. 2015
Implantable Beta-Emitting Microspheres for Treatment
of Malignant Tumors
Medical Policy
March 1, 2015
Jan. 2015
Feb. 2015
Mechanical Stretching and Continuous
Passive Motion Devices
Medical Policy
March 1, 2015
Jan. 2015
Feb. 2015
Nerve Graft to Restore Erectile Function
During Radical Prostatectomy
Medical Policy
March 1, 2015
Jan. 2015
Feb. 2015
Obstructive Sleep Apnea Treatment
Medical Policy
March 1, 2015
Jan. 2015
Feb. 2015
Omnibus Codes
Medical Policy
March 1, 2015
Jan. 2015
Feb. 2015
Radiofrequency Therapy and Tibial Nerve Stimulation
for Urinary Disorders
Medical Policy
March 1, 2015
Jan. 2015
Feb. 2015
Sensory Integration Therapy and Auditory
Integration Training
Medical Policy
March 1, 2015
Jan. 2015
Feb. 2015
Surgical Treatment for Spine Pain
Medical Policy
March 1, 2015
Jan. 2015
Feb. 2015
UPDATED/REVISED
UnitedHealthcare
Community Plan
Medical Policy &
Coverage Determination
Guideline Updates
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Network Bulletin: November 2013 - Volume 58
Network Bulletin: February 2015
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or visit UnitedHealthcareOnline.com
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UnitedHealthcare
Community Plan
Medical Policy &
Coverage Determination
Guideline Updates
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Policy Title
Policy Type
Effective
Date
Medical Policy
Update Bulletin
Transcranial Magnetic Stimulation
Medical Policy
March 1, 2015
Jan. 2015
Feb. 2015
Intrastromal Corneal Ring Segments
Medical Policy
Jan. 1, 2015
Jan. 2015
Temporomandibular Joint Disorders
Medical Policy
Jan. 1, 2015
Jan. 2015
RETIRED
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 between the information provided in this Network Bulletin and the posted policy, the posted policy prevails.
Network Bulletin: November 2013 - Volume 58
Network Bulletin: February 2015
For more information call 877.842.3210, or visit UnitedHealthc
For more information call 877.842.3210,
or visit UnitedHealthcareOnline.com
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UnitedHealthcare Military & Veterans
E-Prescribing – Now Available
at Military Pharmacies
On Dec. 31, 2014, the Military Health System
(MHS) deployed electronic prescribing capability.
TRICARE providers can now send prescriptions
electronically to military pharmacies, offering a new
option for their patients.
To send a prescription electronically to a military pharmacy,
providers only need to find the local military pharmacy name in
their existing e-prescribing software application. Military pharmacy
names usually start with the prefix “DOD”. TRICARE patients
who fill medications at a military pharmacy can get up to a 90-day
supply for most medications, compared to a 30-day supply through
a retail network pharmacy. They also have no copay or cost share
for medications from military pharmacies.
One thing to keep in mind is that military pharmacies may
have more limited formularies than some retail pharmacies. All
pharmacies in the MHS stock medications that are on TRICARE’s
“basic core formulary” can also carry additional medications
based on the needs of the military population they serve. Military
pharmacies will not be able to accept electronic prescriptions
for controlled substances. You will still need a hand written
prescription for these medications.
For the latest information on electronic prescribing at military
pharmacies, you can visit the Defense Health Agency
Pharmacoeconomic Branch website. For more information
on the TRICARE members filling prescriptions at military
pharmacies, or to find a military pharmacy near you that your
TRICARE patients might want to use, please visit the TRICARE
Pharmacy page.
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or visit UnitedHealthcareOnline.com
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UnitedHealthcare Commercial
Reimbursement Policy
Unless otherwise noted, these reimbursement policies apply to
services reported using the 1500 Health Insurance Claim Form
(CMS-1500) or its electronic equivalent or its successor form.
UnitedHealthcare reimbursement policies do not address all factors
that affect reimbursement for services rendered to UnitedHealthcare
members, including legislative mandates, enrollee 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 or conflict between the information provided
in the Network Bulletin and the posted policy, the provisions of the
posted policy prevail.
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or visit UnitedHealthcareOnline.com
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UnitedHealthcare Commercial Reimbursement Policy
Revision to the Nonphysician Health Care Professionals
Billing Evaluation and Management Codes Policy
UnitedHealthcare does not currently reimburse Evaluation and Management (E/M) CPT codes
99201-99499 when submitted by specific nonphysician health care professionals. According to
the Centers for Medicare and Medicaid Services (CMS), E/M services are reimbursable to certain
non physician practitioners, limited to nurse practitioners, clinical nurse specialists, certified nurse
midwives, and physician assistants.
Effective in the second quarter of 2015, UnitedHealthcare
will expand the scope of this policy to not reimburse
E/M CPT 99201-99499 when reported by the following
nonphysician health care professionals:
•
Other mental health counselor
•
Christian science practitioner
•
Registered social worker
•
Licensed practical nurse
•
Marriage and family social worker
•
Licensed vocational nurse
•
Pharmacist
•
Home health/private duty nurse
•
Visiting nurse
•
Behavioral analyst
These professionals should review the CPT and healthcare
common procedure coding system (HCPCS) national code
sets to select a more accurate code that describes the
services they are providing.
•
Genetic counselor
•
Alcohol and drug counselor
•
Crisis diversion
•
Employee assistance program (EAP) counselor
•
Empowerment coach
•
Marriage & family therapy/licensed marriage
and family therapy
•
Licensed professional counselor
•
Substance abuse services, alcohol & drug
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UnitedHealthcare Commercial Reimbursement Policy
Modifiers Being Added to Services and Modifiers Not
Reimbursable to Health Care Professionals Policy
UnitedHealthcare will not reimburse modifiers H9,
HU-HZ, QJ or TR, effective in the second quarter
of 2015. The use of the following modifiers
indicates that a service has been funded by a
county, state or federal agency; therefore, no cost
has been incurred requiring reimbursement:
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Modifier
Description
H9
Court-ordered
HU
Funded by child welfare agency
HV
Funded state addictions agency
HW
Funded by state mental health agency
HX
Funded by county/local agency
HY
Funded by juvenile justice agency
HZ
Funded by criminal justice agency
QJ
Services/items provided to a prisoner or patient in
state or local custody, however the state or local
government, as applicable, meets the requirements in
42 CFR 411.4 (B)
TR
School-based individualized education program
services provided outside the public school district
responsible for the student
Network Bulletin: November 2013 - Volume 58
Network Bulletin: February 2015
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Doing Business Better
Claim Reconsideration and
Appeal Process Summary
We continue to monitor and review our processes
to provide the best service to our constituents.
We completed our annual review of the claim
reconsideration and appeal process for our
Provider Administrative Guide for 2015 and
wanted to take this opportunity to highlight the
following summary*:
The Two-Step Process
Step one is the reconsideration level: Requests for
reconsideration must be submitted within 12 months of the date
on the initial Explanation of Benefits (EOB). It is important to
submit the reconsideration level early in the process since the
reconsideration level and the appeal level share one 12-month
timeframe. The request must include the Claim Reconsideration
Form located online and all supporting documentation.
For more information on how to obtain the form, please
see the Provider Administrative Guide located at
UnitedHealthcareOnline.com > Policies, Protocols and
Administrative Guides > UnitedHealthcare Administrative
Guide for 2015.
If the reconsideration does not result in an overturned decision, the
EOB or response letter will include next level rights and where to
submit a request for further review.
Step two is the appeal level: Appeals must be submitted within
the same 12-month time period as stated above. Please submit
all supporting materials that you wish to have reviewed in the
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Network Bulletin: November 2013 - Volume 58
Network Bulletin: February 2015
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TABLE OF CONTENTS
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Doing Business Better
Claim Reconsideration and Appeal Process Summary
appeal including a letter requesting a formal appeal. Please
submit to the appropriate address located in the Provider
Administrative Guide. Appeals must be submitted in writing.
If the appeal does not result in an overturned decision,
the provider must review their contract for further dispute
resolution steps.
If you have additional questions on the claim
reconsideration or appeal process, please reference the
Provider Administrative Guide under the applicable section.
* Claim reconsideration does not apply to California or Colorado
Commercial, or as required by state law, refer to Provider
Dispute Resolution (PDR).
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Network Bulletin: November 2013 - Volume 58
Network Bulletin: February 2015
For more information call 877.842.3210, or visit UnitedHealthc
For more information call 877.842.3210,
or visit UnitedHealthcareOnline.com
TABLE OF CONTENTS
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UnitedHealthcare Affiliates
UnitedHealthcare of the River Valley
Preauthorization List and Policy Updates
For complete details on the policy updates listed in the table
on the following page, please refer to the monthly Policy
Update Bulletin at UHCRiverValley.com > Providers >
Coverage Policy Library > Policy Update Bulletin.
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Network Bulletin: November 2013 - Volume 58
Network Bulletin: February 2015
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or visit UnitedHealthcareOnline.com
TABLE OF CONTENTS
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UnitedHealthcare Affiliates
UnitedHealthcare of the River Valley
Preauthorization List and Policy Updates
These updates apply to
UnitedHealthcare of the
River Valley commercial
and hawk-i plan
members only.
Policy Title
Effective Date
Coverage Policy
Update Bulletin
To be decided
Feb. 2015
Balloon Sinus Ostial Dilation
April 1, 2015
Jan. 2015
Feb. 2015
Clotting Factors and Coagulant Blood Products
April 1, 2015
Jan. 2015
Feb. 2015
Entyvio™ (vedolizumab)
April 1, 2015
Jan. 2015
Feb. 2015
Hysterectomy for Benign Conditions
April 1, 2015
Jan. 2015
Feb. 2015
Radiology/Advanced Outpatient Imaging Procedures
To be decided
Feb. 2015
April 1, 2015
Jan. 2015
Feb. 2015
Alemtuzumab
March 1, 2015
Jan. 2015
Feb. 2015
Anemia Drugs: Darbepoetin Alfa, Epoetin Alfa and Peginesatide
Feb. 1, 2015
Jan. 2015
Deep Brain Stimulation
Feb. 1, 2015
Jan. 2015
DME, Orthotics, Ostomy Supplies, Medical Supplies
and Repairs/Replacements
Feb. 1, 2015
Jan. 2015
Electrical Stimulation and Electromagnetic Therapy for Wounds
Feb. 1, 2015
Jan. 2015
Epiduroscopy, Epidural Lysis of Adhesions and Functional
Anesthetic Discography
Feb. 1, 2015
Jan. 2015
TAKE NOTE
New Preauthorization Requirements for Radiology/Advanced
Outpatient Imaging Procedures
*Implementation delayed
NEW
*Implementation delayed; previously announced with an
effective date of Feb. 16, 2015
Simponi® Aria™ (golimumab)
UPDATED/REVISED
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Network Bulletin: November 2013 - Volume 58
Network Bulletin: February 2015
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or visit UnitedHealthcareOnline.com
TABLE OF CONTENTS
Next Article >
UnitedHealthcare
Affiliates
UnitedHealthcare
of the River Valley Prior
Authorization List and
Policy Updates
Policy Title
Effective Date
Coverage Policy
Update Bulletin
Hip Resurfacing Arthroplasty
Feb. 1, 2015
Jan. 2015
Immune Globulin (IVIG and SCIG)
Feb. 1, 2015
Jan. 2015
Implantable Beta-Emitting Microspheres for Treatment
of Malignant Tumors
Feb. 1, 2015
Jan. 2015
Infertility Diagnosis and Treatment
Feb. 1, 2015
Jan. 2015
Mechanical Stretching and Continuous Passive Motion Devices
Feb. 1, 2015
Jan. 2015
Nerve Graft to Restore Erectile Function
During Radical Prostatectomy
Feb. 1, 2015
Jan. 2015
Obstructive Sleep Apnea Treatment
Feb. 1, 2015
Jan. 2015
Omnibus Codes
Feb. 1, 2015
Jan. 2015
Preventive Care Services
Feb. 15, 2015
Jan. 2015
Radiofrequency Therapy and Tibial Nerve Stimulation
for Urinary Disorders
Feb. 1, 2015
Jan. 2015
Sandostatin®/Sandostatin LAR® (Octreotide Acetate)
Feb. 1, 2015
Jan. 2015
Sensory Integration Therapy and Auditory Integration Training
Feb. 1, 2015
Jan. 2015
Stelara (Ustekinumab)
Feb. 1, 2015
Jan. 2015
Surgical Treatment for Spine Pain
Feb. 1, 2015
Jan. 2015
Temporomandibular Joint Disorders
Feb. 1, 2015
Jan. 2015
Transcranial Magnetic Stimulation
Feb. 1, 2015
Jan. 2015
Feb. 1, 2015
Feb. 2015
RETIRED
Intrastromal Corneal Ring Segments
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 between the information provided in this Network Bulletin and the posted policy, the posted policy prevails.
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Network Bulletin: November 2013 - Volume 58
Network Bulletin: February 2015
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For more information call 877.842.3210,
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TABLE OF CONTENTS
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UnitedHealthcare Affiliates
SignatureValue™ Benefit Interpretation Policy Updates
For complete details
on the policy updates
listed in the following
table, please refer to the
monthly SignatureValue™
Benefit Interpretation
Policy Update Bulletin
at UHCWest.com >
Provider Log In > Library
> Resource Center >
Guidelines &
Interpretation Manuals.
Policy Title
Applicable State(s)
Effective
Date
Update
Bulletin
Complementary and Alternative Medicine
All (California, Oklahoma,
Oregon, Texas, & Washington)
Feb. 1, 2015
Jan. 2015
Medical Necessity
All
Jan. 1, 2015
Jan. 2015
Nutritional Therapy: Enteral
and Oral Nutritional Therapy
All
Feb. 1, 2015
Jan. 2015
Member Initiated Second and Third Opinion
All
Feb. 1, 2015
Jan. 2015
Post Mastectomy Surgery
All
Feb. 1, 2015
Jan. 2015
Telemedicine/Telehealth Services
All
Feb. 1, 2015
Jan. 2015
UPDATED/REVISED
Note: The inclusion of a service or procedure on this list does not imply that coverage is provided for the service or procedure. In the event of an
inconsistency between the information provided in this Network Bulletin and the posted policy, the posted policy prevails.
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Network Bulletin: November 2013 - Volume 58
Network Bulletin: February 2015
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For more information call 877.842.3210,
or visit UnitedHealthcareOnline.com
TABLE OF CONTENTS
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UnitedHealthcare Affiliates
SignatureValue™ Medical Management
Guideline Updates
For complete details on the
policy updates listed in the
following table, please refer to
the monthly SignatureValue™
Medical Management
Guidelines Update Bulletin
at UHCWest.com > Provider
Log In > Library > Resource
Center > Guidelines &
Interpretation Manuals.
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Policy Title
Effective Date
Update Bulletin
Balloon Sinus Ostial Dilation
April 1, 2015
Jan. 2015
Hysterectomy for Benign Conditions
April 1, 2015
Jan. 2015
Deep Brain Stimulation
Feb. 1, 2015
Jan. 2015
Electrical Stimulation and Electromagnetic
Therapy for Wounds
Feb. 1, 2015
Jan. 2015
Epiduroscopy, Epidural Lysis of Adhesions
and Functional Anesthetic Discography
Feb. 1, 2015
Jan. 2015
Hip Resurfacing Arthroplasty
Feb. 1, 2015
Jan. 2015
Implantable Beta-Emitting Microspheres for Treatment
of Malignant Tumors
Feb. 1, 2015
Jan. 2015
Mechanical Circulatory Support Device (MCSD)
Jan. 1, 2015
Jan. 2015
Mechanical Stretching and Continuous
Passive Motion Devices
Feb. 1, 2015
Jan. 2015
Nerve Graft to Restore Erectile Function
During Radical Prostatectomy
Feb. 1, 2015
Jan. 2015
Obstructive Sleep Apnea Treatment
Feb. 1, 2015
Jan. 2015
Omnibus Codes
Feb. 1, 2015
Jan. 2015
Preventive Care Services
Feb. 15, 2015
Jan. 2015
Radiofrequency Therapy and Tibial Nerve Stimulation
for Urinary Disorders
Feb. 1, 2015
Jan. 2015
NEW
UPDATED/REVISED
Network Bulletin: November 2013 - Volume 58
Network Bulletin: February 2015
For more information call 877.842.3210, or visit UnitedHealthc
For more information call 877.842.3210,
or visit UnitedHealthcareOnline.com
TABLE OF CONTENTS
Next Article >
UnitedHealthcare
Affiliates
SignatureValue™
Medical Management
Guideline Updates
Policy Title
Effective Date
Update Bulletin
Sensory Integration Therapy and Auditory
Integration Training
Feb. 1, 2015
Jan. 2015
Surgical Treatment for Spine Pain
Feb. 1, 2015
Jan. 2015
Temporomandibular Joint Disorders
Jan. 1, 2015
Jan. 2015
Transcranial Magnetic Stimulation
Feb. 1, 2015
Jan. 2015
Jan. 1, 2015
Jan. 2015
RETIRED
Intrastromal Corneal Ring Segments
Note: The inclusion of a service or procedure on this list does not imply that coverage is provided for the service or procedure. In the event of an
inconsistency between the information provided in this Network Bulletin and the posted policy, the posted policy prevails.
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28
Network Bulletin: November 2013 - Volume 58
Network Bulletin: February 2015
For more information call 877.842.3210, or visit UnitedHealthc
For more information call 877.842.3210,
or visit UnitedHealthcareOnline.com
TABLE OF CONTENTS
UnitedHealthcare Affiliates - Oxford®
Oxford® Medical and Administrative Policy Updates
For complete details on
the new and/or revised
policies listed in the following
table, refer to the monthly
Policy Update Bulletin
at OxfordHealth.com >
Providers > Tools &
Resources > Medical
Information > Medical and
Administrative Policies >
Policy Update Bulletin.
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Policy Title
Policy Type
Effective
Date
Policy Update
Bulletin
Balloon Sinus Ostial Dilation
Clinical Policy
April 1, 2015
Jan. 2015
Feb. 2015
Hysterectomy for Benign Conditions
Clinical Policy
April 1, 2015
Jan. 2015
Feb. 2015
Accreditation Requirements for Radiologists
and Radiology Centers
Administrative Policy
Feb. 1, 2015
Jan. 2015
Agents for Migraine - Triptans
Clinical Policy
Feb. 1, 2015
Jan. 2015
Alemtuzumab
Clinical Policy
Feb. 1, 2015
Jan. 2015
Ambulance Policy
Reimbursement
Policy
Jan. 1, 2015
Jan. 2015
Assistant Surgeon Policy
Reimbursement
Policy
Jan. 1, 2015
Jan. 2015
Bilateral Procedures
Reimbursement
Policy
Jan. 1, 2015
Jan. 2015
Contraceptives
Clinical Policy
Feb. 1, 2015
Jan. 2015
Co-Surgeons; Team Surgeon Policy
Reimbursement
Policy
Jan. 1, 2015
Jan. 2015
Drug Coverage Criteria - New and Therapeutic
Equivalent Medications
Clinical Policy
Feb. 1, 2015
Jan. 2015
Drug Coverage Guidelines
Clinical Policy
Feb. 1, 2015
Jan. 2015
Femoroacetabular Impingement
Syndrome Treatment
Clinical Policy
Feb. 1, 2015
Jan. 2015
Global Days Policy
Reimbursement
Policy
Jan. 1, 2015
Jan. 2015
TAKE NOTE
UPDATED/REVISED
UPDATED/REVISED
Network Bulletin: November 2013 - Volume 58
Network Bulletin: February 2015
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TABLE OF CONTENTS
Policy Title
Policy Type
Effective
Date
Policy Update
Bulletin
UPDATED/REVISED
UnitedHealthcare
Affiliates
Hearing Aids And Devices Including Wearable,
Bone-Anchored and Semi-Implantable
Clinical Policy
Feb. 1, 2015
Jan. 2015
Immune Globulin (IVIG and SCIG)
Clinical Policy
Feb. 1, 2015
Jan. 2015
Oxford Medical
and Administrative
Policy Updates
Injectable Chemotherapy Drugs: Application
of NCCN Clinical Practice Guidelines
Clinical Policy
Feb. 1, 2015
Jan. 2015
Injection and Infusion Services Policy
Reimbursement
Policy
Jan 1, 2015
Jan. 2015
Inpatient Consultations
Reimbursement
Policy
Jan. 1, 2015
Jan. 2015
Multiple Imaging Rules
Reimbursement
Policy
Feb. 1, 2015
Jan. 2015
Multiple Procedures Policy
Reimbursement
Policy
Jan. 1, 2015
Jan. 2015
Oral Anti-Diabetic Agents (Janumet, Januvia,
Janumet XR, Invokana, Farxiga, Empaglifloxin/
Metformin, Jardiance, Xigduo XR)
Clinical Policy
Feb. 1, 2015
Jan. 2015
Practitioner/Provider Administrative Claim
Reconsideration and Appeal Process
Administrative Policy
Jan. 1, 2015
Jan. 2015
Preventive Care Services
Clinical Policy
Feb. 15, 2015
Jan. 2015
Preventive Medicine and Screening Policy
Reimbursement
Policy
Jan. 1, 2015
Jan. 2015
Prolonged Services Policy
Reimbursement
Policy
Feb. 1, 2015
Jan. 2015
Radiology Procedures Requiring Precertification
Clinical Policy
Feb. 1, 2015
Jan. 2015
Sandostatin Lar Depot (Octreotide Acetate)
Clinical Policy
Feb. 1, 2015
Jan. 2015
Stelara (Ustekinumab)
Clinical Policy
Feb. 1, 2015
Jan. 2015
Telemedicine Policy
Reimbursement
Policy
Jan. 1, 2015
Jan. 2015
Temporomandibular Joint Disorders
Clinical Policy
Jan. 1, 2015
Jan. 2015
Time Span Codes Policy
Reimbursement
Policy
Jan. 20, 2015
Jan. 2015
Treatment of Infertility for New York Large
and Small Groups
Clinical Policy
Feb. 1, 2015
Jan. 2015
Note: The inclusion of a service or procedure on this list does not imply that coverage is provided for the service or procedure. In the event of an
inconsistency between the information in this Network Bulletin and the posted policy, the posted policy will prevail.
Oxford HMO products are underwritten by Oxford Health Plans (NY), Inc., Oxford Health Plans (NJ), Inc. and Oxford Health Plans (CT), Inc. Oxford
insurance products are underwritten by Oxford Health Insurance, Inc.
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For more information call 877.842.3210, or visit UnitedHealthc
Network Bulletin: November 2013 - Volume 58
Insurance coverage provided by UnitedHealthcare Insurance Company or its affiliates. Health plan coverage provided by UnitedHealthcare of
Network Bulletin: February 2015
Arizona, Inc., UnitedHealthcare of California, UnitedHealthcare of Colorado, Inc., UnitedHealthcare of Oregon, Inc., UnitedHealthcare of Utah, Inc.
Doc#: PCA15610_20150120
and UnitedHealthcare of Washington, Inc. or other affiliates. Administrative services provided by UnitedHealthcare Services, Inc. or its affiliates.